General Medical Services Contracts
The final item of business is a members' business debate on motion S2M-728, in the name of Alasdair Morgan, on general medical services contracts. The debate will be concluded without any question being put.
Motion debated,
That the Parliament is concerned that the provisions made for contracting-out out-of-hours care from GPs to local NHS boards may be insufficiently funded to meet the unique challenges encountered in rural practices; believes that rural practices thus unable to opt out will have serious difficulty in recruiting new doctors, and considers that the Scottish Executive should re-examine the level of funding allocated to NHS boards providing these services in rural areas.
I am grateful that the Parliament has the opportunity to debate the issues arising from my motion on the implementation of the new contracts for general medical services, particularly as they affect the provision of out-of-hours services in rural areas of Scotland. I thank the members who signed my motion.
The issue is important not only for individuals, but for the viability of rural communities, which are under so many other threats at this time. I do not think that any of us would disagree with the motivations that led the British Medical Association side in the recent negotiations to achieve a position whereby most of its general practitioner members would be able to opt out of the out-of-hours service. It is reasonable that, for most GPs, the days are gone when, in addition to working a full day, they are expected to contribute to out-of-hours services, at a disproportionate cost to their own quality of life. I acknowledge that some GPs, particularly those in very remote areas, might feel that they can and want to provide on-call care as well as daytime provision but, to quote Michael Forsyth's words in another context, I think that many GPs feel that it is time to get a life.
The changed nature of society means that what is acceptable in terms of professional duty has changed considerably over the years. It is also the case that, in many instances, the public are putting much higher and sometimes unreasonable demands on out-of-hours services, with the result that on-call cover has become increasingly unpopular among GPs.
The problem has not been keeping GPs happy, because in rural areas potential recruits to the profession increasingly have been voting with their feet and not joining practices in which on-call cover is part of the package. The difficulty in getting GPs to apply for vacancies in rural practices, and to stay in them once recruited, has been serious for some time and is getting worse. Therefore, the status quo is not an option.
I do not believe that the public are in any way ready for the magnitude of the change that is about to hit them. I remember attending, before I was elected in 1999, a public meeting that had a large audience. The meeting's purpose was to discuss the introduction of an out-of-hours co-operative service among the GP practices in the Castle Douglas area. The public reacted to that modest proposal almost as if their medical services were being eliminated altogether. There was considerable concern about the length of time that it might take a called-out GP to travel from Castle Douglas or Kirkcudbright to Dalry, for example, which would be a distance of 15 or 20 miles.
Whether that concern was reasonable is one issue, but we are talking about an entirely different situation when we measure the distance between Stranraer and Langholm, which is more than 100 miles. I have not picked those two towns to exaggerate the case because they give me the longest possible journey that can be undertaken between any two houses in Dumfries and Galloway. In fact, that distance of 100 miles is far from being the longest possible journey in the area. I picked those two towns because they give one of the longer distances between two substantial towns, one of which has 10,000 people, while the other has well over 2,000. I do not wish to diminish the problems that other members may raise about their own areas and constituencies, but a particular factor in Dumfries and Galloway is that not only is the area to be covered by the out-of-hours service a large one, but the population is well distributed throughout the area rather than being concentrated in any one part. That raises substantial extra challenges in the provision of any public services.
Distance is not the only problem associated with rural areas. The lack of public transport, which is non-existent for much of the out-of-hours public, is another factor that exacerbates the out-of-hours situation. Although car ownership is higher in rural areas, 25 per cent of households in Dumfries and Galloway still have no vehicle, and the percentage in the Highlands is much the same. In addition, the percentage of the population aged over 60 is also more than 25 per cent—significantly higher than the Scottish average. The age profile of the population in the region makes the frequency of needing medical intervention higher, and the proportion of people who need the intervention to come to them—rather than the other way round—is also high. Against that background, members will be well able to understand the level of public concern that was caused by the recent statement by the medical director of the local health board that, as a minimum, there would be two on-call doctors available in Dumfries and Galloway—two people to cover two towns that are 100 miles apart and all the towns in between.
The minister has assured me in correspondence that all will be well and that the new national standards for out-of-hours services are being developed. The working group for that includes representatives from NHS 24 and the Scottish Ambulance Service. One might infer that those bodies will have a significant role to play in the new service. Certainly, we accept that NHS 24 can assist in the triage of cases, especially given the perception that an increasing number of call-outs are not strictly necessary. However, NHS 24 cannot cut the number of real emergencies. I cannot speak for other areas, but in Dumfries and Galloway the ambulance service is already operating pretty much at the limit of its budget and capacity. I and other members in the area have raised concerns about the level of cover that the service is able to offer over such a wide area even without its being given any additional responsibilities.
The BMA says that, historically, the provision of out-of-hours services has been subsidised by GPs and that its cost has not reflected the true cost of providing such services. It would say that. However, to a layman, it seems credible that the 6 per cent that will be deducted from a practice's global sum when it tries to opt out of 24-hour cover is not the true cost of the service. If there is any truth to that, it is understandable that health boards are saying that they will be insufficiently funded for the new service even with the extra money that will be allocated to the out-of-hours development fund.
There is still some time to go. The transfer of responsibility for the out-of-hours service will not happen until 1 January next year. However, the deadline is fast approaching. Our constituents need more than simple reassurance that their levels of service will not deteriorate when the deadline arrives.
There is a long list of members who wish to participate in the debate; therefore, I shall restrict speeches to three minutes.
I congratulate Alasdair Morgan on securing the debate on this motion. I was delighted to sign it, as it flags up a major national problem.
A piece of legislation has been introduced that was worthy in its cause. Doctors deserve a reasonable quality of life and patients deserve medical staff looking after them who are rested and capable of carrying out their duties to the utmost per cent. However, it has been a bit of a rush job.
At the Health Committee's away day near Oban, we met members of the public, community councils, GPs, GP practice nurses and GP managers who all asked, "What about us in the remote areas?" It appears that they do not know whether they will get support to opt out of out-of-hours services—quite apart from the feeling of pressure they have from living in small communities but working all the hours that God sends. They do that willingly, but there is a limit to the cover that they can get for quality of life or further post-graduate education.
The only thing that is missing from Mr Morgan's motion is the statement that the issue is not just about money. I would like the minister to tell us where the medics are going to come from, even if the health boards have the money and get the resources and a top-up—which is undoubtedly needed, as the 6 per cent transfer is simply not enough. Health boards throughout the country tell us that there are demands through new burdens on their resources and that their main problem is capacity. Where will they find the bodies from? We have had evidence from Glasgow that some GPs are going to opt out of daily GP life and move to work out of hours in an enclosed area. That is fine, but who will replace them in working the everyday hours of a general practitioner's facility? We need to know those answers. We know that regulations are about to come out, but we have not seen the colour or the quality of them. People in rural and remote areas, such as where I come from in Grampian, are very concerned.
It has been pointed out that there is evidence that accident and emergency departments in the cities are still getting bigger hits than ever, despite the fact that NHS 24 now exists. On a visit that I conducted recently, NHS 24 told us of patients who would phone two or three times and still end up trying to get a GP to come out.
As was mentioned, the Scottish Ambulance Service is stretched. As the Minister for Health and Community Care has said, paramedics may run an out-of-hours accident and emergency facility in north Aberdeenshire, but frankly that is not enough.
In the light of the figures that we have been given this week and the debate that we will have tomorrow about manpower in the health service, this debate is opportune. The motion flags up the concern throughout Scotland that the provisions in the GMS contracts may provide for some GPs but will not provide for all of them and certainly do not appear to provide for rural patients.
The new GMS contracts, which are being introduced Scotland-wide, have generated quite a debate. I have attended several meetings that have shown that there is much concern not only among medical professionals but, more important, among rural communities throughout Scotland. People are concerned that the medical services that they currently enjoy will not be sustained under the new GMS arrangements.
GP professionals have expressed their concerns, in particular where general practices are located in remote, rural areas where distance and isolation are seen as an absolute disincentive to attracting qualified GPs, as Mr Morgan said. It appears that where it is possible and appropriate to form a group practice, many currently operate. In such cases, there is a rota system that allows regular time off duty and the out-of-hours system seems to work and meet with the general acceptance of the profession and the public. However, in many remote areas of Scotland it is not possible to have co-operative practices. Where such arrangements have not been possible—in isolated areas that have single-GP practices—there are fears that medical provision will not be sustained. That is exercising the minds of many people in those areas because they have come to expect a first-class service and they expect and hope that such a service will continue. Their fear is that it will not.
If those fears are to be allayed, the Executive and health trusts—supported by the medical profession—must listen to the concerns of their dedicated staff and to the voices of vulnerable communities. General practitioners in a single or small practice find themselves on call 24 hours a day, seven days a week. That is an unreasonable work situation that cannot be allowed to continue. Like many members, those people may have young families, and they are entitled and expect to enjoy family time together. We must ensure that they are suitably resourced and that they have physical and financial support so that we can retain their valuable contribution to our rural society.
I was on the phone to Highland NHS Board this afternoon and I was told that it thinks that it will have to spend somewhere between £3 million and £6 million on out-of-hours services. A disproportionate amount of that money will go to remote rural areas.
I have received numerous letters from GPs in remote rural areas. They complain that they are being forced to opt out of providing a service when they want to work in their own practice. They want not to join up with other doctors in neighbouring practices, but to be given the same status as GPs on some of the islands, who are told that they cannot opt out and are given particular support by the health board.
I can give an example from Applecross, where the practice is to join up with those in Torridon and Lochcarron. The doctor in Applecross tells me that it is quite impossible for her to keep to the 45-minute guideline for getting to patients, in particular in winter or if she has to go across the Bealach na bà. Mobile phones do not work well in that area and there is only one ambulance, which is in Lochcarron. In Applecross, there is not even a police car for emergency use, so there is no infrastructure to support doctors. The doctor would be quite happy to carry on doing what she has done for the past 13 years and look after patients from her own practice, with support, and she fears that her independent practice is earmarked to disappear in time.
An Argyll GP writes that the lack of appropriate transport is a major safety consideration. Air ambulances are based in Glasgow and Inverness. If out-of-hours services are to work in remote rural areas, we must consider—and afford—better air ambulance provision that would be based in the west Highlands. A GP from Shetland tells me that there is no solution to emergencies in outlying areas: a fast four-wheel drive has been mooted, but it would still take an hour for a GP to get to the hospital from her practice and they cannot afford a helicopter. Perhaps we will have to afford helicopters or air ambulances if we are to provide the service that remote rural areas need.
The doctor in Shetland would rather be told by the health board that her practice cannot opt out of out-of-hours care. I want to ask the Executive: what are the criteria for such decisions? The Health Committee's report accepted that there would be situations—and not just on the islands—in which practices would be told that they could not opt out, because of their remoteness, but I have yet to hear of a doctor in a remote area who has been told that they cannot opt out and I want to know why. The situation will create extra expense for health boards and I fear that more money will have to be spent on transport, too.
Alasdair Morgan set out in a moderate and fair way the problems that rural GPs, in particular, face. There are no simple solutions.
I represent Inverness East, Nairn and Lochaber and it seems to me that if those doctors who work single-handedly on islands such as Eigg are required not to opt out of out-of-hours care, they might find that, if they want to retire in a few years' time, it will be extremely difficult to attract anyone to take over the practice. They know that they are working round the clock instead of being off duty from 6 pm to 8 am and at weekends, as other doctors are. As Alasdair Morgan said, it is difficult enough to recruit doctors to remote rural areas. I am pleased to say that in Laggan we recently managed to find a new GP, but I think that there were only two applicants for the post, when we would have expected many more.
There is great concern in other parts of my constituency, in particular in Lochaber, where a meeting of three community councils—Arisaig, Mallaig and Morar—took place earlier this month to discuss the implications of the loss of round-the-clock GP services in relation to the threat that consultant-led facilities at the Belford hospital might be downgraded.
There is also the prospect that the new system, which I think has been designed without adequate thought, might cause resentment and a form of medical apartheid, dividing doctors who decide not to opt out from those who do. For example, I understand that the practices in Nairn and Ardersier have indicated that they will not opt out. Their general manager has recently opined that the number of GPs in the Highlands who work out of hours will drop from the current figure of 70 to only 10. Highland NHS Board has proposed that it should provide alternative care in about 10 areas, which is difficult enough to do.
I heard from one GP about a new breed of GPs who will work solely out of hours. Although what I was told was anecdotal—the minister might be able to put his own figure on it—I understand that the new breed of GP might be able to earn in excess of £150,000 a year.
Although the change is necessary, the impact has not been thought through. Much more work is needed if people in rural Scotland are to continue to receive the first-rate service to which they are entitled.
I thank everybody for the comments that they have made. The trouble is not only that the new contract has not been truly thought through, but that the finances are not in place.
Rural GPs have a lack of choice. Thought is being given to the recruitment of GPs, but at present it is very difficult for GPs in rural areas to get another GP to provide locum cover so that they can have a holiday. I do not see anything in the new contract that will improve the situation or that will enhance the prospects of GPs who want to work in rural areas. Last night, I spoke with an ex-GP. He is a young man who has gone into another field—something that many city-based general practitioners are doing. People are getting out of general practice because of the depression that results from working in it and the lack of finances.
No GP likes doing 24-hour cover. That is not because they do not like their patients; the fact is that the number of hours that GPs have to work is growing and being a GP is very hard work. In rural areas, one night call could take a GP all evening.
As Fergus Ewing said, when we think about out-of-hours provision in rural areas, we also have to think about the lack of consultant services. If someone lives or wants to live in a rural area—or in any community—they need to have work and housing, health care and education services. General practitioners need all those things for themselves as well as for their patients. People might have broadband and be able to work from home, but why would they want to do so if they do not have adequate medical services?
It is extremely difficult for general practitioners in rural areas to work round the clock. It is also extremely difficult for them to get to their patients. That said, I believe that rural patients are not as taxing on their general practitioners as patients in the cities are. The job of a rural GP is quite different from that of a city GP.
A friend in Orkney sent me an article from Orkney Today; the article was written by a general practitioner and expresses his concerns. He emphasises the differences in the situations of rural and urban GPs. I would not say that one is better than the other, but rural and urban GPs are two different animals that need different training. The article emphasises that fact. I wonder what Orkney NHS Board is going to do about the situation that the GP describes.
My friend also sent me a cutting about patients who were sent from Orkney to Aberdeen only to be told when they arrived at Aberdeen royal infirmary that NHS Orkney did not have the money to pay for their treatment in Aberdeen. If things are that bad I wonder how health boards are going to work out the out-of-hours service provision. We still do not know how many GPs are going to opt out. It is not possible for GPs who practise in rural areas to opt out—those GPs do not have that choice. The Executive has to go back and think again—carefully—about the new contract.
Because of the shortage of time that is available to me and because there is a lot of consensus, I will not say some of the things that I was going to say about the present problems, including those that have been thrown up by the new GMS contact.
Following on from what Jean Turner said about recruitment in general practice, it is true that we are talking about different types of job. We should look at the undergraduate training of doctors and give undergraduates experience of rural medicine. I know that that is done in other countries, including in Western Australia. I heard of an experiment in that part of Australia in which selected students—usually those with a rural background—spend a fair chunk of their undergraduate training in a rural setting. The experiment means that those students do not only their general practice but all their subjects in a rural setting during that chunk of their training.
In Norway, new graduates have to spend at least a year in a rural practice immediately after graduation. As I said, we should look at medical training. There comes a point at which it is not possible simply to throw money at a recruitment problem. We have to look at the kind of people whom we are recruiting in order to see whether we are selecting the right people for the job.
Practising medicine in rural areas is entirely different. In connection with that, the remote and rural areas resource initiative—RARARI—is coming to its end, and it is not clear what will replace it. We have discussed that issue quite a bit in debates. We need something that builds on the expertise that was built up with RARARI, in terms of a faculty of rural medicine. Rural medicine is a specific form of medicine that some people would like to practise, but it is not part of the undergraduate curriculum and people do not know about it. The Executive could consider that in connection with medical schools.
On the current problems, I would like the minister to say something about inducement practices. I understand that progress has been made, but that the details have not been announced.
I echo what a lot of members have said. Relatively recently there were reports in the papers of a quite high-profile case involving somebody who left an island practice because she had been on call without a break for 18 months. Clearly, such situations are not on. However, I accept Jean Turner's point that in comparison with urban patients, rural patients make different demands on their GPs. For the right people, rural practice can be very rewarding in its own way.
I have issues with the way in which medical students are recruited, because there is too much emphasis on the academic, rather than on the caring side of people's characters. We should consider more mature students and late entrants, and examine the kind of people we are recruiting in the context of the kind of primary care health services that we want to deliver. We should also examine the undergraduate programme and include a rural element in it.
I thank Alasdair Morgan for raising this subject for debate. My concerns about the new GMS and GP contracts are well-documented and consistent. I am afraid that my fears are now being realised in consultations, such as that in Lanarkshire. Today we are talking about the specific impact of rural issues, but we should consider the overall picture.
I am sure that members will be interested to know something about the Lanarkshire proposals for putting the GMS contracts into practice. Ninety five per cent of GPs in Lanarkshire said that they would opt out; only 33 per cent have said that they might opt into any new provision for which the health board has responsibility. What does that mean in practice for the service models that Lanarkshire is proposing? It means that for a population of 576,000 people, out-of-hours services will involve, according to the preferred option, three primary care centres to cover the whole of Lanarkshire, with one GP in each, and five GPs in cars to provide home visits. The ratios for overnight primary care contact work out, on average, at one GP for 72,000 people. The ratio is worse in North Lanarkshire, because there is only one GP for the whole of North Lanarkshire. For home visits, there is one GP for 115,000 people. That is the practical impact of the contract. I fear that it has not been thought out, planned for or resourced.
I quickly pulled off the internet the GP to population ratios in Africa. We are not exactly comparing like with like because these figures are not about out-of-hours services, but in Tanzania, the figure is 1:26,000 and in Uganda it is 1:6,000. That is the context. Those figures should be put alongside the commitment to make home visits only to housebound and terminally ill patients, and alongside transport times of 40 minutes, which does not include how long it takes for a GP to get to the patient, for the person to be transferred, or for child care to be arranged, nor does it include the waiting time at the other end in the primary care centre. The implications for young children and families are horrendous.
It is time to step back and understand the practical implications of the contracts, and to redraw, rethink and resource properly before the impact is felt badly by patients who will not be served. I hope that, as the issue concerns the minister's constituency, he will ensure that the ratios that I have discussed are not those that we end up with.
I congratulate my colleague Alasdair Morgan on securing the debate, and I echo many of the points that he made about transport links and age profiles. The situation is even worse in the Scottish Borders, an area that goes from Coldstream in the east to Peebles in the west. The longest travel distance that will be involved in out-of-hours provision is 44 miles, either to Newcastleton or to Eyemouth. The demographics and topography of rural areas make the issue a special one for them. I support Maureen Macmillan's point about the particular difficulties in winter. In fact, just two winters ago, the A68 was closed at Soutra for four days. That gives members an idea of the prevailing conditions in the Borders; it is not only in the north and north-east that there are blizzards and snow-blocked roads. The issues are special to rural areas such as the Borders.
When the Health Committee considered the Primary Medical Services (Scotland) Bill, a GP from the Hay Lodge hospital in Peebles said in evidence:
"it is completely unacceptable. Over-tired GPs … who are probably not even fit to drive, never mind treat patients … have to go out and treat patients, because there is no alternative. The new contract will offer much greater scope for GPs to limit their working hours, so that they do not turn up at a surgery at 9 o'clock in the morning exhausted and sleep-deprived."—[Official Report, Health Committee, 2 September 2003; c 74.]
Hear, hear. That is a worthy principle and it is what we want to happen. Unfortunately, as many members have said, the working out of the structure of the services that will be put in place has been rushed.
The services will require multidisciplinary teams to take over the work that, in some cases, is done by GPs. Some teams are in place already, but the system is still to be developed. The existence of such teams in large areas will create special difficulties for personnel. For instance, it will take pharmacists or practice nurses much longer to reach people than it would in urban areas.
I have looked at Borders NHS Board's local health plan, which shows that the board is well aware of the funding difficulties that it will have. At present, the board has an annual budget of £127 million, but it already carries a recurrent £3 million overspend, even though Scottish health authorities are not allowed to overspend. Of course, as has happened with many other boards, the board has been allowed, with the Executive's consent, to borrow for the next five-year period. However, the board is already in financial difficulties. Its fear is that savings will have to be made—not expenditure, but savings. There are plans to reduce the number of hospital beds in the Borders and hints about the possible reduction of community hospitals. That is not the way we want to go. The concern has been raised elsewhere.
The minister must consider the special issues for rural areas and accept that additional funding will be required.
I welcome Alasdair Morgan's motion, which I signed. The debate throws up several serious issues, many of which have been touched on. The general underlying concept is that the proposals are ill thought out and will have many repercussions. The impression that one gets in areas such as Dumfries and Galloway is that the system is being made up as people go along.
For example, take the provision of out-of-hours cover by taxi service. As Alasdair Morgan said, many people do not have access to public transport. It appears that we will have a fleet of taxis for night-time use throughout Dumfries and Galloway, although I do not know where they will come from. We must also factor in the point that there is supposed to be a first aider in each taxi. Where will those first aiders come from? The inevitable consequence is that, when people are faced with the choice of phoning for a taxi or for an ambulance, they will phone for an ambulance, which will put added pressure on the Scottish Ambulance Service. In the eastern part of Dumfries and Galloway, that cover would not be deliverable, given that the Scottish Ambulance Service has reneged on its plan to invest in Annan's ambulance service and turn it into a 24-hour facility.
A local GP raised a concern with me yesterday about admissions to Dumfries and Galloway royal infirmary. It will take a very brave GP to send somebody back 40-odd miles to Langholm in the middle of the night having said, "No, I'm sorry, but I'm not going to admit you." Overnight, we will find that the admissions wards of hospitals such as Dumfries and Galloway royal infirmary are clogged up. People these days are very conscious of the legal implications of what they do. Such aspects have been particularly ill thought out.
Local GPs have raised the concern that, whether or not GPs opt out, what will happen is that, if people know that a GP lives in their community, they will knock on that GP's door in the middle of the night rather than face a lengthy journey to a GP in a centre. Many GPs will feel that they need to respond to such knocks on the door.
The Scottish Executive is in a cleft stick. For people who are currently able to get out-of-hours visits from GPs, things in the health service are not, Mr McCabe, getting better; they are getting worse. Everybody understands why there are difficulties in recruiting rural GPs, but the Scottish Executive must be a lot more honest in telling people what will happen. The Executive must think out its policies much more before implementing them.
Alasdair Morgan's motion focuses on the fact that local NHS boards may be insufficiently funded to meet the unique challenges that are encountered in rural practices. In answer to a written question from David Davidson back in November, Malcolm Chisholm said:
"There will be an unprecedented increase in funding for the new contract of 33% over three years."—[Official Report, Written Answers, 19 November 2003; S2W-3462.]
In an answer to Sandra White at a different time, the minister said that the out-of-hours development fund would be increased from £6.3 million last year to £10 million next year.
On the Health Committee's visit to Loch Melfort, I do not recall GPs who approached us talking about their problems in the way that David Davidson described. They talked about their problems with the minimum practice income guarantee. That was their focus, rather than the issue of not being able to opt out of 24-hour care. The GPs in the islands, in particular, pride themselves on the fact that they look after their patients 24 hours a day. That is a point to be remembered.
On the minimum practice income guarantee, Malcolm Chisholm said in the chamber during the passage of the Primary Medical Services (Scotland) Bill not so long ago that all practices would be at least as well funded and that most would be much better off.
The brief that we have received from the BMA claims—I think that this is what has prompted this debate—that local medical committees report that many health boards claim that they have insufficient funds to provide an alternative out-of-hours service.
I have a sense of déjà vu. I hope that, over the next few months, we will not hear the same sort of arguments that we have heard between the Executive and local government over local government finance. The Scottish Executive says, "We are giving this money," but the BMA says, "The local health authorities haven't got the money." Somebody is not playing the game. Somebody is not being open and honest and I want to know who it is. When the debate goes back to what Alasdair Morgan was talking about, the Scottish Executive should re-examine the level of funding that is allocated to NHS boards that provide services in rural areas. I would have no hesitation in supporting that. I hope that Tom McCabe and Malcolm Chisholm will go back and re-examine the level of funding. If, as they are saying, they are allocating the funds, what is going wrong? That is what I would like to know.
I would like to speak about some local issues in my constituency, starting with GP vacancies. We have two GP vacancies in Banff; two in Fraserburgh; one and a half in central Buchan; and, on the fringes of my constituency in a practice that is used by many of my constituents, two vacancies in Turriff. That is a huge number of GP vacancies, and most of them have existed for more than two years. That shows the problem against which we have to consider the out-of-hours provision. I suspect that things can only get worse. Some GPs in my constituency are telling me most vigorously that they fear that we will slip into the situation that we have with dental provision. I accept that the health board has a duty to provide GPs to those who cannot find them for themselves and that no such duty exists in dentistry. However, given the number of GP vacancies in the area that I mentioned, there is a real problem.
For Grampian NHS Board, which supports 10 per cent of Scotland's population, but receives only 9 per cent of health service funding, the provision of out-of-hours cover is a particular problem, given the rurality of the area. It is likely that costs for providing the service in Grampian will rise faster than they will in urban areas. There is no sign that the money that is provided will solve that problem.
My father was a GP. He used to have Dr Wilson come down from St Fillans to Cupar every year to be his locum. It is not without relevance that Dr Wilson was the grandson of David Livingstone—today we are looking for some new missionaries to fill the gaps in rural areas. The key point is that my father had to pay 17 per cent of his income to Dr Wilson each year to cover a gap of 7 per cent of his time. Out-of-hours cover is expensive relative to everything else.
We are coming up to the deadline. We do not know how the out-of-hours service will be provided and serviced. When I met representatives of NHS Grampian a few weeks ago, I found that the plans were pretty damn fluid.
GPs are concerned that the change in the contract will lead to their referring more injuries to accident and emergency units because they will not be paid to deal with them. That puts GPs in a difficult position.
GPs in my constituency want categorical assurance that there will be money for personnel to provide out-of-hours care. They want to know how we are going to address the problem in our rural areas. It is clear that transport will be a big issue. My father used to drive a Mini Cooper S and he occasionally took patients directly to hospital in Edinburgh, there being no other way. There are none of those cars around and my father has been dead many years. We need to hear from the minister.
We will hear from the minister now, because I call him to respond to the debate.
I thank colleagues for the contributions that they have made to the debate and I acknowledge that Alasdair Morgan brought the subject to the Parliament. The debate is important and the Executive and I welcome the opportunity to have it, because we recognise that change to out-of-hours responsibilities under the new GMS contract should be the subject of serious discussion—I emphasise the word "serious"—not only in the chamber but in the public meetings organised by health boards throughout the country.
I emphasised the word "serious" because I want to return to part of Carolyn Leckie's speech. I have said before in the chamber that at the end of this parliamentary session we will be spending £9.3 billion on our health services in Scotland, so to draw comparisons with parts of Africa is ridiculous. The health service produces miracles for the people of Scotland day in, day out.
Will the minister take an intervention?
No, I will not. Carolyn Leckie has said quite enough. The question that we should ask ourselves is how the people in the countries that Carolyn Leckie mentioned would feel to have £9.3 billion spent on their health care each year. I think that I know the answer to that. It is ridiculous to draw comparisons between the service in third-world countries and the service that we provide here. Moreover, I say to Mr Mundell, with the greatest of respect, that I will take no lessons from him on honesty, given the outrageous scaremongering in his speech tonight.
The new GMS contract introduces a major change in primary care. The new right for GP practices to transfer to health boards the responsibility for providing cover in the evening, at night and at weekends is a key element of the contract. The change is not about cutting services. Anyone who needs access to primary medical services outside normal hours will get it. That is an absolute guarantee.
How long will it take?
I am listening to noise from the sidelines, Presiding Officer. I do not know whether I have to put up with that while I am speaking.
If the minister would take an intervention, he would not have to put up with it.
I will not be taking Carolyn Leckie's interventions; I have told her that.
There is no requirement on anybody to take an intervention.
As I said, that access is guaranteed. The change is about improving patient care by providing services in a different way. I was pleased to hear Alasdair Morgan acknowledge that no one should expect a tired GP who has worked all day to work through the night as well. It was never right to impose that burden and we are in the midst of creating a system that will end that unfair burden.
We know already that 75 per cent of patients in Scotland are covered by out-of-hours co-operative arrangements and that out-of-hours services are complemented by NHS 24, which, as members will know, is a confidential 24-hour nurse consultation service.
Will the minister acknowledge that the concern is that the new system will lead to an out-of-hours service that covers a far greater area and that will be manned by fewer GPs than the current out-of-hours co-operative service is?
I am perfectly happy to acknowledge that the change is about providing a comprehensive service in a different way. One of the greatest lessons that we have learned in the NHS in the past few years is that we have a range of allied health professionals who have much more to offer than has ever been asked of them in the past—in particular, nurses across the country are teaching us that lesson.
Paramedics can also teach us that lesson. Some of our paramedics are now equipped with telemedicine that allows an image to be relayed to a consultant so that the consultant can take a decision to administer clot-busting drugs. In Tayside, for example, the administration of such drugs takes place some 40 minutes earlier than previously. Things are happening all the time to broaden the number of allied health professionals who can play a part in the delivery of the service in the way that we envision.
Sometimes, the new way of delivering the service might not involve as many GPs as previously but, quite frankly, there are many circumstances—particularly the most serious ones—where people need not a GP rushing to their door, but a paramedic or an ambulance that can get them to the most appropriate treatment. A mature attitude will help us to rethink our approach to out-of-hours services.
Transferring responsibility for out-of-hours care to health boards gives the boards the opportunity to build on those developments and to co-ordinate the efforts of the clinical team, linking ambulance staff, nurses, GPs and hospital staff in health centres and accident and emergency units. That will forge an integrated approach to all emergency care outwith normal working hours, ensuring that patients get the right response in every case.
Our proposals are fundamentally about delivering better patient care. The new contract will mean for the first time that any new out-of-hours service must meet new mandatory accreditation standards. That will ensure that anyone who provides out-of-hours services is fit for purpose. Those standards will be available for public consultation in March.
We have heard some scare stories today about the lack of funding. The truth is that boards are still at the early stages of planning and have not yet determined definitive costings. We would not expect them to have done so at this stage. People have said that we are approaching the deadline, but the deadline is 31 December 2004, which means that boards are not required to assume responsibility until the end of this year and that they therefore have the opportunity to plan for the developments within the record uplifts in allocations that they will be receiving from this April.
Will the minister take an intervention?
No, I will not.
I stress that the spending on general medical services will increase from £433 million to £575 million.
As he does regularly, Mike Rumbles made a good point, the answer to which is that I fully expect the BMA to make the representations that he refers to when I meet its representatives in Inverness at the end of the week. The BMA negotiates on behalf of its members and is perfectly entitled to do so. We are in the midst of a negotiation process, whether we like it or not, and that process will continue for some time. I have no problem with that, but I think that, in order to give some context to some of what we hear about costings, we need to bring that process into the forefront of our minds.
The changes must be well planned and carefully managed. That is why the Executive has set up a national working group to support boards in sharing best practice as they develop their plans. The group brings together all the key stakeholders, as has been said in the debate. Boards are beginning the process of sharing their plans with the communities that they serve. The public will therefore have the chance to make their voice heard and to shape the out-of-hours service that is provided in their area.
We are also making more money available to help the boards. As Mike Rumbles rightly said, the out-of-hours development fund will increase from £6.3 million to £10 million in 2005-06. Boards will also have money paid back to them from each GP who decides to transfer responsibility. If 90 per cent of GPs decide to opt out, a further £15.1 million will return to out-of-hours services. Of course, all that is against the background of the substantial increase in general medical services expenditure, which will reach £575 million.
Presiding Officer, I know that I am over time, but I want to take a few moments to focus on rural areas. For many GPs in rural areas, the change in out-of-hours responsibilities will be pivotal to sustaining their practices. They can at last expect a reasonable work-life balance, which means that general practices in rural areas will become a more attractive place to work. In response to Maureen Macmillan, I stress that we must be clear that no practice will be forced to opt out of out-of-hours arrangements. Any practice that wants to continue with its existing arrangements will be allowed to do so—that is a perfectly feasible option. We expect that all but the most isolated practices will be able to opt out. However, we recognise that, for a few practices in the most isolated locations, that will be impossible, not because of a lack of funding for the service, but simply due to the geography in the most isolated parts of rural Scotland.
My point is that there are some very remote practices—they are not island practices—that are being told that they are not allowed not to opt out. They are being told that they must go into a group of three practices to provide out-of-hours services even though they would prefer to provide the service on their own, as they have always done.
I hear what Maureen Macmillan says. I would be delighted to hear details of those situations and I will do my best to address those concerns as soon as I receive the information.
Where practices cannot opt out for reasons of geography, they will be fully supported. They will of course retain the out-of-hours money and they will receive a share of the out-of-hours development fund and any increased investment in that fund. They will also receive a further payment to cover any differential between the total of those payments and any locally agreed premium that is payable for providing out-of-hours services, so they will certainly not lose out financially. Rural boards will have greater flexibility to employ salaried GPs to provide out-of-hours services directly throughout their area. Those salaried doctors could be used to provide additional support and cover to the most isolated practices.
As I said at the outset, I welcome the chance to debate this important issue. No one denies that the changes are challenging, particularly for rural practices. We are under no illusions that some testing times lie ahead for all those who are involved in delivering the reforms. We are alive to that and we are working with the boards and the professions to rise to the challenges. In doing so, we firmly believe that we will help to bring lasting benefit to rural GPs, to their practices and, most important, to their patients. We will do that by re-invigorating rural general practice and delivering sustainable and improved services to patients throughout Scotland around the clock.
Presiding Officer, I thank you for your indulgence.
Meeting closed at 18:04.