Health Board Elections (Scotland) Bill: Stage 1
The next item of business is a debate on motion S2M-5478, in the name of Bill Butler, that the Parliament agrees to the general principles of the Health Board Elections (Scotland) Bill.
First, I wish to draw attention to my entry in the register of members' interests relating to the financial support given to me by Unison to aid the development of the Health Board Elections (Scotland) Bill that is before the Parliament today.
I wish to record my thanks to the 160 individuals and organisations who took part in the consultation on the bill proposal, and the various organisations that took part in the ad hoc bill steering group, such as Voluntary Health Scotland, the National Childbirth Trust, the Scottish Trades Union Congress, the Royal National Institute of the Blind Scotland, Capability Scotland and Help the Aged Scotland. Their contributions have been invaluable. There has also been support from the printed media, most notably from the Evening Times and The Herald, for which I am duly grateful.
I welcome the Health Committee's stage 1 report and the diligence of all its members in their detailed interrogation of the bill at stage 1. I am pleased that the committee recommends that Parliament should agree to the general principles of the bill and allow it to go forward to stage 2. However, I am very aware that the committee expressed several continuing concerns in three specific areas, and voiced its belief that changes should be considered in those areas if the bill is to proceed to stage 2. If I may, I will address those concerns and make an initial response to them.
To quote the committee report, the first issue is:
"The absence of any remuneration, loss of earnings or expenses for elected members discriminates against people with low earnings and favours candidates who are retired and well off."
When I appeared before the committee on 14 November, I acknowledged in response to a question from my colleague Helen Eadie that the lack of remuneration or compensation for loss of earnings was a gap, and that I would seek to bridge that gap at stage 2. That is still my intention. My suggestion will probably centre on introducing loss of earnings compensation capped at just over £7,000 per annum, which is the average for appointing members to health boards. Given that members will serve an average of three days per calendar month, that would mean that people who earn up to £80,000 per annum could put themselves forward to serve. I hope that such a proposition would be at least a starting point for debate in the Health Committee at stage 2, and I thank the committee for pointing out that omission.
The second area in which I agree with the committee that more discussion is needed concerns the bill's proposal to have 14 constituencies mirroring the existing 14 area NHS board boundaries. I was struck by the apprehensions that were voiced by several colleagues on the committee, particularly Kate Maclean and Roseanna Cunningham, that such constituencies would not accurately reflect the diverse geographical areas that many national health service boards encompass. I am open to the suggestion on page 15 of the Health Committee's report that
"it would be fairer to sub-divide those board areas into a number of more representative electoral ‘wards'. These smaller areas could for example reflect local authority boundaries or the rural:urban characteristics of particular board areas."
I am only too happy to discuss with the committee at stage 2 how such an amended geography could be effected. I have no problem with that notion in principle. My legal adviser, Mike Dailly of the Govan law centre, has been turning his mind to that very matter, among others, in anticipation of stage 2.
The third area of concern that was raised by the committee—the percentage of board members to be directly elected—might prove to be more challenging. I agree with the committee that there is a debate to be had on that, but I remain of the view that 50 per cent plus one, or a simple majority, would produce a reasonable blend of appointed members with their experience of the NHS and a directly elected element that would inject a welcome degree of direct accountability to the workings of the board. However, if the bill proceeds to stage 2, I stand ready and willing to enter into the debate on the matter in a spirit of collegiality.
I believe that there is strong support across Scottish society for the introduction of direct public elections to Scotland's NHS boards. I also believe that the case for greater democracy, accountability and transparency in the decision-making process for local health services is compelling. I continue to believe that the best way to achieve greater accountability and transparency is through the introduction of direct public elections.
The Health Board Elections (Scotland) Bill would significantly increase public involvement in local NHS services. It would involve people in the planning and delivery of health care services in their communities. The bill's main aim of introducing more democracy into the operation of health boards does not mean—I emphasise this—that I believe that all board decisions are necessarily wrong and detrimental to local health services. That would be absurd.
Bill Butler said that he would be prepared to accept various amendments at stage 2, but what would he do if health boards as we know them were abolished? There has been talk of such a move. Also, what are his thoughts about the operation of the community health partnerships?
I believe that the CHPs are not inimical to the reasonable reform that I have suggested. In response to David Davidson's first question, I point out that no such proposal is before us so the question is hypothetical.
The undeniable problem with the way in which boards currently operate and reach decisions lies as much in public perception as in the nature of the decisions. The anger that some people feel about certain decisions is, to an extent, generated by the manner in which those decisions are seen to be made. They are made in secret with little or no explanation, are often predetermined and often ignore the views of the community and the responses that have been made to the board's consultation processes. Many people believe that health boards' consultations are predetermined. That is not a happy situation.
The member has pointed out the need for democracy, openness and accountability. Might they not be provided by a better system of accountability and report back on the part of health boards?
The improvements that have taken place in public participation—I think that that is what the member alludes to—are to be welcomed. In fact, every witness who gave evidence to the Health Committee welcomed the reforms in public participation. However, I believe that we should go just a little further. The direct democratic accountability that would be introduced by the bill would be complementary to the public participation reforms that have rightly been introduced by the Executive.
There is no perfect method for consulting the public on major local health issues, so I do not believe that direct public elections would lead to everyone being happy with every NHS board decision. However, I contend that decisions that are made by health boards on which there is a large democratically elected element will have much more credibility than those that are made under the current system.
Accepting that decisions are legitimate is at the heart of representative democracy. Democracy is not always about getting our own way, but it is a way of making decisions that takes serious account of people's opinions. Unfortunately, that does not happen with NHS boards at the moment. Direct public elections would allow the public a mechanism to influence service delivery in their area. If we are to address public apprehension—and, indeed, suspicion—there must be greater openness and transparency and there must be direct accountability. The bill, if enacted, would allow such an approach to thrive and prosper.
During the evidence-taking sessions, my ears were open but I did not hear a convincing explanation of why the make-up of regional NHS boards should not contain a strong element of direct democratic accountability. Introducing greater democracy would mean more than just structural change. Introducing electoral accountability would involve patients and communities and provide an opportunity for public debate and greater access to information. The bill would lead to a sea change in the culture of NHS boards. That is a positive reform that needs to be made.
The bill proposes a simple majority of 50 per cent plus one. I admit that some people whom I have consulted in recent months argued that a greater proportion of health board members—up to 100 per cent—should be directly elected. However, I feel that the blend of experience and direct accountability that is offered by the bill is just about right.
I emphasise that the bill supports the retention of local authority members on NHS boards. Unhappily, however, even with the inclusion of local authority members on each NHS board, which is progress, the feeling remains out there that the boards have failed to engage effectively with the communities that they serve. Some proposals that are made by NHS boards are not popular with the public, but will result in improvements to local health services.
I hope that my bill will succeed in making health boards work harder at explaining their proposals to the communities that they represent, engaging with the public more directly and explaining clearly and openly the pros and cons of any changes to local health services. Only when that greater level of direct accountability and transparency has been achieved will communities feel in any way reassured that health boards listen to their views. If the bill succeeds and direct elections become a reality, not every decision that is taken by an NHS board will be universally popular, but I hope that the elections will help to make health board decision making more open and relevant.
I move,
That the Parliament agrees to the general principles of the Health Board Elections (Scotland) Bill.
It is perhaps no surprise to anyone in the chamber that the Executive is opposed to the bill. I will spend some time explaining the reasons for our position. The bill raises fundamental and important issues, and it is right that those issues should be clarified and that everyone here understands the points at issue.
It is worth reminding ourselves that the Health Committee looked at the proposals carefully and came up with a report that stopped well short of being a ringing endorsement. One has only to look at the conclusions in paragraphs 81 to 91 of the report to see that. It is clear that the committee recognised the bill's shortcomings and deficiencies. We need to take careful note of that.
There are five distinct reasons why we oppose the bill as it stands. Before I list them, however, I make an important point about our intentions. We see merit in considering further the concept of local democratic participation in our NHS. We believe that it needs to be approached in a considered manner that carefully tests all the complex issues involved, which were identified by the Health Committee in its report. Testing out those ideas through piloting the concepts is the right thing to do, rather than rushing in with proposals that have not been considered adequately and which might not be fit for purpose. That will allow us to undertake the dialogue and consultation that the issue deserves.
My objections to the bill are as follows. First, the bill would introduce major changes to the structure of the NHS by proposing that a majority of members be elected. That is not about a technical detail, as Bill Butler acknowledged. A majority of members means that there is a risk that ultimate control of the direction and actions of our national health service would lie with that majority.
To my mind, that would fundamentally alter the existing clear accountability of the NHS to ministers through its appointed boards, and subsequently to this Parliament. That would lead inevitably to competing mandates at national and local levels. It would create conflict that would detract from our core purpose of creating better health services and improving health in our communities.
Why does the minister think that it is perfectly acceptable for Edinburgh's man in Glasgow, for example, to be accountable to the public through the minister, but not to be accountable directly to the public? Councillors have their own mandate; why cannot health board representatives have their mandate too?
Because it is the national health service. Week after week in this chamber I hear from members about postcode prescribing, about boards not doing what they should do, about waiting times and about cancer targets. The resources for those boards are voted on by this Parliament. The bill would remove the centrality of the NHS and create a competing mandate. The bill does not address that point.
The bill's proposals would lead to uncertainty about who is responsible for monitoring and improving performance, for making hard decisions in the interests of patients and for planning tomorrow's health service.
There is a risk that the bill would have serious consequences for boards, patients and communities. The Health Committee recognised that. Its report refers to the New Zealand model of governance arrangements, which I agree is potentially relevant. The issues are complex and we would wish to give such a proposal careful consideration. However, it is not reflected in the bill and we are advised that amendments along those lines would be beyond the scope of the present bill. As I have made clear, we should not in any case seek to change NHS governance arrangements in a hurry and without proper consideration, dialogue and consultation. That is why we have shown our willingness to look further at piloting the concept.
My second reason for opposing the bill is that, as the Health Committee recognises in paragraph 85 of its report, it risks putting difficulties in the way of implementing the important national policies for which the Executive has a mandate and which the Parliament has already debated.
We need look no further than "Delivering for Health", the implementation of which represents a vital step in the NHS's progression. At the moment, we are deeply engaged in that work. With all respect to everyone who is directly involved, the task of working through those changes is difficult enough, without our making it even more difficult by electing boards in the manner proposed.
It is worth noting that the Health Committee has accepted that directly elected members on NHS boards might undermine the NHS's national element. As it stands, the bill risks fragmenting our national health service and will make it increasingly difficult to ensure that key national policies that are vital to our local communities are implemented. That undermines the vision that we all share for the NHS in Scotland of having equitable services that are available to everyone on the same basis throughout the country. It risks introducing an unacceptable postcode pattern of delivery; could cause real problems for initiatives to reduce health inequalities; and could mean that services such as mental health that have a lower public profile and services for learning disabled people have less of a priority.
Simply electing people to a board would not remove the need for tough decisions to be taken. Such decisions would still have to be made, and public concern about them would not magically disappear with the introduction of direct health board elections. Boards would still need to inform their public; to persuade them that it is right to modernise services; to improve efficiency and effectiveness; and to ensure that services are safe and sustainable. I am worried that the proposal to elect a majority of board members runs the risk of increasing dangerous short-termism and self-interest in how NHS services are looked at, and might ultimately put patients at risk.
My third reason for opposing the bill is that it will do nothing to sustain and promote the improvements in NHS performance that we have witnessed over the past five years. For example, the service has managed to get on top of the long waits that used to dominate our debates about it. Moreover, the tremendous strides in providing more vital operations such as hip and knee replacements and cataract operations have been achieved through rigorous management and planning and by boards working together across boundaries. I do not believe that the bill would benefit patients and the public by improving performance further. On the contrary, the risk is that boards would be distracted from that task.
Fourthly, the proposed elections would cost money and time. The Health Committee has accepted that its costs would be well above the estimates that were provided by the bill's promoters and we must be very careful about diverting resources away from patient care.
Fifthly, the bill would not—to put it simply—do what it says on the tin. It would not promote effective public engagement and the involvement of patients and service users in our NHS, even though that is what those who support the bill seek to achieve. I make it very clear that we strongly support the effective engagement of the public and patients with NHS boards in planning and delivering services and that our track record in that respect is very strong.
Does the minister agree that the estimated cost of £5 million, which is at the top end of the Executive's approximations, would be a drop in the ocean compared with the more than £10 billion that is spent on the NHS? Does democracy not have to cost something?
Yes, it does. However, the Electoral Reform Society does not believe in Mr Butler's approach to the elections, which could be even more expensive than has been estimated. Furthermore, as far as the health budget is concerned, there is no such thing as a drop in the ocean. Every penny is—and should be—well spent in the interest of patients.
I remind members of the improvements that we have made. Senior local councillors now sit on all NHS boards, which have a statutory duty to involve the public. We have established the independent Scottish health council; community health partnerships have public partnership forums; and I personally hold NHS boards to account through annual reviews. Many other mechanisms make our NHS work for the benefit of patients, but not in a way that undermines the national element of our national health service.
These serious issues need serious debate. We are discussing 60 years of NHS history, not issues that we can rush through in the last few weeks of the parliamentary session. If we are thinking of making fundamental change, we should at least give ourselves time to do so properly and to consider the implications—which means being realistic and accepting that the proposed changes are fundamental and will have very serious consequences for our NHS.
I understand Bill Butler's points about his bill and about public engagement and involvement, and indeed share some of his concerns. However, as I, the British Medical Association, the Royal College of Nursing and many other witnesses to the Health Committee have argued, steps to improve public engagement need to be given time to bed in more effectively.
You should be finishing now, minister.
The bill is emphatically not the answer to the concerns that have been expressed. Our opposition to the bill is long standing and principled and there are good reasons for it. Make no mistake—significant changes are being made and we want to involve stakeholders in implementing those changes, but we need to ensure that we get the process right. I believe that our approach gives us the best of both worlds. It allows us to progress some of the principles of the bill, but in a way that safeguards the future of our NHS. I commend that course of action to the Parliament.
I pay tribute to the work of Bill Butler and his bill team in developing the bill.
The Scottish National Party has supported the principle of direct elections to health boards for some time, not because of some notion that it is a panacea that would resolve entirely any local disagreements about how health service changes are managed, but because we believe that it is the right thing to do. Supporting direct elections to health boards is about saying to Scotland's people—who are, after all, the consumers of health care—that we trust them to have a strong say in what happens to local health services.
That is important, given the significant disillusionment that exists and the belief that decisions in the health service are being taken by unelected and unaccountable people who have little regard for the views of the local population. Far too often, health boards make clear their preferred option at the start of a consultation process and do not deviate from it, even though the consultation process might throw up sensible alternative suggestions and options.
I believe that the proposal in the bill would help to restore some of the public's confidence in how our health service is managed and delivered. I remind those members who do not think that there is a problem with public perception of Bill Butler's evidence to the Health Committee last year. He said:
"according to a survey that the Executive commissioned in 2004, 73 per cent of the public feel that they have little or no influence over how the NHS is run",
which represents
"a rise in dissatisfaction of 16 percentage points over a survey in 2000."—[Official Report, Health Committee, 7 November 2006; c 3200.]
I simply want us to get our statistics in order. Do we know what percentage of the public is satisfied that they are properly represented in the decisions that are taken in the Parliament?
I am sure that there are a number of views about that and that many members of the public feel that they are not properly represented in the Parliament's decisions but, ultimately, it is for Margo MacDonald and other members to ensure that they are effective in representing the people whom they have been elected to represent.
The issue that we are debating is about the public having a voice at the top table where health service decisions are made. We must acknowledge that people feel disfranchised. If we had direct elections to health boards, difficult decisions would still have to be taken, but they would be taken in an open and transparent manner and local people would be involved at the heart of the process.
There are some areas of the bill that we would like to be changed at stage 2. For example, we agree with the recommendation of Fairshare Voting Reform that a single transferable vote system would be a better way of running the proposed elections. The fact that Bill Butler mentioned the need to reflect the geographical balance in health board areas has reassured me that he is willing to take on board the committee's concerns on the issue at stage 2.
Cost has been an area of debate. Predictions of what the elections would cost range from Bill Butler's estimate of £1.2 million over four years to the Executive's estimate of £5 million over that period. I suspect that the actual figure would be between those two sums.
I am surprised by what the member has said, because it is my understanding that Bill Butler is not willing to discuss having a fair voting system and that we would be lumbered with the undemocratic system that he has proposed. Perhaps Bill Butler could clarify that later.
Mr Rumbles knows how the Parliament works. It is a question of trying to persuade people of the merits of one's arguments at stage 2. That is all one can do. We know from experience that compromise is necessary so that the best elements of a bill can be progressed. We should not throw the baby out with the bath water.
I am aware of the opposition to the bill of some of the professional bodies, which fear that the adoption of direct elections to health boards would prevent changes from being made to the health service at local level and would politicise the NHS. However, we would be fooling ourselves if we pretended that politics do not already feature in the NHS. The professional bodies should have a little more faith in the ability of local people to make difficult decisions and to weigh up the competing demands and pressures that arise.
Will the member give way on that point?
I have taken two interventions and I need to make some progress. [Interruption.]
The member is not taking an intervention.
Surely the same arguments and concerns could be raised against involving the democratic process in the management of education or social work. Even so, I assume that the minister agrees that no one is suggesting that we do away with democratically elected local authorities.
The Minister for Health and Community Care's vehement opposition to the bill and its principles is disappointing. In commenting on the balance of opinion in the committee, he should have said that, at the end of the day, the committee came down in favour of the bill. If the Executive is now saying that it will take forward only legislation that has the overwhelming support of committees, that sheds an interesting light on some of the decisions that it has made.
The minister said in evidence:
"The bill is … unnecessary. It adds nothing to the programme. Indeed, it undermines the current clear and unambiguous lines of accountability from NHS boards to ministers".—[Official Report, Health Committee, 7 November 2006; c 3183.]
I disagree. The minister is taking a rather blinkered view of the matter, which portrays little trust in those who seek to serve as public representatives on elected health boards.
It is good that many of the minister's back benchers do not share that view. I refer to the 16 back benchers who supported Bill Butler's bill from the start. That is positive. I hope that the Tories may change their position in the way that Tory members of the Health Committee did. I hope that they will support the general principles of the bill. Tory members can argue their position on the percentage of elected members at stage 2.
I am very surprised about the continuing reluctance of members of the party of liberal democracy to allow people to have their say on this and other matters. Surely denying the public a say in the way that our health services are delivered is not a very liberal view for them to take. Despite the opposition of Liberal Democrat members, the 16 Labour back benchers who pledged their support for the bill mean that we should have a parliamentary majority in favour of the general principles of the bill.
The member should be closing.
Surely that option is preferable to that which the minister is taking in fudging the issue by calling for pilots. Clearly, he is diametrically opposed to the principles of the bill. We require a clear mandate from the Parliament, and I hope that the Parliament will give that today.
I came to the stage 1 consideration of the bill with a completely open mind. I fully understand Bill Butler's reasons for introducing it. Over the past year or two, there has undoubtedly been a growing sense of dissatisfaction about the way in which health boards engage with the public on the provision of local health services.
I remember the extremely well-attended meeting in the chamber a couple of years ago, ahead of the publication of the Kerr report on the future of the NHS in Scotland—the public were well represented. I recall people's enthusiasm and optimism because, at last, they felt that they were making a real and meaningful input to the future shape of their national health service.
Unfortunately, when it came to the reconfiguration of local health service provision in the wake of the Kerr recommendations, too many people in too many parts of Scotland felt that health boards were not consulting fully. They felt that boards were treating the subject of the consultation as a fait accompli, which meant that responses fell on deaf ears. That generated very strong feelings and major campaigns against proposals to close hospitals, accident and emergency departments and maternity services in various parts of Scotland. Despite those campaigns, most health board proposals gained ministerial approval in the end, which has left local residents and their representatives feeling very short changed.
Will the member take an intervention?
No.
There have been exceptions, including the fight to retain the option of giving birth in community hospitals in Aboyne and Fraserburgh in Aberdeenshire. I suspect that Mr Rumbles may have wanted to refer to that. The fight was hard won in the teeth of opposition from the health board.
Is the member aware that, in all the major configurations—including the one that Lewis Macdonald conducted in Lanarkshire—major concessions were made in favour of the community? Is she also aware that major conditions were put on boards in respect of service change?
I hear what the minister is saying, but I am dealing with a point on Aberdeenshire. The outcome in that case was successful, but only because of a committed and articulate campaign by local people that was backed up by extremely robust representation from constituency MSPs such as Mike Rumbles who became involved in the campaign, as the minister well knows. Winning that battle took time, commitment and resources. I cannot help feeling that much of that could have been avoided if the health board had been aware of the strength of public feeling and merits of the case before it took its decision to recommend closure of the maternity units in question.
I have a great deal of sympathy with the general principles of the bill, as it would give directly elected members of the public a seat at the health board table when important changes are discussed and a direct input into the process before decisions are made. I know that health boards now have a duty to involve the public via the public partnership fora of the CHPs and that the Scottish health council must oversee the quality of consultation in the NHS. I accept that those arrangements are new on the ground and are not yet fully tested, but many people in our communities feel that the approach is still very top down and they are extremely sceptical about the consultation process. Health boards are certainly accountable via the minister and Parliament, but the public often feel left out.
Will Nanette Milne give way?
No.
However, I accept the other side of the argument, which is that having a majority of directly elected health board members could lead to short-term decision making, single-issue candidates and, on occasion, distortion of priorities or delay in making difficult decisions. In some instances, that could lead to inequalities of care or an undermining of regional services planning.
Will the member give way on that point?
I would like to carry on.
Because of that possibility, I am not happy with the bill's provision under which 50 per cent plus one board positions would be directly elected, thereby giving those members a majority on the board. Honour could be satisfied by the election of a smaller proportion of board members, which would give communities a direct voice without giving them absolute power over board decisions. To achieve that, we do not need to increase the size of health boards. Instead, I would like a proportion of the non-executive board members who are currently appointed by the minister to be replaced with directly elected members of the public.
Does Bill Butler find those proposals acceptable? I appreciate his willingness to enter into debate at stage 2, but I would like a clearer indication from him today of how he would respond to my proposals.
I am of course willing to take part in discussion, which will involve all the Health Committee members and, if the bill gets to stage 3, all the members of the Parliament. To quote the committee's report,
"there is a debate to be had".
I hope that that gives Mrs Milne some comfort.
Not entirely.
I share the Health Committee's concerns about the size of the electoral wards that are proposed, although I welcome Bill Butler's earlier comments on that.
I agree that the absence of any remuneration would discriminate against people on low earnings and dissuade them from standing for election. I look forward to hearing more details of Bill Butler's proposals on that, which he mentioned earlier.
The Conservative group is, by and large, willing to support the general principles of the bill at stage 1, but our continuing support beyond that depends on significant amendments being accepted. In particular, if our proposal to reduce the proportion of directly elected members to less than 50 per cent of board membership is not accepted at stage 2, we will withdraw our support for the bill.
I congratulate the member in charge of the bill, Bill Butler, on the way in which he has progressed his proposal thus far. I appreciate the courtesy that he extended to me personally and to my Liberal Democrat parliamentary colleagues by coming to discuss the bill with us on two or more occasions. Today, we are asked to debate the general principles of the bill and it will be no surprise to Bill Butler, from reading the Health Committee report, that we intend to oppose the bill's further passage for reasons that I will set out. I emphasise that we oppose the bill because we disagree that it is the right way forward and not because we have any quarrel with Bill Butler or his backers—I hope that that is clear from what I have just said.
The Liberal Democrats want increased democratic input into the NHS. We are in favour of greater accountability and scrutiny of geographical health boards and we wish more effective consultation to be developed. On that point, part of the impetus for the bill has been the apparent inadequacy of several consultations, which has sometimes arisen from a lack of engagement, although on other occasions the consultation process has been exhaustive. The common thread is that consultations have not been considered to be genuine because they have been seen as exercises that were undertaken to give legitimacy to decisions that were made in advance.
In one way, the bill would indeed increase democratic input to the health service, though I doubt that it would bring about greater accountability or improved scrutiny. Under the bill's proposals, direct elections to the 14 geographical health boards would have a majority of health board members elected on a first-past-the-post system and on a non-party-political basis. However, members so elected could be single-issue advocates, or people with particular preoccupations, or people from certain pressure-group backgrounds. Such would be the size of the electoral areas, especially in rural parts of Scotland, that members might not be able to represent all the communities of the area in quite the way that might be hoped for, and they might not be representative of those communities. However—and this is a key point—when elected, those people would become part of the decision-making process. They would be bound in and would be responsible not only for the decisions but for their implementation and, of course, for their outcomes. Would those members be accountable? In theory, yes; but in practice they might be remote figures, not well-known to the public, who might achieve their single-issue purpose and then retire. Under the bill, there would be no necessary individual or collective commitment to the longer term.
Would the public be convinced of the independence of directly elected members? I doubt it. There needs to be a separation between the scrutiny and the accountability role; they should not be incorporated together within the board.
How are those individuals to be equipped to scrutinise, in effect, their own decisions? The bill proposes a continuing role on NHS boards for professional staff at director level—which I think is appropriate—but it would mean that independent advice to help formulate an alternative view might not be readily available.
An alternative to the bill's proposals exists. It is to give a role to an appropriate committee of the relevant local authority to allow it to scrutinise health board proposals. Where more than one local authority covers a health board area, a joint committee would clearly be required.
What support does the member have for that proposal? Who out there supports the idea?
Me!
Ms Robison has just heard an indication of support for the proposal from within the chamber.
The committee I was referring to would likely be based on social work services, in which there is an increasing need to co-ordinate activities with health care professionals. I believe that that is the way forward. The members of the committee, as councillors, will have been democratically elected; independent professional advice will be available to them; they would keep the board accountable; and they could be effective scrutineers. The members would work on major issues on which they were called in for discussion and debate, and they would then refer their conclusions back to the NHS board or the minister. That would ensure the integrity of the national health system as it presently exists.
Is the member on the brink of supporting some new Liberal Democrat pledge to give responsibility for primary care to the local authorities?
No; that question shows a fundamental misunderstanding.
I want to discuss the three subsidiary points mentioned by Bill Butler. First, I do not think that he really addressed—although he tried to—the issue of remuneration. Secondly, as he said, the 14 constituencies will have to be changed by the bill, if it progresses. Thirdly, the percentage of board members to be elected will clearly give rise to debate if the bill progresses.
Bill Butler did not mention the first-past-the-post system, nor did he understand clearly enough, I feel, that costs would be involved and that those costs would clearly come out of patient care.
Will the member give way?
No, I am in my last minute.
The issues that I have just mentioned are subsidiary to the main point, which is that there is a better way to achieve the objectives that Bill Butler has set out in his bill. Those objectives are shared, and the search for an alternative way of achieving them is shared by many of the professional witnesses who appeared before the Health Committee, including witnesses from the BMA and the RCN. Those witnesses made that point clear, and I repeat it this afternoon.
This is not the first time a committee convener has had to speak to a stage 1 report after everything has been said umpteen times. It is a very odd procedure indeed to have the stage 1 report presented after the horse has bolted. That is a deliberate mixing of metaphors. It is an issue that we must address.
I thank everybody involved in bringing the report together—the witnesses, the clerks and committee members—for all their work throughout the process, and of course Bill Butler for introducing the bill in the first place.
It is fair to say that all members of the Health Committee understood precisely why Bill Butler introduced the bill. Regardless of views about the general principles, or indeed about some of the specifics, we were absolutely clear about the general levels of voter discontent with health board decisions, which were often expressed vociferously in long-running campaigns. Many of those giving evidence acknowledged that problem regardless of their final position on the bill's proposals. Of those opposed to the bill, sympathy was expressed by, among others, the BMA, the RCN and the boards themselves. Hand in hand with the issue of public discontent came the question of accountability, or, one should more correctly say, lack of accountability. Those currently part of the status quo do not accept that criticism; those not part of the status quo see the lack more clearly.
For a concise summary of the main reasons for the complaints about the current method of working, I direct members to paragraph 26 of the report, which I will not read out here. Suffice to say that none of those criticisms or comments will be at all unusual to the vast majority of us here today, nor are they unknown to the current establishment. The question is, what should the response be? For the committee's part, it felt that Bill Butler's proposals provided a useful starting point for a response, which is why we rejected the arguments of those opposed to the bill.
In a nutshell, we say that it is not enough to recognise the huge gulf in perception that exists, then effectively say that everyone else is out of step, bar the professionals. The Convention of Scottish Local Authorities offered a compromise of sorts by suggesting that the existing role of councillors on boards could be beefed up, but a degree of scepticism was expressed as to how effective that would be, given that it is not clear that the existing role of those councillors is to provide any sort of real democratic representation.
A more serious concern of those opposed to the bill is the worry that the NHS's role as a truly national service may be compromised by the addition of locally elected board members. It was said that that would lead to inconsistency of policy and programme implementation. Professor Stevely of NHS Ayrshire and Arran and Professor Arbuthnott at NHS Greater Glasgow and Clyde spoke in surprisingly negative and emotive terms about risk, about endangering the NHS and about interfering with the local delivery of services. The minister himself has talked about the risk of fragmentation; his comments today in that regard were profoundly negative. For those of us who have long had concerns about so-called postcode prescribing, and are already aware of considerable differences in service delivery from one board area to another, that argument seems rather odd.
More specific arguments were also canvassed. Those included concerns about voter turnout—though some of the comments about that and the level of turnout below which an election has no validity would seem to carry some more general warning regarding the continued validity of any election. In any case, Bill Butler himself was able to counter those arguments with his own statistics suggesting that, on single issues, the voters are considerably more engaged than we might think.
There were other, more technical, issues that concerned the committee and that were raised directly with Bill Butler. It is fair to say that the committee was sceptical as to the usefulness of an electoral area where that encompassed the whole of a health board area. There are one or two areas where that might not be a problem, but for most of us there were concerns about heavily populated urban areas always being able to outvote the more widespread and sparsely populated rural areas. We were also surprised at the lack of any reference to remuneration in the bill, not because we think it a popular argument to make—far from it—but the truth is that people should not be put out of pocket if they are prepared to put themselves forward and get elected. The committee did not come to a view on the perfect proportion of directly elected members per board either. In our view, there is still a debate to be had about that. The proper place for that debate is at stage 2.
The committee—with one named exception—therefore took the view that it approved the general principles of the bill, for the following reasons: we have sympathy with the arguments about public involvement, consultations and decision making and agree that change is needed; and the NHS is already no stranger to politics, so the addition of non-party political members will not change that dramatically.
I refer Roseanna Cunningham to paragraph 85 of the committee's report:
"The Committee recognises concerns that the addition of directly elected members on NHS boards may undermine the national element of the NHS, and notes the New Zealand example as a possible mechanism for overcoming this potential problem."
That is outwith the scope of the bill and therefore not possible to deliver. That is a significant point.
An interesting argument might be had at stage 2 about what is and is not within the scope of the bill.
There are ways around the concerns about departing from a national service—I was just coming on to that point when the minister intervened. It was also suggested that, because the proposed electoral system may lead to its own undemocratic representation, board areas should be subdivided to arrive at smaller electoral areas. There should also be a debate about the suitable proportion of directly elected members on any given board, and directly elected members should be paid or compensated for any expenses or loss of earnings that they might incur.
As all its concerns could be considered at stage 2, the Health Committee commends the bill to Parliament.
It is difficult not to have real sympathy with the aims and intentions of the bill. The policy memorandum speaks about democratising Scotland's health boards, the public influencing health service delivery within their local communities, locally generated legitimacy for the decision-making process, greater openness and transparency and increased public confidence and trust. It is difficult for anybody to say that they are against those without saying that they are against virtue itself—it is all good stuff.
On top of that, we have all, at times, been less than completely satisfied with the existing system and processes—I think the minister knows that. Some so-called consultations do not seem to have been genuine. There has been a feeling that health boards have been going through the motions formally without a genuine, meaningful dialogue and there is no doubt that there has been a lack of public confidence.
Despite all that, I remain against elections to health boards, not because the idea is without its plus points—few proposals contain nothing positive—and certainly not because I am somehow agin people having their say, as Shona Robison caricatures the bill's opponents as being. On the contrary, we want people to have their say. I oppose the proposal because I do not think that the end result would be an improvement in health care and health provision. In fact, I rather fear that it would be the opposite.
We have political accountability within the health service. Ultimately, that accountability rests with the minister and the Parliament. No really major decision is taken without the involvement of those accountable bodies.
Does Gordon Jackson agree that the only part of the National Health Service (Scotland) Act 1978 that the bill seeks to change is the percentage of directly elected members of a health board and that, under the bill, the minister and Parliament would have all the powers that they have at present?
I will come back to that point later, because it somewhat disingenuously avoids the conflict between the national and the local. I am not avoiding the point.
On top of the minister's and Parliament's responsibility, there is real input at council level, and I do not see how another elected layer would produce any more genuine accountability. On the other hand, there could be and, I think, would be an obvious downside to it. Decision making in the health service involves some serious, hard decisions that often cause a great deal of controversy and heat in a locality. I cannot think of anything—not even closing a school—that does that more than closing or changing a health facility. I will be blunter than politicians are sometimes prepared to be: most of us have found that situation difficult. I say that because the debate is not always terribly rational. As a local politician, I have been torn between supporting a health board decision that I know in my head is correct or supporting the local community in demands that, deep down, I know are sometimes irrational. I suspect that other members have been in the same position, whether or not they admit it.
Will the member give way?
I do not have time. I am sorry.
In the back of people's minds—Jean Turner is in the chamber—is the fact that local politicians end their careers over hard decisions on health matters. That is because sincere and genuine local demands are not always rational.
Will the member take an intervention on that point?
No. I do not have time for that.
Recently, I sat with intelligent people on the south side of Glasgow who argued with me that every neighbourhood should have its full service hospital. No amount of talking to them about work patterns or consultancy numbers would change that—they wanted it and they must have it. The allegation is made time and again that if we close this or that facility, people will die, as if those in charge of the health service did not want the best care for people. The reality is that there is no statistical record that such hard decisions, which Andy Kerr takes from time to time, result in people dying.
I therefore ask myself how having locally elected health boards would help to make that decision-making process better.
Will the member take an intervention?
No.
Even leaving aside all the questions whether the health board would be truly representative of the community or have a genuine mandate—which I think is doubtful—I come to the conclusion that it would make unpopular but correct decisions much more difficult to take. It would paralyse proper, correct decision making and would offer no real improvement.
Roseanna Cunningham referred to what Professor Stevely said about risk. The risk that he emphasised was the right risk, that there would be scenarios where there was conflict between the local agenda and the national agenda, the result of which would be a diminution in care at a local level.
I do not think that the bill helps. We have political accountability, but we have enough distance before the hard decisions are made. The balance is broadly right at the moment. Of course we could improve it—we could improve accountability and consultation—but the balance that we have is better than what is proposed and I for one see no advantage in changing it.
I will not mention why I am here, but I congratulate Bill Butler on listening to the people and realising that there is still a gap out there. Although health boards have put in place many new processes to involve people in the decisions that they take, people still do not trust that the health boards will do that, or that they will be accountable for their actions.
I do not think that health boards really wanted any more change—nor did the RCN or the BMA. Anyone who has ever worked in the NHS will know why. Just when we got local health care co-operatives sorted out, they were changed to community health partnerships, which are not yet working fully enough to take on board the issues that we want them to take on board. If they do not work and public involvement does not work, what are we left with? What is wrong with having elected people on a health board, as long as there is the right kind of voting system?
Does the member acknowledge that the decision to establish CHPs was taken by ministers, for which we are accountable to Parliament and to the electorate, and does she agree that that is an appropriate democratic form of accountability for making changes in the delivery of health services?
I agree. I do not think that there is anything wrong with CHPs on paper. However, it was difficult to get LHCCs up and running and there is a difficulty with CHPs and with ensuring public involvement.
The minister talked about fragmentation. We have that at the moment. It is difficult for someone with an eating disorder to get a bed. People with chronic pain in the Highlands cannot even get Highland NHS Board to reply to letters from their consultants. Given the differences in provision throughout Scotland, I do not see that having elected members on health boards would make any difference. We are to depend on the Scottish health council, which comes under NHS Quality Improvement Scotland, to scrutinise the consultation processes that health boards undertake. What happens if they do not actually scrutinise those consultation processes properly? We will still be left with people who do not trust the system.
I have an open mind on the subject and I would like to think that this Parliament has the courage to take the bill past stage 1, so that views can be aired. I do not have a view one way or the other. That is what debate is all about. I think that it is a good thing to listen to the people out there, because many people are cocooned from public opinion.
In the Health Committee, Bill Butler asked Robert Cumming of the Scottish health campaigns network:
"You will know that some of the bill's opponents have said that direct elections would impede the modernisation of the national health service and that there would be no change or progress because of parochial interests. What is your opinion of that argument?"
Dr Cumming replied:
"I think that the complete reverse is true. More involvement from and consultation with the local community would progress matters better than people taking stances that are not fully understood. I take a diametrically opposite view to the opponents and suggest that elected health board members would improve modernisation because there would be much greater input from people and dialogue with the health boards."—[Official Report, Health Committee, 31 October 2006; c 3168.]
We all know—if we listen to our constituents—that input from the people and that sort of dialogue is precisely what we do not have at the moment.
The bill might not be perfect at this stage, but it could be improved if it goes forward to stage 2. We owe it to the public to think about the issue and not take a stand on one side or the other at this point. That is what debate is all about.
A few weeks ago at Stobhill—the hospital that I was fighting for—we had a bit of a flu outbreak. We were taking in elective cases and we had people lying on trolleys—a 90-year-old man lay on a trolley for 13 hours. That is still happening. I cannot believe that we are not ashamed of the fact that we do not have enough beds, that people have to lie on trolleys and that we cannot organise the system to ensure that people can get beds. If there were elected members on the health board, they might try to bring that tragedy to an end.
I was shocked by the minister's speech. Now that he has come back to his seat, I will tell him why. I thought that part of his speech was sheer scaremongering. To use words such as "dangerous" is quite inflammatory. I was disappointed in the choice of words that he used when making his points.
I refer the member to Professor George Alberti, the president of the Royal College of Physicians, who suggested to me that, in many cases, the best result for the patient can be secured by bypassing their local hospital and getting them to a specialist centre. That is exactly the strategy that is set out in "Delivering for Health". I understand that that strategy is opposed by many communities. However, at the heart of the strategy lies patients' best interests and their survivability.
I take on board what the minister says but patients' best interests are what lies at the heart of this bill, which is why I think that the minister's speech was inflammatory. The minister talked about postcode prescribing and cancer strategies not being delivered. However, as Roseanna Cunningham and Jean Turner said, that is the situation at the moment. The Public Petitions Committee receives petitions almost every month on the issue of postcode prescribing. It exists under the present system, so the minister cannot use that as an excuse.
Like many others who have spoken, I agree with the principles of the bill, which will be an immensely positive step towards restoring people's faith in our health service. Everyone in the chamber knows that the state of the health service is one of the voters' main concerns. For too long, people have felt ignored in relation to decisions that will directly affect them. If one of the principal aims of Bill Butler's bill is to redress that situation, we should all support it, particularly at stage 1.
I remember campaigning on the Queen Mother's hospital and Yorkhill hospital—Gordon Jackson will probably remember that as well. I see that the minister is leaving us; he does not need to come back to hear the rest of my speech.
I remember being assured by the health board and the minister that the replacement facilities would be as good as, or even better than, those provided at the Queen Mother's hospital and Yorkhill hospital.
I understand what the member says about public confidence and perception, but will she say how and why the proposal would result in better decisions being made?
It would result in better decisions because board members would be directly elected and the public would have a say. Health boards would not be made up of placemen. That is the guiding light of the proposal.
I return to the situation with maternity services in Glasgow, although the same thing has happened throughout the country. We were assured that the service would be as good as or better than the one that we had before, but the number of beds is already being cut because of financial constraints. Staff and the public have been alerted to that and they are concerned. During the health board's consultation, however, we were never told that that could happen. Where does that leave us?
It is easy to see why change is needed. One of the Executive's objections to the bill is that changes have been put in place to make the health service more transparent and responsive to what people want and that time is needed for those changes to bed down. That is ironic, given that the Executive objects to the bill.
The member will appreciate that cross-border health care is an important issue in my constituency and in Euan Robson's constituency. We need to attract patients from the Lothians to the Borders to make health care in the Borders more sustainable. If the Lothians had a directly elected health board with a mandate to keep health care and the budget in the Lothians, that would work against the principle. Would the member defend that?
I understand from what Bill Butler has said that we will examine the cross-border issue at stage 2. The situation is not as simple as Mr Purvis suggests. We have to examine the detail.
Another example of the problems with consultation—again, such problems have happened not only in Glasgow but throughout the country—is the centralisation of accident and emergency services. Jean Turner mentioned the ambulatory care and diagnostic units that are sprouting up all over the town. The downgrading of the great Victoria infirmary and Stobhill hospital to ambulatory care and diagnostic units will leave Glasgow with only two full accident and emergency departments. Regardless of what Gordon Jackson said, we have to look at that carefully. There will be trouble ahead if we have only two full A and E departments in the Glasgow area.
Many people took part—in good faith—in the consultation. The consultation process went on for a number of months and cost nearly £1 million, but all that happened was that the health board's original proposal went through. As Nanette Milne said, the health board saw it as a fait accompli. We can understand why people want directly elected health boards.
In his evidence to the Health Committee, the minister said:
"The bill is an attempt to address a concern, which I think that we share, through a mechanism that I am not sure will solve the problem." —[Official Report, Health Committee, 7 November 2006; c 3189.]
That sounds a bit of a conundrum to me. I am sure that members agree that to have doubt about whether something will work is, in itself, no reason not to try to make it work. I urge the Executive and the other parties to rethink their stance, to offer more constructive input and to support the bill. We have to consider all the details of the bill if we are a truly democratic Parliament. We should support it at stage 1 and continue to examine it. Let us listen to the concerns, consider the evidence and make up our minds at stage 2.
I ask members not to stop the bill at stage 1. It is a worthwhile bill. I certainly support it and I look forward to hearing further evidence on it. The people out there—the public—elected us to look after their interests, but we will not do that if we fail to support the bill at stage 1.
For the past couple of days, the chamber has rung with voices from across the world, talking about the need for us to embrace and accelerate the pace of change and recognising how important it is to innovate, to be creative, to be flexible and to modernise. As politicians, we cannot talk the language of change unless we are prepared to put it into practice. It strikes me as a sad irony that, now that Bill Gates and Gordon Brown have left the room, instead of talking about how we drive forward strategic change in the NHS in Scotland, we are talking yet again about how we tinker with structures.
The big question is how we drive forward strategic change, and it is a £10 billion question. This year, for the first time, the health budget in Scotland will reach £10 billion. As somebody who had a health budget of £4.5 billion, I say that £10 billion is serious money. Serious investment is going into the NHS in Scotland.
Will the member take an intervention on that point?
Not right now.
I would support the bill if I thought for a moment that it would do anything to add value to the process of leading change, but I truly believe that it will not.
We can all agree that what the NHS in Scotland needs is first-class leadership, first-class management and first-class governance. I spent more time than most examining those issues in the early years of the Parliament; I got in about the guts of the history, culture and practice of the NHS in Scotland. That is why—on my watch—we began the process of dismantling the trusts, put in place unified health boards, put councillors and staff partnership representatives on to boards and set in train the process of radical change in order to involve meaningfully the public and patients in decisions that affect them. I ask members to believe me when I say that, if I thought—either now or then—that any of those processes would be improved by the proposal in the bill, I would embrace it. However, I absolutely do not think that.
Will the member give way?
I would like to make a bit more progress.
The other thing that any of us who have served in government can testify to is that change is hard. As others have acknowledged, it requires difficult and sometimes unpopular decisions to be taken.
If I may dust down another bit of ancient history, I recall from my time as the Minister for Health and Community Care that I had to deal with some real war zones in different parts of the country—there have been others since—over controversial change. I also recall having to deal with some pretty dysfunctional health systems. Some of the changes that have been made to structures helped to address some of those situations, but I can tell members that what really made the difference for the board areas that were turned around, both in respect of the services that they delivered and in respect of the cohesion and good stewardship of the health service in their area, was changes in people—changes in the leadership of those board areas.
It is wrong to single out anybody, but the Parliament—and I, as the minister—spent quite a bit of time looking at the development, if I may put it that way, and transformation of the NHS in Tayside. I cite the difference that individuals made, both in leading that board forward and in taking forward change. The kind of people who are needed are people who are leaders, who can cope with strategic change and who can connect with the public. Boards do not simply need one or two folk from a local area who have a particular interest, be it sectional, geographic or whatever, however well informed or well motivated they are; they need people who can connect with the entire population and harness modern technology and modern methods of engagement and communication to engage with the population, absorb what they hear and translate that into what it means for the way in which services need to be delivered in the future.
Is Susan Deacon arguing that good leaders must be appointed? It seems to me that she is very close to arguing that democracy prevents change. Is she seriously asking us to believe that?
What I am arguing—I have argued the point passionately throughout my political and professional life—is that we need leadership of the highest order, particularly in our public services. The structures and governance arrangements that we put in place will differ for different parts of public services in different parts of the public sector to suit the arrangements and the task in hand.
Will the member give way?
I cannot for the moment.
As I said, in the case of the health service, we need the highest possible standards of leadership and management, which will come from many different people: from clinical leadership and, yes—I dare to say it—from managers. It will also come from people who adopt a non-executive role and, incidentally, from people who have come through an elected process, because councillors sit around the board table. The challenge that they face is that of managing change.
It is not good enough that, time and again, politicians—not only politicians in this Parliament, but people who have gone before us—sign up to documents such as the Kerr report, health plans, white papers and the like, but when the chips are down and it comes to considering how they put in place the mechanics, the arrangements and the people to take forward change, they bottle out of some of the challenges.
We must move on from the bricks-and-mortar debate that we have had about our health service of late. We must move forward and have a vision of the health service for the future. Members may think that we can somehow fix and fudge the bill in a few weeks in the dying phase of this session of Parliament, but I suggest that that is not the way to run our health service, as it is too big and too important to us all. I urge members to reject the bill.
We are broadly in favour of the bill, subject to the changes to which Nanette Milne referred being made at stage 2.
Let us make no mistake about why the bill was introduced. Local communities' dissatisfaction with the remoteness of health boards is growing. The bill was introduced as a result of a desire to make health boards reflect more accurately the wishes of local communities, which is a logical and commendable aim. One need look no further than the protracted indecision that has affected the hospitals in Oban and Fort William in my area to demonstrate the local problems that exist.
Let us consider what has been proposed. Fourteen health trust areas would become constituencies in which an absolute majority of the positions would be elected. As Nanette Milne said, we have serious concerns about that, and the issue will be debated further. Elections would take place every four years and would be funded by trust budgets. Elected members would receive no remuneration for loss of earnings, which could obviously limit interest in the proposals.
Members of the Health Committee, except for Euan Robson, voted in favour of the bill. The arguments in its favour are that it would increase local accountability and reflect local needs better than they are currently reflected, and it could mean that wider points of view, backgrounds and experiences would be reflected on boards. Furthermore, elected representatives may enable more prudent management of the large budgets for which trusts are responsible.
Paragraph 90 of the Health Committee's stage 1 report on the bill states:
"The Committee is also concerned that the bill as drafted does little to promote and encourage fair and equitable public representation."
That is contrary to what the member has just said.
I cannot agree with that.
There are arguments against the bill. The national health service is centrally planned. Elected members could inhibit centrally planned initiatives and entrench a postcode-lottery system. Turnout for the elections would almost certainly be low, which would mean that it would be easy for special-interest or single-interest groups to gain influence and further their agendas.
The majority of trusts cover a mixture of urban and rural areas, in which there are different conditions. Because urban areas contain denser populations, there is a real danger that rural communities' needs and requirements could be overlooked. Elections every four years could lead to short-term planning and reactive policies, which could damage the system's fluidity. Rolling budgets over the four-year term should therefore be considered. Furthermore, the cost of the elections—which has been estimated at between £1.2 million and £2.4 million—would remove valuable resources from the front line and patient treatment. I call on the Executive to re-examine the bill's key areas and to lodge appropriate amendments at stage 2.
I hope that the bill will raise the Executive's awareness, which is urban based, of the financial and operational challenges that are involved in serving a wide urban, rural and island mix of areas. It is essential that rural areas are not neglected, as they have been by recent Executive legislation and policies.
As members have said, it is important to rationalise trust boundaries to reflect accurately urban and rural demands and aspirations. It is also important that NHS budgets do not suffer, particularly at a time when they are very stretched. The financing of elections must reflect rural sparsity. We must not fall into the free personal care trap so that rural councils such as Argyll and Bute struggle to cope.
Refusing to remunerate board members would reduce the ability of elections to provide members from a wide range of backgrounds and with wide experiences. The costs involved in such an approach must be considered.
As I said, we broadly support the principle of local communities getting more involved and taking more action in the provision of public services. Our argument is that a system in which big government tells local people what to do and how to do it does not work. It is important that the new system does not disadvantage our rural areas, potential elected members on low incomes and already stretched health budgets. I look forward to re-examining the bill at stage 3 and hope that the Executive will take my suggestions on board.
We all know that public accountability has been a huge issue in the relationship between health boards and the people whom they serve. In my area, for instance, closing the maternity unit at Aboyne and centralising all births in Aberdeen has been proposed. The proposal was deeply unpopular, flawed and contrary to the interests of the people of Deeside, but there was no one on the board from our area to speak up against it. The board therefore unanimously voted to proceed with its closure proposals.
On such a major issue, nobody was willing to disagree with the line that was put forward by NHS Grampian staff. No one was willing to stand up and be counted on the issue; people had, effectively, bought into the decision. The people of Deeside felt that they had no voice in the board's decision-making process.
Will the member give way?
In a moment. Let me proceed.
Thankfully, an extremely well-run campaign was undertaken by the save Aboyne maternity unit group, which was supported by MSPs from all parties across the region. To return the compliment, I thank Nanette Milne, in particular, for her valued support. The board's decision had to be fought by MSPs all the way to the Minister for Health and Community Care. Thankfully, Andy Kerr made the right decision on the basis of the evidence that a birthing unit in Aboyne for planned births for low-risk mothers is indeed required. Thank goodness, the board now seems to have accepted that. I place on record my personal thanks—and, more important, the thanks of the people of Deeside—to Andy Kerr for making the right decision on the basis of the evidence that was available to him.
Given the fact that the Liberal Democrats' health spokesperson has today talked about the potential role of councils in undertaking scrutiny of such matters, can Mike Rumbles explain the fact that a councillor of that party who was serving on the board of NHS Grampian voted in favour of the board's decision and against his council's policy? How was that going to help?
I say to Brian Adam that individuals who make those decisions must answer for themselves. I have been pleased to note that the whole campaign has not been party political, but has been about ensuring that we get the right decision. I am afraid that he is bringing party politics into this, which is to be regretted.
The fact that the issue had to be fought all the way to the minister is indicative of the fact that there is something wrong with the way in which our health boards are structured. They certainly do not represent the people whom they exist to serve. Contrary to what Sandra White said earlier, I was pleased to hear Andy Kerr say that we need to examine the whole issue carefully in order to get it right. I support the view that the minister expressed.
Will the member give way on that point?
In a moment.
I believe that the proposals in the bill could be termed the nuclear option—electing a majority of board members by an outdated and unrepresentative voting system. If the problem that Bill Butler identifies is the fact that the boards are unrepresentative of the people whom they are meant to serve, how can the solution be to elect people on an unrepresentative, winner-takes-all basis? That is just absurd. It is for that reason that I cannot possibly support the proposals in the form in which Bill Butler has laid them out. If he was trying to build consensus for his bill, he would not insist on electing people through the discredited system that he proposes.
Health boards need to be reformed, but I do not believe that this proposal is the right one. I do not want an undemocratic system in our health boards replaced by the winner-takes-all form of the democratic process. If we agreed to have locally elected representatives, what would happen if there was a dispute—disputes occur all the time—between them and the minister, who has to run the whole of the NHS, is directly responsible to the people of Scotland in the Parliament and has shown himself to be responsible to MSPs across the party divide in this chamber? It would be a recipe for disputes and conflict to have two democratic mandates—one for local health boards and one for the Parliament.
It is for those reasons that the Liberal Democrats will not support Bill Butler's bill at decision time.
As Roseanna Cunningham—who has left the chamber—said earlier, lots has been said and it is difficult to say any more. I apologise before I start for the fact that I will repeat some of the points that have been made today.
We all agree why we are here. Susan Deacon alluded to that earlier in her point about leadership, how it is used and whether it is used effectively. Such issues have brought us to this point and brought about Bill Butler's bill, which I supported initially because I felt, and still feel, that the imbalance between the medical profession and everyone else in our health boards is not only perceived but definite. However, I do not believe that it is right to go from that point to a point at which we treat the subject as if it were a numbers game and say that the more people there are in the room, the stronger their argument is. This is not a numbers game. We speak of trust, and we need there to be trust between those who provide the services and the communities that they serve, and the community needs to be able to trust the professionals who deliver those services. We will not reach a position of trust if we start out by saying, "We have a majority, irrespective of what anyone else says."
We have to congratulate Bill Butler and those who have supported his bill on the work that has been done. At this time, we all agree that the status quo is not an option. The committee heard in evidence that moves have been made because the Parliament is not completely unheard in the right circles. Moves have been made over the piece by councillors who have used more modern and serious ways of consulting their communities both at the point of crisis and to keep people up to date on an on-going basis. That is as important as anything.
We have moved on, but we now need to evaluate the risks and the benefits that the bill would bring.
In his opening speech, the minister referred to a pilot scheme run along the lines that Bill Butler suggests. Does Mr McNeil support such a scheme? How would it work?
It would be a more sensible way of proceeding. We have been asked to put the risks in the bill to one side and trust in the stage 2 process. If that does not work, we have been told that we can come back and see whether post-legislative scrutiny works. Hard questions have to be asked about the number of boards, who would be on them and whether we would be able to take people off them. Nanette Milne suggested that we should take the vote away from some people who are already on the boards. When we ask such questions, we are told to leave things up to the stage 2 process, to post-legislative scrutiny or to the minister, but we have a decision to make today about whether, with all the risks still in place, we should proceed. Of course, the committee recognised that. Its report said that it is unlikely that direct elections to health boards would change the political nature of health issues.
Will the member take an intervention?
I am sorry, but I cannot. I have limited time; I did not get the time that others got.
The report also said:
"The Committee recognises concerns that the addition of directly elected members on NHS boards may undermine the national element of the NHS … The Committee has concerns that the electoral system, and in particular the size of the electoral ward may result in undemocratic geographical representation … Where this is the case the interests and needs of those living in different parts of the board area can be quite distinct."
The committee recognises that it is very difficult to balance the needs of the majority of people who live in the cities with those of people who live in outlying and rural areas. Many problems and antagonisms came about with the process of centralisation. The bill does not answer many of those questions. I believe that, as suggested by the minister, it is better to address the issues by testing the proposals in the bill rather than subjecting the health service to additional upheaval.
I believe that the issue is important, that trust is important and that we need to create a system that gives the public—not just two or three people—a greater say in the running of health services. I believe that what is important to the public whom we serve is the quality of the health service. Whatever decision we take as a result of the pilots, our focus must be on the objective of improving the quality and delivery of the health service. I believe that what people really want is those improvements rather than elections with dubious outcomes.
I call Eleanor Scott, who is to be followed by Carolyn Leckie, both of whom have four minutes. I express my regrets to the three remaining members who have not been called to speak.
Like other members, I have a great deal of sympathy with the concerns that lie behind the proposals in the bill.
Many communities have lost trust in the local NHS that is meant to serve their needs. On previous occasions, Parliament has debated specific examples of that, including redesign of maternity services that communities have perceived as being a loss of provision, and the closure of accident and emergency departments that—whether closure was justified or not—definitely represented a loss of services. We are all aware of the widespread perception that health boards do not engage in real consultation but simply devise proposals that are presented to the public as faits accomplis. Those criticisms can be justified. It is clear that a democratic deficit exists in our NHS—the question is whether the bill represents the best way to correct it.
Of course, the present system of governance in our NHS is not the only possible system. Health is a local authority function in some countries; for example, in Norway primary care is the responsibility of local councils. That idea has, I think, some merit. The Scottish Parliament information centre briefing reminded me that such a set-up was considered in the UK in the 1960s. Although councils were dead keen, the medical profession in particular threw up its hands in horror—a bit like some members did today when Euan Robson suggested something along those lines—when the idea was proposed.
However, today we are considering what is on offer in the Health Board Elections (Scotland) Bill. I acknowledge that the current make-up of health boards is better, or at least broader, than it was 20 years ago at the height of the Thatcherite NHS. In my region, Highland NHS Board now has a chair, six executive members, five stakeholder members and 11 non-executive members. By contrast, in the 1980s the board had a chair who was appointed by ministers, six non-executive members who were appointed by the chair—all of them were, directly or indirectly, political appointees—and six executive members whose role was, I presume, to scrutinise themselves. The present system is at least better than that, but it is still in no way democratic.
It is often pointed out that democracy consists of more than putting a cross next to a name every few years. That leads me to my concerns about the bill—a bill that, on balance, I cautiously support. Will having direct elections for some seats on boards mean that boards will feel that they have done democracy and so do not need to consult further? Will the voting system result in fair representation of all sections of the community and all geographical areas? I am concerned that, if we have one large multimember ward for the whole health board area, the sparsely populated rural areas could end up with no representation.
Does Eleanor Scott have any information on whether a proportionately higher number of people would stand for elected health boards than stand for, for example, our community councils?
I have no information on that. I actually have quite a lot of concerns about that because serving on a health board will be a lot more demanding than serving on a community council. However, at least the remuneration issue is being addressed. I am happy that Bill Butler is prepared to reconsider the size of the voting areas.
I have concerns about the voting system that is proposed in the bill. I very much agree with Fairshare Voting Reform Limited and others that the single transferable vote system would be much better. If the bill proceeds to stage 2, I hope that an amendment can be lodged to that effect.
If the bill were passed, would the people who put themselves up for election be truly representative? I note that in New Zealand, which has direct health board elections, women and Maori are underrepresented. Although elections could be non-party-political like those that take place for community councils, parties would not be prevented from trying to get their man into the post.
I am concerned about voter fatigue—we have rather a lot of elections in Scotland and, in recent years, turnout has been worryingly low. Would the health board elections be tagged on to the Scottish Parliament and council elections? If that happened, it is unlikely that local health issues would get much of an airing.
Will the member give way?
No. I am sorry, but I am in my last minute.
If the health board elections were held separately, there would be the risk of woefully low turnout.
The bill raises some questions that are still to be answered. However, with reservations, I will support the bill at stage 1.
I am happy to confirm that the Scottish Socialist Party whole-heartedly supports the general principles of Bill Butler's bill and we congratulate him on introducing it.
Like other members, we have reservations about the proposed voting system but, unlike Mike Rumbles, we do not think that it means, in principle, that we should vote against having more democracy rather than less. Mike Rumbles is not in the chamber, but I wonder whether the Lib Dems would have opposed the establishment of the Scottish Parliament if all its members were to have been elected through a first-past-the-post system—I think not—[Interruption.]
There is a serious matter at the heart of the debate. There are big debates to be had about the strategic direction of, and democratic accountability in, the national health service. I do not have time to deal with the many controversial issues about the health service's strategic direction, so I will concentrate on the bill.
People do not just feel disenfranchised; they feel patronised and treated with contempt. The Gordon-Jackson-knows-best attitude drives people up the wall because they are capable of understanding the issues if they are given the proper information. That is part of the problem.
Will the member give way?
I am sorry, I have only four minutes.
When consultations take place, information that would enable people to examine the issues objectively is not provided up front, alternatives are not presented and the issue is not placed in a context in which the politics, policy objectives or financial parameters could change—for example, if a private finance initiative is proposed.
Andy Kerr talked about "dangerous short-termism and self-interest", in another display of the patronising attitude of politicians who describe what they think would automatically happen if we asked the people how to run the NHS. That was disgraceful.
Will the member give way on that point?
Sorry—I have only four minutes.
Mr Kerr talked about the Executive's mandate, but his comment drew attention precisely to where there is a democratic deficit: the Executive did not have a mandate for private finance initiatives, for the corporate takeover of general practitioner practices, or for the shutting of hospitals and centralisation of services. That is why there is a clash with communities and why communities feel disenfranchised, and it is why the minister is running scared of increasing democracy.
Mr Kerr said that the NHS could be undermined. However, the minister's policies, such as increasing use of the private sector, are doing exactly that. They are undermining the NHS.
Will the member give way?
Sorry—I have only four minutes and I have a lot to get through. I have already had to ditch quite a lot of my speech.
Fears have been expressed about politicisation of the NHS, but the NHS is political. If it was not for political campaigning, the NHS would never have been established because the professionals in the medical establishment did not want it. If it was not for the people on the ground, we would not have an NHS. We need more democracy, not less.
I have only one minute left, but I want to respond to some of Susan Deacon's remarks. I was concerned that she seemed to be arguing for professional managerialism rather than for democracy in the health service. By the way, who elected Bill Gates and why should we take counsel from him?
Will the member give way?
I am in my last minute.
I have a lot of respect for Susan Deacon, who was Minister for Health and Community Care when I was a trade union activist. However, I have to tell her that I met some of her appointees and I would not give them such shining, glowing reports. Susan Deacon argued that people with professional qualifications, professional backgrounds and a managerial perspective are more able to deliver strategic change. Well—I say that change has to be right in the first place and has to be progressive. My experience shows that the people who deliver and receive services are much more capable of identifying and delivering the changes that need to be made, but they are not trusted in that. That is why we need elections.
I thank Bill Butler for the characteristically diplomatic way in which he described the bill, which is close to his heart, as I think all members acknowledge. He gave a fair description of what the bill is about and, in fairness, drew attention to the Health Committee's concerns about remuneration, other constituencies and the number of board members who would be elected—he is holding out for 50 per cent plus one, or something of that nature.
Andy Kerr, the Minister for Health and Community Care, said that the Health Committee's report
"stopped well short of being a ringing endorsement"
of the bill. Other speeches have borne that out. However, he concedes that there is some merit in considering local democratic involvement. I think that all parties concede that point.
Will the member give way?
Not at this stage—I need to make progress.
The minister made it very clear that he will not countenance major changes to the NHS's structure. He also made a point that members have returned to again and again and which I endorse whole-heartedly: we are talking about a national health service, not a postcode health service. At the end of the day, our lives, our deaths and all matters relating to our health are very important to us and to our loved ones. I certainly agree with the crucial point that the elected members of this Parliament are responsible for that service.
It has also been suggested that the NHS is not working. On the contrary, considerable improvements have been made in delivery of the NHS services that matter to ordinary people. Are they getting better services? Is their health improving? The answer to both questions is, "Yes."
The minister also mentioned the cost and timing of the proposed elections. Every pound that is spent on such an election is a pound that is taken away from patient services.
Given the member's comments, will he explain why he signed up to Bill Butler's bill in the first place?
The member should know me well enough by now. I think that, in this Parliament, one very good principle is that one should sign a bill if one feels that there is merit in debating its principles.
Oh, come on.
No—someone who thought otherwise would very much lack a free mind. An argument about the bill has developed since it was introduced and, notwithstanding Bill Butler's honourable intentions, I see now that the bill has some very real flaws.
Shona Robison referred to the perception that the health service is not being well managed. That is not fair to people who, as Susan Deacon said, are some of the best managers whom we have. Ministers have worked very hard to ensure that such management has been put in place.
Nanette Milne's speech highlighted an interesting theme in the Conservatives' argument. She paid a generous compliment to my colleague Mike Rumbles's role in saving maternity services in Aberdeenshire; however, when she expressed concern about the bill's proposal for an elected health board membership of 50 per cent plus one, one could see a trend emerging in Conservative thought to which I will return in a moment.
Euan Robson outlined my party's alternative of separating service delivery from the service's decision-making structures. He again drew attention to the crucial fact that the cost of NHS board elections will have to be met by money that is meant for patient care.
Roseanna Cunningham provided a very fair description of the Health Committee's view and admitted not only that the Convention of Scottish Local Authorities had offered an alternative but that the boards, including the health board in my constituency, are against the bill as it stands. She also highlighted the issue of non-party-political members. From my experience of community councils and so-called independent local government in the Highlands, I do not know how such a position could be guaranteed. I have seen for myself how all sorts of strange single-mission people have come under the banner of so-called independence.
In making it clear that the issue is about service delivery to patients, not about messing around with the structures, Gordon Jackson and Susan Deacon gave two of the strongest speeches in the debate. I say that with all due respect to Bill Butler, to whom I will now give way.
Is not the beauty of democracy that elections cannot be guaranteed in advance? After all, this is not Albania in the 1980s.
That is a very good point, which I will take as the pretext for the next part of my speech.
Elections and elected representatives come and go—indeed, in a few weeks, I might well find to my horror that that is the case for me. However, as Mike Rumbles said with regard to the decision on maternity services in Aberdeenshire, geography does not come and go. He mentioned that none of the members on the health board comes from the area that has been affected by the decision. He certainly has a point. Personally, I think that it is a disgrace that, for many years, not one single health board member in the Highlands came from the counties of Caithness and Sutherland, although I should say that two new appointments, one from Inverness and the other from the Black Isle, have recently been made. However, the issue is not about electoral systems, but about how appointments are made and the boards' views of where their membership should come from. I concede that that question should be examined when people's involvement in decision making is reviewed.
That is why we had the stramash—to use a good Highland word—about maternity services in Aberdeenshire. It is why we had the near miss with maternity services in the far north and why my constituent Mr Gordon Murray, who lives in Sutherland, cannot get any pain management. We need Highland NHS Board to include members from the vast county of Sutherland to give people like him some support at the centre of power.
The debate has certainly been worth our while. I have been deeply convinced by the merits of the minister's argument, but we must look to our hearts on this issue. The structures do not matter a tuppenny damn to the people out there who are on waiting lists for life-saving surgery—they want their health and their lives.
Bill Butler has been stoical in canvassing support for the bill. As he made clear, today's debate is about its general principles, not about the nuts and bolts of how his proposed system would work. I was pleased that in his opening speech he talked about changes that he would be willing to accept, such as on loss of earnings. He also said that he wants to re-examine the rural-urban split. People who come from rural areas know well that arrangements in such areas are different from those that prevail in the central belt, which are what ministers seem to be concerned about.
We have a little problem with the percentage of board members who would be directly elected under the bill. The arguments in today's debate have been about democracy, accountability and the public's influencing how health services are delivered. I do not doubt that the minister did fine work to influence Grampian NHS Board—although he said that he did not tell the board what to do—in its decision on maternity services. We do not knock the fact that he paid attention to the case that was made; in fact, we welcome it. Bill Butler said that he does not want to lose the experience of existing board members, but I am not sure that his proposal for 50 per cent plus one board members to be directly elected would achieve that.
The minister had quite a cheek when he came out with the classic line that we should not rush legislation through in the final few weeks of the session. What have we been doing for the past three months?
With due respect, that is not what I said. I asked whether we should undermine 60 years of our NHS, which was set up by Nye Bevan, who turned down the idea of directly elected health boards.
I take the minister's point, but the same argument applies—the Executive is hell bent on getting through legislation that is not well written.
The minister mentioned the conflicts between local and central decision making and the uncertainty that would be created if the bill's proposals were adopted. I do not argue with the fact that the NHS is a national service. If the minister had said that he was going to abolish postcode access and postcode delivery when he took up the job of Minister for Health and Community Care, we might have taken a bit more notice. That is what he should have said. Many of us would have supported him for doing do.
I will give way in a minute, minister.
The minister has taken a short-term approach. We are discussing the principle of allowing the public some input—whether on a geographic basis or otherwise—to health board decisions at local level.
Like Jamie Stone, Mike Rumbles is keen to have directly elected health boards, but apparently his support is conditional on the use of STV. If the proposal does not include the use of STV, the Liberals will not support it. However, that is just a technicality; we are debating the principles.
Will the member take an intervention? It is a bit unfair to misrepresent our position.
It is not the first time the Liberals have changed their minds.
I think the Scottish National Party, too, favours adoption of an STV system. Shona Robison spoke about keeping politics out of the health service.
My colleague Nanette Milne laid out of our case for continued negotiation. We cannot support the proposal for 50 per cent plus one of board members to be directly elected, but if Bill Butler wants our support, we will certainly be prepared to consider at stage 2 what percentage would provide democracy and accountability while ensuring that we continue to have a properly and professionally managed health service.
Susan Deacon said that we need first-class leadership, but that must start on the front bench. She mentioned the example of the chairman of Tayside NHS Board, but all the health board chairmen are appointed by the minister. There is no democratic input to that process, which is a system of central management. The delivery systems on the ground are what need to be addressed.
Will the member acknowledge that the NHS is the only part of the public sector that has a direct line of accountability, through a Cabinet minister, to Parliament? Surely that is democracy.
I do not argue that there is no direct link or that the minister is not accountable to Parliament, which is accountable to the people. However, we need to ensure that there are people on health boards who will fight local people's corner. Some of the people who have been appointed to health boards do that, but the situation is not uniform across the country.
The whole point in all this is that the minister can, in effect, overrule unelected people. If we were to have both elected health boards and a minister responsible to Parliament, who would win the conflict?
I am not suggesting that there should be majority control—I have never said that about health boards. Elected members should not take over the ship, but there should be a percentage of influence by them. Bill Butler knows well that that is the position of the Conservative party. If the bill gets to stage 2, we have no intention of continuing to support it unless Bill Butler gives way on the numbers.
The debate is about democratisation. It is not about designing delivery from the centre, but about ensuring that people locally get a say on health boards and can influence delivery on the ground. On that basis, the Conservatives will support the general principles of the bill.
It has been an interesting and challenging afternoon. In saying that, I am paraphrasing Harold Wilson, as I did at the SNP conference in Dunoon more years ago than I care to remember, when I persuaded the SNP to adopt a policy that is similar to that which Bill Butler has brought before Parliament today. I am absolutely delighted that we will have the chance to vote on the proposal today. However, if Mr Butler is not successful in getting his bill through on this occasion, greater consensus may emerge in favour of its passage post election.
We have had some interesting debate around the tension between the local and the national. Gordon Jackson and Susan Deacon very firmly argued the case for the national perspective. Gordon Jackson posed the question whether elections to health boards would result in better decisions. The answer is that they would, because elected health boards would more closely reflect local views, which would inevitably lead to better decisions.
Will the member give way?
No, thank you.
Susan Deacon said that we should have good leadership because that would drive forward change and develop our health service.
Will the member give way?
No, thank you. I want to develop my point.
What Susan Deacon said could be put in a different context: that of there being more central control. It is little wonder that the two professional bodies that are most closely engaged in the decision-making processes in the health service accept that point of view. One of the reasons for the disengagement between the public perception of and hopes for the health service, and delivery on the ground is that bodies such as the royal colleges, for example, continue to develop policies that lead to centralisation of services.
I am not aware of any public concern whatever about proposals to deliver more local services. It does not matter whether such decisions are made by health boards or ministers; the only thing that drives concern is a proposal to deliver more central services. By more truly reflecting local views, Bill Butler's proposal would help to deliver better decision-making processes and it would do so in a way that would be better than the appointment systems of the past or present.
The member makes an interesting point about centralisation. Will he simply ignore the weight of clinical evidence out there in our communities? Will he ignore the peer-reviewed research on the relationship between volume and outcomes—the evidence on the number of times that a surgeon or clinician undertakes an operation and the positive outcome for the patient? People do not dispute that evidence in terms of neurosciences, coronary heart disease, cancer or other illnesses. We must ensure that we make the right decisions on behalf of patients.
Undoubtedly, a case can be made for some services—some highly specialised services—to be delivered in specialist centres, but that is not the case for all services. The general thrust of the evidence from the royal colleges tended to focus on the places where there are large numbers of consultants in such specialties. That reflects neither the situation in Scotland nor the evidence that was put before the Health Committee.
To a lesser extent, that point was made by one of the Liberal Democrat members—I think it was Mr Purvis—in relation to cross-border flows. He said that, with an elected element, boards will somehow decide, "It's oor budget; we're no spending it on you." I do not believe that the bill would in any way affect the commonsense approaches that have delivered agreements on managed clinical networks across boundaries. However, the bill would affect the attempt by those who already have power and influence to draw more power and influence to the centre. There are what we could call political—although not party-political—debates within professions about, for example, whether Glasgow or Edinburgh will get a centre of influence or type of surgery. People get caught up in such debates already. An elected element would at least help to balance out those debates.
If the member is saying that decisions of local health boards with a majority of elected members will not ultimately be binding, that will not ultimately change the procedure. He also misses the point about cross-border care, which is that, under the bill, health boards would be mandated to provide care for the electorate in their areas and there would be no incentive for them to develop regional cross-border care, which is what all our constituents want.
I disagree fundamentally with Mr Purvis's view. I believe that people who are elected to boards and who have an interest in health will display much more common sense and will aim to deliver health care for everybody as locally as possible.
I want the deputy minister, in his response to the debate, to spell out in more detail the proposals for a pilot, to which the minister referred earlier. If that is an attempt to fix and fudge, we deserve to know in advance of the vote tonight exactly what the pilot would deliver.
We agree on two key issues: the importance of effective public engagement and involvement with NHS boards, and the importance of promoting patient focus and public involvement, as vital in delivering the largest single public service for which the Parliament and ministers are responsible. The NHS is making good progress on improving patient focus and public engagement, but that does not immunise health boards or ministers from public comment and criticism when major service changes are proposed. However, we must not pretend that changing the governance of the NHS will in any way end the need for major service change or the public criticism of some health board decisions. Health boards have tough decisions to make if they are to implement the "Delivering for Health" agenda, which this Parliament approved several months ago. To do that, they must be clear about to whom they are accountable and which policies they should implement.
The coalition of Opposition members who support Bill Butler's bill is bizarre, in that their reasons for doing so are mutually incompatible. Nanette Milne said that she wants only a minority of board members to be elected, but that is not in the bill and Bill Butler has not said that he will accept it. Shona Robison said that her party supports the bill, subject to the board members being elected by the single transferable vote system, but that is not in the bill either and Bill Butler has not said that he will accept it. Eleanor Scott rightly worries about direct elections being seen as a substitute for proper consultation, about all interests not being properly represented and about the risk of woefully low turnouts, but the bill addresses none of those concerns. Jean Turner accepts that elected members on a health board would not necessarily make any difference to the issues that actually matter to patients, such as waiting times.
It is not enough to say that we can explore those issues at stage 2, because if Nanette Milne or Shona Robison get their way at stage 2, we will end up enacting a different bill from the one that Bill Butler introduced.
Does the minister accept that, frequently in the Parliament, amendments are agreed to at stage 2 that make bills different, and that bills can become even more different at stage 3? The Executive lodges such amendments all the time.
I accept that point absolutely, but if members approved the general principles of the bill on the basis that board members would not be elected by STV, but then they were elected by STV, something would have been enacted that members did not intend. If we approved the principles of the bill on the basis that 51 per cent of board members would be directly elected, when in fact members wanted only a minority to be directly elected, something different from what members intended might be enacted. Those are key points.
Nanette Milne said that changes to health board proposals in cases such as that in Aberdeenshire were achieved after hard-won fights in the teeth of opposition from health boards. However, as Mike Rumbles said, changes were achieved when local people and local elected members of this Parliament convinced ministers that ministers should take a different approach. It is not only that health boards are accountable to ministers; their decisions on major changes to services are subject to being overturned or amended by ministers. That is not an exceptional power; it is an ordinary part of democratic accountability through MSPs to the Scottish people.
The minister has chosen to neglect the main thrust behind my remarks. If local people had been involved, and if the health board had been aware of the strength of feeling, much time would not have been wasted in arriving at a final decision. Elected members on the health board could have made all the difference.
As Brian Adam pointed out, on that health board were local elected members and leaders of local authorities. They had decisions to make and they will have made them as members of that board.
As has been said, whether someone is or is not an elected member will not of itself change the decisions that they make. However, what would change under the bill would be health boards' mandates. At the moment, those mandates come from this Parliament, from these elected members, and from the Scottish ministers who are accountable to this Parliament, which is as it should be.
Will the minister take an intervention?
I am afraid that I do not have time to take further interventions.
Shona Robison made much of public concerns about people not being listened to in the NHS, but she was a little less forthcoming when Margo MacDonald asked her about her own accountability. As members of this Parliament, we are all part of the accountability of the Scottish NHS. It is part of what we are here to do. That is why we have held debates in this chamber on major service changes, why parties will go into the elections in May presenting different views on the way forward for the NHS locally and nationally, and why, as Gordon Jackson said, each of us is accountable to our own electorate for the stance that we take on health issues that matter to our local communities. That is as it should be.
Will the minister take an intervention?
I am afraid that I do not have time.
We are clear that we want public engagement with and public involvement in the decisions that we make as ministers with responsibility for health and in the decisions that are made locally by health boards. We want that engagement to be more effective. As Eleanor Scott conceded, we have made a good start: there are senior local councillors on NHS boards, there is a statutory duty on all health boards to involve the public, and the Scottish health council has a duty to ensure that health board consultations meet a set national standard and that each community health partnership has a public partnership forum.
We believe that the concept of direct elections to NHS boards is worth exploring, but only in the context of continued good governance of the NHS in Scotland and the wider agenda of public service reform. Building on what has been said today, and in response to Brian Adam's request for further information, we should seek to pilot that concept in a way that allows us to take into account the costs, implications and effects of changes, and the concerns that have been articulated by members of the Health Committee and other members this afternoon. That will allow us to examine further whether having a directly elected element on health boards can assist in increasing the accountability of the health service, while safeguarding the future of the NHS in Scotland and its accountability through the Scottish ministers to the Scottish Parliament and thereby to the Scottish people. We have to safeguard the coherence of a national health policy that is truly national and covers Scotland as a whole.
This afternoon's debate has been detailed and, especially with the summing up from the deputy minister, passionate. It has allowed members to express a variety of views, which I welcome, as I welcome this opportunity to respond to what has been said.
I regret that the Executive seems to have set its face against what I argue is the reasonable, moderate reform in the bill, but I hope to persuade the minister, even at this late stage, that voting for the bill in principle will not produce the negative consequences that he fears and that he described in some detail. In fact, it strikes me as rather strange that both the minister in his introduction and the deputy minister in his summation—both detailed and cogent—mentioned the idea of pilot projects. As far as I am concerned, if the bill is agreed to at stage 1, the Executive can lodge amendments at stage 2 to introduce such pilot projects. I am told by my legal advisers that all the Executive will have to do is lodge amendments that affect the commencement date of the act.
Have the ministers given the member a commitment that they will lodge such amendments, since neither of them has told us exactly how they intend to deal with the pilots?
I cannot read ministers' minds, so I cannot properly say. The point about pilot projects is reasonable—the ministers raised it. Unless I am mistaken—I will give way if I am—the minister said that the Executive intends to introduce pilot projects in the next session of the Parliament. However, if the bill is agreed to at stage 1, there will still be time to lodge stage 2 amendments on pilots in the next two or three weeks. We will have to wait and see. I accept the minister's sincerity on that point.
Would the member like pilots to incorporate the basic principle of majority decision taking by elected members on the board? It seems to me that that is the absolute basic requirement of the bill.
Yes, I would, although, to reply to concerns expressed by Nanette Milne and the Conservatives, that is a debate for stage 2. However, there may be a technical problem, since changing the percentage of directly elected members in the bill might not be possible, because that percentage is the core element of the bill, and is, in fact, the only change to the 1978 act.
The ministers and others have concerns about the bill taking the national out of national health service. Such fears represent genuine apprehension, but such disaggregation would not happen, because the bill proposes to amend only the percentage of members under the 1978 act. All the powers of the Parliament and the ministerial team to set the framework and targets nationally would remain.
First, I think that the member has conceded that the condition that the Tories imposed could not be achieved by the bill, therefore I challenge the Tories on their position. Secondly, it is important to say that, in relation to scope, many committee members told me that we could correct some of the imbalance in national and local policy by using the New Zealand model. Will the member confirm that, like the Conservatives' position, that would also be impossible to incorporate within the bill?
I do not know, because I am not legally trained. All I am giving is my opinion, which I am giving in good faith to Conservative members. It would be up to the convener of the Health Committee to take from the clerking team legal advice on amendments and to decide on them, and, if such an approach were to progress, it would be up to the Presiding Officer at stage 3 to decide.
The Conservatives were told by the Health Committee clerks that the legal advice was that what we were asking for was possible without wrecking the bill.
I am grateful for that information. If it is the case, there will obviously still be a debate to be had. Whether I agree or not, Mike Rumbles—who is commenting from a sedentary position—will know that it would be up to the committee to decide at stage 2. I have tried to answer the questions that have been asked , but I cannot give a definitive answer because the matter is not within my power.
Many members, including the minister and Euan Robson, mentioned cost. Of course, a cost would be attached to the postal ballot. By the way, the postal ballot would, I hope, address the concern which some members expressed, about low turnout: the bill team reckons that postal ballots by and large, although not uniformly, attract a greater voter turnout. Costs range from those in the financial memorandum, which estimates a cost of £1.2 million for a 30 per cent turnout and £2.4 million for a 60 per cent turnout, up to the Executive's estimate of £5 million. I think that the Association of Electoral Administrators estimates something in the middle. Life being what it is, the cost probably will be somewhere in the middle but, whatever it is, it is small. It is a drop in the ocean compared with the £10 billion that is rightly spent on the health needs of the people of Scotland, and it is not too much of a price to pay.
I am still waiting for information about the costs of the welcome public participation reforms that the Executive has put in train. I am sure that that information will come from the minister if we reach stage 2. Nobody gainsays those reforms or questions their cost, which is quite right, because they are good steps forward. One must take a proportionate view of cost.
I agree with Roseanna Cunningham that the problem is the lack of accountability. The problem is also the growing lack of trust among the public, which is not good. It can be corrosive and can undermine the confidence that the people whom we seek to represent have in our national health service. We must avoid that.
I could not agree with Bill Butler more about the lack of trust. Does he acknowledge that the changes in services at the Vale of Leven district general hospital over the past several years have been based on decisions by clinicians, not ministers, and that that causes a problem with trust in what the Parliament does? There has been talk of communities not being rational, and leadership and governance have rightly been mentioned. Does Bill Butler think that it is rational for a health board to make people travel two and a half hours from the Vale of Leven to Paisley for a basic service?
Trust is important, but I do not know enough about the specific issues that Jackie Baillie raises to be able to comment. Nonetheless, I take her word for it that they are real concerns in her constituency and I accept that she will do her utmost to represent her constituents' concerns.
It is not irrational to say to people that we trust them to participate in direct elections to health boards. Susan Deacon and Gordon Jackson may have been veering towards the view that to introduce a reasonable amount of direct accountability is to risk the national delivery of health services. I do not take that view, as I find it to be exaggerated. Susan Deacon is saying that it is nonsense. She is right and, if she is coming to that position now, I agree with her. It is dangerous, anti-democratic nonsense.
I do not want to end on a sour note. The debate has been wide ranging and good. I am grateful that there is support for the bill throughout the Parliament—we will see how much in about 15 minutes' time, or perhaps a wee bit longer. That support echoes the call that can be heard throughout Scotland for a change in the structure and culture of health boards. Direct elections of themselves would not be a panacea, but they would encourage people in our communities to feel that what they thought about the development of their local health services mattered and that proper account would be taken of it. The bill is a rational, reasonable and moderate proposal, and I ask members to support it at decision time.
On a point of order, Presiding Officer. Before we make a decision on this matter in 15 minutes' time, I seek your guidance. At the Health Committee meeting on 7 November 2006, the Minister for Health and Community Care and other members—Duncan McNeil in particular—confirmed that the pilot proposals are purely a matter for the Labour Party. Is it therefore appropriate that what amounts to nothing more than a possible Labour Party manifesto commitment should be put forward today by ministers on behalf of the Executive, particularly given that they will be in no position to implement it after the election?
I think that that is essentially a political point, but, given that I have just come to the debate and have just taken the chair, I will reflect on it for a few minutes. In the meantime, we should get on with business.
On a point of order, Presiding Officer. This relates directly to a matter of some debate, particularly in the closing speeches. I have now had clear advice from the clerks and should advise the minister that an amendment at stage 2 to reduce the percentage of directly elected members on a health board below 51 per cent would indeed be competent. That is perhaps more a point of information, but it is important in the context of the debate.
Those points have been made. We will find out in due course.
We know that. What about New Zealand?
Order. We will move on.