“Partnership for Care”
Our first item of business is a statement by Malcolm Chisholm on "Partnership for Care: Scotland's Health White Paper".
Today's white paper, "Partnership for Care", is about the promotion of health in the broadest possible sense, and the creation of a health service that is fit for the 21st century. At the heart of the white paper's vision is a culture of care that is developed and fostered by a new partnership between patients, staff and Government.
In the next session of Parliament, we plan to increase investment in health from £6.7 billion to £9.3 billion, which is an annual increase of 5.5 per cent in real terms. That is high by historical standards, but it will deliver the necessary improvements only if it is matched by a programme of modernisation that is based on patients' needs. Our aim is to have a national health service that delivers faster and better-quality health care and that delivers that care at local level whenever it is safe and practical to do so. We want a service that responds to patients' needs and the interests of local communities and that meets national standards of health care.
Those objectives require new reforms that will streamline the NHS so that it relies on simpler structures that have stronger local roots. That will require devolution of authority to front-line units and promotion of integrated services for the convenience of patients, which is what the white paper aims to deliver. The white paper sets out radical measures to achieve those objectives. Of course, the implementation of the measures, including the legislation that is involved, must be a matter for the next session of Parliament.
By redesigning services, we can deliver a new pattern of local health care services. At local level, health professionals have established local health care co-operatives to enable them to plan and manage services on behalf of their communities. We propose to build on the LHCCs, to match them better with local authority social work services and to ensure that they have stronger roots in their communities. We will strengthen the LHCCs to become new community health partnerships, which will be based on those teams of primary care professionals, and we will empower them to serve their communities within local NHS systems, with appropriate resources and devolved authority.
Our emphasis on integration and decentralisation has implications for the future of NHS trusts. The existence of separate NHS trusts that cover the same areas as NHS boards has not yielded clear benefits, but has confused accountability and obstructed the integration of services. We shall require NHS boards to submit plans to dissolve trusts and to establish decentralised operating units that have a strong role for front-line staff. By bringing together the boards and trusts, we will reduce bureaucracy and produce efficiency savings for front-line services.
Within NHS boards, we shall ensure that there is a leading role for health professionals to drive forward the necessary changes in the service. We will require each NHS board to establish a service redesign committee that has the strong involvement of clinicians and other health professionals and which includes representation from each community health partnership. We will require boards to produce service redesign plans to show how they will tackle the challenge of modernising services. We will support the boards with a new change and innovation fund, which will provide an extra £26 million for NHS boards in the next financial year. The centre for change and innovation will also support boards by funding pilot projects, supporting redesign and helping to share best practice.
The challenge of redesigning services will not be met by professional experts working in isolation; rather, NHS boards will need to engage better in public consultation. A new Scottish health council will promote the involvement of patients and the planning and delivery of better services. At local level, we will require community health partnerships to engage with their communities through local public partnership forums.
Our first priority in improving services must be to improve waiting times, because that is what we hear patients express concern about first. Today, the latest quarterly report on the performance of the NHS in reducing waiting times is published and it shows how the service is making real progress. By the end of 2002, the NHS had met its target of ensuring that no one waits more than 12 months for in-patient treatment. The number of people who had to wait nine months before receiving treatment had fallen to the lowest level since the census began in 1992, and there was a 48 per cent reduction in those waiting more than nine months for in-patient and day-case treatment between September and December last year. Therefore, our initiatives to tackle waiting times are now bringing concrete results. A lot has been done, but there is a lot more still to do.
If we look more closely, we can see actual examples of sharp cuts in waiting times that have happened through the redesign of services. For example, in Ayrshire and Arran, the development of a one-stop diagnostic clinic in urology, and the nurturing of team working have reduced waiting times from about 40 weeks in August 2002 to 12 weeks now. Major national work has been launched to reduce out-patient waiting through redesign and other changes.
Earlier this month in Dundee, the First Minister announced the next stage of our approach on waiting times. For the first time, we are giving a guarantee of treatment on time. We will guarantee treatment within national waiting times—initially for coronary heart disease procedures—for all in-patient waiting by the end of this year. We will set new clinical targets for specific conditions such as hip operations or cataracts, and NHS boards will set new local targets to drive up performance ahead of the national targets.
Waiting times, however, are just one element of the new emphasis on standards and quality of service in NHS Scotland. In Scotland, we have an international reputation for our work on measuring the quality of care; we are determined to sustain that. We will underpin the drive to tackle standards by ensuring that there is independent inspection and audit, as well as by publishing the findings. We will review our systems of incentives for good performance and support for weak performance, and we will ensure that we have powers to intervene effectively when there is service failure.
A key theme of the white paper is the importance of partnership working among different parts of the health service, patients and social care. We believe that that approach will encourage the development of integrated services that are in line with the wants and needs of patients. We shall break down the traditional barriers between primary and secondary care and between health and social care. One important way of doing that will be through support for the development of managed clinical networks for cancer, coronary heart disease, diabetes and many other conditions. Community health partnerships will also have an important role to play; they will establish substantive partnerships with local authority services and will act as the focus for integrating local health services, both primary and specialist.
Information technology, or e-health, is an important tool for change and integration. We shall invest in clinical information systems, require the appointment of a clinician as director of clinical information in each NHS board area to champion that work, and work towards an integrated care record that is owned jointly by the patient and their health professionals.
Patients must be at the centre of all this drive for reform. We have talked for some time about patient-centred services, but today we are signalling a step change so that looking at services from a patient's point of view becomes the key driver of change in the health service. That will have specific outcomes, such as a new complaints procedure, a patient information initiative and a new statement of patient rights and responsibilities. However, underlying those specific initiatives is a more fundamental culture change that involves patients at every stage as partners in care and as key contributors to quality improvement.
There is also a new emphasis on the role of staff, particularly front-line staff, as leaders of change in the health service. We shall increase the capacity of the NHS work force, develop new work force planning arrangements, improve opportunities for continuing professional development and establish reformed pay systems. We shall also ensure that health care teams are given the support, the tools and the freedom to redesign services and improve patient care.
All those measures will ensure the improvement and modernisation of health services, but we will never achieve the health outcomes we want unless there is parallel progress on the broader health improvement agenda. That will require a sustained effort that involves not just the Scottish Executive and NHS Scotland but local authorities, employers, trade unions, community planning partners and local communities.
We will publish soon a health improvement challenge to set out in more detail how we will focus actions on four groups: children in the early years, teenagers, people at work and local communities. We are backing that up with plans on a range of measures to improve health that will cost almost £250 million over the next three years. Underpinning all that will be action to narrow the health gap between the poorest and richest communities through targeting health improvement initiatives and particular focus on community action. The NHS itself has an important role to play in promoting good health. We need to ensure that front-line NHS staff, especially the primary care teams in communities, work to promote good health.
The "Partnership for Care" white paper signals a direction of travel to enable us to go forward together. It takes a broad view of health and it puts patients first. It recognises the importance of national standards of health care and of independent inspection of performance, and it sets out specific reforms to devolve power, involve health professionals, modernise services and so reduce waiting times. It is a comprehensive but pragmatic set of reforms that address the real challenges that face the NHS in Scotland. Many of those reforms will require legislation by the next Parliament and I commend them to the Parliament.
I thank the minister for his statement, which is an attempt—albeit a poor one—to deflect attention from the fact that, according to today's figures, there has been no improvement whatever in median waiting times.
There are one or two good ideas in the white paper, but I say that because most of them are SNP ideas. Does the minister recall that, in May 2002, I said that we would strengthen local health care co-operatives? Today, he says that he will build on LHCCs. Does the minister recall that, in May 2002, I said that we would abolish health trusts? Today, he says that he will dissolve health trusts. Does the minister recall that, in May 2002, I said that we would establish an independent health inspectorate? Today, he says that he will ensure that there is independent inspection. I am glad that the minister is listening.
However, will he listen a bit more closely? Will he agree that the proposals in the white paper will, on their own, do nothing to reduce waiting times—which is, after all, what matters most to patients? Will he agree that, in order to do that, he must adopt two more SNP policies that are designed to tackle the core problems in the national health service, which are undercapacity and the fact that there are too few beds and too few front-line staff? First, will the minister today commit to a national beds review, such as that which has been carried out south of the border, to ensure that the health service has the right number of acute beds to meet demand? Secondly, will the minister pay our nurses 11 per cent more than the United Kingdom settlement, to give Scotland a competitive edge in recruitment to ensure that we have enough nurses in our hospitals to treat more patients and to do so more quickly?
I note with interest the fact that Nicola Sturgeon says that she had a policy in May 2002—although she has not been promoting it very widely in the past year—to strengthen LHCCs. I refer her to the debate on primary care on 25 April 2002—which, by my reckoning, was before May 2002—in which I made strong statements in favour of primary care throughout my speech. I have been consistent in advocating that more power and responsibility be devolved to primary care, not only during my time as the Minister for Health and Community Care, but for several years before that.
The main point that Nicola Sturgeon made was about waiting times. I am glad that she spared us the disgraceful misrepresentation of the issue that she gave in a press release yesterday, which was the most disgraceful misrepresentation that I have seen since I became an MSP. In effect, she said that everybody who has waited longer than nine or 12 months should be counted. I am quite happy to speak from experience today and advise Nicola Sturgeon that I have been on a deferred list for a minor leg operation; however, I will now be transferred to the single list, because I have abolished the deferred list. I will have a guarantee exception code, as I should have, because I have said that I do not want the operation at this time: people will understand that I am quite busy. Why should I be counted among the figures that Nicola Sturgeon cited yesterday to peddle misinformation about the state of waiting in the Scottish health service?
Nicola Sturgeon says that there is nothing about waiting in the white paper; perhaps she will read it more carefully in the next hour or two. There is a major emphasis on service redesign. I admitted in the debate yesterday that we need to take more radical approaches to out-patient waiting in particular and we will do that. That is the centre for change and innovation's first priority.
On in-patient waiting, Nicola Sturgeon should acknowledge the progress that is reflected in today's figures and the fact that the series of initiatives that we have taken in relation to using the private sector and the Golden Jubilee hospital has had some effect. It would be better if members took a more balanced attitude towards such problems—as they did yesterday—and recognised that what I said about a lot having been done, but there being a lot still to do is the correct approach to these matters.
I advise the Parliament that 14 members would like to ask questions. If there is to be any hope of calling them all, we need brevity in these exchanges.
I find the white paper interesting. It feels very familiar to one who has read the Executive's health plan, "Our National Health: A plan for action, a plan for change". As we have received the white paper only in the past hour, I have examined the summary, which is the best thing to do when time is short.
The white paper proposes "Unified NHS boards", which have already been delivered, under section 4 of the health plan; change and innovation centres, which are promised in section 9 of the health plan;
"A Patient Information Initiative and a new complaints procedure",
which are mentioned in section 5 of the health plan; health improvement initiatives, which appear in section 2 of the health plan; "New Community Health Partnerships", which is a new name for the joint future agenda;
"A new Scottish Health Council",
although health councils already exist; and guarantees and targets for waiting times, which the Executive has been giving us for four years. My question for the minister is this: what is new?
We are prepared to admit that we are building on the health plan. I have talked to NHS staff over the past year, and the last thing that they want is complete structural upheaval of the health service. The white paper builds on the health plan and carries it forward in significant ways. My statement indicated the new ways in which we are carrying the initiatives forward. I highlight in particular the move towards a decentralised and integrated system that carries forward significantly what was outlined in the health plan.
Everything that I mentioned in my statement is new. The community health partnerships will strengthen LHCCs and build on their good aspects. We have set up a new body to provide independent inspection, building on the health plan and carrying it forward in significant ways. Our health improvement strategy started with the £26 million health improvement fund, but we are now putting far more money into it and we are targeting our efforts to achieve the step change that is required in health improvement. I am proud to announce continuity that is balanced with significant new steps and a new emphasis on the devolution of power to front-line staff, with a more fundamental role for patients at the centre of the health service.
I thank the minister for his statement. There is quite a lot to welcome in it, especially the health improvement challenge. Not only the concept of the challenge, but the £250 million is very much to be welcomed. I also welcome the devolution of decision making.
However, one of the concerns that many members have had about the LHCCs is that they have been patchy throughout the country. In certain areas they have been very good, but in other areas they have been non-existent. Can the minister tell us whether community health partnerships will spell the end of LHCCs? When the appropriate resources and responsibilities are devolved to them, will they also become fully accountable, and will he anchor them in legislation in due course?
It would also be interesting to know how community health partnerships will work with local authorities to deliver the whole community care joint future agenda. I agree with the minister that NHS staff who talk to us tell us that they do not want wholesale reorganisation of the service. Can the minister assure us that this is not change for change's sake, that NHS trusts will be replaced by local alternatives that have been well thought through, and that there will not be a vacuum?
I agree entirely that we do not want wholesale reorganisation. That repeats the point that I made to Mary Scanlon: we want change without upheaval. What we propose for LHCCs is a good example of that. We will see the evolution of LHCCs, building on the strengths of LHCCs but using them as a basic building block for the health service.
In my statement, I talked about strengthening the LHCCs. We will anchor them in legislation and, to ensure local accountability, we will set up public partnership forums for each LHCC. Therefore, we will build on the strengths of the LHCCs, which we consider to be fundamental building blocks, especially in terms of our emphasis on devolving decision making and power to front-line staff.
I welcome the minister's statement and its attempt to tackle bureaucracy and give patients a greater say. The minister will be aware that Argyll and Clyde NHS Board is creating a single board structure and that staffing difficulties are creating a pressure to centralise services, especially maternity services. How can the minister reassure my constituents that the reforms that he outlined in his statement will give patients a real say in the NHS and halt the march towards centralisation of services?
I am glad that Duncan McNeil welcomes our pledge to tackle bureaucracy to a greater extent. It is obvious that we have made great advances from the internal market bureaucracy that existed under the previous Administration. Argyll and Clyde NHS Board is a good example to give, because it has made the decision to go for single–system working. I know, having talked to several people in Argyll and Clyde, that the board's decision has been widely welcomed. Clinicians in particular welcome the fact that they are involved in discussing how the new forms of services will develop.
Duncan McNeil made an important point in relation to his concerns about centralisation of services. A key message of the white paper is that, over time, more services will be developed in primary care settings and community settings. The fact is that upwards of 80 per cent of health service activity takes place in communities. However, some services must be concentrated in specialist units. That is the hard issue that arises in relation to acute service reviews; it is an issue in Argyll and Clyde and in Glasgow. One of the white paper's points is that we want to, and will, involve the public far more effectively in discussions about reorganisations than we did in the past.
Does the minister appreciate how fed up the public are becoming with glossy documents being produced but no action being taken? Is it not time that there were fewer documents and more action to address the core problems in the NHS, which are lack of beds and a lack of staff? When will we see progress on those matters? Does the minister think that it is a bit desperate on his part not to describe progress on waiting times as being encapsulated by an increase in out-patient waiting times? Does he think that progress on in-patient waiting times is represented by—according to the figures that were produced today—a staggering 0.4 per cent increase? Does his claim that those facts show progress in waiting times not reflect desperation on his part?
I am not sure what the 0.4 per cent refers to. I have been open and frank about the need for more radical solutions to tackle out-patient waiting times. That is why the issue has been at the top of my agenda and the First Minister's agenda over the past few months. We have started work on waiting times with the centre for change and innovation. I am always willing to admit failure to make progress in an area but, equally, Opposition parties should acknowledge that progress has been made in some areas. That point was a key feature of a parliamentary debate yesterday.
I talked to staff at Edinburgh royal infirmary today and a doctor said to me exactly what I said in the debate yesterday, which is that there is nothing more demoralising for staff than to hear relentless negativity. Let us hear about the problems, but let us also hear about the success stories. Shona Robison knows that in her part of the world, which I have visited more than once recently, Tayside NHS Board has many success stories. That health system has been turned around in the past three years and is trail-blazing in many important ways for patients.
We are, of course, taking action on staff; staff numbers will be announced tomorrow. The numbers of qualified staff—nurses, doctors and other staff—are increasing. We said in the Scottish budget that there will be 600 more consultants in the next three years of the spending review period. No issue has been more important to me over the past year than recruitment and retention of nurses. The issue is partly about pay, which the "Agenda for Change" seeks to address, but many other issues are involved in recruitment and retention of nurses, including issues around continuing professional development, which is highlighted in the white paper. We believe that, as a fundamental part of dealing with those problems, we must increase the health service's capacity.
However, the difference between the Labour party and the SNP is that we realise that more is required and that we must work differently. A key message that I also got this morning at Edinburgh royal infirmary is that we need people in health-care teams—which are the basis of the white paper—to work in different ways and, in some cases, we need people to perform different roles. We are prepared to put in the money and to modernise and reform, but the SNP wants to put in money—which it does not have—and to change nothing.
I must begin by declaring that I am a member of Amicus MSF, the British Medical Association, the Scottish Association for Mental Health, the Royal College of General Practitioners and the Royal College of Psychiatrists.
I welcome the tenor and approach of the minister's statement, which builds on the changes that we have been making since 1997. The recognition of the need for service redesign is now made explicit, as is the imperative of integrated primary and secondary services. A clear definition of the role of community health partnerships, which embraces the best practice of the LHCCs, is particularly welcome.
I want to ask the minister about the IT systems that are needed to underpin an integrated national health service. The NHS IT systems are ineffectual and dysfunctional. The general practice administration system for Scotland, which is the primary care system that is used by 85 per cent of GPs, has always been the poorest of the UK systems. What will the minister do to ensure that the IT proposals in the white paper will not be just another piece of rhetoric, such as we he have heard repeatedly from health service executives over the years? In addition, will the minister consider using the proposed new community hospital in my constituency, which is to provide integrated primary and intermediate care, as a model for the vertically integrated networks that are crucial to the delivery of care for diseases such as diabetes and respiratory disease? Finally—
Order. I think that that is enough. Mr Chisholm will reply.
I welcome the proposed community hospital to which Richard Simpson referred, which is precisely the model of care that is encapsulated in the white paper in terms of more being done in community systems to link in an integrated way with more specialist services. Richard Simpson is right that IT—or e-health, as I prefer to call it—is fundamental to integration; it is one of the subjects about which I have listened this year. Certainly, I was no expert in IT matters a year ago.
Clinicians throughout the country have told me repeatedly about the fundamental importance of e-health for developing integrated care. That is why we have such an important section on e-health in the white paper. We will require a clinician to be appointed director of clinical information to lead change in each NHS board area because one of the messages that I have heard is that e-health should be led by clinicians. However, I shall chair the e-health programme board as a mark of the importance that I attach to e-health.
I thank the minister for the advance copies of his statement and the "Partnership for Care" white paper.
Page 35 of the white paper, on the development of partnership integration and redesign, states:
"If necessary, we will bring forward legislation to require NHS Boards to devolve appropriate resources and responsibility for decision-making".
Does that mean that the minister will devolve funds to LHCCs or to community health partnerships? Will he allow those partnerships to commission care from outwith their board areas? If he answers yes to either of those questions, will not that just be the reintroduction—under another name—of the internal market?
Resources and decision making will be devolved; that is a fundamental message of the white paper, but trusts will be dissolved only on the condition that decentralisation schemes are in place.
However, we do not believe in recreating the internal market. In fact, the abolition of trusts will get rid of the last vestiges of the internal market because the funds that primary care will have will not be for the commissioning that existed under the Tories. That is a key point, because there is no doubt that people will try to make general descriptions of what my statement proposed. What we propose is a non-market system of decentralisation that contrasts with the Tories' internal market, which was a centralising system. There was never as much command and control in the health service as there was under the most recent Conservative Government's management executive.
People will try to distort what I have said today as being about centralisation, but the key or fundamental message of the white paper and of my statement today is that we will have a more decentralised health service with more power to front-line staff.
I welcome the minister's commitment to scrap the health trusts, but I seek an assurance from him that there will be a genuine cull of the unnecessary bureaucracy and senior management posts in the trusts. Will the resources that are freed up by that process be made available to the front-line staff who serve in our local trusts and provide an excellent service?
As I indicated in my statement, there will be savings in bureaucracy. At the same time, I want to send out the strong message, which is contained in the white paper, that we attach a high importance to operational managers. It is important that we recognise that the health service has not been well enough managed. We want improved management. I want to send out a positive message about management, but I link that with the strong message that managers and clinicians must work together better, as that area has been one of the historic problems in the health service. I expect and will encourage a culture of mutual respect, in which the importance of clinicians and managers is recognised.
Will the minister please review the position on in-patient waiting times for cardiac surgery? I ask him to do so particularly in light of the fact that the existing spare capacity in both Grampian and Lothian is being used to allow private patients to queue-jump using NHS facilities and NHS surgeons. Will he give us an assurance that the existing capacity in the NHS will be used for cardiac surgery so that people do not have to be sent to private hospitals or abroad?
In-patient waiting times for cardiac surgery are one area in which we have had a significant fall, although we want to see further improvements. The median waiting time for cardiac surgery has fallen from more than 150 days at the beginning of the Parliament to fewer than 50 days now, but there is room for further improvement. I shall certainly ask questions about how that works in Grampian and I shall write to the member when I have a full response from his local trust.
I welcome the minister's statement. As Duncan McNeil said, Argyll and Clyde is already moving to a single NHS delivery system. I can tell the minister that that has proved to be not only popular but, more important, sensible. Already, we have seen a reduction in bureaucracy, with much more focus on patient care and people in the service working together rather than against each other. There is also a renewed emphasis on front-line delivery.
I welcome the enhanced role for LHCCs. However, does the minister agree that it is important that general practitioners not only have a closer working relationship with social work, but are involved in shaping acute services? I am particularly keen that, alongside clinicians, the public are directly involved in shaping services, too. Will the minister indicate how that will be realised, as it is clear that we will require a fundamental cultural change among some clinicians as well as managers?
Once again, I acknowledge the way in which the changes in Argyll and Clyde have been welcomed. Jackie Baillie's comments are in accord with all the conversations that I have had in that area, where the move to a single system has been welcomed. If people want to see what the white paper proposes, they should perhaps look at what is happening in Argyll and Clyde, where work is already going on to come up with more integrated arrangements at locality level.
On the enhanced role of LHCCs and GPs, I said in my statement that someone from each LHCC will be on each board's service redesign committee. One problem has been that people in primary care have felt that they do not have enough influence over the rest of the health system, including acute services. Through the white paper, we are taking direct action to deal with that problem, as I know is happening in Arygll and Clyde.
Finally, Jackie Baillie referred to the importance of public involvement. People should perhaps remember that there are two parts to patient/public involvement. There is the public involvement in service change—the white paper proposes that that should happen quite differently from the way it has in the past—but there is also the whole patients agenda, whereby individual patients are involved as partners in their own care. We need to listen far more carefully to what patients are telling us, as patients are a key factor in improving the quality of services. The white paper gives a good example from Ninewells hospital in Dundee, where nurses asked patients about a whole series of issues concerning their experience of care. That feedback was then used to improve services. That is an important model of how we can improve the quality of care.
The headline figures that the minister came up with at the beginning of his statement were very big indeed. He suggested that the Scottish health budget would rise to £9.3 billion by the end of the next parliamentary session. For those of us who take an interest in how money is raised as well as in how it is spent, that is a big number. Will the minister explain to what extent he believes that that number is achievable? Has the number simply been plucked from the ether in order to be placed in the Labour party manifesto so that he can buy back the votes of the people whom he has been letting down for the past four years?
The number has not been plucked from the ether. I would have expected Alex Johnstone to have some knowledge about how spending reviews are carried out and the role of Westminster in announcing spending plans. All the matters to which he referred are matters of macroeconomic policy. I have great confidence in Labour's management of the economy and that confidence is borne out by what has happened in the past six years. I am therefore confident about the figures in the white paper.
It was slightly foolish of Alex Johnstone to raise the question of money given that the fundamental problem with the Conservatives' proposals at Westminster is that that money would not be available for the health service if ever the Conservatives were to come into government. Fortunately, I do not think that my spending projections are threatened by that possibility.
We are running out of time for the statement, so I will take the final three questions together.
I welcome the minister's statement and I assure him that there is nothing wrong with following Susan Deacon's lead. He should try that more often in other policy areas.
A major gap in the redesign of the NHS is the continuing lack of local democratic accountability at the health board level. Partnership forums are fine, but the 15 NHS boards will remain appointed, unelected, undemocratic and unaccountable to the local communities that they serve. Will the minister assure me that the democratic reform of health boards is still on the Government's agenda, as we consider the white paper?
I was interested in the minister's opening sentences, in which he said that he wants to ensure that the NHS
"responds to … the interests of local communities".
In the light of that, when will he and the First Minister respond to the communities of Kirkintilloch and Bishopbriggs by accepting their invitation to come and explain to them why, month after month, they see department after department at Stobhill hospital closing and transferring to the Glasgow royal infirmary?
In welcoming the statement, I note the contrast between the minister's substantive comments and the lack of substance and the relentless negativity that has come from the Opposition benches this morning.
Given the bruising experience of the Glasgow acute services review and other such experiences around the country, does the minister agree that we have a major task on our hands to re-establish trust among our constituents in the principle and practice of local accountability? I welcome his clear commitment to patient involvement. People accept that difficult decisions must be made, but they want to see good examples of when and where their views will be taken into account and they want to be clear about the criteria that will be used and the limits that might exist in that process.
On John McAllion's question, my mind is certainly not closed to further local democratic accountability, but we should also acknowledge the progress that has been made. I certainly pay tribute to Susan Deacon and to the way in which she constructed the unified boards, which have given a much greater degree of local accountability both through the involvement of local authority members and through the important contribution of staff members. We have a whole agenda around patient focus and public involvement. The correct way of viewing the issue is to recognise that patients and the public can be involved in a variety of ways, so I would not say that John McAllion's proposal was the only way.
Fiona McLeod and Ken Macintosh raised important points about public involvement in service change. If there is a choice between two sites for a hospital—Fife perhaps illustrates the difficulty better than Glasgow—it is not always possible to satisfy everybody. The white paper has a section about acute hospitals. We cannot avoid the fact that, in the interests of patient care, some acute hospitals must be organised differently. I accept that we have not always persuaded the public of the merits of that, which is why it is important to pursue public involvement far more effectively, although I accept that it will not always be possible to keep everyone entirely happy with what is going on. On patient involvement, I think that it is possible to be far more responsive directly to what patients are telling us about the quality of care.