Democracy in Local Health Care
The next item of business is a debate on democracy in local health care.
I am pleased to open an important debate that, in many ways, will go to the heart of the kind of national health service that we want to build for the next 60 years. We made a deliberate decision to hold the debate during the consultation on the proposed local health care bill in order to give members of all parties an opportunity to contribute to the consultation. I make it clear at the outset that all contributions are welcome and will have an impact on developing the proposals in the consultation paper.
I have no doubt that, although members are divided on many health and well-being matters, we all agree on the need for good public and community involvement in, and engagement with, the national health service. A view that has been repeatedly reinforced in my mind over the past few months—as I have travelled the length and breadth of the country talking to people who work in the NHS and to the many thousands of people who use its services—is that people desperately want to be involved in their local health services. They want to be involved in the key decisions about the future development of the NHS and they want to be able to participate actively in their own care. In stating clearly that we must do more to encourage and enable such participation, "Better Health, Better Care: Action Plan", reflects the strong views that have been expressed by patients and the public during the consultation.
It is important to say—I hope that members will agree—that some NHS boards are already doing a good job in fostering and encouraging community and public involvement. All NHS boards now have a statutory duty to show year on year how they are improving their engagement with the public. That represents good progress, and the Scottish health council plays an important role in ensuring that boards live up to that statutory obligation. In my experience—albeit that it is short, so far—as Cabinet Secretary for Health and Wellbeing, examples of innovative good practice are perhaps not as widespread throughout the NHS as they should be, so I have no doubt that there is room for improvement.
For too long, public opinion has been viewed by too many people as an obstacle that is to be navigated around. There has been evidence of such an attitude in many recent consultations on major service change proposals, but that attitude must change. Last year, when I launched "Better Health, Better Care: Action Plan", I set out our vision of a mutual NHS, in which ownership and accountability are shared with the public and the staff who work in the service. The action plan contains proposals that will bring the concept of mutuality to life and will start to shift ownership and accountability to the people of Scotland: for example, later this year we will launch a consultation on the possible contents of a patients' rights bill.
We have experienced the real benefits of independent scrutiny panels. For example, an independent scrutiny panel exposed the complete lack of evidence to underpin the decision to close accident and emergency departments at Ayr hospital and Monklands hospital. When we have consulted the Scottish people, we will shortly announce how independent scrutiny will be embedded in how the NHS develops proposals for major service changes in the future.
We will develop a participation standard, to ensure that patient focus and public involvement become the core drivers of decision making, rather than afterthoughts or side issues. We will require boards to produce annual ownership reports setting out information on how to access local services, how to raise issues and concerns and how to get involved in the design and delivery of local health services.
Perhaps most important, for the purposes of today's debate, we are undertaking an extensive consultation on proposals that might be included in a local health care bill. The consultation started on 8 January and will run until 1 April. The consultation document has been distributed to a wide range of organisations representing the public, patients, professionals and many other interested parties. I look forward to receiving a substantial response.
In the context of a mutual NHS, the consultation is a major step towards strengthening public and community involvement with NHS boards. The consultation seeks views on two key themes. They are not presented as alternatives—we must make progress on both. First, the consultation seeks views on how the current process and procedures for public involvement can be improved. For example we are, with a view to strengthening existing mechanisms, seeking views on the future role of the Scottish health council, on the role of local authority members on NHS boards, and on how public partnership forums and community planning partnerships can support improved public involvement.
Secondly, the consultation seeks views on a range of issues that relate to direct elections to NHS area boards. I appreciate that direct elections raise complex issues, some of which are already being considered during the consultation. There is an issue about the proportion of elected members on boards and whether elected members should be the majority. I was amused the other day to read that Bill Butler will support the approach only if the majority of board members are elected, whereas Jackson Carlaw will support it only if the majority are un-elected, which might present me with interesting challenges in bringing opinions together.
There are also issues about the accountability of boards. Boards are currently accountable to ministers and to Parliament, which should not change. There are issues about the type of elections and who might stand. I am sure that no member wants further party politicisation of the NHS—many of us think that we have enough of that in Parliament. There are questions about whether we should pilot elections and about the relationship between elected and other board members. It is important to acknowledge the important work that stakeholder, lay and executive members play, and to consider how we incorporate elected members into the mix without making NHS boards unwieldy.
Is one way of avoiding an unwieldy number of board members to return executive members to their pre-1981 state, when they simply offered advice? There is a solution.
I agree very much with Bill Butler that that is an option. It will be considered, and I look forward to receiving his contribution to the consultation. He has many important things to say on the subject.
There is a range of views on all the issues. I have views and our manifesto set out clear views on some of them—for example, on the proportion of elected board members. However, as a minority Government, we must build consensus for change: that should be seen as a strength, not a weakness. That is why the consultation deliberately steers clear of fixed positions. We will listen to all strands of opinion and seek to move forward on the basis of agreement, but move forward we must.
Some people take the view that direct elections are too radical a step for the NHS. However, in this year of all years—the 60th anniversary of the founding of the NHS—we should be wiling to countenance radical change, just as the founding fathers did 60 years ago. Other people say that direct elections will not have the effect that people think they will have. If, by that, they mean that direct elections will not remove the need for tough decisions, they are absolutely right. As I am finding out with every passing day in this job, difficult decisions will always have to be made in the NHS. Nevertheless, I believe that directly elected members on NHS boards will enhance and improve the quality of decision making. In my experience, when people are allowed to be involved in decision making—when they understand and are persuaded of the reasons for change—they are more likely to become drivers for change than barriers to change. Problems arise when people feel excluded, ignored and cut out of decision making, and when they are treated as though they do not understand the issues.
This is an important debate that goes to the heart of the kind of NHS that we want to develop for the future. It is absolutely right to see the Scottish people and the NHS staff as equal partners in—indeed, as co-owners of—the national health service. With "Better Health, Better Care", we have made a positive and encouraging start to the process of building mutuality into the very fibre of our national health service, and the consultation on the proposed local health care bill will maintain that momentum. Everywhere I go, I see evidence of people's willingness and desire to be involved and to play a full part in the delivery of health care services in their areas. It will be to the advantage of all of us if we encourage and embrace that willingness and desire.
I look forward to hearing views from across the chamber. It is an important and welcome innovation, although it is not the first time that it has happened and it will not be the last. Nevertheless, it is important during a consultation to give Parliament the opportunity to have a debate without the need to divide at the end of the debate, so that our views can be incorporated and, I hope, reflected in the final decisions that are made. I very much look forward to listening to the range of views that I have no doubt will be expressed.
I welcome the debate. Nicola Sturgeon was correct to contextualise it as she did. We acknowledge formally that, when Labour requested a subject debate on the issue because we felt that it was appropriate, it was readily agreed by the SNP business manager.
As the cabinet secretary has outlined, the performance of the health service and all that is around it is of critical importance to the Parliament because it is crucial to the well-being of Scotland. How the health service operates and functions and how it is scrutinised and held accountable are of critical importance as we conduct our day-to-day affairs. The cabinet secretary referred to what I would call the unequivocal commitments that were made in the SNP manifesto. If the SNP wants to move away from them, it should give us fair warning of that. Nevertheless, it is important that we are having this discussion in the manner that has been outlined, rather than in the manner that was suggested in earlier political discussions.
There has been a perceived democratic deficit in health services for some time. We should remind ourselves that the health board landscape has been significantly decluttered. Richard Simpson reminded me just yesterday that, some years ago, before we came to power, there were 42 health boards in Scotland. Board meetings have now been opened up and a tough freedom of information regime has been applied. Over recent years, we have also extended the influence of locally elected councillors, introduced new standards of consultation, introduced patient partnership forums and established the Scottish health council. I welcome the fact that the cabinet secretary said that she would examine and strengthen those mechanisms. Despite those many changes and the progress that I argue strongly has been made, the sense of democratic deficit remains. We have to acknowledge that and appreciate some of the reasons for it.
Some members of the community remain critical of the consultation processes that health boards have undertaken. Some believe that boards are too remote and are not responsive enough to local opinion and experience. Some believe that boards are dominated by professional interests—both managerial and clinical—and it seems that, at times, they do not explain their reasoning properly and do not engage with other voices and perspectives.
There is another argument. Given the powers that boards wield, the resources that they command and the decisions that they make—and the centrality of all that to the lives of Scots—it is important that we attempt to improve scrutiny and accountability. We should make the processes more comprehensive and thorough. There is a substantial argument that the greatest stimulus for that is democratic involvement.
Overall, it is fair to say that there is a substantial argument for change, so we should consider how such change happens and what shape it takes. Of course, we need to be careful about the implications of any changes. I am sure that we have all had representations about that. None of us can afford to play fast and loose with the NHS—it is just too important for that. Therefore, any change has to be well thought through and we have to be fully aware of its implications. I acknowledge that many of the challenges that have been flagged up have been added to the consultation paper. If we are to proceed with changes, we must appreciate the arguments of those who oppose elections to health boards and ensure that we address their substantial concerns.
How will we maintain a national health service with national targets and standards if we further decentralise decision making? Could a minister reasonably overrule decisions that had been reached democratically? What would be the implications? What would be the relationship with national programmes and facilities? How do we ensure national and effective decision making without undue influence of vested interests, whether they are issue-related, political or geographical? I acknowledge the comments that the minister made on that issue.
How do we ensure adequate participation? I have to say that I probably disagree with Nicola Sturgeon, who seemed to emphasise that there is a huge appetite for participation. I worry that participation would not be at an appropriate level and that we would have to give great consideration to ensuring that people were encouraged to participate if we were to adopt the direct elections model. We have to be careful; Scotland is perhaps on the verge of voter fatigue, given how many regular elections we have. We have to ensure that we do not downgrade the significance of further democratic involvement in the national health service.
Of course, we have to ensure that decision making is rational and effective. I would never argue that democratic involvement somehow undermines rational and effective decision making, but in any model that we introduce, we have to ensure that the weakest voice is not crowded out so that only the loudest voices exert influence. That will have to be given great consideration, particularly given the challenge that we face with health inequalities in Scotland.
There are powerful arguments on both sides of this debate. We cannot just tinker. The democratic imperative is always a powerful driver, but it is critical that we are aware of the implications of changes.
If we are to alter the governance arrangements of the NHS in Scotland, we have to do so in a manner that leads to an improved service. Any alteration will have to be settled for some time. We will not be able revisit arrangements time and again if we think that they are not working for us.
Given those factors, I do not suppose that it will come as a surprise that I think that our policy of pilots, which was set out in our manifesto, is worthy of consideration and is possibly the most appropriate model. I am interested to see what comes out of the consultation exercise, which the minister said would be extensive. I hope that she will present the evidence and conclusions to Parliament in various ways, whether through the committees or in the chamber. I am sure that Nicola Sturgeon would never dream of doing this, but I hope that she will not dismiss the idea just because it was Labour's policy at the election. Pilots will be a helpful and constructive way forward that will allow the policy to be tested, allow us to address any concerns and allow us to iron out any difficulties.
Members will know that the Labour Party has held discussions over the years on direct elections, so Nicola Sturgeon will know the strength of commitment of many Labour members. Bill Butler in particular has supported the idea. We cannot dismiss the arguments lightly.
I hope that the minister will come back to Parliament when the consultation is complete, and that she can find the means to ensure that Parliament is systematically involved in understanding the evidence. I hope also that she will commit today to consulting Parliament before any firm decision is taken.
We, too, welcome this debate on the consultation on a local health care bill to directly elect members of health boards. Like Margaret Curran, we will monitor the responses to the consultation. It is fair to say that we would welcome another parliamentary debate.
My colleague Jackson Carlaw is unable to be here today, which is unfortunate given his interest in independent scrutiny panels. However, I understand that ISPs will be the subject of a separate debate in the future.
A publication from the Scottish health council landed on my desk this week. Its new website is a step in the right direction on the issues that we are discussing today. The publication says:
"The Scottish Health Council Evolving Practice website will enable healthcare professionals to share their experiences of how they have engaged with patients and the public to improve services."
It does not cover everything but, as I say, it is a step in the right direction.
The current chairman of the British Medical Association is on record as saying that
"the Government should strengthen local structures and support NHS boards to improve their own consultation processes and communicate better with the public".
I am inclined towards that view. Much of the enthusiasm for directly elected health boards arises from dissatisfaction with the current consultation process. All too often, communities are presented with what are seen as faits accomplis. They have to argue against eminent health professionals and economists such as Kerr and Andrew Walker as to what is the best option for the delivery of services.
The issues surrounding consultation of communities on health issues have rarely been off Parliament's agenda since 1999. I remember the petition on Stracathro, which attracted 48,000 signatures. The petitioners felt that they were not being listened to. I also remember the petition on Stobhill, where the local community felt strongly that no one was listening to them. I remember, too, our being concerned about the consultation process and I remember the work that was done by Dr Richard Simpson on the Stobhill proposals.
My colleague Jamie Stone is in the chamber, and I want to acknowledge the campaigns in the Highlands to save the Belford hospital in Fort William and the consultant-led maternity services in Caithness. In both cases, communities were united to stand against a mighty health board. My goodness—it was quite something to watch.
Surely public involvement at the earliest opportunity, so that people can understand why change is needed, and their further involvement in drawing up options, would help. The public should not just be involved in the final stages.
Representation is another issue—Margaret Curran spoke about it. For example, if all of the Highlands was to be one constituency, it could be that all board members lived in Inverness. The area now takes in Argyll and small communities such as Appin, so ensuring that people are heard will be a huge challenge. I do not think that having a representative from each multi-member ward would be acceptable, given the numbers involved.
Scottish Conservatives are concerned that single-issue campaigners may wish to be elected and that they are very likely to be elected, especially when they are recognised as the guardians of existing services. That could work well, but, equally, it could be a block to innovation, modernisation, development and change, which are inevitable in the NHS.
When I was thinking about that issue, I thought of the former Tory health minister, Michael Forsyth, who proposed that ambulance personnel should upskill to become paramedics and fought tooth and nail to ensure that that happened. The Opposition of the day said that that would lead to a two-tier ambulance service and campaigned strongly against the new paramedic post. However, I do not think that any MSP or health board member would argue against the excellent work that paramedics and ambulance staff do. I use that example to show that difficult decisions have sometimes to be taken and changes have to be made. We do not always like change but, in the long term, it can deliver a better outcome.
We support the appointment of at least one councillor to each board, given the need for people to work together on delayed-discharge issues and care in the community. I see no reason why a councillor who has been elected to a council need be elected again to gain a place on a health board.
My party supports the inclusion of a general practitioner on each board, given that 90 per cent of patient contact with the NHS is in primary care. Based on recent experience, having a representative of the Scottish Ambulance Service on each health board and a health board member on the Scottish Ambulance Service board would also lead to much better working relationships.
Will direct elections to health boards of less or more than 50 per cent of their members enhance transparency and accountability and lead to greater public satisfaction and agreement over decision making and consultation? The truth is that we are not entirely convinced that that will be the case. However, we think that improvements can be made to the existing process.
I welcome the opportunity to participate in this debate on the consultation on democracy in local health care. I note that the consultation ends, somewhat unpropitiously, on 1 April. I hope that no one will read too much into that.
The debate was going quite well until we heard mention of Michael Forsyth.
Paramedics.
Never mind the paramedics. I well remember that when Michael Forsyth first campaigned in Scotland, he came here with a reputation for campaigning avidly for privatisation of the ambulance service and the fire service. I have never really been a great supporter of him since then.
The cabinet secretary touched on two issues that ought not to be confused. One is how in delivery of care one tries to allow the individual patient to exert greater influence on that care. The second is how we deal with the democratic deficit in health boards, which are charged with delivering that care in a broader sense.
One of the issues that the cabinet secretary and the rest of us must address is the role of health boards and how they discharge their duties. I mention that because of what came out of the scrutiny panels' reports on Ayrshire and Arran NHS Board and Lanarkshire NHS Board. Those reports contained some excoriating criticism of the way in which those boards consulted. If we want boards that are properly representative, that understand their function and that will, crucially, be responsible for dealing with all that, we have to sort out such failures. I do not wish to debate the nature of those failures, but I must say to the cabinet secretary that I do not believe that embedding scrutiny panels is necessarily the right idea. Although it might have been justifiable to set up those panels to examine the failures in the boards, my view is that we should remedy the failures in those boards and not subject well-constituted boards to second guessing. In the long term, that will not ensure good governance of our health boards. I am not disputing the fact that the scrutiny panels have unearthed some serious issues, but the answer is not to embed the panels—it is to address the failings that they have exposed.
If we get that sorted, which I am sure is not beyond the wit and imagination of the cabinet secretary, we come to the composition of the boards themselves. In modern corporate governance—whether in the public or private sector, but particularly in the public sector—there is a question of striking a balance between executive and non-executive directors. There is an issue with regard to non-executive directors having a majority—albeit a small one—even if that is in the hands of the chair. In particular, we must recognise that, in our health boards, health professionals must be the key drivers of the executive side, and are to be held to account by non-executive directors.
We then come to the question of what we are looking for in those who will hold others to account. There has been a development, as exemplified by the title of the Cabinet Secretary for Health and Wellbeing, in sending a signal that health embraces and embodies much more and is much wider than the NHS. One cannot work in the NHS unless one understands the particulars of the local community, the local housing environment and the background—the social factors—that surround health care. One must also be acutely aware of what is involved in relation to primary and acute care.
If we require that kind of governance, and if we are looking forward to a modern health system that will last for the next 60 years—as the cabinet secretary mentioned—we must also consider how to square the proposed development of community health partnerships and the issue of local authorities and health boards. With all that in the mix, the Liberal Democrats are not persuaded that pitting elected local authorities against elected health boards is the best recipe for achieving the integration in delivery of health care towards which most people, and most parties in Parliament, are moving.
Of course, as has been mentioned by all the members who have spoken previously, single-interest individuals have to be respected. They hold a view, but they are not necessarily the people who are going to bring the breadth that is necessary to deliver and discharge the functions that I described earlier, which are required to provide balanced local health care across the board. Their presence might work in the same way that local councillors find to their cost when they are dealing with planning applications—if one has a single interest, one has to declare it and cannot take part, so that could become a slightly self-defeating exercise.
Like every member, I am interested in listening to the consultation. However, if a democratic element is to be introduced to health boards, it would be far better to recognise that, in trying to square the circle between the health boards, the local authorities and the community health partnerships, serious consideration should be given to extending substantially the number of local democratically elected councillors who participate in management and running of health boards. That would address the democratic deficit, but it would also mean that people would come to the table with a balanced and rounded view of what health care actually means in their community. At present, subject to reading with care the detail of the consultation on which the cabinet secretary has embarked, that is the direction in which we incline.
This is an extremely interesting debate—I keep scoring things out and changing my mind as I am persuaded by one or other of the arguments. As members all know, and as the cabinet secretary has reminded us, we have an ageing health service that is 60 years old and no longer fit for purpose. We have demographic changes; a higher expectation of service—quite rightly—among the public; and extraordinary developments in surgery, medicines and treatments. On the other side of the balance sheet, diseases that were once unknown, such as HIV, put huge stress on the system. The health service is a great tanker of a vehicle. We require it to change tack, and we have to put time and thought into how we go about achieving that.
The Kerr report was an interesting start for the Parliament, although some of us read different things into it, as did the public. In particular, to quote from the executive summary, Kerr said:
"we need to … develop options for change WITH people, not FOR them".
However, I do not think that that was the public's experience of the various closures that took place. I am, of course, thinking back to the past threat to close Ayr and Monklands accident and emergency units. I will not dwell on what the scrutiny panel had to say on the matter, but I will come on to what was felt elsewhere in Scotland—on my own patch, when Jedburgh and Coldstream cottage hospitals were closed. Regrettably, the matter is now done and dusted, but there was a huge campaign by local people to keep those hospitals open. They were very precious to them, and they were greatly used by the elderly for respite care because people could stay in the middle of the community. People marched in a bid to keep the hospitals open, they sent petitions here and so on. However, when it came to the day when Borders NHS Board sat down to make its decision, I do not think that anybody in the room did not know, in their heart of hearts, that the decision had been taken many months previously. Notwithstanding impassioned and articulate speeches in favour of keeping the hospitals open, they were closed.
The interesting thing was that people were sitting round that U-shaped table whom nobody knew. They were from NHS Borders. I am not saying that the individuals are bad people, but nobody knew who they were until that day, yet there they were. Margaret Curran spoke about people making major decisions that affect communities at their core. Nobody knew those people, and nobody had elected them. They were responsible for the decision, but not in a face-to-face way, before their electorate—if I can put it that way. Given how people felt, the word "consultation" became somewhat sullied currency. It was just about boxes getting ticked. Afterwards, an appraisal was carried out, which said that the processes had been gone through properly, but people could not argue against the substance of the decision.
I very much welcome the debate, which I think is timely for the Parliament, eight years down the line. We are a small country of 5 million people. We can be much more in touch with our communities than Westminster can be, with its greater representation.
I congratulate Bill Butler on the work that he did on his member's bill, which I supported. I have listened carefully to what has been said about the genuine difficulties on the path towards—I hope—some form of direct elections to our health boards, and I acknowledge those difficulties. They include the mechanics of the elections and turnout issues which, as members of the Parliament, we know about to our cost. There is also the potential hijacking of elections by self-selecting interest groups—goodness me, there are a few community councils on the planet like that, some of which we might say are not very representative. There must be a careful balance between lay people, professionals and councillors, bearing in mind the cross-cutting provision of care in the community, including social work, housing and the whole shebang as we know it.
However, one cannot say that we should not proceed because of all that. As a back bencher, I can say that I am quite attracted to Margaret Curran's piloting idea. However, if one was to go down that route, because of some of the issues that Mary Scanlon raised about remote and rural areas, we would have to choose several different areas with different problems, including logistics and local campaigns and issues. If I were to pluck three areas from the air, I would choose a really remote area, a rural area and an urban area, and we could see how the pilots operated in practice. There would be no egg on anybody's face; there would be no difficulties in that regard. I was going to make a comparison involving a pilot boat pulling a tanker. Anyway, we would be able to step back and measure progress.
This is not a party-political issue. Everyone knows from experience in their constituencies that the status quo is simply not an option. As has been said, people must feel that they are properly involved in what happens in their health service. We do not expect lay people to make clinical or medical decisions, but we expect them to be able to have a say in what suits their community and what works for them. I am pretty sure that if we had had a different health board in the Scottish Borders, with a different balance, we would have kept at least one of our little cottage hospitals, which were happily located and which were doing a super job with respite care. However, that possibility was not open.
As I have said, I welcome the debate. I am actually enjoying it. It is interesting to have such an exchange of ideas, instead of just trying to head-butt one another politically.
I will refrain from head-butting anybody, politically or otherwise.
I am pleased to take part in this subject debate on democracy and local health care. I congratulate the cabinet secretary on the tenor of her speech and welcome other speeches that have been made.
The Parliament last had an opportunity to debate this important issue just over a year ago, on 31 January 2007. I hope that this debate will mark the beginning of a process that will succeed in moving the matter forward. I also welcome the Government's consultation, to which I intend to make a detailed submission.
I am more committed now than I was even a year ago to the notion that there is a need for greater democracy in our NHS. It remains my belief that there is strong support across Scottish society for the introduction of direct public elections to Scotland's NHS boards. The case for greater democracy, accountability and transparency in the decision-making process for local health services remains compelling and I continue to hold the view that the best way to achieve that greater accountability and transparency is the introduction of direct public elections. Such a reform would go a significant way towards increasing public involvement in the planning and delivery of health care services in our communities.
I am pleased to say, as Margaret Curran has confirmed, that the Labour Party has moved to a position of having no in-principle objection to the direct election of the majority of health board members and I am glad to have played a small part in moving my party towards that position. Given the current situation, that policy stance is correct. An undeniable problem remains with the way in which boards operate. The anger that some people feel about certain decisions is, to an extent, generated by the manner in which those decisions are seen to be made. There is a perception that they are made in secret with little or no explanation, that they are often predetermined and that they ignore the views of the community and the responses that have been made to boards' consultations. In summary, many people believe that health boards' consultations are artificial, contrived exercises. That is not a happy situation for the NHS or anyone in Scotland.
I was gratified that the cabinet secretary talked about ownership and accountability, which are the nub of the matter. I acknowledge that improvements in public participation have taken place in recent years under the previous Executive and the present Government, which must both be given credit for those changes. However, we still need to go further. Direct public elections would complement the public participation reforms of the previous Executive and the present Government.
Of course, there is no perfect method for consulting the public on major local health issues. I do not believe for a moment that direct public elections will lead to everyone being happy with every NHS board decision. That would be absurd. However, I contend that decisions that were made by health boards on which there was a large, democratically elected element would have much more credibility than those that are made under the current system. That is the point.
Accepting that decisions are legitimate is at the heart of representative democracy. Democracy is not always about getting one's own way, but it is a means of making decisions that takes serious account of people's opinions. At the moment, that does not happen with NHS boards. Direct public elections of a simple majority of board members would give the public a mechanism to influence service delivery in their area.
If we are to address public apprehension—indeed, suspicion—there must be greater openness and transparency and there must be direct accountability. Direct public elections would allow such an approach to thrive and prosper. Democracy is a pretty good system. That is why we are here. I have not heard a convincing explanation of why the make-up of regional NHS boards should not contain a strong element of direct electoral accountability. Those who favour the status quo—as the BMA does—make poor arguments. Their self-interested arguments do not hold water.
Introducing greater democracy would mean more than just structural change. Introducing electoral accountability would involve patients and communities and provide an opportunity for public debate and greater access to information. There is nothing wrong with that. Direct elections would lead to a sea change in the culture of NHS boards. That would be a good thing, given the real danger of corrosive cynicism spreading among the public. Such cynicism does no good for our NHS in its 60th year or for Scotland as a whole.
I hope that the Government's consultation will lead to legislation to introduce direct public elections to health boards such that elected places constitute a simple majority of the board. If a radical, balanced, reasoned proposal is introduced, I will support it. However, it must be radical in blending the experience of appointed board members with the accountability of those who are directly elected. Anything less than a simple majority—pace Jackson Carlaw—of directly elected health board places would be tame, disappointing and absolutely unacceptable.
It is with great pleasure that I support the concept of democracy in local health care, which is long overdue. Since the start of the current parliamentary session, I have been involved in three health service issues on which the health board would have benefited from having direct input from people with local knowledge who would be directly affected by the board's decisions.
In his member's business debate on parking charges at Stobhill hospital, Paul Martin put forward the argument that there should be no parking charges—a view with which I had, and have, some sympathy—and gave some compelling arguments based on his local knowledge. However, with my insight into the damage that vandals can do to parked vehicles in large unsupervised car parks and my local knowledge of how the parking is set out at Stobhill, I am equally aware that people might be happy to pay a small charge for parking facilities—although I have in mind shillings rather than the pounds that the health board proposed. Given our insight and our local knowledge of Stobhill hospital, I am sure that, after a little debate on the matter, Paul Martin and I could live with any of the outcomes that we have separately promoted.
In Dumbarton, thousands of people came on to the streets to show their support for the retention of threatened services at the Vale of Leven hospital. A common concern in the community was the aloof manner of the board's consultation, which lacked any other options. There was only one game plan: the health board's plan. Another concern was the perceived lack of accountability to the people whom the hospital serves.
In Clydebank, there is a massive public campaign to retain beds that are threatened with removal at St Margaret's of Scotland Hospice. Just this week, campaigners turned up at the Public Petitions Committee to hear how the committee intends to progress the petition, which was signed by 60,000 people. One of the main grievances is that the hospice was not consulted at any time about the loss of the 30 beds.
Those three different cases share some common issues: the perception that people would not be heard; the perception that people's views would not be taken into account; and the perception that people's views were not worth considering. In all three cases, if local involvement and accountability had come into play, there would have been two benefits: giving the public some ownership of the process would reassure them about decisions; and the boards would benefit because it would give them back some of the credibility that, sadly, they have lost among the public that they represent and serve.
Most people think that health boards work to a plan that has been preconceived in some other place, with no room for changes that reflect the public's views. The master plan is what you get—like it or lump it. The health service is paid for and, indeed, owned by the public. The best way in which to show that ownership is to have members of health boards who are directly elected by the public. In that way, confidence in the boards will return.
Therefore, I support the Government's plans for democracy in health boards. Some decisions will still be difficult and indeed contested, but the public will be reassured that they have ownership of decisions, because they will know that their concerns have been aired and responded to by those whom they elected rather than by those who have been selected.
I thank the Cabinet Secretary for Health and Wellbeing on two counts. I hope that she does not faint. First, I trust that you will forgive me, Presiding Officer, if I take a liberty and thank her for an unrelated piece of work. At the Subordinate Legislation Committee's meeting on Tuesday, I noticed that Shona Robison and the cabinet secretary have listened to my appeals on behalf of the Skin Care Campaign Scotland on the matter of wigs. They have addressed that fulsomely, and I thank them for that.
I also thank the cabinet secretary for bringing the important matter of democracy in local health care to the chamber for debate today. I was a member of the Health Committee when my colleague and friend Bill Butler's bill was considered and I was happy to support it. In principle, I still support the arguments that he advanced. I would qualify that because of what I heard in the evidence-taking sessions, but I do not demur from the principle that he espoused today.
I listened to and heard the concerns of those who oppose the proposition. I believe that Bill Butler's proposal should be tested in pilot schemes, and I was delighted at the time to secure a commitment in writing from the then First Minister, Jack McConnell, that one of the two pilots in Scotland would be in Fife. I heard what Christine Grahame said earlier, however, so perhaps we should have three pilots—I do not know. I imagine that Alex Salmond will not be disposed to deliver on a promise that was made by his predecessor, but if the question is not asked, no one will know the answer. Therefore, through the cabinet secretary, I appeal for one of the pilots to be in Fife, which is an urban and rural area. If the answer is no, I can only say, "So, SNP back benchers, take note of what has happened to me. Be careful when Alex Salmond promises something. There may be reasons for back benchers to think carefully before agreeing to any First Minister's advances. Play hard ball with him. First and foremost, get what your constituents want."
Will the member give way?
No. I do not have time.
In oral evidence on Bill Butler's bill, Pat Watters of the Convention of Scottish Local Authorities said:
"The bill would simply tinker with part of the public services. We also believe that any change to how we organise the public services must be able to deliver improvements. We fail to see how the bill would demonstrably improve the public service."—[Official Report, Health Committee, 24 October 2006; c 3117.]
I will be interested to find out whether COSLA will change its views on that. Time will tell.
I recall arguing for direct elections to health boards before I became an MSP, so it was instinctive for me to support Bill Butler's bill and his ideas. My thinking was underpinned when I witnessed and experienced the harsh reality of public engagement and consultation in Fife. I think that the health board in Fife was first off the block in Scotland when it came to changing the delivery of services in the acute sector. The local Queen Margaret hospital was a key element of the campaigning and the local frustration. Members will remember the front page headlines in the Dunfermline Press, which ran a major campaign.
There was a perception of powerlessness, justified or otherwise, which led to anger and frustration and the many uprisings that we witnessed throughout Scotland. Every member who experienced those must have learned lessons. A thousand people turned up at a public meeting in Dunfermline, such was the fury at the proposals, which it was thought would diminish the importance of the hospital in Dunfermline. About 98,000 people signed a petition to the Parliament—some of us turned up to present it—that appealed for the hospital not to be downgraded.
The proposal to have direct elections to health boards is not unique, but the system has rarely been introduced elsewhere in the world. In fact, as far as I am aware, the only other place that has introduced it is New Zealand. In oral evidence to the Health Committee in the previous session of Parliament, the then minister, Andy Kerr, raised several interesting questions about the operation of direct elections in New Zealand, referring to legislation that the New Zealand Government had put in place. I hope that, during the consultation, the cabinet secretary will take account of the Health Committee's report on Bill Butler's member's bill, in particular on the issues in New Zealand. One such issue was control of the directly elected boards in New Zealand, where the Government appointed Crown monitors. It was suggested that if there was potential for intervention by a national Government, Bill Butler's bill would not address the concerns that it was intended to address.
Another issue is the tension between national and local policy. The cabinet secretary may want to set a firm direction for national policy, but there is an issue about how that is delivered locally. That is a matter of serious concern. Another matter is the imbalance that can arise in certain areas, which Mary Scanlon pointed out. In an area such as Fife, we could have board members who predominantly represented west Fife, with nobody at all from the north-east of the area. People who know Fife will know that it is a 70-mile run from Kincardine at one end to Tayport at the other.
I hope that the cabinet secretary will take on board the concerns. Fundamentally, I support the idea, but it should be tested first. Given some of the major concerns that exist, we should not just rush into it.
Like other members, I am pleased to participate in this debate on democracy in our local health care provision. I commend the cabinet secretary for conducting a subject debate on the issue.
Other members have mentioned local experiences and, perhaps unsurprisingly, I will, too. My enhanced interest in the issue stems from experiences in the NHS Lanarkshire area in the past few years, which highlight well some of the dilemmas at the heart of democracy in the health service. Today's edition of The Herald used NHS Lanarkshire as an example in a report that refers to the debate.
I am more than happy to discuss the intricacies of the system of direct elections to health boards at another time, but I want to focus on the reasons why we need elections that would, preferably, produce a simple majority. The report in The Herald made it sound as though the idea of directly elected health boards was the brainchild of the SNP as a response to unpopular decisions, such as the decision on the accident and emergency service at Monklands hospital. Although I am sure that those issues had, and will, rightly, continue to influence in the consultation, I must point out that my comrade Bill Butler put the item on the Parliament's agenda in the previous session, through a member's bill. I commend him for all the work that he has done on the issue.
To set the record straight, the idea is not an original one from the SNP or me. Does the member agree that there is an echo back to the 1980s, when the Tories gerrymandered the health boards and made sure that they had appointees on them?
I am happy to agree with that.
As Bill Butler pointed out earlier, direct elections would not be the panacea that produced democratic accountability in the health service—the issue requires much further debate and discussion—but they would be a step in the right direction of improving democracy and ownership by the people.
In previous debates, it seems to have been suggested that service users might not be best placed to decide on issues relating to health service policy, practice and delivery, and that it would be better to leave decisions on such matters to the professionals. It is perhaps not surprising that that echoes the BMA's view, as we saw in the briefing that was sent to us yesterday. I entirely refute such suggestions—indeed, I find them to be patronising, unfair and simply wrong. People in my community know and understand their health needs and those of their community. That was well demonstrated in the public meetings that were held during the so-called consultation on NHS Lanarkshire's picture of health proposals. Numerous well-informed individuals spoke with passion and clarity about why they opposed the closure of Monklands hospital's accident and emergency unit and the downgrading of the hospital.
The strength of feeling that was demonstrated has persisted, and I can safely say that the people of Coatbridge and Chryston will continue to protest against any plans that threaten their local health care provision and that they will not be patronised into accepting half-baked decisions. NHS Lanarkshire and the cabinet secretary need to realise that. My constituents were as delighted as I was that the cabinet secretary instructed NHS Lanarkshire to continue to provide accident and emergency services at Monklands and that the board agreed to do so, but they also want assurances that that provision will be of a high standard. That means that Monklands must be retained and developed as a level 3 general hospital, for which the required funding must be provided. My constituents were told at the public meetings that continuing to run three accident and emergency units in Lanarkshire was not safe, and they must be assured that it is now safe to do so. The people of Coatbridge and Chryston are entitled to nothing less than first-class provision.
We could discuss many areas covered by the picture of health proposals, but the focus for this debate must be on engagement with local people, transparency, openness and accountability. The public must be not only allowed but encouraged and supported to influence health service delivery in their areas.
During a meeting with NHS Lanarkshire on its decision to downgrade Monklands, a senior member of staff told me that he was not accountable to me. Such arrogance shows why we need more democracy and accountability in our health service and helps to explain why the views of the thousands of people whom I represent were not given any credence in NHS Lanarkshire's consultation exercise. The contributions that were made demonstrated that while health professionals bring to decisions their invaluable medical knowledge and understanding, local people bring their knowledge of and insights into their communities and their own health needs. Both types of knowledge are vital in making decisions about local health services.
The boards of other services and institutions in the public sector should also be democratised—the boards of further education colleges, for example. I hope that the notion of having more democracy is more widely applied.
Directly elected health boards would allow more accountability, but we have heard that that is not the only change that is required. There is a perception that health boards can do what they like even when they are faced with a public outcry—indeed, there is little wonder that there is such a perception in some areas. We must ensure that there is proper respect for consultation processes, that all contributions are fully taken into account and that there is better engagement with and participation by local people and communities.
I could not finish my speech without relating the situation in Scotland to that in Cuba. In the wake of the news that Fidel Castro is standing down, and whatever happens in Cuba now, we have a lot to learn from patient representation at every level in the excellent Cuban health service. Let us hope that Scotland can lead the way in the United Kingdom in aiming for a health service that is as democratic and as rooted in the community as the Cuban health service is. Direct elections for health boards would be a good start.
I, too, thank the cabinet secretary for bringing forward this debate. She correctly set the scene by saying that we are preparing the NHS for the next 60 years, and she reminded us that it is unusual to have such a debate during a consultation period—the consultation period in question ends on 1 April. However, the debate is welcome and a constructive approach has been taken to it.
I welcome the cabinet secretary's comment that all contributions to the consultation would be warmly received. She said that people want to be involved. Perhaps they do; I hope that they do. She said that some NHS boards are doing a good job in involving people, which is true, and that there is a lack of evidence behind closure plans. Many members—Mary Scanlon in particular—have echoed that theme. Finally, the cabinet secretary said that she would listen to all strands of opinion. That is a good way in which to conduct a consultation.
Margaret Curran said that she perceived the democratic deficit—we all perceive it—and that there is a strong argument for change. Later in the debate, it was said that the status quo is simply not an option.
Margaret Curran posed the question, "How do we get people to participate?" Although such participation is desirable, it is not always easy to achieve. We should remember the example of school boards. If I may quote Margaret Curran, she talked about the "weakest voice" versus the "loudest voice". From my own time as a councillor, I remember that there were powerful members of the health board in the Highlands whose voices carried a little more weight than the voices of the quieter members and rather drowned them out on occasion. Mary Scanlon and Peter Peacock will remember those people.
Mary Scanlon put it very aptly when she said that dissatisfaction with the present consultation process has led to the desire for direct elections. That is absolutely true. She also said that we have to beware of single-issue candidates, which is a very stark warning.
I have listened to the debate with great interest and agree with many of the points that have been made about the need for change. I am intrigued by what Jamie Stone is saying. Does he agree that, notwithstanding his point about transparency, the experience that he and I had as councillors of the closing of schools by a democratic institution did not in any way diminish the sense of wrongdoing felt by the communities who were the victims of those decisions? They would tell us that a consultation had been fixed, that the decisions had been made beforehand and that the consultation was a sham. Therefore, would it not be naive to assume that such problems would disappear because of democratisation?
I shall return to that point in my final remarks about my party's position, but the point is well made.
When Mary Scanlon came into my constituency—as she has a right to—she saw that one of the problems that beset both sides of the argument about maternity services in the far north was the perceived lack of local representation, or a local voice, for the areas involved.
As a preamble to my backing-up his thoughts about our party's policy, I note that Ross Finnie was right to separate the two issues of, first, patient involvement, which is hugely important and on which work is required, and, secondly, the democratic functioning of boards. He said, quite rightly, that the issue is about how boards conduct themselves, and I support him entirely when he says that scrutiny panels should not be embedded. It is about fixing the problem and getting it right, and about the balance between executive and non-executive power.
Ross Finnie said that he dreaded pitting elected NHS boards against elected councils. Peter Peacock and many other members will recall the great difficulty between the regional and district layers that we experienced when we were councillors. That situation was not always constructive, and I see parallels with what Ross Finnie said about the prospect of pitting elected NHS boards against elected councils. He is entirely right to say that there is a role for the elected member in democratising NHS boards, and perhaps there is more than one role.
Will the member give way?
In a minute.
Surely it would be appropriate to have the districts of a large NHS area and a council area, such as Highland Council, represented on the NHS board. Some years ago, that would have gone a long way towards addressing the problems with maternity services in the Highlands. Ross Finnie pointed out the responsibilities of the 32 local authorities in Scotland—we think of housing, social work, education and special needs—and an overlapping, joined-up approach to working between local authorities and the NHS would lead to a great improvement in delivering services to the people. Surely that is what we are about.
I acknowledge the points that the member makes as they relate to care in the community and delayed discharge. To correct him, I said that there should be at least one councillor on each board, because of those issues.
I accept that point.
The idea behind the consultation and the debate is about where to set the pointer between an entirely elected board, a board the vast majority of whose members are elected and Jackson Carlaw's position—I am not entirely sure whether he differs with Mary Scanlon.
The point that I, Ross Finnie and my party are making is that there is a role for locally elected local authority members. By bringing those two aspects of democracy together, we can achieve joined-up working and joined-up service delivery, which is what really matters at the end of the day.
This has been a good and timely debate, which is being held during the consultation on the forthcoming—and also well timed—local health care bill. It has allowed a comprehensive airing of many of the issues related to increasing democracy in local health services. Interesting and constructive contributions have been made by members from throughout the chamber.
As many members have said, in the past few years the desire for meaningful public engagement in the development of the NHS has been growing, alongside increasing dissatisfaction with the way in which a number of health boards have interacted with the public when major changes were planned in the local delivery of health care provision.
A number of us in the chamber today—including the cabinet secretary and the minister—will remember the enthusiasm and optimism in the chamber when the anticipated Kerr report on the future of the NHS in Scotland was being discussed, because patient groups and other NHS and public representatives who were present felt that at last they were having a real and meaningful input to the future shape of the NHS.
Sadly, as health boards across the country began the process of reconfiguring services in response to the Kerr recommendations, too many people in too many areas felt that health boards were consulting the public on a fait accompli and were paying scant attention to the reactions and responses of their local stakeholders—as Christine Grahame described graphically with regard to her region in the Borders.
The many campaigns that ensued across Scotland clearly showed the public's dissatisfaction with the consultation process. In my own area, the retention of the option for women to give birth in community hospitals in Aboyne and Fraserburgh was achieved only after a protracted, well-organised and vocal campaign by local people against NHS Grampian's proposals to close those maternity facilities. We are all familiar with the equally strong campaigns to retain A and E provision in various parts of Scotland and with the campaign that Mary Scanlon highlighted to save the Belford in the Highlands.
The battles to retain local facilities have taken time, commitment and resources. They could have been avoided had health boards been made aware of the strength of public feeling and the cogent reasons for that feeling before recommendations for closure were made. Instead, in several cases, the impression was that the consultation process was a sham, with decisions already having been made by the boards, out of the public's view.
I, for one, am pleased that the Scottish Government has brought forward its "Better Health, Better Care" action plan, and I welcome its intention to promote a local health care bill within the first year of this session of Parliament.
There is no doubt that there needs to be improved public engagement. That need stimulated Bill Butler's Health Boards Elections (Scotland) Bill and has led to the current public debate on democracy in local health care.
Like many MSPs from across the parties, I had a great deal of sympathy with Bill Butler's member's bill, which was defeated at stage 1 last year. I saw the merit in members of the public being directly involved in discussions about important changes to services and having a direct input to the process before recommendations are made. However, I also felt—and still feel—that a majority presence of directly elected members on a health board could lead to short-term decision making and, at times, a distortion of priorities or delay in reaching difficult decisions, which could result in inequalities of care or undermine the planning of regional services. Ross Finnie, Mary Scanlon and others have highlighted the fact that there are also issues around likely single-issue candidates.
As has been pointed out in the debate, significant steps have already been taken to improve public engagement with the NHS in Scotland. The legal requirement in the National Health Service Reform (Scotland) Act 2004 for health boards to consult their local populations on service change was a step in the right direction, even though the implementation has sometimes been flawed.
Recently announced plans for the Scottish health council to establish standards for consultation, the independent scrutiny boards that will examine proposed service changes, the intention to strengthen the public participation fora of community health partnerships and the opening up to the public of the annual review process between health boards and ministers should all help, together with other Government initiatives, to ensure that communities have a say in the design and delivery of local services. The BMA, together with some other opponents of direct elections to health boards, thinks that those proposals have greater potential to improve public involvement in decision making than directly elected health boards. They may well be right to say that money would be better spent on direct patient care than on administering elections, with the attendant risk of the voter apathy that has been experienced south of the border.
Clearly, there is a serious debate to be had about the best way to achieve the stronger public involvement and enhanced local democracy that are requirements of 21st century health care planning.
My colleagues and I welcome the Government's drive to improve public and community involvement in the work of NHS boards. We also welcome its conviction that local people must always be at the heart of decision making and that the process for service changes should be rigorous, evidence based and open to scrutiny. We hope that the on-going consultation will be meaningful, as the cabinet secretary indicated it will be, and that the Government will pay careful attention to the suggestions of its consultees when formulating its proposals for the local health care bill, particularly any innovative ideas from those who are most closely involved with the NHS, be they staff or patients. We look forward to seeing the responses to the consultation and the content of the bill in due course, and to the ensuing scrutiny of the bill as it progresses through Parliament.
As many members have reminded us, we have had 60 years of the national health service. During that time there has not been a single model of the health service—indeed, change has been one of the hallmarks of its development—but it has broadly moved from a command-and-control structure, through the internal market structure under the Conservatives, to the current model of collaboration that the current Government is seeking to continue and enhance.
In 1999, when the Parliament came into being, I was fortunate enough to be asked to be the reporter on the Stobhill inquiry. I was astounded at the degree to which the health board had not consulted on the issue. It went further than that: there was a marked culture of secrecy and paternalism, and a deliberate attempt to obfuscate matters and delay public information in such a way that the local community and the doctors and nurses at Stobhill general hospital were not informed about the situation with the new medium-secure unit until it was too late for them to have any influence.
The report, which was adopted by the Health and Community Care Committee and the then Government, has led to huge changes over the past few years. One of my concerns is that we may not be allowing those changes to bed in adequately before we proceed. The one thing that all speakers have agreed on today—many have referred to it—is that local accountability is vital. Important changes have been made, including the reduction in the number of health boards and trusts. Whereas there were 42 trusts and boards, there are now 14 boards. Community health partnerships are new, but have enormous potential to increase the involvement of the community and the participation of all stakeholders. That move, and others involving elected councillors, is a change that has only recently begun.
In evidence to the Health Committee on the Health Board Elections (Scotland) Bill, Sir John Arbuthnott said that 43 elected members are represented on NHS board or as chairs or members of local community health partnerships. He believed that that level of representation could be lost with direct elections. I do not agree with that sentiment, but I believe fundamentally that we need to consider carefully before we establish a third democratic focus. Peter Peacock made an excellent point when he said that democracy of and in itself produces accountability in the ballot box but does not necessarily improve consultation. We have learned that to our cost on a number of occasions.
Other structures have been put in place, such as the Scottish health council—it, too, is a relatively new body that is still finding its feet—to try to ensure that the consultative process works. The revised consultation to which Nanette Milne and others referred means that the guidance on consultation has been improved. The staff partnership forum and its representation on the board brings in an important element of representation.
The cabinet secretary referred to the fact that boards now consult much earlier, much more frequently and much more openly. We all agree that there is still a degree of imperfection there that needs to be strongly addressed. Innovative measures such as open forums, citizens juries, community forums and the involvement of independent facilitators have all been tried out. We need to collect the data and ensure that all boards follow it.
The independent scrutiny of the consultation process, not only by the Scottish health council but, in the case of Lanarkshire, by PricewaterhouseCoopers, was still not sufficient to produce an adequate consultation process. I believe that the combination of the scrutiny mechanisms, including NHS Quality Improvement Scotland and the joint improvement teams, will help to make boards meet national standards to a greater extent than was previously the case.
We have pretty well got the national accountability upwards in place. The HEAT—health improvement, efficiency, access and treatment—targets that replaced the performance assessment framework, combined with the national outcome indicators and the outcome agreements with boards, put the cabinet secretary in a strong position to hold the health boards to account but, as I said at the beginning of my speech, today we are concerned with local scrutiny, which has been served in part by measures such as providing open agendas for health board meetings, making those meetings public and publishing minutes of them, and facilitating public participation in the annual accountability reviews, all of which allow open scrutiny and are most welcome. But are they enough?
As members such as Jamie Stone have said, we all agree on the concept of local ownership and local involvement, but the issue is how best we achieve it. We must look at models elsewhere in the world and find out whether they have worked. Elsewhere in our world, in England, the NHS foundation trusts conduct elections to their boards of governors. One foundation trust had an opt-out system—in other words, someone had a vote unless they opted out of having it. The turnout was 18 per cent. As a result, a high proportion of the representatives were retirees—that is not unreasonable, given that we have an ageing population, many of whom use the health service—and professionals. It worries me that the groups whose ownership of the health service I want to see enhanced and which needs to be enhanced—the deprived communities—might not have a voice. We all agree that it is the members of those communities whose health needs to be improved and who need to have ownership of the process by which that is achieved.
Some members have mentioned the possible clash between national and local priorities, but that does not concern me too much as there are processes for dealing with it. Governments have had to deal with local government for a long time. However, there are sometimes delivery problems. It will be interesting to find out whether the outcome agreements and the concordat with local authorities deliver the outcomes that the Government wants.
Nanette Milne spoke about short-termism, which will be a danger in an elective system if single-issue candidates are elected on to boards. I regret to say that, in 30 years in the health service, it was my experience that the people who shouted loudest got the most. There is a serious danger that we will find that the people who are elected on to the boards are those who have shouted loudest and got organised.
Another danger that has not been mentioned is the possibility of an increase, rather than a decrease, in the postcode lottery effect. How many times has the problem of a postcode lottery, whereby certain services are available in some areas but not in others, been mentioned in parliamentary debates? If we have increased democracy with regard to the boards, we will have to live with that—in fact, the problem will probably get worse.
My major concern is to do with the role of local authorities. In Sweden, the local authorities control the local health boards and there is a concordat and an agreement between the national Government and the local authorities. That model provides for democratic input, but in a way that is different from what the Government is proposing. The Swedish model seems to work quite well, but the New Zealand model has led to a significant drop in turnout as the process has proceeded. There is also an indication that the type of people who have been elected to boards is not truly reflective of the communities that they have been elected to represent.
I will be interested to hear the minister's summing-up speech. The message from today's debate is that we all agree that we need to have local accountability and ownership of our health service by people in their localities, but that we do not agree on the best means of achieving that.
I return to Margaret Curran's point: if we are to alter the governance arrangements of the health service in Scotland, we must do so in a manner that leads to accountability and improvement and which is settled and will last over time. If the Government chooses to proceed with its plans, I hope that it will do so on the basis of pilot schemes, because I genuinely believe that it will be difficult for us to be sure that having health boards on which, if Bill Butler's suggested model is adopted, 50 per cent of members plus one will be directly elected will truly deliver the consultation and ownership that we all seek and in which we all believe.
We have had a constructive and stimulating debate and I thank members of all parties for taking part. We have debated a topic that is of crucial importance to the NHS and to the public and patients who use NHS services, as many members have said.
As the cabinet secretary said, the Government is committed to improving public and community involvement with NHS area boards. We will bring about improvements in the context of our mutual NHS, of which the public and staff are regarded as partners and co-owners. We will launch a consultation on a patients' rights bill by May this year. As the cabinet secretary said, that will allow us to engage with the people of Scotland to develop a charter of mutual rights. We will shortly announce how we will take independent scrutiny forward as an integral part of how the NHS develops proposals for major service change. We will develop a participation standard and we will require boards to produce an annual ownership report with the people whom they serve.
We accept that some NHS boards are doing a good job in fostering and encouraging community involvement—Richard Simpson talked about that—but there is room for improvement, as many, if not all, members said. Many communities still do not feel that their voices are being heard and listened to, particularly when major proposals for service change are considered by their local health board. Given the contributions to the debate from Christine Grahame, Elaine Smith and other members, I judge that that concern is widely shared. We can build on and enhance the current processes and mechanisms to help to achieve greater community involvement. We have heard many positive suggestions about how greater involvement could be delivered, to which we will give our fullest consideration.
Simply improving the current mechanisms will not go far enough to allay the deeply felt public concern that community involvement is not good enough. The introduction of an element of direct elections to NHS boards will make a significant difference. As the cabinet secretary said, we do not consider improvements to current mechanisms and direct elections to be mutually exclusive and we are committed to taking both forward.
I listened carefully to the constructive and thoughtful contributions that members made to the debate on direct elections. We are in the middle of an extensive and substantial consultation on the matter. We sent more than 1,500 copies of the consultation document to the widest possible range of national and local bodies across the length and breadth of Scotland. We are holding open consultative meetings at the invitation of many bodies, so that we can seek out all relevant views. This debate is an important and integral part of the consultation process, which will take account of the views of colleagues from all parties.
As part of the consultation process, will the minister take a close look at areas in Scotland where some of the most difficult arguments have been taking place? For example, will she consider the background to the proposals for maternity services in Caithness, so that she can identify where the democratic deficit has arisen?
Of course we will do that, and we encourage people from the area to contribute to the consultation.
As we are in the middle of a consultation, members will not expect me to give definitive answers to all the points they have raised, but I will mention some points. Margaret Curran asked that the involvement of the Parliament continue as the debate moves forward. I am happy to give her an assurance on that point. Given the agreement that change is required and the breadth of views on the matter, it is important that we build on the debate to reach as much of a consensus as possible on how to take the issue forward. We are keen to take the opportunity to involve the Parliament in the debate.
Ross Finnie expressed concern, which Jamie Stone followed up, that the presence of a directly elected element on local boards might lead to power struggles with local authorities. I am not convinced about that. What is important is the way in which local authorities and health boards relate to each other and work together, not how their governance arrangements are put together. In some areas of Scotland, health boards and local authorities have worked together very well; in other areas, the situation needs to improve. That is how things stand under the current arrangements. We need to reconsider that relationship and joint working, but that does not relate to how the health boards have their governance arrangements in place. Nevertheless, Ross Finnie made some interesting points.
Bill Butler and Gil Paterson made the point that difficult decisions will still have to be made with directly elected health boards. No one is arguing otherwise. The important point is that the ownership of the decisions will be different—more transparent and accountable.
Peter Peacock made the point that, sometimes, even by people in elected positions, difficult decisions are made that are unpopular with the public. That would be the case with directly elected health board members as well—it would be naive for anyone to think otherwise—but that does not detract from the fact that transparency and accountability are important to the process, and people must feel that they have someone to challenge about the decision that has been made. At the moment, that is missing from health boards.
It is clear that there are some fundamental issues that need to be addressed: the people who would stand for election; whether there should be a political element; the impacts of elections on boards' governance; and accountability to ministers—a point that was well made by Helen Eadie, who talked about how New Zealand has handled that issue. Of course we will consider the New Zealand experience and other international experience.
We recognise the need to ensure that directly elected members are properly equipped to undertake the job when they work with other board members who have expert knowledge. Richard Simpson made an important point about how we can ensure that there are a range of voices around the table, representing all backgrounds. The weaker voices need to be heard, not just those of the strong and those who have a firm view. That will be a difficult balance to achieve—it is difficult to achieve it in local government—but it is something that we will need to work at. We must encourage people to come forward and we must support them in having their voices heard, so that they see themselves as having something to offer in this context. These are serious issues and the Government will give them serious consideration.
I am heartened by the number of positive and constructive views that have been expressed today on the merits of direct elections and the positive impact that colleagues feel they would have on community involvement with NHS boards. The debate has focused on a subject that we all agree is crucial to the NHS and the communities it serves. I thank all members for their contributions and look forward to further debate on the issue.
Meeting suspended.
On resuming—