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Chamber and committees

Meeting of the Parliament (Hybrid)

Meeting date: Wednesday, March 3, 2021

Agenda: Portfolio Question Time, Primary Care, Scotland’s Recovery, Standing Orders, Business Motion, Parliamentary Bureau Motions, Decision Time, Autism and Learning Disabilities


Primary Care

The Deputy Presiding Officer (Christine Grahame)

Before we get on to the debate, I should mention that we have a little bit of time in hand. I know that members speaking in the open debate were expecting just three minutes for their speeches, but I can be really generous and allow four-minute speeches. Has that not made your day? I know that every politician here can talk for an extra minute without any encouragement from me.

The next item of business is a debate on motion S5M-24247, in the name of Lewis Macdonald, on “What should primary care look like for the next generation?” I call Lewis Macdonald to speak to and move the motion on behalf of the Health and Sport Committee. Please proceed, convener.


Lewis Macdonald (North East Scotland) (Lab)

Thank you, Presiding Officer. I am delighted to open this debate on the Health and Sport Committee’s report, “What should primary care look like for the next generation?” The title of the report is deliberately framed as a question, and I start by thanking all those who offered their answers from the point of view either of patients and the general public or of the healthcare professions, whose views we also sought.

I also thank all those who have supported me in my role as convener of the committee over the past three years. They include the clerking team, ably led by David Cullum, who, like me, has three more committee meetings to look forward to—the same is true for one or two other members in the chamber; the researchers of the Scottish Parliament information centre; the press and public engagement teams; and other Parliament staff, including the broadcast and information technology teams, who allowed the committee to continue to meet throughout the pandemic; members of the committee, past and present; and those witnesses who have shared their expertise with us on a vast array of subjects.

I thank ministers for their positive engagement in general and for a quick response to this report, in particular. Although there are many areas of agreement, there are other questions that will clearly be for the relevant committee to pursue in the next session of Parliament—and, hopefully, for the health secretary to answer in the next session. I will mention Jeane Freeman by name because of the work that she has done with the committee over the time for which I have been the convener. It is appreciated.

Our starting point for the report was to ask the public what kind of primary care service they wanted to see; we then asked representatives of the healthcare professions whether the public’s vision could be realised and, if so, how. We received more than 2,500 responses to our public consultation; we ran a session with the Scottish Youth Parliament, which surveyed its members; and we held detailed discussions with public panels over two weekends in Aberdeenshire, Lanarkshire and Fife.

The public told us that they wanted to be able to access primary care just as easily as they can access a community pharmacy, with weekend opening and longer hours, and to be able to make appointments online. They were clear that patient data should belong to the patient and that new technology could help to improve patient care.

Covid-19 delayed our report, but it accelerated some of the changes that the public told us they wanted to see. The next challenge will be how to provide the personnel, the resources and the governance structures to embed those positive changes in the future delivery of primary care.

Contrary, perhaps, to some interpretations, our report is supportive of general practitioners and seeks to make best use of their valuable time in seeing those who are in need of the skills that only they possess while, at the same, time making best use of the skills of each of the other professions in the wider multidisciplinary team.

There is broad consensus that primary care should be at the heart of the healthcare system, that care should be delivered by multidisciplinary teams and that patients should be able to access the right professional at the right time, to let them remain at or near home whenever possible. The challenge is how to turn that shared vision into reality. We believe that there are key roles for health and social care partnerships, for multidisciplinary teams, including GPs, and for the public.

Health and social care partnerships, as integration authorities, are responsible for the whole range of primary and community health services and account for more than a third of the total budget for health and social care, which, in turn, accounts for half of all expenditure by the Scottish Government. Partnerships themselves recognise that primary care needs to change if it is to align with a community approach. Edinburgh Health and Social Care Partnership told the committee:

“Primary care is not established to focus on the priorities of local communities—its priority is the (ill) health needs of individuals”.

Partnerships can help to change that, through their strategic commissioning plans and the localities that they have established. Primary care improvement plans should be in place very soon—we might hear more about that from the cabinet secretary—and should reflect local needs and priorities.

Our report highlights early evidence from partnerships of the benefits that have been gained from changes in how services are delivered, such as improved use of GP time because patients are accessing other members of the multidisciplinary team.

GPs rightly want to remain at the heart of healthcare in the community. They recognise the key role of other professionals, from occupational therapists to district nurses. The change that we need is one in which doctors and patients reset expectations about who will help and in what way, so that support and care from each member of the multidisciplinary team is seen as of equal value when it is the care that the patient needs.

National workforce planning must take account of a shift in the balance of care from hospitals to the community. The committee is keen for the principles of the Health and Care (Staffing) (Scotland) Act 2019 to be put into practice as soon as possible.

The public told us that they want a more preventative approach and more emphasis on social prescribing, and those aspirations are reflected in our report. So, too, is the view of all healthcare professions and the general public that access to data in primary care must be improved, not least by having IT systems that talk to each other, so that health professionals can access information and patients have to tell their stories as few times as possible in order to receive the care that they need.

The Covid pandemic has been challenging for everyone who is involved in primary care—and health and care in general—but it can also be a starting point for the delivery of real and lasting change if we find ways to embed the improvements that have perforce been made in responding to the emergency over the past 12 months. I look forward to that happening, and I commend our report to the chamber.

I move,

That the Parliament notes the Health and Sport Committee’s 8th Report 2021 (Session 5), What should Primary Care look like for the next generation? (SP Paper 939).

I can be a little generous to the opening and closing speakers, too. I do not want to make you feel disadvantaged in any way.


The Cabinet Secretary for Health and Sport (Jeane Freeman)

Thank you, Presiding Officer, for your generosity.

I welcome the report. Before I talk about it, I thank the members of the Health and Sport Committee with whom I have had the privilege of working—in particular, Mr Macdonald, the convener. I have found our engagement constructive, positive and helpful.

The committee’s report is a helpful contribution to our current work on reforming primary care, and I am grateful to the committee not only for the report’s contents but for the way in which the committee gathered evidence. The committee sought the views of not just health professionals but the public, especially younger people, who want to be engaged in how services are delivered now and in the future and who, in many ways, want their engagement to be different from that of older generations.

The committee raised a number of important questions and suggestions for how we can continue to strengthen primary care, and I have now formally responded. Much of what has been raised is, of course, for the next Parliament, Government and health secretary, but I hope that, as I say a few words now and in closing, I am able to give committee members reassurance that their report is being taken very seriously. Some of what they are asking for has already begun. Some of the thinking has certainly already begun.

Before I turn to the report, I restate my thanks to all primary care staff for their work, particularly during the past year. GPs and their practice teams, pharmacists, dentists, optometrists and allied health professionals have all responded tirelessly to the pandemic, continuing to provide essential services but also adapting to new ways of working—some of which point to new ways for the future—most recently, through their current and huge contribution to the vaccination programme. In many areas, such as digital, urgent care and multidisciplinary team working, the response to the pandemic has both benefited from previous investment in primary care and provided foundations for future reform.

I will now touch on some of the key findings from the committee’s report—first, on the need to bolster and secure the role of multidisciplinary teams as part of a growing workforce in general practice. Since the landmark 2018 GP contract offer, we have invested £205 million in expanding and enhancing multidisciplinary teams across Scotland, with the number of GPs also having increased by 234 over that period. That significantly helps us to ensure that people can expect to see the right person at the right time, whether that be, for example, by direct access to a pharmacist to manage medication or to a physiotherapist for musculoskeletal issues. That enables GPs to spend more time with those individuals who have complex care needs. In the current work on the redesign of urgent care, some of that investment is coming to fruition and we are seeing the real value of making sure that, in having the right care in the right place for individuals, primary care in its widest definition has an absolutely central role.

I also acknowledge the importance of improving access to general practice. For many, that is the first and often only point of contact with the health service when issues arise, and it is really important that we get that right. As I have said before in other places, for me, primary care in its widest definition is the foundation of our health service. It is where most of us will have most contact—for some, it will be their only contact—with our health service throughout our lives. It matters that we get that right—that it is accessible and that it addresses our needs. In saying that, I commend the work of our out-of-hours GPs, paramedics, dentists and other health professionals who provide urgent care services at evenings and weekends.

The report highlights that the citizen’s voice must be at the heart of shaping our reform programme. That was also identified as a key theme in the recent independent review of adult social care, and I completely agree with that. This morning, I was party to a discussion with very senior members of the Scottish Government health directorate, looking at how we will continue to respond to the pandemic and at how we will build on many of the lessons of that and on some of those foundations. Central to that was how we ensure at every level of our development of health and social care services that we are able to hear the citizen’s voice. In some ways, we can draw on lessons of how that has been done elsewhere in Government, but it matters greatly to me that we embed that approach as we develop innovative ways to hear what people are saying and to engage with them in the development of policy and in the reform of services that are vital to their health and wellbeing.

The report recognises the growing need for mental health support and the role of primary care in early identification and prevention. We are committed to further building mental health capacity and capability through the GP contract offer.

Social prescribing is also fundamental in supporting people to address the wider challenges that they face. That work was necessarily paused in response to the pandemic, but I am happy to confirm that it has been restarted and is being embedded into our thinking. We are well on track to deliver on our commitment of an additional 250 community link workers by the end of this session of Parliament, which is but a few weeks away.

The report also rightly identifies that technology will play an increasing role in services in the future. Throughout our response to the pandemic, we have seen major shifts in the use of television and video consultations where that is the right approach, without reducing the importance of having face-to-face appointments where that is the right thing to do for both the patient and the clinician.

Despite my generosity, I must ask you to conclude.

Finally, I will turn briefly to data in general practice—

The Deputy Presiding Officer

We do not have time. I have given you an extra two minutes. Sorry, but I just want to be fair to people.

I call Donald Cameron to open for the Conservatives. I will be generous with you, Mr Cameron, but go at the same tempo, if you do not mind.


Donald Cameron (Highlands and Islands) (Con)

I record my thanks to my colleagues on the Health and Sport Committee for their work on the report, and to the committee clerks for their efforts in producing it. I also thank those who gave evidence. Broadly speaking, I feel that we have a report that can set in motion a wider debate on how we deliver primary care services in the future.

I have long been of the view that, when we discuss the future delivery of health and social care in general, we should look not only at the next five years but at the next 25 years. We, in the chamber, need to ask ourselves how we would like to see such services being delivered when we are older, and what national health service and social care service we want to leave for future generations.

The committee’s report covers a broad range of issues, including the general medical services contract, the future role of multidisciplinary teams and the status and purpose of integration joint boards going forward, to name but a few.

However, I will focus on the recommendations for general practice, which is an issue that the Scottish Conservatives have long believed needs to be debated properly and fully by Parliament. Before delving into some of the specific issues, I thank our doctors, nurses, ancillary staff, office staff and all those who work in general practice for their efforts during the Covid-19 pandemic--in particular, for their role in the vaccination roll-out.

One of the more important aspects of the pandemic with which we require to grapple is its long-term impact on the health service. For instance, does it mean that we should pause or accelerate the changes that are under way? In its response to the committee’s report, the Royal College of General Practitioners made a number of comments, including that it welcomes the

“focus on improving data sharing and technology within primary care ... which will bring huge benefits for patients and increase efficiency within the NHS.”

Both the RCGP and the British Medical Association welcomed the recommendation that the Scottish Government should devise

“an information campaign to inform the public on what their primary care service will look like, what they can expect and when”.

The RCGP stated that it would like to ensure that

“the target of increasing the GP workforce by 800 by 2027 is reached”

and that it wanted to

“see workforce numbers across the primary care multidisciplinary team bolstered”.

I agree. Over the course of this parliamentary session, the Scottish Conservatives have consistently called for investment in additional GPs in order to address that particular aspect of the broader workforce crisis that we see in our NHS and social care services.

In particular, the committee report notes that

“more innovative approaches… were required to attract professionals to rural practices, where it was more difficult to recruit.”

I represent the Highlands and Islands, so that is a pertinent point for me, given the real difficulties of recruiting GPs in remote and island communities.

In addition to the need to recruit more GPs, current data shows that the number of GPs who are aged over 60 and approaching retirement is at a 10-year high. In 2020, some 250 GPs were over 60 years old, and from 2010 to 2020 the number of GP practices decreased by 9 per cent. Therefore, it is clear that there are multiple challenges in general practice that we need to address to ensure that it is properly staffed and supported and can meet the demands of a growing and ageing population.

Patently, there is more that we need to discuss and debate about the future delivery of primary care services. I am afraid that, undoubtedly, general practice is facing a workforce crisis, as are other areas of our NHS. It is also evident that existing ways of delivering primary care might not be financially sustainable.

We need a primary care system that keeps pace with modern life, that embraces technology and, above all, that is shaped around the needs of patients. That is something the Scottish Conservatives will continue to focus on as we move forward.


Sarah Boyack (Lothian) (Lab)

I thank the committee for its excellent report. As we reach the end of the parliamentary session, it is timely that we debate what needs to happen next.

After 14 years of the Scottish National Party being in power, we have not seen the major changes in our NHS that Scottish Labour believes we need. Recruitment of staff, support for patients, greater focus on delivering in our communities and investment in preventative health are all vital. If we are to see a reduction in the pressures on our acute emergency services, the issues that are raised in the report need to be addressed urgently.

GP surgeries and primary care are fundamental to people’s access to our NHS, so it is vital that capacity is provided when communities such as Musselburgh expand. The challenges that are posed by the Riverside medical practice there make the case for community concerns being acted on early. More work is required in GP and community services in relation to recruitment and making services more accessible to people where and when they need them, as well as in ensuring that patients are supported by digital records and systems and by robust data collection.

The issue of ensuring that services are more patient focused comes across strongly in the committee’s report, through the consultation feedback that it received. Preventative healthcare, which is critical in terms of access to services and reducing health inequalities, has to be part of that agenda.

During the pandemic, the British Lung Foundation has raised the issue of people with asthma and respiratory conditions. It is shocking that people from low-income households are less likely to have good health outcomes in managing their conditions—[Inaudible.]—poorer health and shorter lives as a result of poverty comes across starkly in the evidence on health inequalities that is referred to in the report.

We must ensure that, as we come out of the pandemic, people who have Covid, especially long Covid, get the support that they need in their local communities. We need to think more about community health agendas. The report is strong on that.

Addressing mental health pressures for all age groups and supporting people’s learning disabilities and families who have experienced isolation will be critical issues for our health and social care partnerships in ensuring that we have the support that we need in our communities as people recover from Covid.

Over the past few weeks, constituents have been in touch with me about access to cancer testing and to call for increased awareness in our communities. For example, concerns about pancreatic cancer awareness and access to cervical tests and links to ovarian cancer for women have been raised. Early detection is critical, followed by treatment where it is needed, for all types of cancer. The more aware people are of symptoms to look out for and the better the information that they get, the better placed they will be to seek help and achieve better health outcomes.

I also want to thank the Royal National Institute of Blind People Scotland and Sight Scotland for their briefings about the importance of ensuring access to more work on preventing sight loss. That issue came up strongly in discussions that we had following the debate on the eye pavilion a few weeks ago. RNIB Scotland suggests a public awareness campaign to raise awareness of what people can do to support their eye health, and to encourage people to get their eyes tested. That relates to an issue in the report about the range of services that need to be available in local communities. We need a joined-up approach.

Investing in preventative health and in supporting people’s access to a range of local health services and community prescribing is critical. If that is done strategically alongside measures to reduce pressures on families, address poor health and give people the opportunity to eat healthily and have access to decent exercise opportunities, those things should lead to better life chances and reduce the likelihood of, for example, obesity-related diseases.

Investing in preventative health will take pressure off our hospitals if it is followed through, but that does not mean that we will not need hospitals that are accessible centres of excellence. Let me take the opportunity to say that if we are to deliver good-quality sight-loss services and preventative treatment, we also need investment in the new eye pavilion for Edinburgh.

I hope that the Scottish Government will listen to the cross-party calls and the calls from clinicians and our constituents for a reversal of its decision and that it will act on them.


Sandra White (Glasgow Kelvin) (SNP)

I, too, take this opportunity to thank quite a few people. I thank the committee clerks, who have already been mentioned and who worked hard during the inquiry. Committee members, regardless of party, worked well together. We may have disagreed on some matters, but we came to a conclusion, so I thank members for putting issues aside to work together as grown-ups for the benefit of the people of Scotland. I also thank members of the public and stakeholders who provided invaluable evidence and opinion during our panels. Their input was vital to the report.

The Health and Sport Committee’s inquiry’s remit included that it was to look at the sustainability of current primary care provision and at the shape it should take for the next generation; how it should provide care for a growing and ageing population and for people with complex medical conditions; and at governance changes. Those are just a few of the areas within the remit of the inquiry.

The inquiry began in 2019, which seems almost a lifetime ago, given what we have all endured recently. In the first phase, we heard from panels, primarily members of the public, in order to gather information. That was a necessary and vital step in understanding people’s experience of primary care, and it allowed committee members to focus on users’ needs. We heard directly from them about current delivery of services, whether it was working for them and what they thought the future of primary care services should look like. We all found it very interesting to listen to the public. It was not rocket science; it was about people and how the health service should work for them. The people who attended those public sessions certainly told us how the health service should work for them. I found that very interesting.

The second part of the inquiry focused on what we have at present, including current Scottish Government policies, integration joint boards and the role of GPs and other healthcare providers, including multidisciplinary teams and third sector organisations. That was quite an undertaking, particularly because those services have been under increased pressure due to the pandemic. It gave us an insight into the demands on our primary care providers and the impact on users.

I appreciate the cabinet secretary’s response to the report’s conclusions and I acknowledge the substantial steps that the Scottish Government has taken to date to reform primary care. The doubled primary care improvement fund, revised GP contract and support for multidisciplinary teams will go some way. I also acknowledge the support that the Scottish Government has provided for primary care services as a direct result of the pandemic.

The Government’s vision of having a world-class public health service that delivers the right care in the right place at the right time in order to improve population health and address inequality is very good, and I support it. The committee’s report should provide further insight into how that can be realised. I have confidence in the Government and in the committee that that will be delivered.


Alex Rowley (Mid Scotland and Fife) (Lab)

I welcome the report and believe that we must tackle the issues that it mentions. The report comes at the end of a parliamentary session, and I hope that it will not end up on the shelf, like many others, but will be used to make progress.

One of the report’s key recommendations is that prevention must be prioritised and mainstreamed across all areas of health services and beyond. [Interruption.] Excuse the ice cream van outside, Presiding Officer.

I was looking round in an accusatory fashion at members in the chamber, but the noise is outside your hoose.

Alex Rowley

It is outside my office.

In 2011, the late Campbell Christie chaired a commission that looked at the future delivery of public services in Scotland. In that report, the key action that was required was to look at and invest more in prevention, not just with regard to health but across public services and in local government. Sadly, that has not happened. We are now coming to the end of this parliamentary session, in 2021, and a report is saying that a focus on prevention needs to be prioritised. I suggest that it should have been prioritised, and doing that is key if we are going to move forward.

In their current form, health and social care partnerships and the IJBs lack democratic accountability. They need to be reviewed, and we need to look at how they can be structured to function better than they do currently.

There has always been a tug between funding acute services and funding community care. In the Parliament last year, Alex Neil made a speech in which he talked about the need to introduce bridging funding, so that we can bridge the gap between less money going into acute services and more money going into primary care. Again, there has been a major failure, because we have failed to introduce that over the past number of years.

I will pick up on what the BMA and the Royal College of GPs said, which is that it is clear that, in Scotland, there are not enough GPs. They make the point that it should not be a choice between investing in and recruiting GPs or focusing delivery on other well-staffed workforce areas; it has to be both. The Government has made a commitment to an additional 800 GPs. Perhaps in summing up, the cabinet secretary can advise on how that is progressing. Factors such as rising patient lists, an ageing population and ever more long-term conditions continue to pour pressure on GP services and health centre services and increase demands on GPs’ time. Equally, GPs face restricted funding and premises that are not keeping pace with new demands for care, and they are now working through the Covid pandemic. That leaves our GPs exhausted and facing burn-out.

Before the previous election, there was a promise from many politicians that a new health centre would be built in Lochgelly, where I am sitting today, because the one that is here is not fit for purpose. It is the same situation in Kelty, the village that I come from, which also needs a new health centre. If we do not put the resources and facilities in at a community level, we cannot expect to get the results.

Although I am grateful for the extra time that you have given me, Presiding Officer, my time has been brief and there needs to be a much bigger debate. The committee’s report highlights some of the issues, and I hope that the next Parliament gets to grips with the issue, because it is key for the future of all our health services that we get community care right.


David Torrance (Kirkcaldy) (SNP)

As a member of the Health and Sport Committee, I offer my thanks to the clerks, everyone who gave evidence to the committee, and my fellow committee members for their hard work in contributing to the second phase of the inquiry.

We recognised that there have been multiple developments in primary care services in recent times, so we agreed that it was appropriate for us to look at the provision of services and approaches. Our principal aim was to consider whether they were meeting current needs and how they should be provided in the future.

It is clear that primary care requires a radical revision to ensure that everyone receives the primary care that they want and need for the next generation and beyond. A focus on prevention needs to be prioritised and mainstreamed across all areas of the health service and beyond.

The inquiry was driven by our work in hearing from the public what primary care services they want and need. When we began the second phase, the world was a very different place and the delivery of primary care has—negatively and constructively—been significantly affected by Covid-19. The many challenges that the pandemic has presented have advanced positive and potentially sustainable changes in primary care.

Across our society, largely thanks to technology, the 9-to-5 work day is quickly becoming obsolete, and the current delivery methods and model of 9-to-5 primary care services, five days a week, are no different—they are not keeping pace with modern living.

The necessity of finding new ways of working has led to the discovery of many benefits for patients and practitioners. It is recognised that digital services can bring many exciting opportunities, and it is vital that they are embraced. They include the continued provision of phone and video consultations, when appropriate, because they offer greater patient choice and more flexibility in people’s day-to-day lives, and they reduce the need to travel. I welcome the Scottish Government’s commitment to improving IT and to supporting health boards in the transition.

During our evidence sessions, the committee heard from panel members who recognised and stressed that primary care services do not operate in isolation from other local services and environments, and who were keen to see a community-wide approach to wellbeing. Indeed, that vision is shared by the Scottish Government, as we look to a future where multidisciplinary teams work together to support people in the community and free up GPs to spend more time with patients in specific need of their expertise.

The message that delivery of healthcare is about seeing the right person in the right place at the right time is important. All professionals who are involved in patient care have a leadership role to play, which will require collaborative working with a wide variety of professionals who are involved in primary care multidisciplinary teams. To that end, I am pleased that significant progress has been made. There has been a substantial increase in the workforce in order to develop multidisciplinary teams, and the primary care improvement fund to recruit multidisciplinary teams has doubled from £55 million to £110 million this year, with a further increase to £155 million in 2021-22.

I welcome the recommendations in the phase 2 report, which highlights how the lessons that we have learned can be applied in the future to improve the delivery of our care and support systems in Scotland. We are all keen to get back to business as usual, but it is only by understanding how primary care has changed since lockdown, and for whom, that we can direct the focus and ensure that those with the greatest need get the right help. I also welcome the Scottish Government’s response to the phase 2 report and the continuing focus on delivering a world-class public health system that delivers the right care in the right place at the right time to improve the population’s health and to address inequalities.


David Stewart (Highlands and Islands) (Lab)

It has been a great honour to serve on the Health and Sport Committee for the past few years. I, too, thank all fellow members—I see that several of them are in the chamber—the hard-working clerks, SPICe and, of course, the Government minister Jeane Freeman, who is standing down at the next election. I thank the cabinet secretary for all her efforts over the past number of years.

This has been an excellent debate, with thoughtful and insightful contributions from across the chamber—not least from my Labour colleagues Sarah Boyack and Alex Rowley and, of course, the convener, Lewis Macdonald, who has convened the committee in a very helpful and affable way.

As the cabinet secretary said, the report is a very helpful contribution not just because of its contents but because of the way in which the committee gathered the information. I will say a little bit about that later. Those comments were echoed by Donald Cameron, who focused on general practice and talked about the future workload crisis. There were also helpful contributions from Sandra White and David Torrance.

As we have heard, and as the cabinet secretary said, primary care is often people’s first point of contact with healthcare services. In many cases, we equate primary care with general practice and all the excellent work that is carried out in that regard. However, if the global pandemic has confirmed anything—if confirmation is necessary—it is that healthcare is a 360-degree package. It is about mental health care, emergency care, preventative care and long-term palliative and recovery work, which all need to knit together on a multidisciplinary basis to ensure healthy lives for people in Scotland.

For many years, I have been concerned about the appalling health inequalities in Scotland, where, in simple terms, the poor die younger than the rich. When I was working on my members’ business debate on the Dewar report—the 1912 inquiry into health services in the Highlands and Islands—I was struck by the appalling problem of health inequalities in the Highlands and Islands at that time. We might argue that the problem exists now to a different degree, but it still exists and we need to tackle it. That will certainly be a job for the new Government and the Parliament in its new session after the election.

As we heard, the report that the committee published in 2019 predominantly focused on the experiences and views of members of the public—the service users of healthcare. Although I have been on lots of committees over my 14 years in the Parliament, it was probably the first time that I have been involved in such an innovative way of interacting with the public. If I remember correctly—I am looking at Lewis Macdonald—we spent a very pleasurable day in Inverurie, talking to ordinary members of the public about what they wanted to see in relation to health. We planned it like something in the first year of a planning degree. I thought that the visit was extremely useful, and the feedback was extremely good. I hope that the new Parliamentary committees consider that structure carefully. Across the board, there was a resounding call for a more patient-centred approach as well as an increase in preventative wellbeing care.

We considered the role that technology should play. A number of members have considered that issue. As I represent the Highlands and Islands, I have been concerned about it for some time.

I refer members to the fit homes project, which many of them will be aware of. The concept behind it is that a home should adapt to the changing needs of its residents. If members have an opportunity, I recommend that they look at Invergordon Carbon Dynamics, which makes homes for that fantastic project.

Technology in healthcare is key in the Highlands and Islands, as the rurality and peripherality of many of my constituents often makes access to the right health professional at the right time difficult.

Clearly, Covid-19 has had a drastic impact on our healthcare, and it was right that we took stock and focused on the pandemic in front of us. That led to divorce diversion. I said “divorce diversion”, but I meant to say “resource diversion” and staff burn-out—[Interruption]. Many a true word is said in jest, Presiding Officer.

There needs to be a process of rebuilding and renewal. However, we cannot go back to normal business.

The Government responded to the report on 1 March and, as far as my quick reading went, it looks like it responded positively to the recommendations. I look forward to seeing the action taken on this great report, and I remember the words of Thomas Edison, who said:

“Opportunity is missed by most people because it is dressed in overalls and looks like work.”

Let us roll our sleeves up and get to work.

I hope that that was not a Freudian slip, and that all is well with Mrs Stewart.


Brian Whittle (South Scotland) (Con)

I am delighted to close this crucial debate on behalf of the Scottish Conservatives. Such an important topic deserves more time than the short debate that we are now having. Nonetheless, it has been a good and consensual debate across the chamber.

I thank my committee colleagues for the consensual way in which we have managed to work during this parliamentary session. It has been an honour to serve with them.

I have long suggested that a change in the way in which we deliver healthcare has to happen, because the current trajectory is unsustainable. The increasing percentage of the Scottish budget that is allocated to health has to reach a ceiling at some point. That is against the backdrop of Scotland’s unwanted ill health tag—we are the unhealthiest nation in Europe and the unhealthiest small country in the world. The impact of that on the wellbeing of the people of Scotland, not to mention the Scottish economy, is significant.

If Covid has taught us nothing else, it has surely taught us about the impact that health has on the economy. Poor health also specifically impacts the outcome of a positive Covid-19 diagnosis, with obesity, diabetes, chronic obstructive pulmonary disease and heart conditions present in an overwhelming number of Covid deaths.

Shifting investment further upstream toward a more preventative approach is essential to the sustainability of our health service, and the committee’s report agrees. There is a need for a shift in primary care to focus more on the needs of local communities and less on ill health, and for a shift on health that is closer to the community rather than on the secondary healthcare system.

To be fair, the Scottish Government has accepted that as the direction of travel that it would like to follow. The issue is that the practical steps that will be required to attain that ambition are yet to be put into play.

The most basic need to enable our GPs to be as effective as they can and want to be is the need for time. They need time to spend with patients to fully explore their needs. Crucially, a variety of treatment options should also be available to the GP to allow them to treat the patient in the most appropriate way.

The roles of allied healthcare professionals, pharmacists and occupational therapists need to be integrated to a much greater extent into GP multidisciplinary teams. A simple example of that is that a physiotherapist is more likely to be specifically qualified to deal with musculoskeletal conditions than a GP, as the cabinet secretary mentioned. Given that one fifth of all patients present with MSK conditions, it would seem logical that, if a GP had the ability to triage those cases to a physio within the practice, not only would the potential outcome for the patient improve, but the GP would save a significant amount of time that could be spent with other patients.

The same could be said of dieticians, opticians and mental health practitioners, who will be needed increasingly post-Covid. We need to have those alternatives to the overuse of medicating poor mental health.

Continuity of care is a challenge for GPs, but the committee’s report states:

“by better utilisation of the other healthcare professionals, including AHPs, we consider increased continuity of care should be achievable”.

It goes on:

“We are clear AHPs, and others, play an invaluable role in enabling people to live an active life and encourage the Scottish Government to include the full range of staff involved in supporting health care when planning future workforce.”

The work that the third sector and others do to support patients must be fully integrated and incorporated into local planning, and that must include the ability of GPs and HSCPs to use social prescribing, giving patients the potential to be active participants in solving their health and wellbeing issues. The committee states:

“Efforts must be made to make social prescription accessible to all, including making better use of ... community facilities”.

It adds:

“We reiterate the recommendation made in our December 2019 report, Social Prescription, an investment, not a cost, that 5% of Integrated Authority budgets should be allocated for social prescription.”

Public Health Scotland has a significant role in working with GPs and public agencies to enable and encourage that direction of travel.

In the current crisis, there is a clear and present danger to the third sector. Too many organisations are at a financial corner and may not be there when we come out of the Covid pandemic, which will be when we need them the most.

We all agree on the outcomes that we would like. That is extremely positive. So far, however, there has been little from the Scottish Government in response that suggests that plans are in place that can lead to those crucial outcomes and deliver primary care for the next generation. I look forward to hearing the cabinet secretary’s response.

I call Jeane Freeman to close for the Scottish Government.


Jeane Freeman

I am afraid that I am going to disappoint Mr Whittle in that, in the time that I have available, I will not be able to go through all the plans. However, I will happily do that on another day.

I start with what I did not say in my opening speech on the question of data, which the committee rightly identifies as critical. I assure the committee that work is under way on that, building on the progress that has been made in response to the pandemic and in discussion with the BMA and the RCGP. Work is also under way on what more can be done to give the citizen access to their health data and health advice, using some of the learning from building our test and protect app. That is actively under way as we speak.

I confirm, as the convener asked me to, that work has been restarted on implementation of the Health and Care (Staffing) (Scotland) Act 2019. That is a very important act and it will come into its own in relation to the independent review of adult social care.

The pandemic did not start the reform of primary care. Primary care, which is provided by GPs, dentists, pharmacists, optometrists and their teams, has benefited from sustained and record investment under this Government, and our primary care reform focuses on new models of care that put individuals at the centre of decision making.

While the pandemic has paused some work, it has accelerated work in other critical areas. I would argue that the role of community pharmacy is now much better understood and embedded in primary care than it was pre-pandemic. The use of digital technology is now widespread across primary care and it is moving into secondary and acute care, improving access for the citizen but also providing speedier care and more accessible care. Community pathways were initially stood up to respond to Covid, but they are now a central element in the redesign of urgent care.

Importantly, there is increased partnership working between primary, secondary and community care and the third sector. That is providing a foundation in, for example, patient-centred diagnosis and care, which is specifically relevant to how we respond to issues around long Covid. We have the primary care team as the central holder of care for the individual, but it can use digital technology to access specialist, peer-to-peer support in order to determine whether further tests, diagnosis and intervention are necessary.

The centre for sustainable delivery was stood up during the pandemic response. It is situated at the Golden Jubilee hospital, but it has the very specific job, as a stand-alone centre, of getting us past that thing that has bedevilled us for so long—having examples of good practice and good delivery that are not rolled out across the country. A central part of the centre for sustainable delivery—I know that Mr Whittle will welcome this—is to make sure that, where we have good examples of the use of social prescribing linked to primary care, we roll them out across the country, as well as other innovations that exist more in the acute setting.

The workforce is, of course, the central underpinning of any improvement in primary care. We have more GPs per head of population in Scotland than elsewhere in the UK. We have increased the number of student nurses in training, with their fees paid, of course, and with the bursary. We will have trained 500 advanced nurse practitioners by the end of this year. We are increasing the number of pharmacist training posts and the number of paramedics, and we are on track for 800 additional GPs by 2027. However, what is critical is not to be thirled to plans that were in place previously but to recognise that, if we are going to improve primary care, we need to review constantly the skill mix that is needed and therefore the workforce planning that is right to deliver it. That is all currently part of our forward planning work. I doubt that we will have time to advise the chamber of the work before the parliamentary session ends, so I intend to write to all MSPs advising them of the work that is under way in forward planning for the rebuilding of our health and social care service.

Again, I thank the committee for what is a very helpful report. I assure the committee of the Government’s commitment to taking forward its recommendations within the overall planning for that foundation—I repeat—of our NHS: our primary care.

The Deputy Presiding Officer

Before I call Emma Harper to speak, I warn members who will be in the next debate that we are running slightly early and that that debate will follow on from this one, so they should be getting themselves to the chamber.

I call Emma Harper, deputy convener of the Health and Sport Committee, to close for the committee.


Emma Harper (South Scotland) (SNP)

In closing on behalf of the committee, I will reflect on members’ comments. I note that our committee convener has chaired the committee well and I thank him for his contribution to the Parliament over the past 22 years. He has also been a great support to me as deputy convener.

It is important to note that much of our work in relation to the phase 2 primary care report was carried out before the Covid pandemic, so the report has been significantly delayed as a consequence of Covid-19. I thank all who contributed to the report, including my colleagues on the Health and Sport Committee and the clerks.

Many of the committee’s recommendations on primary care structures and accessing general practitioners and members of the multidisciplinary team have changed a lot due to the safer engagement practices that are required to reduce the risk of the virus spreading. The cabinet secretary has already affirmed that around 90 per cent of all health contacts take place in primary care, so it is important that we look at primary care and how we can ensure that we have the best processes as we move forward. We know that primary care is provided by many professionals in the multidisciplinary team, with GPs at the helm. From the outset, though, our inquiry looked at the Scottish Government’s vision for the future of primary care services, which states:

“People who need care will be more informed and empowered, will access the right professional at the right time and will remain at or near home whenever possible. Multidisciplinary teams will deliver care in our communities and be involved in the strategic planning of our services.”

The committee endorsed and shared that view and, through the inquiry and our report, has made a number of recommendations that we hope will inform and assist the Government’s implementation of its vision.

The need for change in social care is compelling, as demands and costs are predicted to grow sharply. We debated aspects of the report of the independent review of adult social care in Scotland, which was led by Derek Feeley, in Parliament the week before last. Scotland’s older population is living longer and folks have many complex health issues and multiple comorbidities. We know that the overall health and social care budget in Scotland in 2020 exceeded £15 billion and, for the first time, was 50 per cent of the entire Scottish budget. The committee and our witnesses are clear that we agree with the Government that that trajectory for increased resources cannot continue indefinitely. Mr Whittle raised the issue of financial sustainability in his earlier remarks.

To that end, our evidence indicated that primary care should take on a more patient-centred approach. One example that was cited was having more flexible appointment systems. I am very aware that our GPs already spend long hours in their practices. David Torrance spoke about the modern 9-to-5 life. I have checked with a few of our practices in Dumfries and Galloway, and I know that they are already offering appointments either side of the 9-to-5 schedule and that evening consultation hours have already been adopted. In many instances, flexible appointment schedule times were implemented pre-pandemic or pre-lockdown. That was good to see.

We have heard how the current heavy reliance on paper as opposed to IT systems has caused much frustration in primary care. Many IT systems do not talk to each other.

Easy and accessible signposting to other services that might be available as opposed to people always having to visit their GP was also suggested.

I support the Scottish Government’s response that it recognises the value of social prescribing and that it has established a working group to help to address that. Throughout the pandemic, we have heard about how important the third sector is to health and wellbeing and in helping to support physical and mental health.

The cabinet secretary has covered some of the key findings, including on community pharmacists, the £205 million for expanding and enhancing the multidisciplinary teams, and changes to urgent care. The right care in the right place at the right time is a commitment from the Government. The cabinet secretary also supported further funding for mental health and work on data improvements.

Donald Cameron focused on specific GP issues and the challenge of general practice recruitment, and Sarah Boyack mentioned the challenges for people with poor lung health, asthma and long Covid. The briefing that was submitted by the British Lung Foundation and Asthma UK dealt with those.

Alex Rowley spoke about the balance of funding between acute and primary care, and the bridging funding. I know that Alex Neil has talked about pump priming in previous debates.

Colleagues, including Brian Whittle in his closing speech, have mentioned addressing health inequalities and obesity. The cabinet secretary covered much work that is already under way and workforce planning. My colleagues Sandra White and David Stewart talked about the specific public engagement sessions that informed our report.

Presiding Officer, I am not sure of the time, but I am happy to conclude.

That is a good idea. You got there before me.

Emma Harper

Last year was an incredible year, and this year is starting with further engagement in tackling the pandemic. I look forward to the future and thank everybody who has contributed to helping to support everyone through the pandemic so far.