Meeting of the Parliament [Draft]

Meeting date: Wednesday, February 21, 2024

Official Report 1126KB pdf

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Primary Care (Access)

The next item of business is a debate on motion S6M-12214, in the name of Alex Cole-Hamilton, on improving access to primary care. I invite members who wish to speak in the debate to press their request-to-speak buttons.

14:56  

Before I begin my remarks, I welcome the Cabinet Secretary for Health and Social Care, Neil Gray, to his place. I also recognise and welcome to his place the new member for the Highlands and Islands, Tim Eagle. I met Tim very briefly yesterday, and he strikes me as having the makings of a fine parliamentarian. I pay tribute to his immediate predecessor, Donald Cameron. Donald was a rare voice of calm, clarity and consensus in the chamber, and he will be missed, as will his friendship across the chamber.

I am pleased to open the debate on behalf of the Scottish Liberal Democrats. Our health service is in crisis. We all know it, and we regularly debate it in the chamber. The slow and steady erosion of our health service under successive years of nationalist ministerial disinterest is being suffered by those who work in it and those who rely on it.

Nowhere is that pressure felt more acutely than in primary care. For our hardworking general practitioners, the Government has done little more than add insult to injury with a litany of broken promises, skewed numbers, missed targets and cut budgets. It was not that long ago that, if someone needed to see their GP, they could book an appointment and be seen within perhaps even a few hours rather than days. Across the profession, the alarm is being raised.

Dr Andrew Buist, who is the chair of the British Medical Association’s Scottish GP committee, said of the recent fall in the workforce:

“We are often told GPs are the bedrock of the NHS—but on this evidence the bedrock is crumbling, and it is patients seeking access to their GP who will suffer as that becomes more and more difficult.”

The national health service must aspire to health promotion, the prevention of acute illness, the early detection of serious issues and getting the right intervention to patients fast. If that does not happen, it piles more pressure on other parts of the health system through people being forced to attend already swamped accident and emergency departments or presenting later with cancer and other diseases because of the acuteness of their condition.

That is not happening by a long shot. In fact, people are waiting weeks just to be seen by their GP and they might even struggle to get an appointment over the phone. I have lost count of the number of people who have told me stories of being forced to wait weeks for an appointment with their GP. I know of parents who tried to get their sick baby an appointment only to be told that it would have to be really urgent, because there was no routine appointment for the next two weeks. I am sorry, but new parents often do not know what is severe and what is not, and things can go downhill very fast.

If we are not getting it right for babies, we are not getting right for anyone. People are being left to wait on their own in a state of crippling anxiety, pain or both, with no way of knowing whether their symptoms are innocuous or clinical signs of something that could be far more sinister and even life threatening. It is no wonder, then, that one in five Scots says that their mental health has been impacted by delays in getting a GP appointment and 13 per cent say that long waits have also adversely affected their physical health. We know that conditions become more acute.

Lurking behind many of the issues that we will discuss today is the growing workforce crisis that is impacting on primary care, which has been exacerbated by the brutal cuts of this Administration. The figures on recruitment and retention are really worrying. For example, 42 per cent of practices report at least one GP vacancy. If we look at whole-time equivalent figures, we see that the NHS is down 200 GPs on the number it had 10 years ago. I refer again to Dr Andrew Buist, who said:

“All this shows that it is no longer feasible or plausible to think we can simply go on as we are, believing we are on course to grow the GP workforce as required to care for the people of Scotland.”

In an attempt to pull the wool over people’s eyes, the Government would have us believe that the number of GPs is more than 5,000, but that is the case only when we include trainees. A head count, rather than the whole-time equivalent figure, is used as a measurement. How are we going to improve the situation in primary care if this Government is not even going to be straight with the public about the fact that it deploys such smoke-and-mirrors politics?

None of this is the fault of GPs or NHS staff—let us be absolutely clear about that. We will always owe them a huge debt of gratitude. We are asking far too much of those who work in primary care, many of whom are experiencing burnout as a result. The stress and demands mean that more and more GPs are choosing to work part time or to leave the profession entirely, so the failure to have supported them properly is adding yet more pressure on those who remain.

The Government has promised to recruit 800 more GPs by 2027, but bodies such as the Royal College of General Practitioners and Audit Scotland agree that the Government is not on track to meet that target. Part of the answer, of course, is to train, recruit and draw on the wider skills that exist in other disciplines such as mental health, physiotherapy, pharmacy and more.

GPs are the first point of contact for many people as they enter the NHS, particularly at times of mental ill health. That is why my party works so hard to persuade the Government of the importance of putting mental healthcare practitioners—talking therapists—in every practice in every corner of Scotland. However, progress has been far too slow. One recent Government-run survey found that 86 per cent of GPs said that they had either insufficient access or no access whatsoever to a mental health practitioner over a three-year period. GPs were promised new colleagues to lessen the workload and improve the mental healthcare that is available, but, as we know, with Humza Yousaf as health secretary, the Government actually hit pause on its pledge to train and hire more staff.

Alex Cole-Hamilton mentioned the training of doctors of all sorts. In order to prevent the drift of newly qualified doctors to Australia, Canada and the USA after the state has invested £250,000, on average, in their training, would it not be worth considering the introduction of a bond system whereby, if people chose to work in other countries just after the state had paid for their expensive education, they would be required, over time, to pay back at least a proportion—or all—of the costs of their training, which would be benefiting another country?

You will need to start concluding.

I am grateful to Fergus Ewing for the intervention. The situation is in such a state of extremis that we should explore all options, and I would be open to further discussions on that point.

To conclude, Presiding Officer, we need to be open to new and innovative ideas such as the one that we have just heard, and we need to look at plans for the recruitment and—crucially—the retention of staff. We need to prevent experienced doctors from burning out or being pushed out of the profession that they love. We need to incentivise more people to train and to work in the NHS once they qualify.

It is time to rewrite the failed NHS recovery plan, get recruitment and retention of GPs and local practice staff back on track and get past the culture of endlessly making plans for more plans.

You need to conclude.

Primary care and the entire NHS need new energy, new ideas and new hope. They need a new Government.

I move,

That the Parliament notes the Scottish Government’s longstanding commitment to recruit an extra 800 GPs by 2027 and the views of bodies, including the Royal College of General Practitioners and Audit Scotland, that it is not on track to meet this target; regrets that there is still insufficient access to mental health practitioners working alongside GPs and the £30 million in-year cut to the mental health budget, which Scottish Government documents show will affect primary care; understands that rural and remote communities are among those being severely impacted by high levels of workforce vacancies, presenting barriers to diagnosis, referrals and treatments, and potentially exerting greater pressure on other parts of the NHS, such as accident and emergency, and calls, therefore, on the Scottish Government to rewrite the failed NHS Recovery Plan to get recruitment and retention back on track and to build stronger local health services by expanding the range of services and specialists available, including in mental health and physiotherapy, to meet demand.

I call the cabinet secretary, Neil Gray, to speak to and move amendment S6M-12214.2.

15:03  

I am grateful for the opportunity to speak in the debate as the new Cabinet Secretary for NHS Recovery, Health and Social Care. Scotland’s NHS is an institution that I am truly proud to lead. Although I have been in post only a short number of days, I recognise that our health and social care system is far more than just a series of individual services—it is a vibrant living system that supports every life in Scotland, and those who have dedicated their lives to working in the services across that system help to ensure that all of us can live longer, healthier and more fulfilling lives. I want to set out at the outset how grateful I am to those who work in our health services—in this case, in primary care.

Before I move on, I will take a moment to acknowledge and thank my predecessor, Michael Matheson, who I know gave his all to the role of health secretary. Michael’s commitment to NHS staff and his efforts to work constructively with unions have ensured that Scotland is thus far the only nation in the United Kingdom that has not lost a single day to strike action. That is not a situation that I take for granted, and I want to continue to pursue the working relationship that Michael established, which was fostered on trust with our trade union colleagues.

Our health and social care service is going through the most challenging period in its history. The collective impact of the pandemic, Brexit and the cost of living crisis is one of the biggest systemic shocks that this country and the NHS have faced. All that is against a backdrop of 14 years of UK Government austerity that has left our public services with very little resilience. I am clear that, in order to move forward and recover from those collective challenges, we need reform and innovation right across the health service. I will set out my vision for that reform in the coming weeks, but key to that will be listening to the voices of people who use and work in health and social care.

Let me restate that the fundamentals of Scotland’s NHS will not change. We remain committed to free access to healthcare at the point of need.

The cabinet secretary talks about listening to the voices and lived experience of those at the front line. Does he agree with Liberal Democrat calls for a health and social care staff assembly so that we can put the voices of that experience at the heart of the solution to this crisis?

The reform process that I and my colleagues will embark on will be informed by people with lived experience, people who work in our NHS, experts, academics, service users and trade unions. That will ensure that the reform package that comes forward is informed by those who use and work in our health services.

I genuinely welcome this debate, and I thank Alex Cole-Hamilton for bringing it to the chamber. This morning, in Boroughloch Medical Practice in Edinburgh, I saw at first hand how primary care services, involving a wide range of skilled professionals, can have a huge impact on health outcomes. They are greatly valued by the communities that they serve.

I am proud of the record investment in primary and community care services of more than £2.1 billion in the draft December budget. That represents our continued commitment to ensuring that primary care services are better focused on meeting people’s needs in a joined-up way.

General practice must be at the heart of our healthcare system. It is unparalleled in managing such a wide range of care needs in the community, from long-term condition management through to urgent unplanned care, with more than 1.5 million GP encounters a month and more than 1 million for other clinicians in practice. There are, of course, demand issues, but we are dedicated to ensuring the sustainability of the GP and wider multidisciplinary team workforce.

In 2017, we committed to adding 800 GPs to the workforce by the end of 2027. At the most recent count, in December, 271 additional GPs had been recorded, and record expansion in our GP specialty training has resulted in there currently being more than 1,200 trainee GPs in Scotland. This is the beginning of our efforts bearing fruit, and we are working with the GP profession on developing a series of recommendations to ensure that we also retain our current GPs.

We are reforming the way that general practice works, through the 4,700 wider multidisciplinary team members who are in post, including pharmacists, physiotherapists, community link workers and mental health practitioners, to name but a few elements. That additional capacity allows teams to work together to support people in the community and free up GPs to spend more time with patients who are in specific need of their expertise.

Will the cabinet secretary give way?

I will give way very briefly, for a final time.

Will the cabinet secretary obtain as much data as he can about the number of GPs and newly qualified doctors in general who leave this country for other countries, preparatory to considering the proposal for a bond that I put to Mr Cole-Hamilton?

I would be happy to consider that. The retention of people who go through training in Scotland is critically important, as is the continued attraction of people from other countries to work in our NHS.

We know that health inequalities exist and have been exacerbated by Covid, which is why we are taking further targeted action through the inclusion health action and general practice support project, with £1.3 million of funding dedicated so far. We are also stabilising our highly valued community link worker capacity in Glasgow, with £3.6 million of funding for three years already confirmed.

The needs of rural communities are also at the forefront of our policy making. Our new national centre for remote and rural healthcare is now in its delivery phase and will initially have an intense focus on primary care.

It is clear that our health and social care system, which has primary and community care at its centre, will require reform to remain sustainable and meet growing demand. I will continue to work with our professional bodies and the people of Scotland to deliver on our ambition for a thriving and sustainable primary care service that is focused on both mental and physical health to be at the heart of the healthcare system.

I move amendment S6M-12214.2, to leave out from “the Scottish Government’s” to end and insert:

“that, every day, public services continue to face the aftermath of the biggest shock faced since the establishment of the NHS—dealing with the combined impact of a pandemic, Brexit, which Scotland overwhelmingly rejected, and a cost of living crisis, amplified by catastrophic UK Government mismanagement; recognises that, in the face of over a decade of UK Government austerity, the Scottish Government’s draft Budget will invest over £2.1 billion in primary care to improve preventative care in the community; welcomes that the Scottish Government’s commitment to NHS staff has meant that Scotland is the only part of the UK not to lose any days to strikes; further welcomes an increase of 271 additional GPs in headcount terms since 2017, and a record expansion of GP speciality training, which will see over 1,200 GP trainees in Scotland in the next year; recognises the unique challenges that rural and island communities face and therefore welcomes the Scottish Government’s intention to publish a Remote and Rural Workforce Recruitment Strategy by the end of 2024; welcomes the expanded primary care multi-disciplinary team workforce, with over 4,700 staff working in these services, including physiotherapy, pharmacy and phlebotomy; notes the doubling of mental health spending in cash terms from £651 million in 2006-07 to £1.3 billion in 2021-22, and that, as a result of that investment, child and adolescent mental health services (CAMHS) staffing has more than doubled; highlights the investment of over £100 million in community-based mental health and wellbeing support for children, young people and adults since 2020; acknowledges that the Scottish Government has exceeded its commitment to fund over 800 additional mental health workers in numerous settings, including over 350 in GP practices; welcomes the ongoing £1 billion NHS Recovery Plan to increase capacity and deliver reform, and pays tribute to, and thanks, the entire health and care workforce for its unstinting efforts to provide services through a very challenging period.”

I advise the chamber that there is no time in hand for this debate or the subsequent one, so members will have to stick to their speaking time allocations. I call Sandesh Gulhane to speak to and move amendment S6M-12214.3.

15:10  

I refer members to my entry in the register of interests as a practising NHS GP—I am living under the pressures that we are debating right now. I welcome the new cabinet secretary to his role, and I also welcome my new colleague, Tim Eagle, who will give his maiden speech today.

Successive SNP Governments have watched, as if caught in the headlights, as general practice struggles under sustained pressure on multiple fronts. The SNP—which is now supported by the Scottish Greens—is responsible for failing to develop and implement credible medium-to-long-term strategic plans. The last attempt, which took place three health secretaries ago, flopped before the ink was dry. Humza Yousaf’s so-called NHS recovery plan could well go down as one of the most underwhelming and poorly thought-through pamphlets in NHS history.

It is now important that we truly understand the issues that need to be tackled. We owe it to our amazing front-line staff in primary care to come up with real, workable solutions.

Allow me to run through some stats, Presiding Officer. A quarter of a million more patients are registered with Scotland’s GP practices now than were registered in 2012, but if we look back at the past 12 years, we see that the number of GP surgeries has decreased by 9 per cent. Importantly, during the same period, the number of patients aged over 65 has increased by 20 per cent. Now, an increasing number of GP practices are being forced to close their patient lists because they do not have sufficient resources to meet patient needs.

The Royal College of General Practitioners Scotland says that GPs face such unmanageable workloads that more than half of its members cite poor morale or declining mental wellbeing. As for the SNP Government’s flagship policy to recruit an additional 800 GPs by 2027, Audit Scotland says that it is not on track.

Primary care is the front door to a successful health service. A thriving general practice brings direct benefits to patients and protects the entire NHS from overload. We need to have a serious rethink about how we deliver healthcare and greatly improve access to primary care.

Does the member share my concern about the news that emerged last week that NHS Borders is facing a mounting deficit and will have to cut its budget by 10 per cent next year? Does he share my concern that the SNP Government has failed to properly fund rural healthcare?

I could not agree any more with my colleague.

Over the past two years, I have had candid discussions with patient groups, clinicians, health economists, academics, technologists, third sector organisations and NHS executives, with the goal of developing a vision for our NHS that we can bring to a national conversation. It is clear that Scotland needs an NHS that is modern, efficient, local and accessible to all. To achieve that, our country will need to truly embrace innovation and change.

In addition, in order to maintain universal healthcare as we know it, we need to reduce strain on our health service and its staff. That will require all of us taking greater responsibility for our own health, and it will require our NHS to identify issues before they become big problems.

What impact and what greater strain would Sandesh Gulhane expect following Tory spending plans, which would see a further £0.5 billion reduced from our health service?

Perhaps the cabinet secretary will reflect on the fact that if the SNP had passed on all health consequentials that it received since it took power, we would have £17 billion more to spend on our health service. Shame on you for your pet projects.

Through the chair, please.

A modern NHS would embrace innovation and introduce the latest medical equipment. In rural and remote areas, that would include mobile screening services, and we would take diagnostics—such as lung screening—to the community instead of expecting patients to travel long distances. We need to provide credible backing for community pharmacists, optometrists, audiology services, physiotherapists and link workers if we want to have expertise in the community. To achieve that, we need to reprioritise resources. In plain speech, we need to fund the necessary changes and ensure that we reduce inefficiencies.

Sound healthcare economics is vital. Scotland’s NHS must be geared to deliver at the local level in order to get stronger primary care. It is important that we focus on the fact that central belt solutions for primary care will not work for all of Scotland, which is not what the SNP understands. We are ready to contribute to a national conversation on the future of our NHS, which healthcare professionals are calling for.

I move amendment S6M-12214.3, to insert after “emergency”:

“; notes with deep concern that the number of GPs per thousand people has decreased significantly in the last decade; recalls that investment in new treatment centres was central to the Scottish Government’s NHS Recovery Plan and its promise to improve primary care access; condemns the recent decision to cancel investment in new projects for undermining these promises; strongly urges the Scottish Government to adopt the proposals put forward by the Scottish Conservative and Unionist Party in its paper, Modern, Efficient, Local: A new contract between Scotland’s NHS and the public, including, critically, the pledges to recruit an additional 1,000 general practitioners and to digitise primary care appointment bookings”.

15:15  

I welcome Mr Eagle to his place and look forward to listening to his maiden speech. He will certainly have big shoes to fill replacing Mr Cameron as the representative for Highlands and Islands. I also thank the Liberal Democrats for lodging its Opposition day motion on primary care for debate and say that members on the Labour benches will be supporting it.

We have, over the course of the parliamentary session, considered the issue of long waiting times on many occasions—and rightly so. One in seven Scots is on an NHS waiting list. The reason why we keep coming back to the issue is that it is not going away; in fact, it is getting worse under the current Government.

If primary care had the support that it needed, we would be able to build capacity and give people the timely help that they need in their communities, reducing pressure on our acute hospitals. Unfortunately, primary care does not have that support. The Scottish Government is not on track to deliver on its commitment to recruiting an extra 800 GPs by 2027, and its earlier commitment to recruiting 1,000 new community mental health workers has been abandoned. Patients and primary care teams deserve better than constant broken promises by the Government, and Labour supports the call in the Liberal Democrat motion for the NHS recovery plan to be rewritten.

I welcome the references to mental health in the motion, and I am sure that members will agree that the issue is raised frequently with us by constituents. It is, unfortunately, clear why that is the case: as of September last year, 27 per cent of children and young people who were referred to child and adolescent mental health services were rejected, an average of 26 children a day. Some patients have been waiting in excess of 1,000 days to start psychological therapies, and NHS 24 mental health hub calls about psychotic symptoms increased by 101 per cent between 2021 and 2023. That is an extremely serious demonstration of unmet need.

We know that support for mild to moderate mental health issues in the community has a positive impact on outcomes for patients, as well as reducing the demand for onward care, but the Scottish Government has failed to deliver on mental health services. The Government’s previous commitment to funding mental health and wellbeing services in primary care, before pulling the funding entirely after the health and social care partnerships had spent almost a year planning for delivery, has been a catastrophic failure. As the motion states, the mental health budget has been frozen and then cut in-year for two years running. That kind of incoherence is unsustainable, and these are not the decisions of a Government that takes mental health seriously.

Labour is clear that primary care teams need to be supported and afforded the headroom to innovate and establish the services required to meet the needs of their practice population. My amendment, therefore, notes that members on the Labour benches have serious concerns about health professionals not being meaningfully involved in Scottish Government decisions on service delivery, patient safety and workforce planning. The fact is that there is no service delivery, no patient delivery and no workforce without our dedicated NHS staff. Those workers and our patients deserve better, which is why our amendment calls for a national clinical council that is on a statutory footing to empower clinical experts and to make a better reality for patients and professionals.

I move amendment S6M-12214.1, to insert at end:

“; is concerned that health professionals are not meaningfully involved when the Scottish Government is taking decisions on service delivery, patient safety and workforce planning, and calls for the establishment of a statutory national clinical council, which would empower clinical experts and improve services for patients.”

15:18  

I, too, welcome Neil Gray to his new post and extend a welcome across the chamber to Tim Eagle. I know what it is like to join a new class halfway through term, so I wish him well.

I also pay tribute to all the hard-working NHS staff—those on the front lines, those supporting behind the scenes and everyone who worked through the pandemic. They all deserve our great thanks.

The debate provides a good opportunity to discuss our constituents’ experiences of primary care services. Everyone recognises the pressures that the NHS faced during the Covid-19 pandemic and the challenge of recovery, but years before the pandemic, issues were already building in the health service. Recruitment and retention of NHS staff from primary care throughout the health service have been issues for years. The problems did not start yesterday, nor are they the sole consequence of the pandemic.

The pandemic did present us with something new, however: long Covid. Constituents of mine have raised the issue of the lack of dedicated care for those living with it, with one parent saying:

“Our son is very unwell again and it is utterly devastating to see. The lack of support for children with long Covid and their families in Scotland is a national disgrace.”

Post the pandemic, staff are feeling overworked and undervalued, and we are seeing GP numbers reducing. Cuts to nursing and midwifery university places in 2011 by the then SNP health secretary, Nicola Sturgeon, are now coming home to roost. At that time, my party colleague Alison McInnes asked:

“If we aren't training enough nurses and midwives today, who is going to look after our ageing population in the years to come?”

At the end of last week, in my constituency, NHS Shetland was looking for a salaried GP in Unst and another in Lerwick, as well as a psychiatric nurse team leader. The surgery in Hillswick has been advertising a GP post for well over a year and, within the past year, the community of Fetlar struggled to fill nurse cover for the island. Those adverts are for primary care posts. Overall, NHS Shetland has been advertising to fill 14 posts, ranging from GPs to support services.

As islanders, those in the communities that I have mentioned are fully aware of the unique circumstances in which they find themselves. Every community and every individual is entitled to healthcare, and where that cover is missing, it has a greater and disproportionate impact on small communities who have already done everything to extend, supplement and retain existing provision.

As with urban areas, island and rural areas face significant challenges to healthcare provision, such as ageing populations, depopulation and geography. In turn, the reasons behind depopulation and ageing populations are keeping healthcare posts from being filled. Where will the new GP or nurse live, given the shortage of housing to rent or buy? What attracts a healthcare professional to an island community when ferries do not run and are unreliable in providing lifeline services? That is just one way in which travel concerns significantly impact on patients in rural and island areas.

Beatrice Wishart describes the shortages of medical personnel in Shetland, and I am sure that that is the case in many rural parts of Scotland—it is certainly so in the Highlands. A bond system could include the requirement for young qualified medical doctors to work in such remote areas. I believe that such a system of ensuring that rural provision is met and that personnel are available is applicable in other countries. Might it be worth emulating here?

Beatrice Wishart, you need to conclude.

I think that all options should be looked at.

Travel expenses are paid to patients travelling distances beyond 30 miles by road or 5 miles by sea to get to their hospital or health centre for treatment. The Scottish Government needs to look again at how best we ensure that patients are not financially burdened when undergoing treatment. The anomaly that residents in Bressay face has still not been addressed; their ferry journey does not qualify, but it is the only means of crossing Lerwick harbour to reach the ageing hospital, which I have long called for to be replaced with a modern facility.

Am I running out of time, Presiding Officer?

You are indeed, Ms Wishart. In fact, you have run out of time.

I have plenty more to say, but I will conclude there.

I know that to be true.

15:22  

I am delighted to speak in the debate. First, I must pay tribute to the staff who work in our NHS and social care services and the tremendous shift that they put in, day in, day out.

It is important that we recognise the challenges that we all know the service faces, with waiting lists where they are and, in particular, the challenges with GP appointments, and that we recognise the significant impact of Covid in that respect, as we do across the UK and beyond. It is also important that we recognise the longer-term trends in demographics and health inflation that are pressing down on the service.

It is also hugely important to recognise, as the cabinet secretary has done, the Scottish Government’s commitment to the principles of the NHS, including the principle that exists in Scotland—unlike the rest of the UK—of free access at the point of need. The importance of primary care as the gateway to that service is critical. It is the most cost-effective way of providing that preventative service up front, and it helps the health and social care system operate more effectively. As a result, we should not understress its importance to the whole system.

It is also important that we recognise the performance of the Scottish Government and the NHS in Scotland in that regard, with GP numbers per head of population in Scotland the highest in the UK at 81 per 100,000 population, compared with 62 in Tory-run England and 65 in Labour-run Wales. We must also recognise the steps that the Scottish Government is taking to address the challenges that we undoubtedly face with GP provision. With GP training places now at 1,200, and set to increase by 35 this year and by an additional 35 next year, the multidisciplinary teams—4,700 such workers are in place, as the cabinet secretary has identified—will be absolutely critical in providing a more efficient and effective service at a local level.

I am delighted that the cabinet secretary’s predecessor continued the community link worker programme, and I am sure that the cabinet secretary will do so, too. Week in, week out, the GP practices in my constituency of Glasgow Provan are supported by community link workers. The number of GPs has increased by 270 since 2017, so there is clearly more work to be done, but much is going in the right direction.

I also take this opportunity to mention the particular challenges faced by rural and island communities. As members will know, it is an area being investigated by the Health, Social Care and Sport Committee, which I sit on. It is also worth recognising the Scottish graduate entry medicine programme, which is unique to Scotland within the UK. The University of St Andrews and the University of Dundee already participate in the programme, with its focus on recruiting and training GPs specifically for rural and island communities.

I very much welcome the cabinet secretary’s comments about taking forward plans for reform and innovation across the service, which I hope will happen sooner rather than later. There is much to do, but I believe that there is much opportunity and scope for innovation, both in technology and in process, to deliver service improvements, particularly if best practice is rolled out at scale across all 14 territorial health boards and the whole service.

I recognise the importance of recruiting GPs and other healthcare professionals, but I also recognise, as has the cabinet secretary, the impact of Brexit on the potential to recruit. It has placed the brakes on NHS Scotland’s opportunity to recruit from the rest of Europe—and it also brings into stark focus the Lib Dems’ position. The motion recognises the problem with recruitment; however, the elephant in the room is the Lib Dems’ volte-face or about-turn on their position on Brexit, which speaks to their inability to maintain consistency in such matters. The Scottish National Party is the only party in Scotland that is committed to Scotland rejoining the European Union—

Mr McKee, you do need to conclude.

—as a full member as soon as possible.

I call Tim Eagle. For members who have not been paying attention, you will wish to be aware that this is Tim Eagle’s first speech in the Parliament.

15:27  

I am honoured to give my maiden speech today as a new representative of the Highlands and Islands region. I declare an interest in that my wife is a practising GP.

Before I talk about health, I offer my thanks to the parliamentary staff who have supported me this week and to Donald Cameron as he begins work as a Parliamentary Under Secretary of State for Scotland. It speaks to Donald’s character that politicians from all parties praised his contribution to this Parliament over the past eight years. I did not quite realise how big his shoes were, so I will have to get some big shoes from somewhere. He is well known and respected, and the UK Government’s gain is our loss.

Like my colleague Douglas Ross, I live in Moray with my family, and I share Douglas’s infectious passion for the region. No two communities are the same, and residents across the Highlands and Islands face distinct and unique challenges, whether that is needing to get a ferry, paying more for deliveries, recruitment difficulties or needing to travel hundreds of miles for healthcare. The news on Monday that there will be a significant delay to the delivery of an MRI scanner and to the refurbishment of the mental health ward at Dr Gray’s hospital in Elgin is yet another serious blow for Moray and the wider community.

Although those challenges are many and varied, our region and its people have much to offer. As I mentioned earlier, my wife is a practising GP, so I know and live with the daily challenges that are faced by those on the front line in primary care. However, it is not just the GPs; there are the advanced practitioners, the physios, the front-line staff at the desk, the administrators, the practice managers, the pharmacists and more. People in those professions and many others do not just switch off at the end of the day. Their job is a part of their lives, and they do an amazing job despite the difficulties that they face.

There are many great things that this Parliament can and will do, but it is a fundamental essential that we get the most basic needs of the Scottish people right, and access to healthcare that delivers quality, timely care to patients from staff who are valued is one of them.

GPs are the beating heart of primary care services, yet Public Health Scotland’s website today shows a drop of 40 GPs in the past year alone. The SNP’s promise to deliver 800 more GPs by 2027 is, frankly, looking increasingly hollow. It leaves me asking big questions. Where will the Government get those GPs from, and is it truly listening to patients and GPs at present?

To add to that pressure, the number of registered patients is increasing. Reform is clearly needed to deliver modern, efficient and local health services and, in the case of my constituents, it is vital that the trend of rural depopulation is tackled.

Although I enter Parliament at a later stage in this session, I bring with me many lessons learned from serving the community of Buckie during my time on Moray Council. I am deeply proud to be a part of that community. It has immense spirit, which was so prominently displayed when a large part of the town travelled to Glasgow to support Buckie Thistle Football Club against Celtic in the Scottish cup recently.

As a councillor, I firmly believed that I was only truly capable of serving my community if I listened to those whom I served. Ultimately, it is their lives that are made better or worse by the decisions that we take here. Although I will challenge the Government when it is necessary to do so, I want to work with all politicians, because that is what our constituents expect of us.

I look forward to delivering for the Highlands and Islands, but I end with perhaps one of the most urgent requests to the Government. Primary care is calling out to the Government from the shadows that it needs more help to bring it back into the light so that it can shine. [Applause.]

Well done, Mr Eagle.

15:31  

I congratulate Tim Eagle on his maiden speech today.

I also welcome the cabinet secretary’s statement that he will be listening to the voices of health users and of those in the workforce. I hope that that also means those on the front line of our health services, because when I spend time speaking to front-line health and social care workers, it is clear that they often feel as though nobody listens to them, whether that is those further up the tree in the management of the NHS and the integration joint boards or, indeed, whether that is politicians.

Alex Cole-Hamilton talked about the NHS and health and social care being in crisis. Those on the front line face that crisis every day. It is right that we in the Parliament should unite to thank those who are delivering health and social care services. They are under such immense pressure, but if we speak to anyone who uses those services—this is certainly my experience—they are full of praise for the dedication, the commitment and the care that they take in delivering their jobs every day, despite the real difficulties that they sometimes face in their work.

The value of social care work is a key issue. Over a number of years, I have raised in the Parliament the issue of the value that we place on social care. I suggest that the pay for social care workers does not match the job that they deliver. The level of pay is poor. If we compare the pay, and the terms and conditions, of those who deliver social care in the public sector with those in the private sector, we see that both those aspects are worse in the private sector.

It baffles me that we have not addressed that aspect. We have spent millions coming up with the new social care services that we talk about, and I think that a bill is being introduced in a number of weeks, but why have we not addressed that core issue? If we do not treat care workers with respect or value the service that they deliver through the provision of decent pay and terms and conditions, it is no surprise that there are issues with recruiting people into those services and that people are also leaving them. I make that appeal.

On workforce planning, I raised with NHS Fife a month or two ago a concern that constituents have raised with me: the fact that many GPs are due to retire. There is real worry in many communities about what will happen when those GPs go. The chief executive of NHS Fife told me that it does not hold any data or information, and that it has not carried out any surveys on the GP workforce across our health centres, because they are private businesses. No other business or public service would be run in that way, such that people are clueless as to what staffing requirements will be in the future. We have to address that issue.

I praised the Government many years ago when the Christie commission’s report came out and it focused on prevention. We should not forget that many of the people who are using primary care services are doing so because other services are poor. If people live in damp, wet housing or are unable to get the skills and opportunities that they need to get a job or an education, that will result in poorer health—the statistics show that. We need to take a holistic approach that recognises those factors.

15:35  

I start, as others have, by thanking GPs and their primary care teams for their efforts for their patients every single day. The briefing from the Royal College of General Practitioners rightly calls them “the front door” of the NHS. They make up the service that is in most contact with the public and that is in the best possible position to help us to achieve some of the public health goals that we are rightly proud to have.

I welcome the commitment from the cabinet secretary to speak to those who work on the front line, as well as to patients, about what they want to see from front-line health services.

We need to tackle the issues and challenges that GP services are facing. The pandemic has played a large part in the frailty, deconditioning and complexity of the patients who GPs are dealing with. That is no fault of patients or GPs, but it is a reality that many of them face. Those pressures and that added complexity simply have not gone away, and they will be with us for some time to come.

We also have new conditions for GPs to treat, such as long Covid, as well as advances in how we treat other conditions. I strongly believe that we need to ensure that GPs have sufficient time to update their knowledge and deepen their understanding of complex conditions that they are having to manage. Data is a huge issue across the sector, and I once again call for a single patient record.

There are particular pressures in particular places. I want to touch on some of the interesting work that the Health and Social Care Committee has been doing on remote and rural healthcare. Unsurprisingly, the ability to recruit people into the workforce in rural communities is an issue. Clinicians highlighted to us a range of recruitment difficulties.

Housing came up as a major issue, because of both cost and availability. Some people highlighted to us that, in certain communities, the cost of housing prohibited new workers from moving there in the first place. However, some of the biggest barriers were the types of housing that were available, if any housing was available at all. Cost was highlighted as more often an issue for other members of the multidisciplinary team.

In many rural villages, general practices have only one GP. That causes recruitment challenges, as many GPs want to be part of larger teams for support and collaboration. There are very good wider networks for rural GPs, but some noted that their work can be quite isolating on a day-to-day basis.

Added to that are the issues of an ageing population and the fact that older people can make up a higher proportion of the population in some rural areas. Many people choose to retire to rural locations, which exacerbates the issue. Thought needs to be put into how we can best equip GPs in those areas for the likelihood that the number of older people in their practice areas will increase.

How we deliver primary care services is hugely important across the country, but how we can innovate with GP services in rural areas so that people do not have to travel long distances is particularly so.

Those are just some of the issues that have been raised with the committee as part of the inquiry, which is still on-going. The potential solutions to some of those issues lie in other portfolios within Government, and I hope that the new cabinet secretary will explore those with colleagues.

There is a lot to cover in the debate, but I want to briefly touch on the issue of out-of-hours GPs. They add a huge amount of support and breadth to the urgent care landscape. They are a hugely dedicated team, who do our-of-hours work over and above their normal clinical load. They help to divert people away from A and E but ensure that patients with particular concerns are seen and given help, support and treatment where it is needed. They are an enormously important piece of the GP workforce that we often forget about, but they are hugely valuable.

Our primary care teams are “the front door” of the NHS, and we need to ensure that they get the support and investment that they need.

The final speaker in the open debate is Keith Brown.

15:39  

First, I welcome Neil Gray to his position as Cabinet Secretary for NHS Recovery, Health and Social Care. He is one of the strongest members of the Government and it is one of the most difficult posts, so best of luck to him.

I also welcome Tim Eagle to the Parliament. I hope that I will have the same convivial relationship with him as I have with his colleagues. I ask him to pass on my best regards to Donald Cameron, who left suddenly. We worked together on the Constitution, Europe, External Affairs and Culture Committee, and I always found him to be a courteous and considered individual.

What we heard from Alex Cole-Hamilton raises real issues but, in my view, the contribution is entirely fatuous, because it seeks to ignore some of the big determinants of what we are discussing. First, we get groans from some parts of the chamber when comparisons are made with other parts of the UK—unless it is a comparison that those members want to make—but the amount of resources that come to Scotland is determined by spending decisions that are made in London. The UK Government rightly bases those decisions on what it believes the need to be, but Scotland just falls into place, as does Wales. If we ignore the extent to which resources, including the capital cut to the NHS budget, derive from Westminster, this is not a real debate.

Another thing that is disregarded and ignored in the debate is that Covid seems to be a justifiable reason to give for some of the issues in the NHS in England—as happened this week in the House of Commons—and in Wales, but it is not seen as justifiable here in Scotland.

Will Keith Brown give way?

No—I will not. I have only four minutes, and Alex Cole-Hamilton has not been in the chamber during the whole of my speech, anyway.

Another thing that is unreal is the failure to acknowledge—particularly by Alex Rowley—the fact that Scotland has higher-paid NHS staff. As Ivan McKee pointed out, we have more NHS staff, and we have had no strikes in the NHS. If this was a genuine discussion about the condition of primary care services, there would be some mention of those facts.

A fourth thing that Opposition members have not mentioned, although Ivan McKee mentioned it, is the impact on the NHS of Brexit and of the more recent announcement that further restricts care workers’ ability to come to Scotland. If those things are completely ignored, how genuine can the discussion be?

Much of what Opposition members say in the chamber is derogatory towards the NHS and its staff, although it is usually dressed up by saying that it is the SNP NHS. My experience, whether of primary care or otherwise, including cancer care, is different. In the past couple of weeks, somebody I know who has cancer was seen within three days—they had a mammogram and an ultrasound, saw the consultant twice and were dealt with in three days. I am not saying that everyone gets that service, and I am not trying to pretend that there are no issues and no waiting lists, although the waiting lists here are substantially shorter than those in many other parts of the UK.

Surely it is more important to discuss how the spend on NHS services in Scotland, including on primary care, compares with that in other countries, so that we get a true comparison, or to consider what other countries are doing that is different and that we could learn from.

There is no question but that the NHS has done an absolutely fantastic job. I just recounted an experience from the past couple of weeks, but there was an even better one in the midst of Covid, which I will quickly recount. A consultant saw somebody who I knew and who had to have their gall bladder removed. After that person’s emergency admission to hospital in the afternoon, the consultant said that, since he was on that night, he would do the operation then—the same day as the person was diagnosed. Given how crammed the hospital was at the time—it was Glasgow royal infirmary—that was an absolutely fantastic job. I just wish that we had heard more about the work that has been done in the NHS.

I wish that we could have a realistic debate in which the Opposition parties at least acknowledged the constraints that operate in Scotland, as they do in Wales and Northern Ireland, because of the way in which the UK is structured. I will support the amendment in the name of Neil Gray when we come to decision time.

15:43  

I am pleased to close on behalf of Scottish Labour and I thank the Liberal Democrats for bringing the debate forward during their debating time. To reflect on the previous speech, by Keith Brown, a key point is that we have such a short time to speak because it is always the Opposition parties that have to bring such debates to Parliament. I would welcome it if Keith Brown put pressure on the front benchers to use Government time in the chamber to talk about such issues, which I agree that we should talk about.

I think that members know that I appreciate the concerning impacts of Brexit and the Tory Governments that we have had. I have said that many times in the chamber, and I do not shy away from doing that. However, it is fair for Opposition parties to come to the chamber to say that patients and staff are getting fed up with the SNP deflecting blame and deflecting from taking any responsibility for how poorly things are going in the NHS for staff and patients. To be honest, it is a key responsibility of back benchers to put pressure on front benchers to talk about and take responsibility for such things.

The direction of travel regarding access to primary care is undoubtedly the wrong one, which is piling pressure on parts of the health service that could do without it, as Alex Cole-Hamilton said when moving his motion. Let us be clear—it is honest to say that the target to deliver 800 new GPs is not being met. Sandesh Gulhane gave the evidence for that. Waiting lists are dangerously long, with many people waiting in pain. In primary care, people sometimes cannot even get to speak to a GP. It is fair for Opposition parties to bring such issues to the chamber.

Mental health appointments for children and, in particular, for adolescents are still extremely hard to come by. My colleague Paul Sweeney outlined that the promise on that has more or less been abandoned. We must make those points in the chamber.

I agree with that—I see nothing wrong with such concerns being brought to the chamber. That was not my point; my point was that, if we are to have a rounded debate, let us acknowledge why some of these things are happening—the root causes of them. We should have a more rounded debate, but I am not challenging the right of members to raise such issues in the chamber.

We are coming at the issue from different directions. I think that I have been fair in my assessment of where we are. The Scottish Government has a massive budget for the NHS and has lots of staff to manage and support, so it must take some responsibility for that.

Beatrice Wishart put it well when she said:

“The problems did not start yesterday”.

She gave a fair reflection of what has happened over many years, before Brexit and Covid. We need to be honest about that.

I see that my speaking time is running out. The cabinet secretary mentioned recruitment and retention and spoke about physiotherapists. We require physiotherapists in my region, but responsibility for our inability to recruit people to physiotherapy courses, in order to gain more physiotherapists far into the future, lies at the door of the Scottish Government. The Chartered Society of Physiotherapy has been trying to speak to the Government about how we recruit and retain more physiotherapists.

Scottish Labour will support the motion, and we hope that members will support our amendment.

I remind all members that those who participate in a debate should be here for opening and closing speeches. Some members drifted out of the chamber during the opening speeches, and some have done so during the closing speeches, which is not acceptable.

15:48  

Neil Gray has inherited an overflowing in-tray from the disgraced Michael Matheson, who missed no fewer than 72 NHS-related targets set by his Government while he was in charge of the health service. As we have heard, it looks likely that the SNP Government will miss another of its flagship targets—the target to recruit 800 GPs. In fact, the British Medical Association believes not only that Scotland is not on track to meet that commitment but that we are going backwards. That matters because primary care is the backbone of the NHS. The majority of patient contact occurs in primary care. Those services are being expected to take the pressure off other parts of the NHS that simply do not have the capacity to treat patients.

General practices are pivotal to the survival of the NHS but, under the SNP Government, patient numbers are up and GP numbers are down. Scotland lost 10 per cent of its GP surgeries between 2012 and 2022. General practice is chronically underfunded and underresourced, as we have heard. Rural communities have been hit particularly hard, because it is increasingly difficult to recruit and retain GPs, so some practices are under increased pressure to close. It is little surprise that one of Scotland’s top doctors has warned that general practice is dying a slow and lingering death.

As Neil Gray gets up to speed with his brief as the new health secretary, he would do well to read the Scottish Conservatives’ recent paper on health, in which we committed to raising the amount of NHS spending on GP services by 12 per cent and to recruiting an additional 1,000 GPs.

Dr Sandesh Gulhane shed light on the flopped plans of the past three health secretaries, against a backdrop of GPs suffering from low morale caused by unmanageable workloads. Sadly, earlier in the debate, we saw more deflection from the latest cabinet secretary, who, according to Keith Brown, is one of the strongest members of the SNP. Let us therefore see the cabinet secretary start to put in place workable solutions to the current crisis, rather than continuing to lay the blame elsewhere, as his colleagues do.

Dr Gulhane challenged the cabinet secretary and his colleagues over not passing on £17 billion in NHS consequentials and instead wasting that money on SNP-Green pet projects. Dr Gulhane is not precious about our policies. The cabinet secretary could swallow the pride that he talks about and consider our workable solutions, which would give him a head start. The cabinet secretary is frowning at me, so clearly he has not looked at our paper—perhaps we could send him a copy of it. If he were to consider those proposals, that would make a refreshing change from the deflection, the cracked record and the smoke and mirrors that Alex Cole-Hamilton mentioned in his opening speech.

In making his maiden speech, Tim Eagle asked the cabinet secretary to listen to those whom he serves. Cabinet secretary, please do something now, listen and show that you mean what you say about making general practice

“the heart of the healthcare system”,

to quote your words to you.

The Scottish Conservatives have a clear plan to deliver a modern, efficient and local NHS. The SNP cannot preside over the permanent crisis in our NHS any longer.

I give a reminder that remarks should be made through the chair.

15:52  

I have only a brief time to close the debate on behalf of the Government. I will try to respond to as many as I can of the points that have been raised.

As a mental health pharmacist who spent 20 years working for NHS Highland, far from experiencing the “nationalist ministerial disinterest” that Alex Cole-Hamilton described, I was so inspired by our SNP ministers’ leadership of our health and social care system in Scotland that I became one.

Mr Sweeney raised the challenging financial pressures that we face and their impact on our mental health budget, which is an issue that is close to my heart. The pressures that we face are recognised as some of the most challenging since devolution. Welsh Labour colleagues recognise that situation; I only wish that Scottish Labour colleagues would do likewise.

Paul Sweeney rose—

One moment.

Of course, Covid and Brexit have lingering impacts, but there has also been the enormously painful effect of Liz Truss’s premiership. It might have lasted only a few weeks, but its impact will be felt for many years.

I will give way to Paul Sweeney.

No one here is charging the Government with not having to deal with a difficult financial position; our issue is the clarity with which it is approaching those points. For example, we know that community link workers have a positive effect in avoiding unnecessary admissions to acute hospitals, yet their numbers in Glasgow were about to be cut and we had to fight a defensive campaign against that proposal. That is just one symptom of a wider issue, in which the Government is often found wanting by not acting intelligently with the resources that it has.

We absolutely recognise the value of community link workers, which is why we have invested in them. They have a record budget this year. The mental health directorate’s programmed budget has more than doubled since 2021 to more than £260 million. In fact, our NHS boards’ investment in mental health services has also increased, despite the difficult situation that we face.

I welcome Tim Eagle in making his first speech as a new representative for the Highlands and Islands region. I have had the privilege of representing the region, and I wish him all the best in his work.

Mr Ewing raised the issue of whether a bond can be applied, particularly in rural practices. A form of that already happens in the successful ScotGEM—Scottish graduate entry medicine programme—initiative that was introduced in 2018-19. Bursaries are available, with conditions attached that can trigger repayment.

I absolutely agree with Mr Rowley that we need to value social care staff. That is why I am very proud to serve in a Government in Scotland that has ensured that our social care staff are the highest paid in the UK—not only that but, thanks to our progressive tax reform, they pay the lowest level of taxation in the UK. I share Mr Rowley’s wish to go further and faster, but I am pleased that we are on a path to improvement.

I am certain that Mr Rowley would join me in opposing the appalling treatment of care workers that is being proposed by the UK Government. Those people who come to this country to care for our most vulnerable people are being singled out and denied family life. That is absolutely brutal and disgraceful, and it should shame each and every one of us.

This Government sees primary care as the foundation of our health and social care system. The cabinet secretary covered the work that is under way to increase and retain our GP workforce in Scotland. We are also committed to reforming the way in which general practice works through expanding the wider multidisciplinary team in general practice, including pharmacists, physiotherapists, community link workers and mental health practitioners, to name but a few elements of that team. That additional capacity is allowing GPs to move into the expert medical generalist role, focusing on more complex care in the community, as intended through the 2018 GP contract changes.

We are further taking forward the work to develop multidisciplinary teams through the establishment of a phased investment programme over the next 18 months, with four demonstrator sites across Scotland showing us what the next phase of multidisciplinary team delivery would look like.

I turn to mental health, in particular. We have exceeded our commitment to fund more than 800 additional mental health workers, many of whom are working in primary care and community settings. To develop a culture of mental wellbeing and prevention in local communities, we have invested £51 million in our communities mental health and wellbeing fund for adults since 2021. We have also ensured access to counselling services in every secondary school and continue to support local authorities with funding for that. Following our record-breaking investment in CAMHS, 13 out of 14 CAMH services in NHS boards in Scotland have, in effect, eliminated their long waits. That is to be celebrated.

I know that we need to further enhance the support that is available in the community for both mental and physical health. Primary and community-based care are priorities for this Government. We are committed to continued partnership working with our professional bodies to ensure that reform and our committed investment in the draft budget are configured for the needs of our communities.

I hope that members can see that this Government is delivering on its ambition for a thriving and sustainable primary care system that is focused on both mental and physical health at the heart of our healthcare service.

I invite Willie Rennie to wind up the debate.

15:58  

I thank everyone who has taken part in the debate. I especially thank Tim Eagle for a fine first speech, which I thought was excellent. He showed his passion for Moray, and he has a good grasp of the issues that are at play. My one bit of advice would be not to follow the lead of Sandesh Gulhane and fail to turn up for the summing-up speeches of the debate; otherwise, it was an excellent first start.

One of the issues that Mr Eagle specifically mentioned was the long distances to get access to some care, especially around maternity services and Dr Gray’s. That was the bit of Beatrice Wishart’s contribution that she was not able to squeeze in because she was far too generous to Fergus Ewing. It was about Jamie Stone’s point about maternity services in Caithness and the far north and how women have to travel hundreds of miles to get treatment. The strain must be incredible.

Alex Rowley was right. All members in the chamber recognise the value of NHS staff. We understand it. We have seen it at first hand. I have seen it at first hand over the past year with far too many family members who have spent a long time in hospital. I have seen at close quarters the pressure that NHS staff are under, and there is no doubt that all members present would thank them for the work that they are doing.

The morning call to the GP is incredibly stressful. People have to make repeated calls. Sometimes, the line is engaged if the practice does not have the right telephone system and, sometimes, people fail to get an appointment day after day. Those long waits add to the pressure, strain and anxiety that patients already feel because they believe that they have an important illness that needs to be addressed. Moreover, something might be urgent without people knowing it, so those waits might prevent us from making the early intervention that GPs often provide.

Ivan McKee was bang on when he said that GPs were the gateway. The preventative service—the old-style family doctor—was an important part of the community. That has changed, and I am sure that everybody recognises the additional health professionals who are now part of the multidisciplinary team that the minister just talked about. We should encourage our constituents to accept the advice from the receptionist to go to another health professional and not just insist on seeing their GP. That helps, alongside going to a pharmacy, which often provides more direct support.

Although Ivan McKee was right about that, he was a wee bit wrong in blaming the Lib Dems for everything to do with primary care. However, I accept that he is allowed to make some political points.

The cabinet secretary acknowledged some of the issues. I accept that there are issues connected to Brexit—to which we are still opposed. The pandemic has added to the pressure, and we know that budgetary pressures apply, too. However, I have to say that there was a bit too much of blaming everybody else and not accepting the responsibility for the inordinate pressures that primary care services face.

In the work that I seek to take forward and the reform that is needed across the NHS and social care services, I absolutely accept responsibility. We need reform in that service. Therefore, I assure Willie Rennie that not only is the context in which we operate important but I take very seriously my responsibilities to ensure that we have reform and that we increase capacity and productivity in our service.

I accept that. The problem that the minister faces is that we have had 17 years of the Government and promises of endless reform. I have to say that we are not much further forward. We still have the long waits that I talked about when people try to access their GP in the morning. I talked about the waits for mental health treatment. I know that the minister is saying that the very longest waits have almost been eliminated, but thousands of people are still waiting a hell of a long time to access mental health services. That is adding to the problem.

The minister did not refer to the fact that GPs are retiring early and hardly any of them go to their full term now. We need to get to grips with that, which feeds into what Fergus Ewing was talking about. We need to ensure that we keep GPs for longer. Secondly, an awful lot of GPs are going part time. That is a symptom of the pressure that they feel in their practices. We are into a vicious cycle, in which the GPs and all the staff feel the pressure. The demand increases, so they go part time, and the demand increases more because of the pressure on the staff who are left.

We have long-term problems with general practice, and I hope that the minister will try to address the issues around GPs. The pension changes at UK level will help a bit, but far too many GPs have already gone.

Paul Gray, the man who used to be in charge of the NHS in Scotland, warned the Government some time ago that, irrespective of the pandemic or Brexit, there were already deep-seated problems in the NHS. I am afraid that the response from the Government has been wholly inadequate. According to the RCGP, the Government is not on track with the recruitment of GPs. It is just not. In the past two years, there has been a decline. According to Audit Scotland, we are not on track to meet the recruitment targets for mental health staff, either. It says that the plan is at risk. I have raised with the minister the issue that there are pockets of the country where we are not able to recruit members of multidisciplinary teams. There has been an in-year cut in the mental health budget, which does not help, either.

We need action on recruitment and retention, and we need to explore the use of a bond. I prefer carrot rather than stick, but we need to think about whether we should consider a bond.

Fundamentally, we need to look at the long-term problem whereby, although primary care deals with the bulk of the work in the NHS and deals with most people, it gets a fraction of the budget. We have not shifted that dial enough. We need to increase the proportion of the budget that primary care gets. That is not easy, especially when there are significant pressures elsewhere in the system, but if we do not address the bit of the problem that relates to the gateway and the early intervention and prevention work that Ivan McKee talked about—

Would you conclude, please, Mr Rennie?

Certainly.

If we do not do that, we will simply add to the problems in the rest of the health service.