Chamber and committees

I asked the previous witnesses about the challenges that we are experiencing in accident and emergency. Knowing how to move people through the system—whether you bring them into A and E and discharge them if possible or move them into acute beds—is a complicated matter, and given what the previous panel said, I am interested in hearing what this panel thinks is driving the increased delays in A and E services.

Good morning, everybody. A and E discharges and the four-hour waiting time target are all over the news all the time. I know that looking at what causes those breaches in the four-hour target, and the on-going issue about delayed discharges or the whole throughput, is complicated.

John Burns just described what actions are being taken. I am interested to hear about what specifically causes the delays in A and E treatment—what causes that four-hour target to be breached? It is not the case that people are just sitting on a trolley waiting for somebody to see them; they are still getting some care at that time, whether it is blood pressure assessment, vital signs or waiting for an X-ray or whatever. It is not that people are just sitting there doing nothing. I am interested in what causes the delays and what further specific action we can take to reduce them.

Last week, we had a chamber debate about out-of-hours GP services and I quoted some percentages in relation to out-of-hours care reducing the number of hospital admissions, so that approach has been quite successful. I know that there are challenges around staffing out-of-hours services in some places in Scotland, but those have been a good way of reducing hospital admissions. Is that correct?

We are planning for the winter but are we projecting an increase in Covid cases? I was part of a team giving Covid vaccines last winter and I agree with Sandesh Gulhane that we need to encourage folk to take up vaccines, whether they are for Covid, flu, pneumococcal disease or whatever.

However, I am also thinking about other things, such as wearing masks. Instead of face coverings, should we be encouraging folk to be wearing FFP2 masks, which require fit testing, rather than surgical masks? I am concerned about what happens when we head into the winter and we are indoors again with the windows closed. I know that healthcare professionals are fed up with wearing masks already, but how do we find a balance to support everybody to reduce the risk of the spread of Covid?

It is sometimes difficult to see whether there is going to be light at the end of the tunnel. Should we just accept that the levels of attendance are high right now and that that situation will continue all through winter? Part of getting people out of hospital involves working with our social care teams, and that will include falls assessments and prevention and the other things that we can do to support people to get back to their own homes. What about the pressure on demand and the resulting impact on everyone across the service? Are there any other mitigating measures that you think could be implemented in that respect?

Does Tess White agree that the ScotGEM—Scottish graduate entry medicine—programme, which is focusing on rural recruitment for GPs and is unique to Scotland, is helping us to get rural GPs?

I welcome the opportunity to speak in the debate and thank my colleague Alexander Stewart for securing it. I supported the motion as it was quite positive, which is different from what we have just heard in the contribution. I want to start by paying tribute to all of Scotland’s GPs as well as their staff, the advanced nurse practitioners, NHS 24 call handlers and drivers. As Mr Stewart’s motion mentions, their work is crucial.

The primary care out-of-hours services are a fundamental part of our healthcare in Scotland and the service provides support to those who require medical assistance outwith normal GP surgery hours. Out-of-hours involves a number of agencies and healthcare professionals working together to provide an integrated service for patients. The quality and safety of out-of-hours care is extremely important and I agree that patients should have access to consistent, high-quality standards of care across the country.

The picture with out-of-hours care in Scotland is a comparatively good one compared to other United Kingdom nations. Each year across Scotland, about 870,000 patients use out-of-hours primary care services, resulting in just under a million consultations. Home visits account for one in five, which is about 187,000 contacts with out-of-hours primary care services, with over half of the contacts—57 per cent—taking place in a primary care emergency centre. Children under five, women in their 20s and people aged 75 and over are the most common age groups of patients contacting out-of-hours primary care services. Treatment was completed by out-of-hours primary care services for just over half the patients who were in contact with them Only 3 per cent of contacts with the services resulted in a referral to accident and emergency or a minor injury unit, showing how out-of-hours services are helping to reduce acute hospital admissions.

Those statistics are welcome and they show the importance of out-of-hours services as a way to reduce hospital admissions. They are also an important way of providing reassurance to the public that care will be provided outwith GP hours.

Andrew Buist, the chair of the British Medical Association’s Scottish general practitioners committee, recently wrote a blog reflecting on NHS out-of-hours care in Scotland now compared with the model in 2004. In the blog, Dr Buist remarked how out-of-hours services, which previously were solely doctor based and involved doctors in long on-call hours, often driving themselves, have now been transformed into a more slick operation in which the primary care sector works together. Dr Buist said in his blog:

“When I think back to what out-of-hours was like before 2004 then what a luxury it feels like now to have a driver.”

He just sits back, having read the patient’s notes. He lets someone else worry about finding the right house, safe in the knowledge that, when he is on the call, there is someone outside waiting on him. Dr Buist continued:

“You work at your own pace alongside other GPs and nurse practitioners all picking from a pool of patients who have been triaged by NHS 24 and given an appointment time slot. The cases were all appropriate, a mixture of children, coughs, urinary symptoms, with the occasional rash, chest pain or alcohol withdrawal. Compared to daytime general practice, it was so much more straightforward. There was no shopping lists ... no paperwork.”

Dr Buist said also:

“Out of hours is part of general practice. We as GPs need to support it and not give it over to hospital care.”

Those words speak for themselves and, although there is, of course, room for improvement in the out-of-hours service, as there is in other parts of our healthcare system, I want to recognise the hard work of all the staff involved to make it what it is today.

That is in contrast to the latest ask of the new UK Government health secretary, Thérèse Coffey, by the Doctors Association UK. DAUK is asking for urgent action to address GP retention, as it is predicting that 16 million people in the UK could lose access to a GP within a decade.

In closing, again I welcome the debate and the opportunity to speak highly about Scotland’s out-of-hours sector.

We have talked about preventative spend, better outcomes and better health overall.

An example that comes to mind is how we keep people out of hospital in relation to asthma attacks or chronic obstructive pulmonary disease exacerbation. An overnight stay in hospital costs a minimum of £1,100. However, renewing a person’s annual asthma plan and ensuring that people use their inhalers appropriately—whether they have COPD or asthma—can help to keep people out of hospital. Such support from a practice nurse or specialist in airway management and respiratory issues has to happen in primary care. Does that mean that we must take money away from secondary care and give it to primary care? Do we get an extra pot of money from somewhere?

Do we have a wee borrowing pot? Oh no, we do not, because we cannae borrow in Scotland. What is the best way to divvy up a pot of money?

On the back of Tess White’s question for Professor Bell—I will be quick—I have a question about recruitment and retention, and the plans for clinical training and career pathways for health and social care workers. The Scottish Government has introduced bursaries for training of nurses, midwives and paramedics, and there is free university tuition in Scotland. I think that that will help recruitment, as well. Should anything else be done or introduced, in addition to the bursaries that have been introduced already, to support further recruitment and retention, and to encourage some of the people who have left the healthcare environment to return?

I picked up from Dr Bell’s submission that a review is being undertaken of the NHS Scotland resource allocation committee—NRAC—formula and that certain recommendations have been asked for in relation to the way in which funding is allocated. I am thinking about remote and rural areas, whether those are in the Highlands and Islands or in the south of Scotland. What, if anything, needs to be changed in the NRAC formula?