Primary Care
The final item is a members' business debate on motion S1M-3357, in the name of Mary Scanlon, on the importance of primary care. The debate will be concluded without any question being put. I would be obliged if members would clear the chamber quickly and quietly.
Motion debated,
That the Parliament recognises the importance of primary care in managing 90% of patient contact with the NHS in Scotland; appreciates the vital role GPs play in providing primary care services as part of the wider primary care team; supports the statement that "if it can be done in primary care, it should be done in primary care", and acknowledges the urgent need for reform and support to invigorate staffing levels, facilities, IT provision and morale for this to become a reality.
I am delighted to have secured the debate today on primary care. This is national general practice week, which is led by the Royal College of General Practitioners with support from the British Medical Association, the NHS Alliance, the Royal College of Nursing, the Royal College of Midwives and many others. The idea of national general practice week is to promote the work that our general practitioners and their colleagues do for the general public and to celebrate the strengths of family medicine. I am delighted that Richard Simpson, who is a GP, is sitting beside our health minister for today's debate.
Primary care has now evolved into a health team in which GPs work with community and practice nurses, midwives, reception staff, managers, pharmacists, physiotherapists, occupational therapists and chiropodists to name but a few. Today I want to emphasise the role of GPs. They undergo five years of undergraduate training followed by three years in a hospital and a year in general practice. It takes nine years before they qualify as general practitioners.
Ninety per cent of contacts with the national health service begin and end in primary care. That figure must be right—it is in the health plan. GPs provide a huge range of services, which expand constantly. Those services include chronic disease management of conditions such as diabetes, asthma and heart disease, minor surgery services and intermediate care. More patients are now cared for by GPs than were previously cared for in hospital. There is no doubt that general practice and the primary health care team is the heart and the cornerstone of the NHS in Scotland. Why then are we facing such problems in the recruitment and retention of GPs?
The health plan gave a commitment to recruit an additional 1,500 nurses and 600 consultants, but no such commitment was made to increase the number of GPs. Although we may all agree to the primary care team approach, GPs have unique skills in diagnosis and treatment. Those skills have been gained through years of education and training; they cannot be delivered by anyone other than a medically qualified GP.
To prepare for the debate, I asked some individual GPs for advice. I will quote from their replies, although I do not have permission to give their names. If I am given permission to do so, I would be happy to hand them to the minister. One respondent commented on the current state of the health service, saying:
"The rubbishy reforms … brought forward to date are at the very root of its current failure … Creation of ‘The Government Doctor' under PMS, is truly soviet in its concept and practice."
A GP from Lanarkshire responded:
"there used to be 20 applicants for each job, now you are lucky … to get 1 or 2."
He went on to state:
"if I'm not writing … medical letters then I'm trying to explain to a patient that there is still a 52 week wait to see an orthopod or 6 months to see a psychologist, even if they are only 5 stone or agoraphobic … more and more consultations are generated by the consequences of long waiting lists and a patient expectation that they are being ‘duped' by a government telling them how much money they have poured into the NHS."
On the subject of primary care modernisation—which has formed the basis of an excellent booklet—the chairman of a Highland local health care co-operative said:
"as yet we have not received one penny of the extra resources that the report mentions. More importantly we have not received any encouragement from either NHS Highland or the Primary Care NHS Trust to redesign services according to the report or even to plan its implementation. On the contrary senior management seem to want to prevent us from taking any initiative that in our view would improve services or streamline administration. We are in many ways disempowered."
The chairman goes on to say that the LHCC is currently receiving "the worst funding" since it was formed and that it has had to curtail services to "save money".
In 1995, the number of GPs in training was 282; last year, that number had increased by one to 283. In a recent job satisfaction survey conducted by the BMA, 78 per cent of GPs said that they had a neutral or negative attitude towards LHCCs. When asked about the value of LHCCs in improving clinical care, 82 per cent had a neutral or negative view. The most shocking figure was that 86 per cent reported that LHCCs had provided reduced quality or no change to the quality of patient care. The same research highlighted that 48 per cent of GPs who were more than 55 years old intended to leave their posts within two years.
Why do we have such problems recognising GPs' contribution to patient care? Why are GPs constantly left out of decision making and why do they keep talking about a mass exodus from the NHS? Like so many others, I welcomed the introduction of NHS 24. Indeed, I still do—it is an excellent project. However, is the minister listening to the concerns that have been raised by GPs in Grampian? Is he aware that, although their service has experienced a 30 per cent reduction in the number of telephone consultations, there has been no reduction in the number of call-outs? Moreover, I understand that the Grampian doctors' on-call service ran at a fraction of the cost of NHS 24 in Grampian. Although I welcome the roll-out of the service to the rest of the country, I hope that the minister will listen to comments about how it can be improved in other areas. That said, I should point out that the BMA remains unconvinced that NHS 24 is an effective use of scarce NHS resources.
As a Highlands and Islands MSP, I could hardly speak about GPs without mentioning the crisis in the north of Scotland. I am sorry that my colleague Jamie Stone is not present, because he has been carrying out sterling work on the matter. There should be eight GPs in Wick, but by the end of the year there will be two and a part-time post. Further down the coast at Lybster, there will be no doctor by the end of the month. I understand from a written paper submitted to the Health and Community Care Committee last week that when the Helmsdale community raised concerns about the loss of its doctor, it was threatened with a Shipman and told that if people did not like the service, they did not have to use it. However, people who live in Helmsdale, Loth or Kildonan do not have a lot of choice.
Given that 2 million appointments are missed in Scotland every year, we can all help our GPs by ensuring that we turn up for appointments and that we cancel when we cannot make them. That might give GPs the consultation time for patients that they would like.
Although I understand that the new contract is still out for negotiation, I ask the minister to speak and listen to the GPs and primary care teams. By addressing their problems, he will show us that he values them as much as the patients do. I also ask him to reassure communities throughout Scotland that they can look forward to security of access to a family doctor in years to come.
If members speak for only four minutes, everyone who has requested to speak should be able to do so.
I welcome the opportunity to speak in the debate in national general practice week.
All of us in the chamber will agree with the statement that
"if it can be done in primary care, it should be done in primary care"—[Official Report, 25 April 2002; c 11239.]
Increasingly, that is the case: 90 per cent of the care that is delivered in the health service is delivered in the local primary care facilities that we all enjoy. Although those facilities deliver 90 per cent of the care, they do not receive 90 per cent of the resources.
We should continue to shift resources from the acute services sector to the primary care sector. That is not always a palatable message to get across to people. Members should consider the amount of time and strength of feeling given to the acute services review in Glasgow over the past few weeks. Although people want to retain their hospital facilities, they also want local accessibility. More people want to be able to undergo treatment from a practice nurse or a GP rather than having to wait for months for a hospital out-patient appointment. There is an on-going shift in the delivery of care across the spectrum of the services that are delivered by primary care teams. Mary Scanlon listed many of those services.
Earlier this week, I visited the Jedburgh health centre with my colleague Euan Robson. The practice manager showed me the list of the people who use the centre's facilities. The professional staff amount to 48 members. The practice manager said that the number had doubled in four or five years, which demonstrates the fact that we are doing more at primary care level. In the Health and Community Care Committee this morning, we discussed the Mental Health (Scotland) Bill and the work of the community mental health teams. Primary care professionals are working hard.
It is essential that the Executive should continue to put the necessary funding into primary care. Over the next three years, I hope that we will seek to address many of the issues that Mary Scanlon touched on. We should have the money and resources available to do that. I note that, in the comprehensive spending review, £36 million was set aside for GP and dental facilities.
Other announcements about capital projects and information technology that were made in the review will also affect primary care. An issue that arises time and again—I am no expert on it—is the misuse of IT in primary care. We can do much better in that area.
One of the great problems facing the health service is recruitment and retention of staff. Mary Scanlon touched on the problem of morale, but we also face a major problem concerning the demographics of our GPs. For example, 25 per cent of them are over 50—I am sure that they will not mind me saying that—yet the number of GPs in training has risen by only 6 per cent in the past five years. We should consider that in the context of a 28 per cent increase from 1997 to 1999 in the number of people having patient consultations with GPs. We are trying to get an increasing service out of dwindling resources.
I would like the Minister for Health and Community Care to answer a question that was put to us in Jedburgh. Are there any plans to extend the GP retention scheme beyond the age of 55 as a means of dealing with the recruitment and retention problem?
We can increase face-to-face contact between GPs and patients—which is what they tell us they want—by making greater use of nurses. I welcome the plans to extend prescribing, which are out to consultation.
I wonder whether the problem of missed appointments gives us an opportunity to launch a campaign to impress on people the impact of a missed GP appointment—not only for the individual, but for the wider medical practice. I hope that the minister will address that question.
No one is opposed to recognising the importance of primary care—it is a bit like motherhood and apple pie, in that everyone is in favour of it. However, significant changes have taken place in primary care in the past few years, not the least of which was the welcome abolition of the fundholding arrangements and their indirect replacement through the LHCCs. Although there are positive early signs, the LHCCs have not been in place long enough to allow a final judgment to be made. Some GPs who are involved with them undoubtedly feel considerable frustrations, which are normally about the constraints of the budget.
Uncertainties about resources restrict the development of the services that GPs and the teams around them provide directly in the community. There must be a commitment on resources. As Margaret Smith suggested, we are trying to provide services in facilities that were never intended for that purpose. We must address that. Services in the community are generally welcomed because they are more accessible to patients, but we will soon reach capacity. If we are to replace acute beds with facilities in the community, we must provide sufficient resources.
There are other uncertainties. I hope that the negotiations over GP contracts will soon be successfully concluded. Against that background, there is the overhang of the Arbuthnott formula, which applies to general medical services. I realise that ministers have said that they will not rush into a decision on that issue, but they should take a long, hard look at it.
I agree with Brian Adam. Ministers must review the Arbuthnott formula quickly. As he knows, the north-east has 10 per cent of NHS activity, but receives only 9 per cent of the budget.
I am more than happy to concur with Mr Rumbles on that matter. The funding formula could exacerbate local problems.
A large proportion of the GP work force is over 55, but there is no great expansion of medical schools. Added to that is the considerable demand for an increase in the number of consultants. When the Mental Health (Scotland) Bill—which is in its early stages—is passed, there will be more demands for psychiatrists and other related staff. Demand for medical staff is increasing, but there does not appear to be an increase in supply. As has been mentioned, the lead time for GPs is around nine years. We must make the job attractive in places where there are shortages. Where will we get the GPs? Margaret Smith's suggestion that we should try to retain staff for as long as possible is worthy, but the minister cannot avoid the problem.
I am delighted that Mary Scanlon has brought the debate to the Parliament and I am delighted to support the motion.
I, too, welcome the opportunity to speak in the debate and I congratulate Mary Scanlon on securing it. The minister will be aware that in the Highlands and Islands the provision of health care services faces significant challenges. In particular, the desire to move away from single GP practices has led to concern about the future delivery of services. GPs rightly want to work in shared practices so that they can share on-call time, but that creates a concern because larger practices need larger geographical areas to get the number of patients required. That results in people facing transport problems. In remote communities, it is not always easy to get to the GP by public transport.
I pay tribute to schemes such as the community car scheme in Aviemore, which provides a service to people who do not have access to a car. The car can take a person to their GP, if that is needed, and is available if the person wants to take part in social activities. That ensures that people are not isolated and it results in health benefits. When people become isolated in remote rural areas, they can suffer from depression and similar illnesses.
There is another example of good practice in Nairn, where I have seen the benefits of joined-up working between local GPs and social services. GPs provide medical cover for the local hospital, which improves patient service. If the GP thinks that more care is needed at a patient's home, they can bring in social services at an early stage, which keeps people out of hospital. Most people want to stay at home if they can. We need to expand such joined-up working. The GPs are involved in the local hospital and, if someone needs round-the-clock medical observation, that person can be taken into the local hospital and still be kept in the primary care sector. The high costs of acute care are therefore avoided.
The GPs and other primary care practitioners also spend much time dealing with preventive medicine and considering ways of preventing illness. Money that is spent in the primary care sector therefore leads in the long term to huge savings in the acute care sector, as people do not end up needing acute care.
Moray leisure centre is another example of how primary care can take the lead in providing preventive medicine. GPs work with the centre to devise and prescribe exercise programmes that help not only patients who need such programmes to recover from major traumas, but people who may be at risk of illness. That prevents trauma in the first place.
On dental services, the minister will be aware of the problems in recruiting and retaining dentists in the NHS in rural areas. There is a real fear that people will be put off having necessary dental treatment and that serious conditions will not be diagnosed because people cannot afford to go private. At question time last Thursday, the Deputy Minister for Health and Community Care made positive comments about the possibility of Highland NHS Board employing more salaried dentists and obtaining funding for that. I urge the minister to work closely with the trust in the Highlands to ensure that problems are tackled and people do not end up with conditions that could have been caught early and dealt with.
I congratulate Mary Scanlon on securing the debate.
The manpower crisis in the general practice is of great concern to us. In general practice week, we should recognise not only the role of the GP, but the evolving role of primary care in the community through the development of primary care teams. Mary Scanlon acknowledged those roles and other members have highlighted the fact that the GP is a cornerstone and key person in the team. There must be evolution towards playing a team game and we must, using professional skills, try to relieve the pressures on our overburdened GPs that often exist as a result of the public purse. Pressure must be relieved through education and we must widen the aspects of care that can be delivered in the community.
The professional skills of my profession—pharmacy—are being used more and more by Government. I congratulate the Executive on the pharmacy plan which, if it is rolled out, will be even better and will result in more health care in the community.
Many nurses are now running specialist clinics, which relieves some pressure on GPs. However, we are simply talking about relieving pressure. That is the key—there is tremendous pressure. As health knowledge develops, more demand is placed on the health service and patients are more aware of their rights and of what treatment is available. It is vital that we support existing GPs and that we can replace them when they leave. As other members have said, there is a replacement crisis, not just in respect of age, but because many GPs, as they come towards retirement, have difficulty taking on young partners. Not everybody seems to understand that GPs tend to be self-employed businessmen who deliver a professional service. Young people are not prepared to invest in that service. Many young doctors qualify, go into general practice for a while and then move on. They are not prepared to put down roots.
We recently had a problem in Banff and Buchan and I was pleased with the way in which the health board dealt with it. When one GP retired through health problems, another became so overloaded that he left to join another practice. That meant that there was no GP and the community had to cope with a series of locums. The locums did their best, but there was no continuity of care. Eventually, the health board managed to find a salaried service to go in, but that is not a long-term solution.
The minister must listen more carefully to GPs' demands that their long-term plight be recognised. A manpower crisis is on the horizon. Despite all the fine words in the world, we see no positive plan that will deliver new GPs to the service by making it attractive. I do not doubt that the minister has seen statements by Dr Ivan Wisely, who is the secretary of Grampian local medical committee. His comments have been highly publicised in the press and he is not speaking as an individual. I have met other people who are on that medical committee. I know that other members will have met GPs in other parts of Scotland who talk about the bureaucracy, about lack of support and about lack of recognition. If GPs are overworked they will be under stress and under pressure and because of that they may worry about their ability to deliver the professional care that people in the community require.
There is obviously a problem with general practice. Brian Adam alluded to the problems of GP fundholding. Many GPs who went willingly into the local health care co-operative system now want to go back to fundholding, because they feel that they could manage their budget better and focus care on individuals who come to see them.
Sorry, I am near the end of my speech.
In conclusion, I say to the minister that he has a role to play from the centre in helping to solve the manpower crisis. He can resource, where he can, the different services that are required and the education that is required. However, to do all that, he must listen to GPs. I am sure that he will recognise, along with other members, the vital role that GPs play in our communities.
I will focus on the last part of Mary Scanlon's motion, which
"acknowledges the urgent need for reform and support to invigorate staffing levels, facilities, IT provision and morale"
in primary care.
I will focus on NHS dental provision in primary care, as I believe that that aspect of primary care is most in need of reform and support. Why is that? It is because there is a crisis in NHS dental provision throughout Scotland. The crisis is particularly acute in my area—the north-east of Scotland.
In Scotland, 51 per cent of adults and 25 per cent of children are not even registered with an NHS dentist. It is not surprising that 56 per cent of five-year-olds have signs of dental disease. Putting fluoride in the water supply is not the only way to tackle the problem; we could have a much better NHS dental service.
Does Mike Rumbles accept that one of the reasons why we have a problem in Grampian is the lack of dentists moving to the area to work? Does he agree that one way round that might be to ask the Scottish Executive to fund a feasibility study into the potential for having some kind of training facility in Aberdeen?
Richard Lochhead is right. I am coming to that.
The crisis in NHS dentistry, specifically in the north-east, exists because of two problems. First, there are not enough dentists. The British Dental Association recommends that there should be one dentist for every 2,000 people. In Aberdeenshire, we have one for every 4,400 people. Secondly, the fees that dentists receive are set at a ridiculous level. Although it is in the power of the Executive to change that, we have agreed to keep the terms and conditions that have been set at UK level.
There are two solutions, to which Richard Lochhead's intervention pointed. We reduced to 120 the number of dentists that we train in Scotland. The Executive is content to keep that number. There use to be 160 places each year and we must go back to 160. We need to open—I go further than Richard Lochhead—a new dental school. I first made that suggestion in the chamber a few weeks ago and I said that the ideal place to have such a school would be Aberdeen. I remain convinced that that is the case. I am glad that Richard Lochhead supports that.
I would also like the Executive at least to consider a radical solution and to really reform—that is what the last part of Mary Scanlon's motion is about—the NHS dental service by considering breaking the link with UK levels of remuneration for our dentists.
It is a radical solution. Funding for health services is coming through in large measure, which has to be welcomed, but some of those funds could be directed where they could achieve the best results. I believe that we have to be radical; we have to think differently and produce Scottish solutions to Scottish problems. We have particular problems in relation to access to NHS dentistry throughout Scotland, but they are most acute in the north-east and particularly in Aberdeenshire.
I also congratulate Mary Scanlon on securing the debate. Sometimes I think that she is in the wrong party, although she is far too left wing to join new Labour.
I want to support what Mike Rumbles said about the dental situation. Ever since the Tories changed the funding arrangements for dentists nearly 10 years ago, we have suffered a shortage of dentists. Indeed, the reason why they changed the arrangements was that, as a result of previous changes, demand for the services was going up too quickly and too many people were going to their dentists. The Tories cut—they did not cap—the fees that are available to dentists, which has resulted in the kind of statistics that Mike Rumbles outlined in his speech. I suggest that the minister revisit the fee arrangements for dentists.
I am glad to hear of Mike Rumbles's conversion to the idea that we need to have Scottish solutions to Scottish problems, which the SNP has long argued in relation to dentists, nurses and so on. I was in the United States of America two months ago and noted that nurses in primary care and the hospital sector in some areas are being paid a lump sum of $2,000 to sign a two-year contract and are being paid a salary of about $80,000. That points to why we are short of people in our health service. It is a fundamental truth that, until we pay doctors, dentists, nurses and auxiliary workers—who are essential—decent wages and competitive salaries, we will never solve the problem of the shortage of people in the health service.
Does Alex Neil agree that one of the problems that we face in relation to attracting health workers to various parts of Scotland is that we are stuck with a national wage bargaining scheme that prevents health boards from competing?
That is precisely the point: the UK bargaining scheme is totally inadequate for us to meet Scotland's particular requirements. I am arguing for a Scottish solution to a Scottish problem.
There are many fundamental pressures on GPs. The supply of GPs is rising at the rate of 1 per cent a year while the number of consultations that GPs deal with is rising by 14 per cent a year. The average consultation time is still only seven minutes, but the recommended consultation time is 10 minutes. We need almost a 50 per cent increase in the time that is spent with patients.
The availability of drugs causes a problem. For example, Infliximab, which can deal quickly with certain cases of rheumatoid arthritis, is not yet available in many parts of Scotland, including Ayrshire. If that drug were available, the pressure on GPs whose patients are sufferers would be substantially reduced because the patients would not have to attend the practice so often.
GPs have experienced an increase in their responsibilities, not to mention their paperwork. The Adults with Incapacity (Scotland) Act 2000, for example, has obviously put additional burdens on the primary care service.
Another problem relates to what I call the knowledge life cycle. It used to be that what doctors learned did not change for five, 10, 15 or 20 years. Now, however, it changes monthly. Continuing professional development is a major pressure in the health service and in many other sectors.
In a short debate, it is not possible to go into all the details. I hope, however, that members have highlighted key points to which the minister will be able to respond.
I thank Mary Scanlon for bringing primary care to a members' business debate. It has, I am sure she will agree, often been regarded as the poor relation of the national health service. That should change.
Yorkhill children's hospital in my constituency does an excellent job. However, it is often associated with the work that it does in acute service, dealing with the most ill children, although I am pleased to acknowledge the investment that we have had in that. We have the biggest accident and emergency service for children in Europe and we are looking forward to the new high-dependence unit. However, I will emphasis the role of the children's hospital in the community and front-line primary care, because that is often forgotten.
I also welcome some new developments that are important for re-examining who does what in the front line. For instance, a welcome development is that Yorkhill will now undertake dental anaesthesia for under-10s in the catchment area that it serves because of some of the tragedies that have happened in that area. That is welcome, because dental caries is the most common reason for children requiring a general anaesthetic in the first place. We must move with the times.
There are striking associations between deprivation and ill health. To improve our nation's health, we must begin with deprived communities. There are no starker figures than those that we find in my constituency and in Glasgow more widely.
Smoking addiction is a problem about which many members have talked in cross-party groups and in the Parliament. Thirty seven per cent of women in Glasgow still smoke and maternal smoking is as high as 26 per cent. Those are staggering figures. Maternal smoking leads to problems among children whose mothers smoked during pregnancy. We know the stark figures on teenage pregnancy. In Glasgow, they are once again higher than the national average.
Heart disease is—thankfully—falling in the Glasgow area, but it is not falling quickly enough. I could go on about Glasgow's problems, but I believe that primary care is our best chance of turning them around and that tackling such problems among children is our best chance to change the nation's health.
I mentioned Yorkhill children's hospital because I know that the work that it does in getting out to the community is vital. Many of the children that Yorkhill staff see on the front line simply do not turn up to ordinary GP appointments. I would like that area to be considered for further investment—it is needed. Primary care is the strategy that will bring our community services closer together. The debate needs to be revitalised.
Sam Galbraith—the minister who set up LHCCs—envisaged that in Scotland LHCCs would be different from those in England because they would create a different dynamism; people would work together and shape their own arrangements. I would like the minister to address that. I fully support the idea behind LHCCs, but the policy needs to be revitalised.
I know that there are bad news stories, but there are also good news stories. One of the good news stories in Glasgow about which I heard recently is the development of back pain clinics—another big issue for the Health and Community Care Committee. The primary care team has had massive investment in clinics so that specialist nurses in the front line will deal with people who suffer from back pain. They can take cases that might not need to be seen by a consultant, thus ensuring that those who need to see the consultant are first in line.
The debate is vital, not only because of some of the issues about which we have talked, such as the need to examine needs in the north of Scotland and salaried dentists. It is important because we must get out into the communities if we want seriously to tackle deprivation.
I say to Alex Neil that most of the GPs to whom I speak are more concerned about the support that they need and the conditions in which they want to work than they are about arguing for higher pay. That is an admirable attitude and I have heard it from GPs in my area. If we can fix some of that, we will go a long way toward tackling the nation's ill health.
I warmly congratulate Mary Scanlon not only on her good research and interest in the subject, but on her utterly dedicated work on the Health and Community Care Committee right from the start of the Parliament. There is a kind joke about Mary in the Parliament, and I ask her to forgive me for this: "Mary, the caring Tory—a contradiction in terms". But we forgive her.
One of the many devastating statistics that Mary Scanlon gave us leapt right across the chamber and hit my notebook: only 283 GPs are currently in training, which is an increase of just one over the past year. That is a complete volte-face compared with what we knew just 10 years ago, when people could not wait to go to Scotland, especially the Highlands. Youngish GPs used to come up from all over the country then, wanting to work and raise their families here. They even came from abroad. That is not the case now, however. That is a dire warning for us all.
The stress of the job has increased enormously for all kinds of reasons, many of which members have mentioned. Part of the stress comes from the old problem of the paper mountain, which is now being added to by the e-mail mountain—e-mail was supposed to remove the paper mountain, but it never has. Every recent Government has come to power promising solemnly to alleviate that paper and administrative mountain; every Government so far has failed to do so. Either the paperwork should be curbed, or more proper, well-paid clerical help should be provided for GP practices and hospital consultants, who have told me that they often have to wait between a week and a fortnight to have a letter written, owing to the pressure on existing clerical staff.
I hardly need remind members that GPs have become so stressed that they have one of the highest suicide rates of any profession. How can we end or ease the strain? I am delighted that Pauline McNeill has stolen some of the pain campaign's thunder. It is great that all MSPs support the pain campaign. It would be possible to ease the strain in surgeries. It could be asked who the regulars are, and why, in the main, people go and see a doctor. They do not go if they can help it—they hang off for as long as they can. People see a doctor when they are in pain. One survey estimated that the real problem for 70 per cent of regulars in GP practices is pain. Their condition may be incurable, but pain is the actual problem. They will keep coming back to the GPs, who feel awful about the fact that they do not have much time to speak to the patients.
If we had specialist pain clinics throughout Scotland—Glasgow is the only place where people are trying hard to create something new in this regard—imagine the pain that we could unload from GPs, never mind from the patients. The GP could refer people regularly to the pain clinic, which would have the time to spend on them. GPs do not necessarily want just to dish out the usual prescriptions. It needs to be established with GPs who the regulars are and why they are in the surgery.
More nurse involvement is of course important. Every example of nurse-led initiatives or teams that I have come across has been highly successful, especially when the service in question has been in a practice.
I ask members to consider the options that I have discussed. In particular, we should remember the Highlands, where there are no proper pain services. The Health and Community Care Committee has just received a shocking report, which states that only 47 NHS workers are involved in coping with the tidal wave of pain in Scotland, which affects 550,000 people in the wider community.
I congratulate Mary Scanlon on securing the debate. It is right that the Parliament recognises "the vital role" that GPs and primary care teams play
"in managing 90% of patient contact with the NHS in Scotland".
As I said in the debate on primary care on 25 April:
"I have a passionate commitment to primary care, which is at the heart of my vision for the future of health care in Scotland.
Our test for new and existing NHS services will be this:
‘If it can be done in primary care, it should be done in primary care.'"—[Official Report, 25 April 2002; c 11239.]
Mary Scanlon referred to the GP contract and the negotiations that are under way. I emphasise the importance of the GP contract, which reinforces the idea of the primary care team as a whole. The contract gives renewed focus to quality and outcomes, and recognises that special arrangements are needed for remote and rural areas. A working group, led by Scots, is currently considering the issues in remote and rural areas. I am confident that its proposals, on top of our recruitment and retention measures, the work of the remote and rural areas resource initiative and our new work force planning arrangements, will lead to progress being made on that important matter.
Will the minister give way?
Not at the moment—I will give way if I have time at the end of my speech.
Mary Scanlon referred to the number of GPs, in the context of different roles in primary care teams. We need more GPs. During the first two years following the establishment of the Parliament, there was a 2.5 per cent increase in the number of GPs, but I accept that more is needed. It will be delivered on the back of the Temple report.
Mary Scanlon asked me to speak to GPs. I assure her that I do so regularly. The week after next, I will once again meet the Scottish General Practitioners Committee. The health department engages in dialogue with the SGPC on ways in which we can more effectively retain GPs. The GP retainer scheme is included in those discussions. That relates to Margaret Smith's question.
I assure David Davidson that we are discussing a raft of measures to reduce bureaucracy.
Will the minister give way?
In a moment.
Last week I spoke to the conference of the Association of Local Health Care Co-operatives. I assure members such as Pauline McNeill who expressed views about LHCCs that LHCCs will be revitalised. They already play a major role and are improving the quality of care in many ways, some of which I will describe in a moment.
The motion refers to the need for support. In the interests of brevity, I will not list all the primary care funding initiatives that have been taken. However, I must refer in passing to the significant funding of £48 million over three years that has been provided for 100 community-based health premises. I have been pleased to open several of those, including Blantyre health centre in the summer and Rutherglen primary care centre last week. We have also invested £18.5 million in the development of personal medical services. I do not recognise the description of such developments as "soviet". It certainly does not apply to the Edinburgh homeless practice, which I visited in August.
We are investing £30 million in expanding the capacity of LHCCs. We have invested £17.5 million in modernising IT infrastructure in GP practices and community nursing. There is more to come on that front. There will be a major drive to cut the traditional bureaucratic paper chase between primary and secondary care. Related developments are taking place in telemedicine and teleradiology, which I was pleased to see in various rural and remote areas during the summer.
As investment is stepped up, the drive to reform will be intensified.
Will the minister give a commitment—a commitment that he did not give in the health plan—to provide money for more GPs?
I welcome the announcements that have been made about primary care. However, people in the Highlands have told me:
"As far as the additional funding for primary care is concerned: no money has of yet been handed down to practice levels or even LHCC's."
The minister may be allocating money, but how can he be sure that it reaches LHCCs and primary care providers?
Mary Scanlon makes a good point when she refers to health funding as a whole. As I said in the debate on primary care, I am determined that resources should reach the front line.
Primary care has a central role in driving change, and in transforming the NHS and patients' experience of it. Through the LHCCs, local primary care teams are leading the way in providing services that are designed around the needs of individuals and communities. They are providing not just more and different health care services—often provided by nurse practitioners and pharmacists, as David Davidson reminded us—but services to improve and protect health, and to narrow the health gap. We are providing £3.6 million from the health improvement fund, so that every LHCC in Scotland can have a public health practitioner to spearhead and co-ordinate local health improvement initiatives.
However, the development of primary care cannot be considered in isolation. There has to be more integration—vertically with specialist services and horizontally with services provided through local government and the voluntary sector.
Will the minister give way?
I will give way if I have time, but I must get through this next bit.
Integration and decentralisation are at the heart of our reform programme. Professionals from different sectors must come together at the front line to drive forward change in partnership with patients and the wider public. There have been important public-involvement initiatives in primary care, spearheaded by our designed-to-involve initiative. We can already see the benefits of that approach through redesigned projects and the managed clinical network approach's addressing our major clinical priorities of coronary heart disease and stroke, cancer and mental health.
Implementing our approach requires crossing professional and organisational boundaries and involving different settings, including acute services, local community hospitals and home-based services. A good example of that is the managed clinical network in Dumfries and Galloway, which provides care pathways for all health professionals and identifies what is required at each stage of a patient's care. The coronary heart disease network has been driven by primary care. The project manager is a GP and all the LHCCs in the area have been enthusiastic supporters. The lessons from our working across primary and secondary care have been fed into our CHD/stroke strategy, which will be launched and debated in the Parliament next week. We are determined that best practice will become common practice and that mechanisms are established for sharing developments on the widest possible basis.
I am sure that members will think it remiss of me not to discuss access. If the Presiding Officer reminds me how long I have left, I will know what to do.
We are over time, but given that the minister is clearly responding to members' questions, I am quite relaxed about him running on a little bit longer.
The minister has not yet responded to the issue that I raised and which concerns me most. There are simply not enough dentists to tackle dental problems throughout Scotland, particularly in the north-east. Will he reconsider moving away from the ceiling of 120 training places in order to train more dentists in Scotland in the future? The solution to the problem must be long term.
The comments about dentistry were covered when I referred to our specific initiatives and Mike Rumbles knows about the specific initiative that Mary Mulligan announced on 25 April. As part of work force planning, we will consider the issue to which Mike Rumbles referred.
Everybody is rightly concerned about waiting, not just for in-patient treatment, but for out-patient treatment. Changes in primary care are vital to our making progress on out-patient waiting, because we will not make the radical progress that we are looking for unless the systems to which I referred are redesigned. The third part of the waiting journey is the initial stage of waiting to see a primary health-care worker. We have set a target of 48 hours for access to the right professional at the right time and in the right place. Last week I received action plans to ensure that patients in every part of Scotland have access to the appropriate member of the primary care team within 48 hours. That is an important development.
Margaret Smith mentioned patients who do not appear. We have a group that is considering that aspect of missed appointments. Recommendations will be coming to me quickly, because that is an important issue both in primary care and in relation to what are in many cases unacceptable waiting times for out-patient appointments. It is appropriate that I end with waiting, because I acknowledge the concerns that the public have about that, but I hope that the public and members will acknowledge the many other developments that are taking place in the health service. Today I have referred to infrastructure, the quality of care and staffing. I hope that we will think about those alongside the waiting time problems that I acknowledge freely and on which I am determined to make progress.
Meeting closed at 17:54.