Health
Good morning. The first item of business is a debate on motion S2M-3468, in the name of Andy Kerr, on "Delivering for Health".
This debate is about setting out our plans for "Building a Health Service Fit for the Future". I believe that we have in place the three elements that we need to bring about a radical transformation in the health service. We have a clear understanding of the changing demands on the service; a clear vision of what type of national health service Scotland needs; and, with "Delivering for Health", we have a clear programme that will, step by step, turn that vision into reality and provide the means to hold the service to account.
Today we are debating our plan to shift radically the balance of health care to focus more on preventive and continuous care in local communities and to target our resources at those who are at the greatest risk of ill health.
Professor Kerr's group was asked to look at the long-term health needs of the population and consider a national framework for service change to guide our work to improve the service. The Kerr report highlighted three interrelated issues that NHS Scotland must face: an aging population, the growth in chronic disease and the rising trend in emergency hospital admissions.
The NHS was built when the focus was on the episodic treatment of acute conditions, such as infections or physical injuries, but health care needs have changed. Long-term conditions such as diabetes, high blood pressure, strokes and coronary heart disease are now the core business of the health service, but the service has not kept pace with that change in demand. We now need to concentrate on preventive, continuous care in the community.
Professor Kerr's report suggests that as a result of the aging population and the growth in chronic disease:
"We will no longer be able to afford a health care system which more often than not waits for a medical crisis before providing care. This reactive approach too often results in an unnecessary, damaging, expensive and prolonged hospital admission."
Let me be clear: we accept the Kerr report analysis and I expect NHS boards to use the report and our response to it as the framework for developing service change proposals.
I acknowledge and agree with what the minister says. I have not had an opportunity to read all the report; we received the minister's response only this morning. Will there be an emphasis on early diagnosis, referral and intervention so that conditions are not allowed to become chronic?
Indeed. That is the backbone of our approach to what we seek to do with our new transformed health service. We need to reflect that such work is already on-going in our communities, but we need to support it further.
We need to change the balance of care that is provided by NHS Scotland to meet changing needs. Our report "Delivering for Health" shows how we will do that and how we will support people to live longer, healthier lives. We have already acted to end smoking in public places; appointed 600 active schools co-ordinators to help our young people benefit from physical activity; promoted healthy eating habits with our ground-breaking hungry for success programme; and provided free fruit and drinking water in our schools. Just yesterday, I was pleased to visit Abbeyhill Primary School in Edinburgh to see its healthy eating programme in action.
We will now accelerate the pace of change in NHS Scotland. "Delivering for Health" sets out the four critical elements that are essential for that transformation. I want an NHS that is as local as possible but as specialised as necessary; that manages patients' long-term conditions; that targets its efforts at those who are most at risk, especially in our least well-off communities; and that manages hospital admissions and discharges.
I refer to the balance between local and specialised care in the health service. I accept the need for specialisation in certain circumstances, but what assurances will the minister give us that the culture of the NHS in Scotland will reflect the desire—I think that it is shared widely throughout the Parliament—for services to be delivered as locally as possible and for specialisation to be driven only by the clinical care that is required and not by a malaise in the health service whereby centralisation is considered to be a solution to particular problems?
I do not support that analysis. However, I agree that we need to be transparent and open about the decisions that we make about what can be delivered locally and what can be delivered at a national centre or centre of excellence. That is exactly what the framework is designed to do. Professor Kerr's work indicated that the public understood and accepted that there were grounds for having national centres when frequency of operation and the expertise and skills of consultants are critical to outcomes. The framework allows for that. I will cover points about that during the debate.
How do we make the NHS as local as possible? To make the shift in the balance of care, we will expand the range of services that is available in the community. That will mean that more diagnosis, more day-case surgery, more rehabilitation and more advice and outreach services are available in the community.
I recently visited Ayr hospital, which provides an excellent nurse-led leg ulcer service. Not only has the service been brought closer to the patients, but healing times and recurrence rates have improved dramatically.
In the future, health and social services will be located together more often and the boundaries between them will become increasingly invisible to the recipient.
Our priority will be to spend our capital resources to expand the networks of community health centres. I paid an enjoyable and interesting visit with Mr Swinney to the Whitehills health and community care centre in Forfar, where we saw a great example of local co-operation. The joint venture between Tayside NHS Board, Angus Council and the voluntary sector brings together a range of services that would not otherwise have been provided, such as out-patient clinics, diagnostic and therapy services, community dentistry and local mental health and home care teams.
We want the centre of our local health delivery to be the local health teams, which will fully involve allied health professionals and other specialists to extend the range of services that is available in the community. We are driving the local health agenda to ensure that the local health teams meet our standards in relation to heart disease, asthma, diabetes and other areas. That relates to Mary Scanlon's point.
Our new general practitioner contract is a powerful tool for changing the way in which services are delivered. We will examine the opportunities to extend the range of services that is available locally.
Another good example is that in NHS Forth Valley dermatology clinics are run by GPs with special interests and specialist nurses, which allows patients to be treated in the community and cuts waiting times for those who need to see a consultant in hospital.
We know that better care for long-term conditions in the community leads to better outcomes. We plan to ensure that local health pharmacies and other local support services are tailored more closely to individuals' needs. I have seen an example whereby health professionals can monitor remotely an individual's asthma through the use of a mobile phone connection. Such approaches enable individuals to take greater control over their well-being and care and provide more help for their family and carers.
For others, there will be a more intensive and supportive relationship with their local health care team—what we will call community based intensive care. A good example of that exists in NHS Ayrshire and Arran, where support is provided to the elderly who are most at risk of hospitalisation. Those older people are given all the support that they might need, such as home care, domestic adaptations, podiatry services and input from a rapid response team. That means that more people can continue to live at home with all that that means for their quality of life.
The example of NHS Ayrshire and Arran helping to keep older people out of hospital is interesting, because that is a worthwhile cause. Will the minister confirm whether that project in Ayrshire and Arran also involves the provision of supplementary vitamins and calcium, which is extremely important in ensuring that people with osteoporosis do not suffer fractures and breaks?
Those are the very preventive measures that we want our local health care to include. I cannot answer the specific point, but such provision fits with the principle of avoiding admissions to our general hospitals that are inappropriate or unnecessary for the individual and their family.
I turn to the unacceptable and widening gap in health outcomes and life expectancy in Scotland between our most affluent and least well-off communities. For men the gap in life expectancy has grown to almost nine years and for women it is almost five years. I am determined to tackle that issue head on by building on the work that is already under way throughout the Executive to tackle many of the determinants of that inequality. That work includes the warm deal programme, the central heating programme, the full employment areas initiative in Glasgow and the healthy working lives initiative, which focuses on the most disadvantaged groups.
I want the NHS to do more to break the link between deprivation and ill health. That point was well made by Duncan McNeil recently in the Health Committee. It is time to shift the balance of our work to give priority to primary care services in the least well-off areas and to target our efforts on those who are most at risk. Therefore, we will provide primary care teams with dedicated resources to identify at-risk populations. We will go to where they are, rather than wait for them to come to us. We will proactively offer them health checks, screening services and other health improvement support. We aim to seek out those who are not accessing our health services to work with them to improve their health.
Will the minister give way?
I need to make progress: I apologise.
By intervening directly in that way, we will reduce the number of emergency hospital admissions that come about precisely because chronic health conditions go undetected or unmanaged. As a result, we will not only improve the health and the quality of life of those who are affected but contribute to improvements in the acute sector, because we will have freed it up to concentrate on its core business of acute health needs. In turn, that will free up additional capacity to tackle issues such as waiting times.
"Delivering for Health" shows how we will build on progress in reducing the longest waiting times through a number of key actions. First, we will ensure that best practice becomes normal practice. Simple measures will be applied to improve hospital admissions and discharges. Regional planning groups will start to separate the planned and emergency care of patients, which will increase productivity, reduce cancellations and waiting times and give the patient a better experience of the health care system. We will achieve the faster access to diagnostic facilities and services that is important to families and their communities by expanding that provision. We will provide better and more appropriate care through community casualty units that are linked to major emergency centres by telemedicine and ambulance services.
The effectiveness of our health care professionals—based on our work in partnership with them—the quality of service that is offered to patients and the overall efficiency of the service will be enhanced considerably if we make the best use of the technology that is commonplace in the 21st century. The Kerr report identified those issues for us.
It is essential that we have a common information technology system built around an electronic health record. That will provide a single patient record for use by all parts of the NHS, which will mean fewer cancelled appointments, fewer delays and more effective personalised services.
We will buy a new national information and communications technology system in 2007 and see its full use throughout the NHS by 2010. Further, the e-health budget will increase almost threefold over the next three years, to more than £100 million in 2007-08.
What action will the minister take to avoid some of the disasters that the Westminster Government has encountered when procuring IT services in relation to passports, the Child Support Agency and so on?
I do not subscribe entirely to the member's comments, but I can tell her that, in Scotland, we will generically build our IT system based on the good work that we are already doing and the existing GP referral system. We want to ensure that there is interoperability, allowing the health service to communicate effectively in a way that will enable pharmacies, GPs, specialist centres, community treatment centres and our acute sector to co-ordinate their activity. In that way, and by involving the professionals in the procurement process, we will avoid the dangers that the member talks about. The system will deliver significant change in the health service.
Scotland needs to be at the forefront of developing approaches to support and strengthen health care in remote and rural areas. I have commissioned work to assess how staff are retained and clinicians' skills are maintained in rural Scotland; to ensure appropriate training for practitioners in remote and rural areas; and to develop proposals for a virtual school for rural health care. Our vision for the NHS—as local as possible and embedded in communities—will mean that a greater variety of services will be provided in those remote rural areas.
Will the minister give way?
I am sorry; I am in my last minute.
I have set out the strategic changes that we will make to our health service. "Delivering for Health" details the action plan for the NHS to build on the clear consensus for change that was established by Professor Kerr's report. That plan allocates actions to specific bodies, so that there will be clear lines of accountability. We will report progress, so that the people of Scotland can see evidence of what has been achieved. The reforms will change the way in which the health care system works in Scotland. They will ensure that people who are old, frail and liable to frequent hospital admission will get local co-ordinated care; that people with a long-term condition will be given help and support to play an increasing role in managing that condition themselves; and that people who stay in a less well-off part of Scotland will have access to community health care centres that have dedicated resources that are designed to prevent them from getting ill.
NHS Scotland needs to change and "Delivering for Health" shows how we will turn our vision into reality. In so doing, we will dramatically transform the NHS in Scotland and improve the lives of all Scots—building a better Scotland; building a healthier Scotland.
I move,
That the Parliament commends the action plan for NHS Scotland, "Delivering for Health", and its acceptance of Professor David Kerr's report, Building a Health Service Fit for the Future, as the basis of NHS boards' future service change proposals; welcomes the report's emphasis on shifting the balance of care to provide more safe and sustainable local services, including intensive case management in the community for the most vulnerable; applauds the commitment to tackle health inequalities by developing anticipatory care in our most deprived communities and applying the approach to benefit people wherever they live; supports the steps to consolidate improvements in waiting times and to put highly specialist services on a sustainable basis, and commends the Scottish Executive's policy of pursuing greater quality and productivity.
I welcome this debate, disappointingly short though it is. I know that there are members across the chamber who will be disappointed that they will not get the opportunity to speak and I hope that the Executive will reflect on that.
The Scottish National Party welcomes the broad thrust of the Kerr report and the Executive's response to it. I will come back to that point later, but it is important to recognise that, as the Minister for Health and Community Care states in the foreword to "Delivering for Health",
"This is a plan for the long-term."
That means that there are other measures that have to be taken to address some of the immediate problems in the health service, not least the unacceptably long waiting times. The minister paints a rather rosy picture of that in the plan document, but I remind him that there are challenges in that regard, particularly in relation to colorectal cancer waiting times—with less than half of the targets being met—and the 112 per cent rise since 1999 in those who are waiting more than six months for hip replacements. We believe that action must be taken in relation to the challenges that are presented by waiting time issues.
Before I deal with the action plan, I will detail some of the SNP's proposals, which are detailed in our amendment. We want to give the patient more power. Each patient should be given a statutory right to an individual waiting time guarantee, based on their particular health needs. If it were deemed appropriate, that individual guarantee could be much shorter than the national waiting time guarantee. That would reinstate the clinical priorities to ensure that the waiting time better reflected the patient's clinical need. For many people with pressing needs, the national targets are too long to wait. Our proposal would put the patient at the heart of the process and ensure that the NHS delivered better for their needs.
Does Ms Robison accept that that already happens and that clinical need is the first consideration of clinicians, which means that the majority of patients do not have to wait at all when they are in urgent clinical need?
Far too often, everyone is striving to achieve the national waiting time target rather than considering the target that is best suited for that patient. We want to put the patient's need first and foremost, which is why we believe that having a right to an individual waiting time guarantee—as happens successfully in many other countries—would be the best way forward.
We believe in a public NHS, but recognise that, if it is to deliver a better deal for patients, the service has to change and reform. We need to be more ambitious for the NHS and for patients. To ensure that a public NHS delivers a better deal, we want to introduce an element of activity-based payment, to encourage hospitals to do more and to do it more efficiently. We have to release the necessary extra capacity within the NHS rather than rely increasingly on the private sector, which the Executive is doing.
That is an interesting point, which marks a fundamental shift in SNP policy. Who will make those payments? Who will be the purchase provider? Are we going back to trusts and competition? Activity-based payments will not allocate resources to where they are required. How would the proposals work in relation to Professor Kerr's point that we should direct resources to where they are most needed? I do not think that the policy that has just been outlined sits well with that.
The Executive, of course, would allocate resources as it does at the moment. However, an element of the payments to hospitals would be activity related to ensure that they better reflected the activities of those hospitals. Our policy is not the same as that of the minister's Labour colleagues in England, where there are 100 per cent activity-based payments; it is more like the model that is used in Norway, which has a level of around 30 per cent. That would allow extra capacity to be extracted from the NHS, which would be preferable to handing over the NHS to the private sector, which the Minister for Health and Community Care is obviously doing. Our policy provides a way of keeping the NHS in public hands and delivering a better deal for patients.
We agree with Professor Kerr that there has to be a separation of scheduled and unscheduled care. That will make a big difference and will reduce the number of cancelled operations, of which there were 13,000 last year. That must be done in the NHS to avoid some of the dangers that the British Medical Association has identified, such as damaging fragmentation between the NHS and alternative providers, the financial inequities, the serious questions about value for money that emanate from south of the border, and the potential effect on junior doctors' training, which is a major problem in England. Another danger is the high number of reported clinical exclusions due to the private sector cherry picking its cases. That is why separation can best be done in the NHS. There are good examples in the NHS in England, in which separation has delivered a very good deal for patients.
We can agree with the Minister for Health and Community Care—there is much to agree on this morning—on the broad thrust of the Kerr report. It was a response to the increasing concern in the chamber about the creeping centralisation of services that was driven by crisis management, financial problems and staffing shortages, not by the wishes of patients in an area.
I am pleased that many aspects of the SNP submission—the increase in undergraduate medical places, better networking across hospitals and support for the rural general hospital model—are reflected in the Kerr report, although we need to know what the core set of services will be. We need to know a great deal more about that, as the devil will be in the detail.
We support a shift in the balance of care to build up community services and to deliver health services more locally. That can be achieved through better-equipped general practices, community health centres and by giving a new enhanced role to community hospitals. That runs counter to some of the health boards' proposals to reduce services in community hospitals. There is no reason why people cannot access diagnostic treatment and procedures in a community setting.
The shift in delivery of services from acute to community, which is central to the Kerr report, has been talked about for a long time. However, we must be cautious, because I am not convinced that there will be a massive freeing-up of acute resources. We caution against any assumption of huge resource savings in the acute sector, as there will always be demand from those who require acute services. The shift should mean that those who require such services are seen more quickly and spend less time in hospital. Of course, by preventing unnecessary admissions we can ensure that the right people are in the right setting with the right staff. That is the prize for patients if this vision becomes a reality.
I want to turn to health inequalities—
I am running out of time.
It is a badge of shame that in a rich country such as Scotland a health gap is widening between rich and poor. Some of our poorest communities are experiencing a fall in life expectancy and that can no longer be tolerated. Anticipatory care is not a single solution in any way. However, it could make a difference by targeting those who are most in need of help but who are least likely to ask for it. There are questions about how such a service will be staffed and how it will be paid for. I would rather see some of the new moneys being ring fenced for that purpose, because robbing Peter to pay Paul would not be an effective use of funds.
The e-health strategy that the minister outlined has my full backing.
Some of the controversial issues, which include neurosurgery and cancer services for children, have perhaps been misinterpreted in the press. My understanding from the plan—I would like the minister to clarify the matter when he winds up—is that, rather than services being provided on one site, a single service akin to a managed clinical network will be delivered across several sites. The minister must get that important message across, because there are genuine fears on the issue.
The key is implementation and delivery and the minister must win public trust. If health boards rush ahead with proposals to reduce accident and emergency services, for example, public trust will be lost. The public must see community casualty units proving themselves in operation. That has to happen, otherwise the public will become more sceptical and cynical. If the minister ensures implementation and delivery, he will have our full backing on the broad thrust of Kerr. We will wait to see the detail and look forward to further debate.
I move amendment S2M-3468.3, to leave out from "supports" to end and insert:
", and considers that more needs to be done to bring down waiting times for patients including the introduction of individual patient waiting time guarantees based on their particular needs, the expansion of diagnostic and treatment centres within the NHS and the introduction of an element of activity-based payment for hospitals to encourage greater efficiency and utilisation of spare capacity in the NHS."
I apologise for arriving slightly late. I thank the minister for the promised advance copy of the Executive's response to the Kerr report. However, I did not track mine down till quarter to 9, so I was not able to get through much of it.
There seems to be a consensus that the NHS in Scotland needs to change. The needs of an aging population, the growing incidence of chronic disease, workforce planning issues brought about by demographic changes, the European working time directive, and public health issues such as our lifestyle and deprivation mean that the status quo is no longer an option and change is unavoidable.
The Kerr report, which looks to set the agenda in Scotland for the next 20 years, addresses the most fundamental issues that face the NHS today. We, like the Executive, are very positive about much of the report. We welcome its focus on primary care services, its recommendation that patients' health needs should be met as close to home as possible and its emphasis on the self-management of chronic disease. All those should decrease the need for secondary care and free up acute hospital services for those who are really in need of them.
It is much better for our many frail and elderly people to access health care in their communities close to home, to keep out of hospital and remain close by their friends and, in that way, to avoid the serious infections that are now, sadly, prevalent in many of our secondary care hospitals.
The proposal for rural general hospitals that are modelled on good practice—the Belford hospital in Fort William is an example—and the proposal for generalist and specialist training for health service staff are what people want to hear. At the same time, few would disagree that highly specialised services need to be centralised. The devil, of course, will be in the detail. There would not be support for such centralisation to the exclusion of existing excellent centres such as the neurosurgical unit in Aberdeen, which not only caters for Grampian patients but provides an outreach service for NHS Highland.
The action plan on neurosurgery, which I managed to read just a few minutes before the debate, makes it clear that the minister accepts Kerr's recommendation to move from four neurosurgical centres in Scotland, including Aberdeen, to one. Has the member any comment on that?
I had not reached that part of the report for the reasons that I gave earlier. However, I would be very concerned indeed if Aberdeen were to lose its excellent unit. A significant population north of Aberdeen as well as south of it depends on the unit for treatment.
To downgrade such a unit, as Kerr suggests, would have serious repercussions for local patients and for medical recruitment and training. Aberdeen has a very good medical school that I would not like to see undermined in any way. That is only one example; other specialties could be similarly affected.
Kerr's promotion of information technology and his recognition of the role that the independent sector can play are welcome. We are pleased with the Executive's stated intention to accept those proposals. We are concerned, however, about the implementation of Kerr's recommendations. A huge amount of workforce planning will be needed if the local delivery of health care is to be effective. Anticipatory care that reaches out to those who do not take care of their health has merit, but I hope that people will be encouraged to look after their health through education and that no coercion will be involved. Lifestyles will not change overnight and patients will have to learn gradually to take responsibility for their health and well-being.
People will have to adapt to major changes in service provision. They will have to get used to dealing with teams of health professionals instead of the general practitioner or consultant whom they routinely expect to see. Major publicity campaigns and education will be necessary before such changes become generally acceptable. The Executive let us down over NHS 24 and the GP out-of-hours services by not publicising them adequately before they were set up.
There must be enough NHS beds to cope with emergencies. Expensive new technologies will be required at community level if high standards of care are to be achieved locally. I do not imagine that the Kerr recommendations will be cost neutral.
Community health partnerships are not yet properly up and running across Scotland, and GPs and consultants will have to be encouraged to participate actively in them if they are to be effective. Problems with NHS 24 and the GP out-of-hours services are, as we all know, serious and will have to be overcome.
If patients have to travel to highly specialised units for diagnosis and treatment, it is essential that proper care and facilities are in place for their close relatives. I make that point on behalf of a constituent—a nurse in Aberdeen—whose son became paraplegic last year as the result of a motorcycle accident. The two-page account that she gave me of her bad experiences in the spinal unit where her son spent several months after his accident told of agency nurses in the unit who did not understand her son's condition; no adequate accommodation for relatives near the hospital; no help with expenses, although both parents gave up work to be with their son; little communication or support from staff; no hospital shop; and poor-quality food for the patients in a run-down, dirty-looking building. I can let the minister see the account later. Her son, flat on his back immediately after surgery, was forced to try to get food into his mouth with the help only of a mirror placed above his head. All in all, it was a miserable, unacceptable experience for that family.
Close to tears, my constituent asked me whether I would quote her case today. She said:
"Coping with my son's accident, injuries and paralysis was difficult enough, without all the travelling to and fro, and the problems we encountered. It was horrendous for us, and I would hate anyone else to have to go through what we did. Our son didn't have brain damage, but I cannot think how anyone could cope down there with that sort of injury."
That is the impact of centralisation on families of seriously ill people. It is difficult for such families to cope with. Where centralisation is unavoidable, proper support for patients and families must be provided. I ask the minister to take that on board.
The Conservatives have significant concerns about the implementation of the Kerr report, although we agree with much of it. It will come as no surprise that where we differ fundamentally from the Executive is that we do not think that Kerr's recommendations will solve the basic problems in today's NHS, which remains largely a monopoly provider. Decisions are made centrally by Government and the service develops according to directives and targets that are set by politicians. What I have seen of the Executive's response to Kerr gives me no comfort that that will change.
The Conservatives believe that the top-down approach must be overturned because, rather than improving performance, it has resulted in rigidity of the system and inefficiencies leading to low staff morale and dissatisfaction with the service. Patients need to be the driving force for the development of NHS services. They need to be given the resources to achieve that, and health care professionals need to be given far greater freedom to respond to patients' needs and wishes. That is why we support the development of foundation hospitals in the NHS. We firmly believe that such a change of direction, coupled with many of the Kerr recommendations, would result in the services that patients need, where they need them, and would in time result in a health service fit for the future, which is what we would all wish to achieve.
I move amendment S2M-3468.1, to leave out from "of NHS boards" to end and insert:
"to discuss the future structure of the NHS in Scotland; welcomes the report's emphasis on shifting the balance of care to provide more safe and sustainable local services, including intensive case management in the community for the most vulnerable; welcomes the commitment to tackle health inequalities by developing anticipatory care in our most deprived communities and applying the approach to benefit people wherever they live; however notes that, despite higher funding for the NHS in Scotland, too many patients are still having to wait too long for treatment; believes that a truly patient-centred NHS will only be possible if professionals are given the freedom to prioritise treatment by clinical need rather than by government targets and if purchasing power is put in the hands of patients so that their choices determine the development of the service, and, to that end, calls for the establishment of foundation hospitals within NHS Scotland and for continuing increase in the capacity available to treat NHS patients by extending the use of the independent sector."
I am sure that everybody has noticed that my amendment is probably longer than the motion and the other amendments put together. I wish to deal with the issue of centralisation. As members will have seen in my amendment, I am not convinced that the Kerr report or the Executive's interpretation of the report will prevent further clashes between health boards and communities up and down the country whose views the boards have arrogantly dismissed. Such communities have not been reassured that centralisation has been driven by patient needs or clinical needs, believing instead that it has been driven by the needs of the system.
Does the member accept any of the evidence that suggests that, in certain specialisms, the higher the frequency of an intervention by a highly skilled surgeon, the better the outcome for the patient? Kerr gives us a framework in which to assess that.
There is evidence relating to highly specialised areas, but there is no evidence relating to general surgery. Unfortunately, health boards are going ahead with centralisation on the presumption that it will be safer. We will face a situation in which there are different interpretations of Kerr. Kerr represents all things to all people, whether they are arch-centralisers or arch-localisers. The power lies in the way in which Kerr is interpreted. In Lanarkshire, for example, there is a consultation on gynaecology centralisation. From anybody's reading of the Kerr report, gynaecology does not fit into regionalisation, but Lanarkshire wants to centralise it in one unit: in-patient services.
No, it does not.
Yes, it does. I do not think that the minister has read the consultation. Again, we have those disputes about interpretation. I would like some assurances about how those disputes will be resolved and how the democratic involvement of the public will be improved—the system is certainly not democratic at present.
That takes me to my next point, which is about staff involvement. I am sure that the minister shares my concern that NHS staff are stressed and overworked. There is a feeling that they have been reorganised to death. Reorganisation within the national health service has not been handled particularly well in the past, resulting in an increase in sickness absence levels, stress and the number of people—valuable people, whom the NHS cannot afford to lose—seeking early retirement. Management of the changes is highly critical and I hope that there will be an improvement in it. In my experience, management of change has caused problems rather than solved them.
In the limited time that I have, I will concentrate on the main body of my concerns. There are good things in the Kerr report, but the report, Executive policy and developments in England represent a marked shift towards the involvement of the private sector. Even the BMA—no great socialists—has voiced its concern about the involvement of the private sector. A BMA briefing states:
"An investigation requested by British Orthopaedic Association members"—
into independent treatment centres run by Alliance Medical—
"revealed 18 adverse events and errors which had led to the suspension of six surgeons. It also found that some patients were being rejected as ‘too complex or unfit' and that one was ‘transferred between five surgeons before being placed back on the NHS waiting list'."
Early evidence from England shows that some of the contracts entered into with independent treatment centres have not even met 50 per cent of the capacity that the NHS bought them for—[Interruption.] That is the evidence from private independent treatment centres in England. They sign up to the contract and get 100 per cent of the money, but they do not achieve even 50 per cent of the activity. They drag resources away from the NHS, undermining its very fabric.
Further to that, we have seen moves by the Secretary of State for Health, Patricia Hewitt, to privatise en masse clinical staff employed by primary care trusts in the English health service. Interestingly, there has been a revolt by the trade unions and other members of the Labour Party, who moved a motion at the Labour Party conference condemning that policy. It will be interesting to see whether a Labour Party motion passed at a Labour Party conference will have any impact on Labour Government policy. We shall watch that unfold.
I am concerned that David Kerr's terms of reference specifically excluded examining the efficacy of private finance initiatives. However, he was invited to jet all over the world, encouraging private companies to tout for business in our NHS. In answer to a question that I asked the minister, I found out that since his appointment Mr Kerr has also been busy meeting no fewer than 27 different private health care providers—it is probably more now—to encourage them to consider the opportunities that are opening up for them in the Scottish health service. In answer to another question on the private sector's share of the health service in Scotland under the minister's new policies, I was told that in three years that share will move to 1.6 per cent. However, that does not include direct initiatives by health boards or a measurement of the impact of policies such as the NHS local improvement finance trust.
I would like an economic analysis of the increase in private activity in the delivery of health care services in Scotland. The massive acceleration in the private health care sector will seriously undermine the ability of our NHS to protect, preserve and improve itself as a public model of health care. David Kerr has said that the recommendations in his report are cost neutral. I do not think that anybody believes that, as it takes no account of the resources that will be necessary for education, backfilling of posts and so on.
The Scottish NHS has a unique record of presenting itself as a public model. The health sector in Scotland was not resistant to the introduction of the NHS, as was the BMA in England. The Scottish NHS is yet again under threat from colonialism at Westminster with health policies being dictated by Westminster—the unique Scottish record of a public health service is under threat.
I move amendment S2M-3468.2, to leave out from first "commends" to end and insert:
"notes the action plan for NHS Scotland, ‘Delivering for Health', and its acceptance of Professor David Kerr's report, Building a Health Service Fit for the Future, as the basis of NHS boards' future service change proposals; is concerned that the over-centralisation of services, which is against the wishes of communities up and down Scotland, may not be prevented by all of the above; is concerned to ensure that any change is democratic in that it actively involves communities and staff in making the key decisions that affect service provision; is extremely concerned about the opportunities for encroachment by the private sector into the NHS which the report represents; notes the Minister for Health and Community Care's and the Executive's increased communication and collaboration with the private health care sector; notes the alarming developments in England where the Government is attempting to transfer NHS clinical staff to the private sector; opposes the idea that incentivisation can improve health care and believes that the NHS is fundamentally under threat as a public health care system and requires urgent action to protect and improve it including increased investment in training to provide more NHS doctors, dentists, clinicians, other professionals and valuable support staff to increase the NHS's own capacity, and believes that Scotland's stark health inequalities will be intensified by increased involvement of the private sector and that the current funding mechanisms of the NHS are inadequate to address inequalities and require wide-ranging reform."
I welcome the debate and thank the minister for the clarity of his speech, although I apologise for not being here to hear the start of it. I also thank him for the Executive's swift response to Professor Kerr's report and for the contents of "Delivering for Health", which I am sure will receive the same positive response as "Building a Health Service Fit for the Future" did. I trust that NHS boards and regional planning groups will use the report and the response as a framework for their service change proposals and future programmes.
I know from first-hand experience and from reports from colleagues that many boards have already embarked on service changes in the spirit of the Kerr report—some did so even prior to its publication. The minister and I recently visited the new Hawick community hospital in my constituency. That hospital is a good example to set alongside the others that he mentioned.
The Liberal Democrats agree that we must rebalance health care services across Scotland with a greater emphasis on preventive and continuous care in the community. We said that clearly in our 2003 election manifesto. It is right that, wherever they are in Scotland, people who are at greatest risk of ill health should receive the help that they need, tailored to their own situation, to ensure a healthier and happier life. I have said before in the chamber that that should happen not only because of the unique value of every individual, but because demographic trends mean that in the future all Scots will need to fulfil as much of their potential as possible for the economic good of all. The Liberal Democrat theme about the development of hidden talent is as relevant in health as it is in education.
The theme of prevention is important. Is Euan Robson aware of the report that the United Kingdom working group on primary prevention of breast cancer published in September? That could make a useful contribution to the preventive agenda.
I am aware of it, but I am not intimately familiar with it. I took the opportunity, along with other members, to visit the stand that was recently located in the garden lobby and I found the information that was provided helpful.
Professor Kerr's report and the Executive's response should be seen not in isolation but as part of the wider agenda to ensure healthier lives. The minister mentioned the hungry for success programme in schools, in which I was proud to play a part. We must build on and develop the health education agenda, but there is already strong evidence from schools that we are influencing positively the eating habits of the younger generation. As the minister pointed out, there are now 600 active school co-ordinators in Scotland in addition to the 400 extra physical education teachers who are to be recruited.
The warm deal programme, involving central heating, insulation and draught proofing, is combating ill health and excess winter deaths. The phenomenon of excess winter deaths is unknown in Scandinavia, where the winter climate is colder and more severe.
The legislation to ban smoking in enclosed public places and the Executive programmes that have been initiated to tackle the deprivation—wherever it lies in Scotland—that leads to ill health are making a wider contribution. The new emphasis on preventing ill health, attacking its causes and targeting its whereabouts is clearly right. The issue is not only about treating those on waiting lists more quickly and effectively; it is about ensuring that people do not have to join the queue.
I will now take the discussion further. Several questions must be addressed to secure what might be described as the high-level vision of the Kerr report and the Executive's response. I will mention two in particular. The first is how NHS boards are to manage the transition to the new paradigm. Liberal Democrats believe that it is particularly important that the public understand the new ethos. That means that the public must see many of the new services before the old ones are removed. Shona Robison made that point forcefully and I agree with her on it. The practical local reality will secure acceptance of the new direction of the NHS in Scotland. In other words, new community health centres or hospitals that deliver relevant local services on a multi-agency basis must be up and running before services that are better delivered elsewhere move elsewhere. If the old closes before the new opens, there is a danger of loss of public confidence in the overall vision. I am sure that the minister understands that, but he needs to reinforce that message to boards and to be prepared to deploy resources flexibly to enable local delivery.
The second major question is how we can ensure that we have the necessary skills in the workforce to make a practical reality of the new vision for the NHS. As the Royal College of Nursing aptly said in its parliamentary briefing,
"the successful implementation of the report will depend to a great extent on the thousands of NHS Scotland staff".
I appreciate the work that the Health Department has undertaken and I particularly welcome the "National Workforce Planning Framework 2005". The challenges ahead are to ensure the availability, affordability and adaptability of staff. It will be interesting to see how the detail of the regional workforce plans, which are due in January next year, and the individual boards' plans, which are due next April, embed the Kerr report and "Delivering for Health". I suggest also that ministers revisit NHS Education for Scotland's "The NES Strategic Work Plan 2005-2008" to Kerr proof it.
I assure the member that Lewis Macdonald, the Health Department and I, as the minister, work closely with the trade unions and our workforce representatives in a unique and effective partnership in Scotland, which, I believe, will address his concerns.
I recognise that. There is a good working relationship and it needs to be built on to ensure that the outcomes that we all desire from the Kerr report and the Executive's response are delivered. I passionately believe that we must do much more to foster career structures that allow greater movement for staff between the health and the social work and social care sectors. There should not be two separate career ladders; there should be connections at every level, with a framework to ensure the maximum opportunities for rewarding and stimulating careers. I believe that the new direction for the NHS that is signalled by the Kerr report and which has now been embarked on is especially conducive to realising that opportunity. The Kerr report is important and the Executive's response will build for a successful future.
I am pleased to have the opportunity to speak in the debate, which I hope will make a contribution in relation to the on-going need to inform people about the changing way in which we deliver health care in Scotland.
The commissioning of the Kerr report was a crucial moment for health policy and we should welcome its findings. Against a backdrop of ever-evolving practices in medicine and of patients with ever-changing needs, it was perhaps the ideal time to consider the future direction of the NHS in Scotland.
In recent years, we have become increasingly aware that health care is about far more than hospitals. That is borne out by the fact that 90 per cent of health care is delivered in local communities. Although it is imperative that we work to ensure that all our hospitals are fit to deliver 21st century health care, the provision of modern health care is about much more than buildings.
Unfortunately, some campaigns on service reorganisation have been misinformed, misleading and deeply concerning for patients throughout Scotland. I hope that the Kerr report can go some way towards reinforcing the fact that changes to service delivery do not always amount to cutbacks. Kerr highlights the need for public consultation to take place at the front end of service change rather than as a last step, but one of the reasons why we ran into problems early on in the acute services review in particular was that we did not take the opportunity to inform people, prior to consultation processes taking place, about the changing nature of health care. It is important that we take up Kerr's suggestion that we review the consultation process, because we have not yet got it right.
There is absolutely no doubt that we need to improve local services. The Kerr report defines clearly a new way of delivering care—it is very much a model of community care that is geared towards long-term conditions and involves integrated and preventive care. We now know that those measures lead to better outcomes. The anticipatory care measures that the minister mentioned will go a long way towards dealing with some of the health inequalities that many members see daily in their constituencies.
The new measures must be underpinned by extensive use of technology. That is a crucial point. I am particularly interested in the Kerr report's focus on the need for a common information technology system. The minister has spoken about that matter and I know that he is committed to it. However, it is incredible that, in this day and age, the NHS, over many years, has not kept pace with advances in information-sharing technology. The Kerr report states:
"The Scottish Executive should procure as soon as possible, and by 2008 at the latest … a single information technology system".
That system should include key features such as
"An electronic health record available to all those who require it to provide patient care across the whole NHS … Electronic prescribing … Electronic booking"
and all the knock-on features that are required to benefit health care in the 21st century. I completely agree with the Kerr report on that and I hope that the minister will act accordingly. The minister will be aware of my commitment to the matter, which I raised at the Health Committee recently. While I welcome the minister's commitment to put e-health high on the agenda, I have concerns that the single system that is vital to delivering new ways of health care needs to be in place by the time that some of the changes take place in Glasgow, such as the new hospitals at Stobhill and the Victoria infirmary site. I hope that the deputy minister will give me reassurances on that in his summing up.
I mentioned inequalities, to which the Kerr report pays particular attention. The report stresses that the ethos of free comprehensive care available to all still commands widespread public support, much to the disappointment, I am sure, of my colleagues in the Tory party. However, that comprehensive care must be of the highest possible standard, regardless of where it is delivered. Sadly, we continue to see huge variations in life expectancy, depending on where people live. It is almost too obvious to state that a person's life expectancy should not be dictated by their postcode, but that still happens in the 21st century.
Professor Kerr is exactly right to highlight the need for a more proactive approach to health care that identifies those who are at greatest risk and provides co-ordinated care that is based on their local general practice team. To the minister's credit, he has responded by asking health boards and other partners to begin the work of identifying patients with long-term conditions who are most at risk of hospitalisation in the future. As Euan Robson said, community health partnerships, which are now fairly well under way in most communities, will be crucial in that regard by ensuring a co-ordinated and locally delivered approach to health improvement in Scotland.
No one can expect Scotland's appalling health record to be improved drastically overnight, but the Kerr report and the Executive's response to it are significant steps on a long road. I support the motion in the minister's name.
It is worth recalling the climate in which the previous Minister for Health and Community Care set up the review in April 2004. Members will remember that, at the time, a wave of anger and frustration was sweeping the country about local health board decisions. Campaigns that were generally profoundly antagonistic to a health board decision or proposal were under way in almost every health board area. There was huge opposition to centralisation and the extensive consultation was seen as nothing more than a cosmetic exercise. The Kerr review has helped to moderate some of the anger and frustration, which might, of course, be the reason why the review was set up in the first place. However, I remind members that there is a danger that if we do not get the health service right, we will return to precisely the same climate.
At the Health Committee's meeting on Tuesday 20 September, we heard directly from Professor Kerr. As well as having questions from members of the committee, we asked those who had participated in the committee's public debate in April to submit questions from which we could draw. We put directly to Professor Kerr some of the questions that people wanted to ask. We are now 18 months down the line from the setting up of the review and it is four months since we last debated the report in the Parliament—on a Tory motion—but I am still completely unclear as to the Executive's intentions vis-à-vis implementation. With the greatest respect, the minister's comments today were full of the phrases "could be" and "might", but I would like a lot more "will be" and "here is the date when". I can underline for the minister the instances in the Executive's report of "should be", "might" and "maybe".
The important point is that many questions remain, not least about the definition of core services. One key message that comes through clearly in the Kerr report is the importance of providing health services as locally as possible, which is accepted by the minister and all members. However, it is difficult to find any clear guidance as to what will constitute the core services. A benchmark is needed against which communities can assess proposals from their local health board. Without a benchmark, concerns will continue to exist, as the matter will be left up to health boards to decide on the basis of expediency, which was the concern that my colleague John Swinney expressed.
That expediency never seems to be what is expedient for the patient; decisions always seem to end up with patients travelling further and further from home to access services that they used to be able to access locally. The experience in Tayside is that patients can be told to turn up at 8 am at a hospital 70 miles away from where they live, passing two other hospitals to get there. People do not understand that. How does the minister propose to turn round that current reality? Professor Kerr clearly understands the travel issue better than many health boards, as he has stated:
"it is unacceptable that it should be necessary to take two trains, three buses and an expensive taxi ride to access services."—[Official Report, Health Committee, 20 September 2005; c 2192.]
We would all agree, but that is exactly what many folk in Scotland have to do. Personally, I believe that Professor Kerr is a bit idealistic about the availability of the public transport options that he mentioned, as they are simply not available in the example that I gave.
I mentioned in my speech the example of Whitehills community unit, where diagnostics, day-case surgery and out-patient clinics are carried out. That is exactly the sort of service that we want and there is evidence of such services in Tayside and elsewhere. Such services stop the need for people to travel and, as our report says, we want more of them.
Tayside is an extremely large area. Right now, the reality is that people are told to turn up at 8 o'clock in the morning at a hospital that is 70 miles from where they live, passing two other hospitals on the way. Folk do not understand that.
The Kerr report has more detailed guidelines for unplanned or urgent care—it talks of four different levels of care. However, even then, Professor Kerr could not outline the basis or the rules for such designations and he declined to outline any such set of rules at the Health Committee meeting in September. That issue must be resolved. The community health partnerships will be vital to any such process, but I am worried about how they will be resourced in practice. Professor Kerr told the committee of his vision: he talked of a diabetes consultant who has some sessions in a hospital and others in community hospitals or general practices. I have no doubt that that vision would be welcomed in all communities, but I am far less convinced that it can be delivered in practice. At the moment, it seems hard enough to get consultants to move from one hospital to another, much less into cottage hospitals or general practices. Again, I must query how the culture change that is needed to achieve that will be put in place in health boards.
We should not forget that what happens on the ground will be the proof of the pudding. On unplanned care, the level 1 services include NHS 24, the mere mention of which brings to mind the great difficulties that exist in translating theory into practice. There is a standing joke in parts of Perthshire that if somebody wants to see a doctor out of hours, they had better be in church on a Sunday, because there is more chance of seeing one there than anywhere else at the weekend. Perhaps that just betrays the level of cynicism that exists about the NHS, but out-of-hours care is a prime example of the rhetoric failing to match people's experience. When that happens, a breakdown in trust occurs, of which the NHS has already had plenty experience. We have had too many promises of jam tomorrow if only we put up with the pain today, except the jam never appears.
Professor Kerr is adamant that public trust must be maintained—he repeated the assertion before the committee in September. I am not sure that I would go as far he has in having confidence that the public mood is behind him. For the past 18 months, the public have been prepared to give the initiative the benefit of the doubt, although the jury has been out. Even after today, the jury will still be out.
I am pleased to be able to contribute to the debate. I thank the Minister for Health and Community Care for giving me the opportunity to meet him last night and for the healthier Scotland report, which I have not managed to read right through. The minister knows that I agree with the bulk of the Kerr report, but think that its success will depend on its interpretation and implementation.
Most primary care work can be done in the community—that is where 90 per cent of it is done. For years, general practice has dealt with the management of chronic pain and chronic diseases, such as different types of arthritis, asthma, chronic obstructive airways disease and diabetes, and has engaged in activities such as blood pressure management and cessation of smoking work.
We have an aging population. People are living longer, with more pathology. Although we deal with many chronic diseases in general practice, extra staffing is required, so I do not think that the treatment of those diseases in general practice will be cost neutral. When I was in general practice, I could always have done with another practice nurse. The one that I had was wonderful; she was better than any doctor at treating leg ulcers. I could also have done with another health visitor and another district nurse.
The issue will all boil down to having a workforce of the correct size and to being able to employ sufficient staff in primary care. Training will be important, too. It will be vital to keep experienced nurses and doctors in the front line. In addition, I think that it would be a good idea to rotate staff so that they work in different hospitals and units. I would include NHS 24 staff in that. It is sad that many people took up posts in NHS 24 to obtain a higher grade and better pay. Unfortunately, they have found the work highly stressful and have been disappointed to leave behind their clinical work. We should allow staff to do both telephone answering and clinical work.
It is important to get discharges from hospital right. Roseanna Cunningham made a good point about the difficulty of getting to hospital. People who go to hospital for treatment have to get there very early in the morning. I heard about a 76-year-old lady who came from town to have her operation in the morning, but it was delayed until about 1 o'clock. About three hours later, when she had had her operation and was recovering, she was asked whether she would be able to leave because there was a shortage of beds and the hospital was desperate to get her to go home. The onus should not be on the patient to make such a decision. That is a medical or nursing decision.
It is important to achieve better communications. I am deeply worried about whether it will be possible to implement a new IT system throughout the health service in time for the building of the new hospitals in Glasgow. I share Janis Hughes's point of view. As someone who worked in the NHS for a long time, I hoped that the community health index system would come in and that electronic patient records would be available so that staff would know what was happening with a patient. That has not happened. I would love to get back all the hours that I spent on software that did not work. America seems to have a wonderful system for following the patient for financial purposes so that, when a needle falls, it is known who should be charged.
I am anxious about private sector involvement in the health service. I note everything that the BMA has said. I know that the minister knows what is going on in England. I am not in favour of an increase in the size of the private sector because the staff in that sector do not get training. Rather than spend money on increasing the capacity of the private sector, we should spend it on increasing the capacity of the health service. I am anxious about the growth of private sector involvement in the NHS. I know that, in the first instance, the private sector allows people to be seen to quickly, but it picks and chooses its patients. People who need hip replacements and who also have other conditions, such as heart and lung disease, will be dealt with not in the private sector, but in the bigger NHS hospitals.
Like several other members, I am scared that the health boards will interpret the Kerr report as favouring more centralisation.
I do not think that Greater Glasgow NHS Board has any idea how many beds it will need. I would not like any more beds to disappear until we know precisely how many are needed. It is a shame that people have had to wait on trolleys, regardless of how comfortable those trolleys were. That should never have happened. Sufficient provision should have been made for the patients concerned.
I want us to check that the European working time directive is being adhered to. The NHS needs to watch that nurses who work three 12-hour shifts and then work as an NHS bank nurse are not doing more work than they should be doing.
The solution to the NHS's problems comes down to a number of measures, such as training, having people on the spot to keep the training going and initiatives such as the Royal College of Nursing's wipe it out campaign. In addition, members of the general public need to take responsibility for their own hygiene. When I was on holiday last week, I watched a 14-year-old boy—who looked as if he was 18—talking to a young lady. He drank beer, smoked cigarettes one after the other and punctuated his conversation by spitting as far as he could. I lost count of the number of times that he spat. The minister is already seeking to address the fact that we have a nation of people who have forgotten all normal standards of hygiene.
I completely endorse the Kerr report, although its success will depend on its implementation.
I begin by apologising to the minister and to the other members who are present for missing his opening speech. That is a matter of genuine regret to me.
In speaking in the debate, I, like other members, want to explain my concern about aspects of the long-term future of the health service in Scotland. All of us favour an improvement in the delivery of service and recognise the need for change, provided that it can be demonstrated that any proposed change would offer a higher level of patient care.
We must acknowledge the changing demographic of an aging population and design our future health service with the greatest of care. Above all, we must take the public with us in any changes that we propose. That is why the emphasis that the Kerr report places on consultation is so important.
We must recognise that much of what we offer patients has evolved over time, perhaps in an empirical way. Although we should not set our face against change, we should acknowledge that the planners of previous generations did a good job. The reality is that, in the main, most members of the public are largely content with our health service. Of course we all want waiting lists and waiting times to be shortened, but very few people want radical change in hospital provision. Patients want to feel that their health service can be improved and expanded locally, but do not want to feel that it is being downgraded or that they will receive a reduced service.
When there is such a matrix of proposals for change, it is vital to convince members of the public, who are all potential patients, that what is proposed is for the long-term benefit. In the words of Professor Kerr, we need to
"develop options for change with people, not for them."
As many members will be aware, proposals are on the table to centralise accident and emergency specialist care for Ayrshire at Crosshouse hospital and a consultation is under way. Naturally, I welcome the fact that consultation is taking place; I also welcome Ayrshire and Arran NHS Board's publicly and privately stated position that no decision on the future of A and E services in Ayrshire has yet been made. There is no doubt that the public are being consulted widely and in a more meaningful way than when the removal of paediatric services to Crosshouse was proposed.
Public engagement and public debate have certainly been achieved. There have been packed public meetings, at which considered views have been expressed on what has been proposed, and I hope that the health board has been listening. Strong but thoughtful views have been expressed against the proposals. It is a matter of great regret to the public that the most popular proposal that was made in the service review—namely, that both A and E units should be kept open, that assessment centres should be created at the two hospitals and that community casualty facilities should be provided at Irvine, Cumnock and Girvan, as well as at Ayr and Crosshouse—has not been included in the consultation. That is the rub—a meaningful consultation process should contain proposals that a sophisticated patient public regards as an obvious improvement. In my view and in the view of many of my constituents, the current proposals fall short.
The extra dimension to the consultation process is that many doctors, GPs and consultants in Ayrshire do not feel that they have been adequately consulted. Members of the public need to be consulted and convinced of the benefits of proposed changes but, at the same time, medical staff must be convinced that those changes will produce better patient outcomes. I assure the minister that a large body of the medical staff in Ayrshire remains to be convinced.
Will John Scott accept that the vast majority—in fact, as I understand it, 100 per cent—of the opposition to the proposals that are out for consultation come from medical staff in the south of the county at Ayr hospital? Does he accept that there is no opposition from others or from clinical leads in Ayrshire and Arran?
I accept that that is the case, because the reality is that the people in the southern part of Ayrshire and, indeed, the doctors at Ayr hospital feel that that is the problem. I am sorry to say this, but the feeling is that the people of south Ayrshire will not be looked after adequately.
Kerr states that the presentation of proposals that the public view as being made in a take-or-leave-it approach by health boards is unacceptable. If several thousand people have taken the trouble to attend public meetings and to make their views known, health boards must listen to them—in all honesty, the downside is too damaging to contemplate.
If consultation is important, it must have value, and it has value only if it is looked at, taken note of and acted upon by health boards. If public views and opinions are not carefully considered, the public will rightly feel that their contributions are not only meaningless but have no value, and they will shy away from engagement in future debates. People and patients across Scotland will take note of the outcome in Ayrshire. Indeed, Shona Robison concluded her contribution on that point. Janis Hughes also spoke knowledgeably on the subject.
I wrote to the minister to invite him to hear the views of medical staff, ambulance men and women and paramedics in Ayrshire. He should hear those views for himself, as they are at odds with the board's proposals. I very much hope that, in the spirit of enhanced consultation that Professor Kerr proposes, the minister will take up the offer.
When Professor David Kerr kicked off the public debate on the future shape of the national health service almost a year ago in my constituency, he did so against a troubled background.
For years, we had been calling for a strategic approach to be taken to NHS planning. As public outrage at health board plans for service redesign across Scotland grew, the calls were becoming impossible to drown out with the sugary words that it was all being done in the patients' interests. In my area of Argyll and Clyde at least, the absence of a clinical case for many of the plans that were being put forward was fast becoming clear. The outcry in Greenock and Inverclyde was particularly fierce: thousands of local residents marched against the health board's proposals to centralise services at Royal Alexandria hospital in Paisley. A petition against the plan attracted some 56,000 signatures.
It is a vindication of our once-derided arguments that, after 14 months of detailed investigation, the expert group that Professor Kerr chaired has published a report that marks the end of the failed board-by-board approach to service reorganisation. Although it is important to remind ourselves of the context in which Professor Kerr's investigations took place, our job now must now be to focus on how to use this valuable report to inform and shape health policy.
The real and radical departure of the report is the idea that services should be designed to meet need and not, as Professor Kerr put it at a recent meeting of the Health Committee,
"planned on the basis of a rather irrational, narrow, geographic bit of Scotland".—[Official Report, Health Committee, 20 September 2005; c 2190.]
He was referring to the old, artificial health board boundaries—the Berlin walls behind which boards sat, drafting grand plans that barely acknowledged the existence of the outside world.
The case for designing services to meet need is strengthened by the fact that, as I have pointed out previously, quality health services tend to be made available most easily to those who least need them—I refer to the so-called inverse care rule. However, in addition to being high in quality, services must also be accessible. The Kerr report rightly focuses on the local delivery of health services where possible. Most people accept that that, if someone needs attention at a world-class neurological centre, for example, they might need to travel to that centre of excellence. However, people do not accept that they will have to travel long distances for what they consider routine treatment.
Will the member give way?
No, thank you.
In evidence to the Health Committee, Professor Kerr also said:
"If we ask patients to move, we should ensure that it is for good reason, is logical and possible and does not involve three trains, two buses and an expensive taxi ride to receive standard care."—[Official Report, Health Committee, 20 September 2005; c 2190.]
I welcome the minister's determination to break the link between deprivation and ill health. If we are serious about our stated ambition to reduce health inequalities, we must ensure that high-quality, accessible services for those who need them most are the cornerstone of our plans. When I say "we", I do not mean just the Labour Party, the Executive parties, the Minister for Health and Community Care and the ministerial team. I harbour a hope—perhaps it is a forlorn one—that the process in which we are all involved will lead to a more constructive discussion of the issues that the national health service must face up to.
I believe that there is already some agreement across the parties on those issues. For example, although we may disagree on where admissions should take place, we agree that elective and unplanned admissions should be separated to improve forward planning and make more efficient use of resources. If there is to be tension, it will not be political but for geographic or economic reasons. If implementing Kerr means giving most help to those in most need, there may be a conflict between members who represent urban populations, with their pockets of deprivation and appalling public health, and those who represent healthy, affluent areas.
I expect all MSPs, from every party, who represent areas across Scotland that have the same poor health profile as my own area to work together on the campaign to end the scandal that sees money and resources directed into making the healthiest healthier at the same time as people such as my constituents are dying in their 50s and 60s.
Although Professor Kerr's report is not a panacea, it gives us more than a course of treatment for the ills that afflict today's national health service; it offers a way forward that could revolutionise the NHS and make it more responsive, effective and efficient. Professor Kerr has done his job; the question now is whether we have the courage to do ours.
When the Kerr report was published earlier this year, it was met with acclaim by almost everyone. It seemed that everyone thought it was a good job well done. Who could argue with the main thrust of the report of ensuring sustainable and safe local health services? However, like most things in life, the devil is in the detail. The problem with the Kerr report is that everyone sees in the report what they want to see.
The local health campaigners, who fear that their local health services are under threat, focus on Kerr's commitment that, where it is safe and practicable to do so, we must deliver health services locally. A prime example is that of maternity services at Aboyne community hospital in my constituency. Aboyne is situated some 30 miles from Aberdeen royal infirmary and serves a population from as far afield as Braemar, which is some 60 miles from Aberdeen. This Saturday, I will attend a rally in Aboyne that has been called to protest at the health authorities' suggestion of closing down the maternity unit at Aboyne community hospital.
As far as I am concerned, the statistics speak for themselves: 34 babies were born in the unit last year; 60 babies have been born there this year; and bookings are up 71 per cent for the forthcoming year. To suggest the closure of this modern, purpose-built facility is ridiculous. We are trying to give mothers the option of giving birth at home, at their local community hospital or, indeed, at one of our regional hospitals. I trust that the Minister for Health and Community Care agrees that the maternity unit in Aboyne is precisely the sort of local health care facility that Professor Kerr and, indeed, Scottish Executive ministers support.
The Kerr report is supportive of the sort of campaign that the Aboyne maternity unit campaigners are mounting. However, what local health campaigners across Scotland perhaps do not see in the report are the comments that Professor Kerr made in it about specialised health care services when he said that they should be delivered on a national basis and on fewer sites. Many health professionals focus on the commitment to move to so-called single hub services run from a central site. We cannot have it both ways: we cannot talk about local delivery and single-centre national sites at the same time.
I summarised the Kerr report by saying that wherever it was safe and practical to do so, health care should be delivered locally. That is what I took from the Kerr report—but how wrong could I have been? On closer inspection, it is quite clear that some people have an agenda of downgrading the services provided by regional hospitals throughout the country. I see the minister shaking his head, but let us look at the facts.
I will take neurosurgery as an example. Most neurosurgery is of a routine nature and is delivered by hospitals in Glasgow, Edinburgh, Dundee and Aberdeen. The service is very successful in Aberdeen, where I am told that waiting times are as short as three weeks. Most hospitals already specialise in certain conditions—there is little new in that. So what does Kerr recommend? What does the minister say that he will do? Kerr recommends that neurosurgery move to a single centre based in a single hub. As far as I am concerned, that is not on. I am hugely disappointed that the minister seems to have accepted the proposal lock, stock and barrel.
Does the member accept that, in fact, the report recommends the delivery of a single national service on three levels, with a prime site but with the national neurosurgery service delivered at a number of sites, precisely as described by Shona Robison earlier in the debate?
This is exactly what the Executive report says, and I am surprised that an MSP who represents Aberdeen Central should advocate this in his action plan. There will be a move from four neurological centres
"towards a single centre for neurosurgical intervention"
and
"paediatric neurosurgery … should be concentrated on one prime site".
As a result, we will get consultants visiting other parts of Scotland on an out-centre basis. Such an approach is not isolated. [Interruption.] I hear the minister say, "Rubbish," from a sedentary position, but I am reading from his report.
The question of child cancer services has been raised recently because a Scottish Executive working group has come up with a beauty—a recommendation to centralise such services in Glasgow and Edinburgh with shared care for Aberdeen. I hope that the deputy minister will knock that recommendation on the head in his response to the debate today by confirming that it does not square with the commitment that the Minister for Health and Community Care gave to me and other north-east MSPs just yesterday, when he stated in a letter that
"the service in Aberdeen would not be substantively reduced."
However, that is what the plan is.
Professor Kerr talks about having centres of excellence in Scotland for specialised conditions, but what exactly does that mean? I took it to mean that we would have several centres of excellence for conditions throughout the country. It seems, however, that some take it to mean that we can have one or two centres of excellence—members can guess where they will be placed.
I have heard suggestions that because Scotland is a small country, people are willing to travel to get the best care. I do not doubt that. My constituents in Braemar are prepared to travel 120-mile round trips for the best care at Aberdeen, but they would not be happy to travel regularly further afield for their care. I suspect that the people of Glasgow would not be happy to travel to Aberdeen. I would be less suspicious of Kerr had he argued that the one or two centres of excellence that he wants for certain conditions should not be located just 40 miles from each other.
We must be wary of taking from the Kerr report those bits of it that we like and ignoring the bits that we do not like. The report is full of generalisations that can be interpreted one way or another and there is a danger that once the Scottish Executive health ministers start to make decisions about neurosurgery, for example, there will be many disappointed people in the country. I am afraid that the Kerr report is full of good, wholesome generalisations, is weak on specific recommendations and is open to different interpretations depending on one's point of view.
I return to my summary of the report that health care should be delivered locally when it is safe and practical to do so—I hope that those are not great get-out clauses.
Professor Kerr's report "Building a Health Service Fit for the Future" has been welcomed throughout Scotland. However, the implications of building a health service fit for the future brings out the shroud wavers. Their attitude is, "It can happen in other hospitals, but not in ours."
Clinicians add fuel to the debate by not being prepared to see the wider picture of the health needs of the whole population. Those clinicians further complicate the issues by disagreeing in public, thereby adding to the fear of the public who attend consultation meetings.
Why do we get ourselves into this situation time and again? The Scottish health service is very good at delivering health services, but it is very poor at consulting on a level that engages with the public. Too often, consultation is limited in its options and uses language that is not public-friendly, and the lack of buy-in by NHS staff is identifiable.
NHS Ayrshire and Arran is in the middle of such a consultation, to which everything that I said earlier applies—John Scott alluded to that situation. We run the risk of missing the boat through piecemeal consultation. Why should we in Ayrshire and Arran be consulted only on emergency and unscheduled care when the big picture has not been made available to us?
If we truly want to engage with the public in "Building a Health Service Fit for the Future", we must make the public's needs central to any changes. The outcomes for patients are what we are about, yet those outcomes are often not mentioned in consultations.
We continually hear of staffing issues, whether in relation to the working time directive, clinicians' rotas or extended practice. The public does not appreciate the impact that those issues have on their health outcomes, which gives the shroud wavers the opportunity to hijack a consultation.
We do not have a clean sheet of paper so that we can start afresh; we have hospital facilities in places where, if the sheet were clean, we would not place them. Facilities often have poor transport links, but such aspects are not part of the same consultation process.
It is our duty to require health boards to deliver health services to suit the needs of their communities and the geography of the area.
Great opportunities for the Scottish people are contained in Professor Kerr's report. It recognises that 90 per cent of patient contact happens in primary care and, as we all know, a significant amount of that takes place in the area of public health.
The emphasis on local delivery is shaping how our services are being planned for the future by taking account of the needs of local communities. Local delivery means taking account of employment, education and housing needs and levels of deprivation to determine how, where and by whom health outcomes will be delivered in a community.
It is recognised that the health service does not have all the answers and that partnership working is the way forward for our communities. Local authorities are charged with community planning, but that must be underpinned by health and other agencies as well as involve community representatives.
East Ayrshire Council has developed one-stop facilities that take that community-planning model into specific neighbourhoods. The minister recently cut the turf at the north-west Kilmarnock neighbourhood services centre, which is now being built. The centre will deliver many diagnostic and out-patient appointments in that community. Instead of people in that deprived community having to travel to the health service, the health service will travel to them.
I encourage sceptics to visit the facilities that are already in place in East Ayrshire to see for themselves the impact that they are having on the health outcomes of the communities that they serve. The result is fewer do not attends, quicker referrals, more appropriate treatments and extended roles for nursing staff and allied health professionals in developing innovative solutions for communities.
We have an opportunity to reduce hospital admissions and manage chronic conditions in the community by developing that model. However, the biggest obstacle to delivering such care is some people's fixation with buildings, rather than with what happens in them. We should be questioning whether using those buildings is still appropriate in today's world.
We have moved on significantly in the past 10 years. Conditions that used to require a patient's admission for a considerable period of time can now be managed by the patient with direction from a primary care practitioner. The type and range of drugs that are available now allow conditions to be managed more effectively than before, which reduces the number of admissions. The technology that is available to clinicians means less surgical intervention, which results in fewer hospital stays for patients.
The health of the people of Scotland is not standing still. Our health service needs to be encouraged to take its services to the people whom it serves. "Building a Health Service Fit for the Future" gives us that opportunity.
I want to pick up some of the themes of Margaret Jamieson's thoughtful speech.
When it comes to considering structural changes to the delivery of services, the key message of the Kerr report is that it is important to
"develop options for change with people, not for them, starting from the patient experience and engaging the public early on to develop solutions rather than have them respond to pre-determined plans conceived by the professionals."
Indeed, the Minister for Health and Community Care himself specifically endorsed that approach earlier this year in his statement to the Parliament in which he introduced the Kerr report. It would be helpful to quote the minister:
"I expect the consultative approach that is commended in the report to be replicated as boards engage with the public. A take-it-or-leave-it approach will not do. I expect people to be consulted about the case for change, and the options for change, long before a preferred solution is reached."—[Official Report, 25 May 2005; c 17155.]
Those assurances ring hollow in the ears of the people of Ayrshire and Arran, especially those who are currently served by Ayr hospital, who are being called to participate in a consultation exercise that, to quote the Ayrshire Post,
"is a sham and nothing but a farce".
Ayrshire and Arran NHS Board wants to close the accident and emergency department at Ayr hospital and centralise specialist A and E services at Crosshouse hospital in Kilmarnock. The refusal of the board to consider other options during the consultation, including the retention of the Ayr A and E department, has created widespread public outrage. For its part, the board claims to have followed to the letter the guidance for consultation that the Executive issued. The minister is well aware of the controversy on the subject in Ayrshire. Will he take the opportunity to repudiate or question the take-it-or-leave-it approach of NHS Ayrshire and Arran and tell the board to think again?
The board claims that its proposals, which were, in the main, worked up by a hand-picked panel of NHS professionals, are the best fit for the Executive's vision for the NHS and that they should deliver safe, high-quality services that are as local as possible and as specialised as necessary. The problem with that vision is that it can be interpreted in different ways, depending on people's perspective. Mike Rumbles alluded to that point. The public's view of what is necessary specialisation is increasingly at odds with that of the medical profession.
The Parliament's Health Committee has criticised what it calls the
"strong orthodoxy within the medical professions towards increasing specialisation",
which, in turn, is leading
"towards centralisation within the Scottish NHS".
Such an approach might be justified for sophisticated specialties such as cancer units and heart surgery, but there is little evidence of achieving improved patient outcomes by having centralised A and E services. In other words, the public are perfectly justified in taking the view that A and E should be a core service within their district general hospital and that the loss of that service would make their community worse off.
Does Adam Ingram agree that there has been an increasing misreferral by members of the public to accident and emergency facilities, which has caused difficulty with regard to true trauma cases?
I am happy to acknowledge that. I would be very much in favour of the introduction of minor injury units, which are being proposed for community hospitals in particular. However, that does not get away from the point that, when we are considering options for change, it is reasonable to apply the test of whether those changes will make some people—hopefully, many people—better off without making others worse off. In Ayrshire and Arran, there is a perception that a big chunk of the area that the board serves will be worse off.
Despite the overwhelming public opposition, Ayrshire and Arran NHS Board appears determined to push on with its proposals. It makes little secret of the fact that workforce pressures are driving the agenda for change. In other words, factors such as the European working time directive, the new deal for junior doctors and the modernising medical careers initiative are dominating future patients needs as determinants of service change. That runs counter to Professor Kerr's recommendations and to the minister's own assertion that
"Patient need should drive the shape of the workforce."
What is happening in the real world is very different from what the Kerr report recommends and from what the minister wants to see—or at least what he has told us here. Of course, he will be judged on his actions rather than on his words and on whether he gives his approval to the proposals that have been made by NHS boards such as Ayrshire and Arran. On current trends, that judgment is likely to be harsh indeed.
I declare an interest: I am still a member of the British Medical Association.
I welcome the chance to debate the Kerr report, as I welcomed the report itself. I also welcome the advance copy of the Executive's response, which I wheeched through as quickly as I could this morning—I did not have time to go through it thoroughly.
When the Kerr report came out, I was very impressed. I was relieved. As I am from a rural area, I had been concerned about the future direction of health care in remote and rural areas, particularly following the demise of the remote and rural areas resource initiative. The report, with its support for community hospitals and rural general hospitals, seemed to address those concerns and to set out achievable models for rural health care.
On rereading the report prior to this debate, and on reading the Executive's response to it, I still feel that it is a good document. However, I have a few issues to raise. Like all MSPs, I have listened to concerns about the perceived centralisation of health services. The report addresses that only partly. I do not think that there is any argument with the principle that some highly specialised services should be centralised—although their exact setting might be disputed—or that an increasing number of services and procedures should be available as locally as the GP's surgery. The issue is about the bit in between.
The report gives some clear-cut, black and white examples of each: paediatric cardiac surgery, for example, is to be centralised, whereas cataract surgery is to be provided locally. However, there are grey areas. What about hip replacement or care for people who have had uncomplicated heart attacks? In my view, in rural areas, rural general hospitals should deal with all the grey areas. There will be arguments about whether certain things are in a grey area or are black or white, and there is some discussion to be had about that.
I very much welcome the vision of rural general hospitals. I assume that dialogue has now been established with the royal colleges to examine the training and support needs of the general surgeons and physicians who will be needed to staff those hospitals. Although the return to the generalist is against the recent trend of increased specialisation, it is welcome. However, the professions need to buy fully into the concept. Health professionals who choose what could be a very rewarding route to becoming generalists should be supported.
The report's proposals for community hospitals, which would offer a wider range of services, are welcome. I would be interested to find out how those proposals are to be realised. Will the community hospitals simply use existing facilities, which are there for historical reasons? The Executive's response seemed to treat community hospitals as being a purely rural phenomenon. That was not my reading of what Professor Kerr was suggesting. I would be interested to know what the Executive really meant by that.
If the Kerr report's ambitions are to be realised, the number of community hospitals will have to expand. The report even talks about having computed tomography and magnetic resonance imaging scans in the primary care sector, which would have huge resource and training implications and seems to reach a bit far. My experience is that a natural law is that resources never flow out from the centre to the periphery, although I would like to be proved wrong. The move to centralise highly specialised treatments has an evidence base; I am not sure how much evidence exists for local delivery to the proposed extent. I would certainly not close hospital departments until it was clearly shown that a service could be delivered in primary care. A crossover period will have to occur. I do not think that hospitals' workload will decrease. The increased role of primary care will be in managing an increase in chronic conditions in our population.
Much has been made of managed clinical networks, which I support, and of telemedicine, which I will support once it is up and running. I recently attended a health conference in Norway, at which I was interested to hear of a project to train GPs in Finnmark—in the very north—in child psychiatry. The GPs were supervised by a person from the teaching hospital at Tromsø via a teleconferencing facility. They worked in small villages of about 1,500 people. When I asked whether all those villages had teleconferencing facilities, people looked surprised that I even asked. We have a long way to go to meet the investment need here.
As I said, I am not sure whether good management of long-standing conditions will prevent emergency admissions in the long term. Some admissions will be prevented but, with an aging population, ill health—including ill health of sudden onset—will not reduce. With good case finding and management, we might prevent somebody from having a heart attack at 70, but he could well still have to be admitted as an emergency with a heart attack at 82. We cannot reduce funding for emergency work until a population trend is clear.
The report was a bit overoptimistic about what information and communication technology could deliver. I do not underestimate the importance of IT, but I have experience in my previous professional life of an IT system—a children's special needs database—that was out of date before my trust received it and was slow and unwieldy. It was eventually abandoned as unworkable. The right IT can be a big help, but getting it wrong is worse than not having it.
You have one minute.
As I am running out of time, I will shorten my speech.
I support and welcome the case-finding approach to diagnosing and treating individuals with ill health in our deprived communities with poor health records. That is important. However, we also need a public health and ecological approach that considers such communities as a whole and what makes a community unhealthy. In some parts of Scotland, it can be difficult to lead a healthy life, and that is even without mentioning the probable role of environmental pollution in some diseases. At the least, we should plan our communities so that people in their daily lives automatically undertake the half-hour of moderate exercise that is all that is required to keep fit. We should not just accept ill health; we should design ill health out of our communities. Otherwise, the NHS will always be under pressure.
I broadly welcome the report and the Executive's response. I agree that more health care should be available in the primary care setting. However, I am not sure whether that will result in a reduced workload for hospitals, because primary care will be fully stretched by dealing with the increasing number of chronic conditions such as type 2 diabetes and osteoarthritis that are a direct consequence of our unhealthy lifestyle.
I call Scott Barrie. You can take four minutes.
I appreciate your squeezing me into the debate, Presiding Officer.
As Professor Kerr's report says, the future of health care is a question that goes wider than the preoccupation with hospitals, but part of the debate has yet again been about hospitals—I will fall into the same trap. We must acknowledge Professor Kerr's statement in the report that the issue
"is not about protecting the bricks and mortar of the local hospital. It is about preventing frail older people for whom hospital is an … unwarranted … disruption from being admitted and looking after them more effectively close to home."
Too often, debates about our health service concern illness and the part of the health service that cures ill health rather than being about the prevention of ill health, which we should promote if we are to do anything about the great health inequalities that several members have mentioned.
As we know, the vast majority of our health care is delivered in the community. Margaret Jamieson gave good concrete examples of that happening in her area. If we concentrated more on improving community health facilities than on what is happening to our acute hospital provision, we would go a long way towards redressing the health agenda and we would focus on what could make a huge difference to people.
The problem is that the Kerr report appeared later than when many people started the health debate. Before the Kerr report was published, several health authorities, including mine—Fife NHS Board—had got well into, if not concluded, their consultation processes. Such processes took place in a vacuum. Local people did not know the main drivers or prerequisites for change. If we had had something such as the Kerr report before we embarked on those processes, much of the pain and anguish that communities underwent would have been avoided, because people would have known the context. One huge difficulty in Fife has been the fact that the health board acted early in the process; it almost trail-blazed for other health boards that are now undertaking similar consultations.
Mike Rumbles was right in one respect: the Kerr report can be taken to mean all things to all people, but only if it is quoted selectively. If the report is taken in its entirety, it makes logical sense. The point is that the report must be taken in its entirety. If the pick-and-mix mentality is indulged in, the report justifies preconceived notions.
I am clear about the differential between scheduled and unscheduled care. For our acute sector, we must be clear that we can have a difference between those forms of care. If our health boards do not consider what is recommended in the Kerr report and what is happening on the ground in other health board areas, if they do not move away from the Berlin wall mentality—to which Duncan McNeil referred—whereby the health board is the sole arbiter of all health service provision and if neighbouring health boards do not work together in consortiums, we will be able to do nothing to improve the health agenda for the people of Scotland.
There is time for only a couple of minutes—for bullet points—from Ms Hyslop.
I will be very brief.
The Kerr report is frank, refreshing, realistic and creative. The challenge is for the minister to match that effort with effective political leadership. The key issue will be implementation. What happens next? The workforce and the public have invested much confidence, trust and good will in the process. We have now had our first cut at how to progress the recommendations. I will reflect on a few matters, including implementation.
The minister will know that I have an interest in St John's hospital. St John's provides a good case study of what the Kerr reports means. Everyone says that the report can be interpreted in different ways. We could consider whether hospitals such as St John's match level 3, what core services are needed and how we ensure that we keep enough intensive therapy unit places to make other services sustainable. If shared networking of children's and cancer services took place elsewhere, what would be the impact on local provision? As we know, there is a domino effect.
The Executive's report contains a phrase about activity and the case mix. Time and again, in all services, we return to professionals saying what is needed for activity and the case mix. We should drill down into what implementation of the Kerr report means, to ensure that we have sustainable services. We must have safe and sustainable futures for our services. The aim is prevention, but the trust, confidence and good will must be realised in practical implementation.
In several months' time, I would like us to debate what has happened and what will happen next. Perhaps we are now on a new platform for debating health, which is to be welcomed.
My lectern is faulty; that is another repair to report, I am afraid.
I moved my amendment not in the vain hope of persuading the four main parties, which have given varying levels of support for varying levels of privatisation in the health service, to support it; I moved it to ring alarm bells as loudly as I could in the chamber and beyond about the threat to our public NHS from private sector encroachment.
I dealt with that issue in my opening speech and will return to some details on it, but I will not go into it much further because there was another point that I was unable to deal with: although the Kerr report and Executive ministers aspire to address inequalities, there is a lack of detail on how that aspiration will be matched by money and on where the money for patients will go.
We know that spending per head of population in affluent areas is greater than that in deprived areas. I am interested in the mechanism to reverse that, the overall funding that will be awarded to health boards and what happens within health boards. Currently, there are absolutely no mechanisms for tracing where money goes and ensuring that it goes where it is needed most. For example, Glasgow might attract additional funding because of its deprivation, but that does not necessarily guarantee that deprived communities in Glasgow will receive that funding. The Kerr report and the Executive's response cannot be taken on their own—there must be an overall review of the health service's funding mechanisms. The Arbuthnott method of redistributing health care funds, which takes into account deprivation factors, redistributes only around 1 per cent of the entire NHS budget. That is not good enough if the scale of deprivation in areas of Scotland—particularly in Glasgow and Lanarkshire—is considered. Even with the Arbuthnott formula, Lanarkshire, whose level of deprivation is second only to that of Glasgow, has lost out—indeed, the Executive owes it money because the formula has not been properly applied in consecutive years. Matters must be placed in that context. We need an overall review of how health services are funded and of how deprivation factors are taken into account.
As I said, Lanarkshire is second to Glasgow in respect of deprivation factors, but it has the lowest number of practice nurses per head of population in Scotland. I want to see hard facts. Will there be more practice nurses in Lanarkshire? That will be the test of the strategy to address inequalities.
I hope that, in summing up, the Scottish National Party will clarify why its amendment mentions the expansion of diagnostic and treatment centres but does not specify whether those centres should be public or private. I believe that it has indicated support for the Stracathro independent treatment centre, which is, of course, privately funded. Will the Jim Mather wing of the SNP win? Will the NHS be seen as an opportunity—a golden goose—for his business pals to increase Scotland's private economy? What way is the SNP facing on the issue? It seems to be spinning like a peerie, inevitably to the right. Why did the SNP not put the word "public" in its amendment with respect to treatment centres? I hope that it will clarify matters.
Whether or not diagnostic and treatment centres should be public or private, there are many unanswered questions and concerns about them in England. There are concerns about their impact on the overall skills levels of staff, about resources being sucked away from the NHS and the overall skills base and about their impact on the educational levels of clinical staff in general. There will be more concerns if such centres are private.
On the separation of planned care and unscheduled care, it is one thing to protect planned care and elective surgery in a general hospital setting or wherever to ensure that patients' operations are not cancelled because of unpredicted care, and I agree that planned care should be protected, but it is another thing entirely to separate planned and unscheduled care geographically. Such a separation has not been proven to be efficacious or safe and there are many worries about it.
There is a danger in the pick-and-mix approach to which Scott Barrie referred, but that danger comes from health boards. For example, in implementing the maternity service requirements of the expert group on acute maternity services, health boards pick the bits that suit their agendas while requirements such as the guaranteeing of one-to-one patient care for women in labour are not enforced by boards or by the Executive. That requirement is still not met in a number of units throughout Scotland.
The debate has been short but good and has highlighted many issues in the Kerr report and the Executive's response and issues that flow from the two documents. As I said in my opening remarks, the hallmark of the report and the response is the change in emphasis to preventive and continuous care in the community. Measuring change as it takes place will be important, which is why a critical part of "Delivering for Health" is the section on timelines for action in annex A. In England, the NHS may have a 10-year strategic plan and a five-year interim review, but I believe that, if they are monitored, the timelines for achieving the stated outcomes by the end of 2009 will be as effective if not more so. None of us underestimates the challenges, but perhaps the Deputy Minister for Health and Community Care will say a word or two more in his closing remarks about how the department intends to carry out the monitoring that will ensure delivery.
Let us consider the example of child and maternal health. A significant number of groups are to be established and reports and plans are to be produced. Implementation is to begin by 2007 or later. How will ministers and the department keep track of things? How will implementation be pressed forward where it is slowed or delayed?
The Minister for Health and Community Care mentioned a welcome investment in ICT, which members have not commented on much. Procuring a new national ICT system in 2007 and aiming for full deployment by 2010 is ambitious. Perhaps the deputy minister will also say more about the new national system in his closing remarks. There have been notable ICT disasters in the public and private sectors in the past. I am sure that lessons have been learned, but are ministers confident that compatibility can be achieved with existing systems? Will the new system allow proper access for those who are involved in allied work, such as child protection?
Duncan McNeil rightly referred to the equality gap in health provision, and I entirely agree that people's life expectancy in our most deprived communities must be increased. The figures speak for themselves and should be entirely unacceptable to us all. However, the motion recognises that there are deprived people throughout the land. We must ensure that the needs of deprived people in affluent areas are also addressed, which is why the motion suggests that we should applaud
"the commitment to tackle health inequalities by developing anticipatory care in our most deprived communities and applying the approach to benefit people wherever they live".
The motion strikes exactly the right balance.
I want to clarify something from a Liberal Democrat perspective. We should consider enhancing the neurosurgical services of the four regional centres in Scotland and not focus the best care in one centre.
I am pleased to be able to deal with that issue, which Mr Rumbles has already mentioned. A letter from NHS Grampian that is before me states:
"In relation to neurosurgery we support the approach to plan services centrally and agree that highly-specialised interventions should be performed in centralised locations."
There must be greatly detailed discussions about the implications of that approach and no decision has been made yet. As the board's letter states:
"the implications for the management of neurosurgical emergencies, neuro-rehabilitation, undergraduate and postgraduate teaching and the recruitment and retention of staff … must be fully understood and addressed".
Those are all issues, but if certain things can rightly be placed in a centre in a managed clinical network and there is access from the four centres, that will be the appropriate way to achieve the best possible care for people at the highest level.
I will say a brief word on rural general hospitals. The danger is not that a common set of functions may be developed for such hospitals, but that sight may be lost of the need to be flexible to meet the needs of specific communities. We must ensure that rural general hospitals can meet the distinctive needs of different parts of Scotland. Also, some rural general hospitals may have developed specialisms, and it is important that we make use of those. Health boards should be prepared to use other health boards' specialisms where they are. For example, there is a very good maternity service in the Scottish Borders, and those who live in the southern parts of Lothian should be able to access that service because it is perhaps closer to them than the services in Edinburgh.
Implementation of the Kerr report and the Executive's response are key to all this. I look forward to future debates on how we are getting on with delivering the messages—indeed, the policies—that flow from those documents, on which there is general agreement.
The Executive's document, which was produced late this morning, does not answer all the questions—if anything, it asks more questions. To follow up Mike Rumbles's point, I draw members' attention to page 62, which contains two contrasting paragraphs on neurological services, which is a big issue.
The minister started off by talking about three core things, which are that he understands the demand, that he has a vision and that he has a programme. Well, we are yet to hear what the programme is. It is all very well that lots of us like bits of the Kerr report, but other bits of it are quite worrying to us and to the public. The minister was not particularly clear on where the Executive is going.
The Conservatives agree that preventive and continuous care should be improved, but if we are going to start doing proper screening, we need the capacity to deliver treatment once people have been diagnosed. I was recently involved in the case of a gentleman who had been diagnosed with cancer. He was waiting for an appointment, but fell through the loop; it was six weeks before I managed to get hold of a hospital to get an answer for him, and he was seen the following day. That is the sort of thing that patients tell us about, and for which the ministers must take some responsibility.
I agree with the minister that we should start people young on the personal responsibility route; in fact, that is a good Conservative principle. However, if we are going to do IT—as many members have mentioned—let us get it right by ensuring that IT systems allow all the allied services to have the appropriate level of access. Let us ensure that we do not have the pig in a poke that we have seen in England.
The minister talked about care in rural and remote areas and he mentioned staffing and training, but where are the details? He did not make any mention of rural general hospitals and what services he expects to be delivered from them. Other things that he managed to miss out include how much implementation of Kerr's recommendations will cost—there is no way that it will be cost neutral—and where the staff, equipment and buildings are going to come from. More important, and as Duncan McNeil and others asked, how will people access the services? Where will the services be located? Will they sit near public transport routes? Those are the things that we want to hear about. Another thing the minister did not say is when it will all be delivered. How long will the consultation be, and who will be consulted?
I like some of the other policies that the minister has adopted from the Conservatives: for example, he talked of a national tariff. His predecessor was quite keen on that when I proposed it in the context of a health bill, but the proposal was rejected because the Executive thought that it was an opening for the private sector. Of course, what we argue is that the money should follow the patient. As other members have said, the system should be about delivering care to the patient; the patient should not have to fit the system. We must get it the right way round, as Shona Robison said early on.
Several members talked about the creeping paralysis that comes from central control and direction, which is something that the minister does par excellence. Nanette Milne, Jean Turner and Roseanna Cunningham all mentioned that. The big point that the public wants to hear about is the understanding and interpretation behind the implementation that the minister thinks is going to come forward, which was mentioned by at least six members this morning. Others have mentioned public understanding. If we do not take the public with us, and the staff along with them, what is the point? The minister has certainly not convinced many people in the chamber today.
Many members have talked about local downgrades and closures. I will join Mike Rumbles and others on Saturday at a protest against the proposed closure of the Aboyne maternity hospital. The hospital was opened in 2003, when it was brand spanking new, and demand for its services went up 100 per cent a year. That demand is increasing again, yet there is talk of possible closure. In Fraserburgh, there have been public meetings, but no one can find out what the outcome of those meetings has been for the maternity hospital there.
John Scott raised a point about Ayr. He mentioned staffing, as did other members. Who is actually making the decisions? We are seeing an awful lot of centralisation of specialist services. I do not argue for world centres of excellence; however, we need to have the next level down available regionally so that people can at least go from there into the centre and back out into specialist care. I want clarity from the minister on that.
We all know that public confidence has been damaged by NHS 24 being rushed out, but I picked up another issue in The Scotsman this morning. There has been a rumour—two Labour members, Duncan McNeil and Scott Barrie, have mentioned it today—about the future of health boards. The previous Minister for Health and Community Care talked in a roundabout way about moving to three strategic authorities. That is fine, but the worrying point is that the ministers are today apparently considering whether local councils should take over health care. Apparently, they have a document in front of them.
That is nonsense.
If the minister wants to stand up and say that that suggestion is out of the way, I am glad. I want a definite statement on the record from Lewis Macdonald, when he winds up the debate, that that will not happen. Community health partnerships—CHPs—involve council services, so why are we not moving to take the staff and budgets from the councils into the health facilities, to give us single patient management with a single budget?
Because the minister's response to this document, which has a lot of quality, is ineffectual, the debate has merely opened the floodgates of demand and criticism. The minister must tell us today when we will hear what he will do with the Kerr report.
This has been an interesting debate. Obviously, it is impossible to cover the whole Kerr report in any of the short speeches that we have made today because there are many detailed proposals in it. Fundamentally, however, this is a debate about change. Most of us—although not necessarily everybody—agrees that change is needed and that we need to move forward. We also agree on some of the points that are made in the Kerr report. Duncan McNeil mentioned separating planned and unplanned care, which is absolutely right. We all agree on the necessity for that and recognise that it would be a step forward, although there are disagreements about how it would be carried out on the ground.
For Carolyn Leckie's benefit and clarification, maybe she should read the SNP's amendment. It says, "within the NHS", not the private sector. In neither of her speeches did she offer any solutions, just the usual moans.
Will Stewart Maxwell take an intervention?
No I will not. Carolyn Leckie has made two speeches; she has had her chance.
Diagnostic and treatment centres help to cut waiting times, but if they are outwith the NHS they will also have other, less welcome, results. Evidence is now coming forward about those problems. In its briefing paper, the BMA states:
"There are widespread reported gaps between agreed payments for predicted activity and the number of patients actually treated."
It also states that
"the private sector is creaming off uncomplicated, profitable activity on preferential terms leaving the NHS to deal with the patients the private sector doesn't want."
There are clear problems in going down the private sector route.
My fundamental concern is about the Executive's implementation. Several members, including Roseanna Cunningham and Fiona Hyslop, mentioned that. There are underlying concerns that the proposals that are laid out in Professor Kerr's report will either not be fully implemented or will be implemented in a way such as Mike Rumbles mentioned when he talked about cherry-picking. Other members have also talked about how implementation will be done. The Executive has a track record of failing to follow through on recommendations from committees that it sets up to advise it.
The first proposal in the Kerr report is for all NHS boards to put in place a way of managing at home or in the community older people who have long-term conditions, and of reducing their risk of hospitalisation. Osteoporosis is the perfect example of such a condition. It is a chronic disease of the elderly that is so common that one in three women over the age of 50 in Scotland has it. The Scottish intercollegiate guidelines network clinical guidelines for managing osteoporosis recommend that elderly frail and housebound women should be offered calcium and vitamin D supplements in order to reduce the risk of hip fractures and hospitalisation. However, when I asked the Executive whether it had any plans to monitor uptake of such supplementation among women in residential care, I was told that that
"is a matter for NHS boards and is not monitored directly by the Executive."—[Official Report, Written Answers, 8 June 2005; S2W-16925.]
How can we know what is going on if the Executive does not monitor what is happening? As in so many other areas of Government policy, there is a refusal to measure outcomes. If we are to meet that aspiration of the Kerr report, we need to know—we must set targets and measure progress against them. If we did that, we could make a difference, and fewer older women would break their hips.
Does the member not see the contradictions that we are faced with? David Davidson accuses me of being a centralist, while Mr Maxwell wants me to count the tablets that are given out in a home. We must give the health boards responsibility for local delivery and we must ensure that they work within our policies; that is what we tell them to do.
It is not about counting tablets. I asked the minister whether the situation was monitored, not how many people are taking the tablets, but the minister does not know. I also asked him when I intervened during his speech; he does not know whether the guidelines are being implemented. It is cheap to prevent such fractures and expensive to treat them, but the minister does not know whether they are being prevented because he does not monitor the situation or track progress. With such a level of commitment, I wonder what hope there is that Professor Kerr's proposals will reduce the risk of hospitalisation among the elderly.
The Kerr report also says that there should be
"action in deprived areas … to prevent future ill-health and help reduce health inequality."
That proposal is widely supported in Parliament. A pertinent example of that problem is the incidence throughout Scotland of coronary heart disease, which is far more common in our deprived communities than in our affluent communities. As the British Heart Foundation has pointed out, last year nearly twice as many people with CHD were discharged from hospital in Glasgow Shettleston as in Edinburgh West. That is why it is so critical that we follow the Kerr recommendation on that point. An example of a project that was designed to do just that was the have a heart Paisley project that was set up in October 2000
"to reduce the total burden and levels of inequality of Coronary Heart Disease (CHD) in the town of Paisley".
Eight of Paisley's 11 postcodes have higher deprivation levels than the Scottish average. A report said that the project did not have the expected impact and the independent evaluation report that was published by the University of Glasgow in March 2005 concluded that
"there are expectations that local agencies can deliver on agendas that central government will not address itself, such as major areas like nutrition retail policy … The solutions to these issues are more likely to lie within national than local policy."
That is another example of the Executive's failing to hold up its end of the bargain. What confidence can we have that the Executive will follow through on that recommendation? The recommendation requires national policy to direct and co-ordinate local action. Although local projects in our most deprived communities are welcome, they will not succeed on their own in preventing future ill-health and reducing health inequality. The Government must take responsibility.
Professor Kerr also states:
"Information and communications technology will give us the tools to fundamentally reshape how health care is delivered."
I could not agree more, but I have to ask whether the Executive has the foresight to employ those tools appropriately. To judge by past examples, the answer to that question would be no. Technology in itself will not save us; we must have the foresight to apply it appropriately. NHS 24 was set up to take calls, not make them. However, when the new GP contract came into effect, the remit of NHS 24 was changed to take on the business of providing a first point of contact and triage services for out-of-hours patients, but no one rethought the technology. It is not possible to make calls automatically from NHS 24. The review of NHS 24 states that an enormous amount of nurses' time is being taken up making calls out of NHS 24. The technology is available to sort the problem, but no one has thought it through.
The Kerr report is all about working smarter, looking ahead and planning to prevent crisis. However, the Executive has declared that it has no intention of producing a national strategy and that it will not monitor supplementations, and it is also looking to the private sector, despite the evidence from England of its negative impact on the NHS. It is failing to implement national policy, but instead hopes that local fixes will do, and it has changed the remit of organisations without changing the tools that they require to carry out their new roles. When I look at that, it seems to me that we do not have a Government that has the necessary foresight or will to implement successfully the Kerr report recommendations. On the evidence so far, this Government is neither capable of nor fit to achieve that goal, which is necessary for all of us in this country.
This has been an important debate, although I am sorry that Stewart Maxwell spoiled a rather good speech with his final rhetorical flourish, because we have discovered that there is a quite a lot of support for quite a lot of what we propose to do in response to the Kerr report.
Scotland is not alone in facing the dual pressures of an aging population and a growth in chronic disease but, we are feeling those pressures more acutely and earlier than many other countries. A recent academic paper on care for chronic conditions reported that
"most healthcare systems have not kept pace with the decline in acute health problems and the increase in chronic conditions … most healthcare today is still trying to manage chronic problems using acute care mentality, methods and systems."
That is what Kerr's report and our response are designed to change: an acute care approach to dealing with chronic conditions simply will not work. Because the pressures are so marked in Scotland, we have the opportunity to take a lead in finding ways of dealing with them. That is what the paper that we have published today will allow us to do.
I am grateful to the minister for giving way and I apologise if I repeat what I said earlier. The minister emphasises chronic conditions. Yesterday, Adam Ingram and I were at a meeting of the cross-party group on mental health, at which it was clearly stated to us that if someone who has mild or moderate depression is treated early, the condition does not become chronic. Will the minister also emphasise early intervention?
The emphasis that I have placed on chronic conditions does not take away from the emphasis throughout the Kerr report and in our response to it on early intervention in dealing with conditions of all kinds.
Several members asked about dates and timescales. I want to be clear about one thing: the paper that we have published today is not the launch of a consultation. "Delivering for Health" sets out a detailed programme of action for the next five years, with actions with clear timescales allocated to named organisations. We will report on progress and members will be able to judge that progress.
Euan Robson and others asked how we will monitor delivery of the objectives. We have set up a delivery group within the Health Department that will focus on that monitoring. The public and annual reviews that we have conducted this year for every NHS board will also provide a clear focus for boards that are reporting on progress to ministers and their local populations.
As David Davidson seems to have picked up some interesting ideas over his breakfast, I will clarify that there are no proposals for full-scale reshuffling of health boards or for local authority hospitals. I hope that Mr Davidson will find more time to read the documents that we publish rather than stories in newspapers.
One of the key issues that was raised by several members, Duncan McNeil in particular, is the importance of tackling health inequality and recognising the increasing gap in life expectancies. It is important to make the point for the record that, with one exception, life expectancies are going up everywhere in Scotland, but the gap is increasing because more affluent communities are more likely to endorse and take advantage of some of our messages about improved health and more healthy lifestyles. We acknowledge that we have to tackle that growing gap and that it cannot be allowed to continue to grow.
We also know that we are in a good position to do something about the situation. We believe that the Kerr proposals that are endorsed by our response will allow us to do that. In 2006, we will pilot anticipatory care approaches in some of our most deprived areas, with a view to rolling them out to all our most deprived areas wherever they might be. We will focus resources in primary care on case finding, health screening and preventive interventions for people who are at high risk of ill health. The focus will shift from fixing and mending to anticipating and preventing. We will put NHS Scotland at the forefront of international practice by the end of 2007 by providing intensive and co-ordinated care to those who need it in their own communities. By doing that, we will also improve the quality and speed of acute services, which will allow them to focus on people who need acute services and to reduce pressures from people who would be best cared for in the community.
Have a heart Paisley has been mentioned. It is a good model and lessons can be learned from it at local and national level. It is the kind of intervention that goes out to people in the most deprived communities, finds out why they are not accessing the services that exist and then does something about it. We need to redesign services in that way to make them more accessible and to ensure that they give people, even those in our most deprived communities, real choices that they do not have at present.
We also recognise that it will be increasingly important to support self-care and self-management to ensure the independence of people who have long-term conditions. In that respect, we acknowledge the valuable contribution of family members and other carers, and we expect NHS boards to support them in their role. In 2006, we will establish a Scottish long-term conditions alliance to support patients' self-management and we will work with that alliance to ensure that patients and carers have the necessary skills and knowledge. Moreover, we will expand primary care by investing in community health centres, which can provide day-case surgery and diagnostic, rehabilitation and outreach services, and will accelerate the development of practitioners who have special interests and extended roles.
The minister has referred to the Scottish long-term conditions alliance, patients' self-management and so on. Who will fund those initiatives, what will the Executive put into them and who will staff them?
We will roll out the proposals over the next year and we will ensure that the alliance brings together people who are already on the front line, dealing with patients. However, we must focus on the patient, rather than create a new bureaucracy and, in order to take a co-ordinated approach to management of long-term conditions, we must ensure that the alliance also includes people who experience such conditions.
As Andy Kerr said in his opening speech, we will implement certain changes to make further progress on waiting times in Scotland. For example, we will treat day surgery rather than in-patient surgery as the norm, improve referral and diagnostic pathways and actively manage admissions, discharge and follow-up after leaving hospital. Starting in 2006-07, boards will develop a three-year plan to introduce those changes, which will increase the health service's productivity and the return on our health spending.
On the cost implications of the Kerr report, which several members raised, we were encouraged by the fact that Andrew Walker, the health economist who examined the proposals for us, concluded that they could be delivered on a cost-neutral basis because of the shift in the balance of spend. However, we also recognise that, having already made available record levels of resources, we must get the best possible value for them.
Members also highlighted ICT. Such technology will enable better service delivery and allow us to connect different parts of the health service for patients' benefit. The Kerr report suggests that we should seek to procure a common NHS system by 2008; however, we have gone beyond that recommendation with this morning's announcement that we will seek to begin the procurement process for such a system by 2007, with a view to implementing it by 2010.
Moreover, we are in the shorter term pressing ahead with a number of work streams to complement that objective. For example, we will ensure universal uptake of the community health intake number by June 2006; the implementation of a national accident and emergency management information system by January 2007; and the national roll-out of picture archiving and communications systems—or PACS—by June 2007.
Janis Hughes asked whether the new Stobhill and Victoria hospitals will be able to use such systems. When those hospitals open their doors in two years' time, they will be fully equipped with modern and effective PAC systems and an IT infrastructure that will support the single patient record system as it is introduced over the period 2007 to 2010. We will ensure that both new hospitals will have the best possible technology and full IT integration from the outset.
We are also discussing with Grampian NHS Board an outline plan for a national centre—or, as some might see it, a centralised service—for telehealth; we expect proposals to be made shortly. As I have shown, we are looking to develop services in a number of ways.
One or two issues that members raised have already been covered in the debate. Euan Robson comprehensively responded to queries about neurosurgery, and I simply reiterate his point—and the point that Shona Robison made in her opening speech—that we are talking about a managed clinical network. Decisions have yet to be taken and we want to develop the best possible service.
Will the minister give way?
No. The minister is in his last 30 seconds.
We will continue to implement the conclusions that we have reached. Indeed, we have set out a clear framework in that respect. In December 2006, we will publish a delivery plan for mental health, which is another important issue that members raised, and we expect to have published by December 2006 a comprehensive report on standards of care in remote and rural areas.
What we have heard this morning indicates a very broad consensus on, and support for, the direction of travel that has been set by the Kerr report and our response to it. I particularly welcome the wide support for improving health service delivery by separating planned and unscheduled care.
The steps that we have highlighted in "Delivering for Health" show how we can turn the vision in the Kerr report into reality. I hope that people with an interest in Scotland's future health will move away from tired old arguments about how we can keep services the same and instead engage in a real and worthwhile debate on how we can make them better.