Chamber and committees

Thank you so much, convener. I thank you all for being so accommodating of my time; I am grateful to the committee for shifting this meeting to a slightly later time in order to help me with childcare issues. I am also grateful for the opportunity to be here today to respond to the committee on questions relating to the public petitions that the deputy convener mentioned.

Let me begin, as I did last week, by reiterating the fact that we are currently experiencing extreme pressures in our health services. This is, by any estimation, the most challenging winter that the national health service in Scotland and the United Kingdom has ever faced. Our NHS and its committed workforce face a perfect storm of intense pressures that are leading to difficulty, disruption and delay across the service—including in remote and rural communities, which too often face their own significant challenges. I suspect that we will touch on many of those issues during today’s discussion.

As I outlined last week, we have advised health boards to exercise their own judgment in relation to their locality and what action is necessary to overcome or, at least, to mitigate some of the challenges that they are experiencing. I am aware of the challenges that rural Scotland faces in healthcare, having visited all our health boards and spent a significant amount of time in boards that cover remote, rural and island communities. I am determined to ensure that our remote and rural areas are not left behind as we continue to invest in and reform our health and social care systems.

I expect NHS boards that service remote and rural areas to take account of the particular needs of their communities, to ensure that services are delivered flexibly and innovatively, to recognise the concerns of local populations and to take account of the significant geographical challenges. A blanket approach for a country that is as geographically diverse as ours is simply not appropriate.

Front-line workers are the foundation of our health and social care services. We have committed to growing that foundation and overall staffing levels have increased by almost 3,000 permanent whole-time-equivalent roles during the past year. That builds on our strong track record of delivering 10 years of consecutive growth, with almost 30,000 more whole-time equivalent staff working in the NHS now than there were in 2006; the actual figure is around about 28,900.

We are making nearly £8 million of funding available to NHS boards to support recruitment of up to 750 nurses, midwives and allied health professionals from overseas this winter. That will, of course, include boards that include remote and rural localities.

We are creating opportunities for an initial 250 band 4 assistant practitioners across acute services, primary care and mental health. We continue to expand the number of trainee doctor posts in line with medical workforce modelling. Since 2014, 725 additional training posts have been created, including 152 that I recently agreed would be recruited in 2023. I am sure that the committee will discuss this, but we know the importance of training posts being available in remote and rural health boards.

I recognise that general practitioners in remote and rural areas also have distinct challenges. That is why we have invested £7 million of funding since 2019 to take forward a range of initiatives to support rural general practice. Those include support for recruitment and retention: a “golden hello” scheme to attract new rural GPs; a £20,000 bursary to recruit and retain GP trainees in hard-to-fill locations; Scotland’s first graduate entry medical programme—ScotGEM—which provides a graduate entry medical degree that has a real focus; and a pilot scheme to recruit experienced GPs to provide support for rural practices. So far, 52 students have graduated from the ScotGEM programme—in fact, I think that the CMO was at that graduation—which has allowed them to progress to foundation year 1 posts.

We are also supporting a recruitment campaign called “Rediscover the joy of general practice”—many committee members will have heard of it—which aims to recruit experienced GPs to provide support for remote and rural practices. I will be happy, as we get into the meeting, to give some detail on how that programme has assisted. NHS Education for Scotland has also developed for doctors a credential in remote and rural healthcare that recognises the unique skills that are required to work in those challenging regions and provides a route for upskilling in those environments.

We are working closely with NHS Education for Scotland on scoping a national centre for excellence for remote and rural health and social care. That is another piece of work that Sir Lewis Ritchie was not just involved in but led. I am grateful for all the work that has been done in that regard. That centre will have an initial focus on primary care, although I imagine that it will be of interest to people from right across health and social care. It will be a resource that boards and health and social care partnerships will be able to use in support of their responsibilities in providing rural health and social care. Our aim is that the centre will identify, celebrate and—importantly—pull together the many examples of innovative work that are already going on, and promote excellence to address the long-standing issues, particularly recruitment and retention, in remote and rural areas.

We remain committed to growing our nursing workforce in remote and rural areas and we look forward to welcoming new pre-registration nurses to the University of the Highlands and Islands in the 2023-24 academic year. Since the programme was established in 2017, we have seen a fantastic increase of 34 per cent in intake.

Although we are committed to investing in reforming the NHS and social care systems nationally, we are fully aware of the challenges of rural healthcare and are responding to them.

Women’s health is a key priority for the Government, which is why Scotland was the first country in the UK to publish a women’s health plan in August 2021. Our ambition is to have a Scotland where health outcomes are equitable across the population, so that all women, regardless of where they live, enjoy the best possible health throughout their lives. There has been substantial progress since publication of the plan. There is now a specialist menopause service in every mainland health board and a buddy support system in place for island health boards. We have initiated new research on endometriosis, launched a new women’s health platform on NHS Inform and increased access to bridging contraception in community pharmacies. However, of course, there is still much to do. I hope that those are important and welcome first steps.

Although a formal review of NHS Highland’s gynaecology services is under way, the board has set up additional capacity for outpatient and theatre treatment. That will provide much-needed capacity across Caithness general hospital, Belford general hospital, Lawson memorial hospital and Raigmore hospital.

I thank our exceptional health and social care staff, who make an incredible contribution to keeping us safe, especially under the current challenging conditions and especially where challenges can be exacerbated by remote and rural geography. I am also grateful to the petitioners for taking the time to bring the petitions to our Parliament.

I am happy to take questions on those matters and any others that members wish to ask.

I will bring in Sir Lewis Ritchie shortly. It is a good question. We know that multiple good innovations are taking place across a number of health boards in remote and rural Scotland. Doing that work more collaboratively might bring a better return for those health boards. Essentially, it could be really helpful for the centre for excellence to multiply those innovative practices across remote and rural Scotland. Sir Lewis might be able to talk more about that, as he was deeply involved in the genesis of the idea for a centre for excellence, which is about sharing effective practice, data and evidence, and supporting boards to deliver a stronger collaborative response to concerns.

The biggest concern by far that I have heard from health boards in remote and rural locations is around recruitment and retention of the workforce. That tends to be the biggest challenge, and the centre for excellence can help in that regard. NES has agreed to host the centre, which makes sense, given its education and training remit. It is a natural fit.

Understandably, the big question is about funding. As you know, convener, we are in discussions about the 2023-24 budget. I will not pre-empt the conclusion of that budget process, but I have asked for a proposal on how much the centre would require in 2023-24 to make progress. I am still waiting for that information to come back from NES; I expect it shortly and will consider the proposal with an open mind.

I will pass over to Sir Lewis, who has been deeply involved in work on the centre.

Let me try to give a few solutions, if I can. Dr Gulhane is right, workforce recruitment, plus the retention of that workforce is exceptionally important. There are a few things that we are trying to do. First and foremost, we have a good record in recruitment and staffing. I referenced some of that in my opening statement. However, I do not disagree with Sandesh Gulhane that the vacancies are far too high. I look at the vacancy rates around nursing and midwifery in particular and they are clearly far too high. We have to try to resolve that.

I have often said in the chamber that we must consider recruitment and retention as separate workstreams, although they are interlinked. There is no point filling the leaky bucket; our recruitment record is good, we must ensure that our retention record is just as good. We start from a strong position, with that increase of staffing of almost 28,900 since 2006 and our having more GPs per head than anywhere else in the UK and more nurses per head than other parts of the UK.

Dr Gulhane talked about solutions. What are we trying to do about it? I will come to retention shortly, but I think about there being a three-pronged approach to recruitment. The first prong is the pipeline: we are ensuring that our pipeline of graduates coming through the system will match our demand for the future. For example, we have made commitments for the medical workforce and fulfilling the commitments to increase them by 100 per annum over the course of the parliamentary session—so, 500 by the end of the session. So far, we are not just meeting, but are exceeding that target—there have been 10 consecutive years of growth, as I mentioned.

The second prong is domestic recruitment, and by domestic I mean right across the UK. We have a very proactive campaign under way to recruit GPs, which has a focus on recruiting to remote and rural Scotland from other parts of the UK. I make no apologies for that, because remote and rural parts of Scotland are very attractive places to work.

The third prong is the international recruitment piece. You ask about solutions; there is £8 million to try to recruit 750 nurses, midwives and AHPs, but that is not a panacea. I will not suggest to you that international recruitment will resolve all the challenges that we face around the workforce, but it can make a difference as part of that three-pronged strategy. I engage with remote and rural health boards, and they believe that we can get more advantage than we currently get from international recruitment, particularly in remote and rural areas.

We are doing a lot on retention. I attended a nursing round table with the Royal College of Nursing, and a couple of members who are at this table were there. Gillian Mackay was certainly there, and she will remember a nurse’s comments about retiring and being rehired. The inflexibility that existed there meant that she was going to leave the health service altogether. That is a huge loss, because she had well over three decades of experience. That was fed back to the chief nursing officer who, I am glad, working with the RCN and others, has in place an updated retire-and-return policy that has been welcomed by much of the workforce.

The BMA, which is another trade union or professional body, has called for a direct pension scheme. It has called for an employer pension contribution recycling scheme to be developed to deal with some of the pensions disincentives that exist in the system. A direct scheme was very much in our gift, so we have devolved that to health boards, and direct schemes have been live in health boards across the country since the end of December. More can be done on pensions, and I welcome what the UK Government has done thus far, but the BMA is calling for it to go even further, and we support that call.

I have taken up a fair bit of time on that answer, but I could speak to more that we are doing on recruitment and retention. Much of it is geared towards helping our remote and rural health boards.

I will get you the latest position. Of course, choice is good only if people are offered it.

I am always of the opinion that we can never have too much engagement, and I think that engagement and visibility are positive. It can be tricky. For example, last week, I had to cancel a meeting with the fantastic women’s hub in north Highland, much to its annoyance—understandably so—because of certain pressures in the parliamentary schedule. There will always be times when engagement can end up being disrupted for understandable reasons.

However, what frustrates me slightly—I will not mention any health board, as all health boards need to be cognisant of this issue—is that it can often feel as though there is a disconnect between the health board management, and health services and provision locally on the ground. My instruction to all the health board chairs, chief executives and senior management is that they should be visible and that they should ensure that engagement happens regularly. There should be not just engagement. What can be done to make people feel that they are being heard, and what proactive action can be taken to demonstrate that we are listening? Although we will not be able to do everything that everybody wants—that is simply the nature of what we deal with—I would say that the engagement has gone well, but there is certainly more to do.

I also encourage boards to make the best use of technology. I know that it is not always possible to travel around the vast expanse of the NHS Highland area, for example, and that it is not always possible to get everywhere all the time in Orkney, Shetland and other islands, so one of my instructions is to make the best use of technology.

It is certainly not a situation that I would want to find my wife in, and I would not want to be in that situation myself if I was driving my pregnant wife along the A96. I am sure that we will touch on Caithness, too. It would be the same for people there. Let us consider what the weather is like in Caithness now and has been over the past few days.

I would not want to be in that position. However, it is worth saying at this stage that there is not another local matter that I have spoken more about in the chamber—in ministerial statements or debates—than Dr Gray’s hospital. Rightly, it gets significant attention from me, as cabinet secretary, and from the Government. I will not rehearse the latest position on it, because I think that Sandesh Gulhane was in the chamber during the last debate, and if not, he will certainly have apprised himself of the latest position.

The safety of women and their unborn children has been at the centre of our thinking on Dr Gray’s hospital. We could not, in good conscience, have a consultant-led service tomorrow, because if we said that all pregnant women in Elgin and Moray should give birth in Dr Gray’s from tomorrow, next month or later this year, we would be putting women and their unborn children at risk of very serious harm.

Part of the discussion on that can be understood if we look at what Ralph Roberts said in his report about Dr Gray’s. He referenced “low risk” elective C-sections. I am very aware that I am talking to a doctor, who I suspect will have far more clinical expertise than anybody else at the table has, and who will therefore be the first to understand that a low-risk elective C-section can quickly turn into a high-risk elective C-section, as there is potential for bleeding or haemorrhaging and for blood transfusions and other such things to be needed. The facilities at Dr Gray’s hospital would not allow for such issues to arise, so even what is termed as a low-risk C-section in Ralph Roberts’s report requires significant investment in the facilities and the workforce.

As the member knows, NHS Grampian has recently come forward with a plan for the return of consultant-led maternity services sooner than was previously predicted. In the chamber, a number of people referenced a 10-year or seven-year timescale, but the member will know that the timescale that NHS Grampian proposes is far shorter than that—it goes just beyond the end of this parliamentary session, in 2026. That is positive, but I do not underestimate how much of a challenge it will be to get there, and that is why workforce and recruitment and retention issues will be at the core. Investment and capital infrastructure are not as difficult as recruitment and retention.

Forgive me—that was a long answer to a short question, but I do not feel that it would be safe if we instructed that all pregnant women in Moray should give birth at Dr Gray’s hospital; it would not be safe for the women or for their unborn children, given the challenges around the workforce and facilities. The chief medical officer might want to add to that answer, given his clinical expertise.

We always do our best to do that. As soon as we have got through one winter, we start planning for the next. Of course, the remote and rural challenges can be significant. I will highlight two aspects that have been central to our planning for winter—and even before winter—with regard to the extreme pressures that we face in the NHS. We take a whole-systems approach to both the front-door and back-door aspects at our very busy acute sites.

At the front door, we try to reduce attendances, which is definitely having some purchase—we see that it is working, although we will continue to look at whether we can reduce attendances even further. We do that by ensuring that people get the right care in the right place at the right time through access to other services such as NHS 24, the pharmacy first Scotland service and out-of-hours general practice.

From a remote and rural perspective, that can be more challenging, because the nearest service might be further away from someone. Even if they have a car, access can be tricky, and if they do not have a car, it might involve taking a couple of buses. That can be tricky, and people might think, “If I’m unable to get there, perhaps the safest option is to go to A and E”, because they are worried about their condition, or a family member’s. That is one of the real challenges.

Our colleagues in NHS boards—and particularly the remote, rural and island boards—have been working hard to try to make services as accessible as possible. That goes back to David Torrance’s very good question on the use of digital. NHS 24 is a service from which anybody across the country can get clinical advice; it has a number of clinical supervisors who provide excellent advice.

At the back door, we know that one reason why we are facing such significant pressures this winter—I note again that we were facing pressures before winter, too—concerns the high levels of occupancy and delayed discharge in the system. Again, I highlight how important social care is, as it is critical for us to be able to discharge people who are clinically safe to be discharged. Looking at the landscape of social care, there is no doubt at all that those social care providers in remote and rural areas, both care-at-home providers and care homes, are really struggling. There are a range of reasons for that, but they include fuel costs, which are often higher in remote, rural and island settings. Our local health boards will work with those care providers to see whether they can make adjustments or provide any additional support to assist with those particular challenges.

To summarise, it is vital that we look at the unique winter challenges that those in remote, rural and island Scotland face. The answer to Evelyn Tweed’s first question, which was about whether our remote, rural and island partners are involved in that winter planning, is yes—absolutely. Of course they are. I have given two examples, but I could give many more, of where there are unique challenges for places in Scotland with particular geographies. We are very alive to them and we are trying to assist during a very difficult winter.

Thank you, convener. Long time no speak. I am keen to take any questions that the committee might have.

As you heard in the session that we have just concluded, it is so important that the health service is able to meet intense challenges, such as we are currently facing, as they arise. The order gives additional flexibility to the GDC and NMC to help the health service to respond to some of those challenges.

Since the end of 2020, European law on recognition of qualified healthcare professionals from the European Economic Area no longer applies in the UK. Current stand-still arrangements mean that the UK professional healthcare regulators continued to automatically recognise EEA and Switzerland-obtained qualifications for up to two years after the end of the transition period. The period of automatic recognition ends in early 2023, when the Secretary of State for Health and Social Care will review the approach to registering professionals who have qualified in the European Economic Area.

The order is being made under section 60 of the Health Act 1999. It will amend the Dentists Act 1984, and the Nursing and Midwifery Order 2001 and other subordinate legislation. The order will change the legislative frameworks of the GDC and the NMC to allow them to amend their registration processes for international applicants.

Both the General Dental Council’s and the Nursing and Midwifery Council’s governing legislation prevents them from making changes to their registration processes. In the case of the GDC, the legislative structure makes it quite difficult and time-consuming to make changes to its registration process. Likewise, the NMC must follow an overly detailed procedure to carry out assessments for international applicants.

The order makes a number of changes to the legislative framework on the NMC’s and the GDC’s international registration requirements. First, it allows the GDC to apply a range of assessment options to determine whether applicants have the right knowledge, the right skills and the right experience to practise in the UK.

Secondly, it removes the requirement for dental authorities to use an assessment for overseas applicants, such as the overseas registration exam, known as the ORE.

Thirdly, it allows the GDC to charge fees to international institutions for expenses that are incurred in relation to international registration, so that it can cover the costs of recognising international qualifications that meet UK standards.

Fourthly, the GDC will be able to make rules that set out the details of its international registration processes without the need for Privy Council approval, so that that change can be made far more efficiently.

Fifthly, a transitional period for the ORE will continue to apply for 12 months after the order comes into force, at which point the GDC will publish new rules for its international registration processes.

Subject to parliamentary approval, of course, the effect of the order will be to allow the GDC to use increased flexibility to set out two international registration routes based on an assessment of an applicant’s qualifications, skills or training, and completion of an ORE-style assessment, and the recognition of an applicant’s qualifications where the GDC has assessed that qualification and considers that it provides applicants with the required knowledge, skills and experience.

With regard to the changes to the Nursing and Midwifery Order 2001, the NMC will continue to apply its test of competence as the main assessment route for international applicants, which will remain in the legislation as one of the ways that the NMC can ensure that an applicant meets its standards.

However, the order will bring in other pathways for registration. First, there will be recognition of an NMC-approved programme of education from outside the UK. Secondly, in limited situations, there will be a qualification comparability exercise, which the NMC will use to judge whether the applicant’s qualification is of a comparable standard to an NMC-approved UK qualification. In either situation, applicants would still need to meet the NMC’s other registration requirements, such as on English language, indemnity and payment of the registration fee.

I fully support the instrument as a pragmatic solution that will improve consistency and give the regulators much-needed flexibility in responding to the changing circumstances. I am happy to answer any questions that members have.

I will let Dr Smith come in in just a second, as he has been integral to the ScotGEM programme. We have already grown the intake. We often get calls for health boards that are not part of the ScotGEM programme to be involved—in fact, the convener is one of the advocates for the expansion of that programme.

Now that we have had the first cohort of graduates, it is important to ensure that the programme is stabilised before we consider expanding it to additional health boards, for example. At the moment, as you say, it is a graduate entry programme. I think that extending it to undergraduates would be challenging and quite disruptive to a model that we are trying to stabilise.

The programme is hugely popular, and we should be open minded about potential expansion in the future. My view is that, at the moment, we need to ensure that it is stabilised and that we are getting the benefit from the programme. Dr Smith might be able to add to what I have said.

I could be very brief and just say yes. There is the potential to use digital or mobile technology and equipment to deliver training. I have seen fantastic examples of simulators in our training facilities. It is incredible just how real it feels—even as a non-clinician, I could feel my heart racing as those who were training were dealing with a medical emergency in that simulated environment. In short, yes, we are exploring that and seeing what more we can do in that respect.