Meeting of the Parliament (Hybrid)

Meeting date: Wednesday, November 17, 2021

Official Report 1165KB pdf

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Medical Students (Funded Places)

The next of business is a debate on motion S6M-02139, in the name of Sandesh Gulhane, on removing the cap on funded places for front-line medical students. I would be grateful if members who wish to speak in the debate could press their request-to-speak button now.

16:33  

Imagine a scenario in which a country’s health service is in crisis, struggling to deliver timely care after years of failed workforce planning. Imagine that that country’s Government is fully responsible for running healthcare and that it controls, by diktat, the number of local school leavers who can enrol as student doctors, nurses and paramedics in our country’s universities. That is where we are in Scotland today. The Government consciously limits the number of locally domiciled students to just over half of all medical school places across Scotland’s universities. Those are the very students who are most likely to stay and work in Scotland once graduated. Little wonder, then, that there are staff shortages, and it is all down to the Scottish National Party.

Before discussing a solution to tackle the damage from a decade of failed workforce planning, let us consider the current calamity in more detail.

According to the Royal College of Nursing, our national health service needs another 3,400 nurses. That situation has not happened overnight but has happened under the watch of five SNP health secretaries. It is important to remind the country that, when the First Minister was in charge of health, she was the one who failed to future proof the workforce by cutting the number of student nurse places in 2012—a spectacular error of judgment. By 2015, our NHS had a shortfall of 1,613 nurses, and that number rose year on year: by June 2019—nine months before the pandemic—the shortfall was 2,879. Let us get this straight: that situation had nothing to do with Covid. The Government might argue that Scotland has more nurses now than ever, but there are also more vacancies now than ever—4,800 nursing and midwifery posts are unfilled. Where is the plan?

Let us now turn to students of medicine—our future doctors. According to the Scottish Government, just 54.5 per cent of nearly 5,000 students are Scotland domiciled, which is down from 63 per cent a decade ago. To be fair, the total number of medical students has risen over the past four years and the annual student intake has increased by 190, but that increase came on the back of year-on-year declines since 2007. Trainee doctors account for 44 per cent of doctors whom NHS boards employ.

I am sure that members now realise that chaotic knee-jerk reactions to a staffing crisis do not work. The situation has been unfolding for more than a decade.

Let us take primary care. It takes at least 10 years to qualify as a general practitioner and every year during that time students enter medical school and highly experienced doctors retire. The chronic shortage of GPs that impacts the health of the country today is a direct consequence of decisions that were made in 2009 when the First Minister ran health.

Let us not pin everything on the leader, because her successors are not crowned in glory either. According to the British Medical Association, 83 per cent of GP practices report that demand now exceeds capacity; 42 per cent report that demand substantially exceeds capacity; and 28 per cent report at least one vacancy, which means that as many as 225 full-time equivalent GPs are missing in Scotland.

Allow me to quote the Government’s own data: the number of full-time equivalent GPs in Scotland in 2019 was 3,613—62 fewer than in 2013. Between 2015 and 2018, only 39 additional GPs were recruited. I stress again that those figures are from before the pandemic.

According to Audit Scotland, even if the SNP managed to recruit 800 more GPs, the number of doctors who are expected to retire would wipe out the gains. When retirements are taken into account, the number of GPs would increase by only 18 in the 10-year period to 2027. The SNP-Green Government risks a bitter legacy. Where is the plan?

In our hospitals, workforce planning is also in chaos. BMA Scotland reports that vacancies for consultants have risen by 15 per cent. We now know that one in five consultants who were 45 to 49 in 2010 had left the profession by 2020. The BMA also finds that 45 per cent of surveyed consultants are considering retirement over the next five years. The SNP-Green Government is clearly too distracted by other matters to focus on retaining those highly experienced doctors, who are vital for patient care and for training the next generation of doctors.

There have been characteristically knee-jerk responses, such as the £32 million to create a further 139 trainee doctor posts, which, although welcome, is not at all part of a well-thought-out strategic plan.

On this side of the chamber, we want to provide solutions. I want to focus strategically on workforce planning. It is important to ensure that more Scottish nurses, doctors, paramedics enter universities in Scotland, because students who have gone to school or have a close connection here are more likely to stay when they graduate from a Scottish university. Those students will stay here to care for the patients in Scotland’s NHS and will go on to train the next generation of healthcare professionals.

I find it shocking to read that Scotland has a lower percentage of home-domiciled doctors than England and Northern Ireland. Around 78 per cent of England’s and 89 per cent of Northern Ireland’s foundation doctors are home domiciled, but only 54 per cent of Scotland’s are.

The problem is the arbitrary cap on the number of young Scots the Scottish Government will fund through medical school. As the workforce stats made clear, yearly decisions on the cap are not based on realistic workforce planning.

It is also not down to our young Scots not getting qualified. More and more Scots are meeting the academic entry requirements for medical schools. That has led Professor Angela Thomas of the Royal College of Physicians of Edinburgh to warn of a brain drain, where high-achieving Scotland-based school leavers with no place to go in Scotland move to England.

The cap also creates a barrier to medicine for students who come from less affluent families. Despite having the grades, if they cannot enrol in Scotland, they will be faced with university fees that they cannot afford. So much for widening access.

Will the member take an intervention?

I am sorry; I am a bit tight for time.

It is important that we listen to the professional organisations that exist to protect patients and improve education and practices across our NHS. The Royal College of Physicians and Surgeons of Glasgow concluded that removing the cap is the right thing to do and it would be a shot in the arm for the NHS. The medical schools need to optimise student numbers, as the standards must remain high and the funding model must be right.

Scotland needs to start training larger numbers of nurses, doctors, surgeons, and other healthcare professionals in order to cope with the demand. Removing the cap on medical school places will not solve the crisis that we face this winter, but it will be a step in the right direction, and it will mean that we can build an NHS in Scotland that will be the envy of our neighbours and of the world.

Let us do this: remove the cap permanently and provide opportunities here in Scotland for our own bright young people, and let us ensure that we have a well-staffed and resourced NHS that is able to deliver world-class care.

I move,

That the Parliament calls on the Scottish Government to remove the cap on funded training places for students from Scotland studying for frontline NHS roles.

16:41  

Sandesh Gulhane’s motion asks us to remove the controlled intake cap on funded training places for students from Scotland studying for front-line NHS roles. I can understand why that might seem a laudable aim, but I fear that the unintended adverse consequences have not been thought out clearly. I will speak to some of those shortly.

We have a controlled intake for medicine for very good reasons, which I will also set out shortly.

Last week, I received advance sight of a soon-to-be published report by the Royal College of Physicians and Surgeons of Glasgow. Although the report talks of the need to grow Scotland-domiciled and widening access student places as part of a planned approach to expansion—something that we agree on—it makes no mention of removing the cap. Our planned expansion will maintain our commitment to widening access and Scotland-domiciled student places. I will come back to that point, which I wanted to make when I tried to intervene on Dr Gulhane and he could not take the intervention.

The Conservatives seem to be attempting to fix a problem that does not exist. Last year and this year, every single Scotland-domiciled student—even those who had requested a deferral or appeal in 2020—who met the conditions of their offer at a Scottish university was offered a place, and we have approximately 6,000 students studying medicine in Scotland.

We would not have known from listening to the Conservatives and Dr Gulhane that, since we took power, there has been a 20 per cent increase in the number of NHS staff, a more than 11 per cent increase in the number of qualified nurses and midwives, nine consecutive years of growth in the number of NHS staff and an almost 60 per cent increase in medical and dental consultants.

Does the cabinet secretary acknowledge that almost every medic we speak to says that there is a shortage of doctors, with one of the reasons for that being the cap on places, particularly in relation to people who are domiciled in Scotland, which prevents some universities with medical schools that would like to take more students from doing so?

I agree that we need to increase the number of medical graduates and, in turn, doctors. That is why our manifesto committed to increasing the number of medical graduates, which is what we are doing. We promised to increase that number by 100 per annum.

Let me turn to some of the reasons why I think that there would be unintended consequences. As I said, we have seen an increase in undergraduate numbers since 2016 in response to a UK-wide undersupply of graduates. Between 2015-16 and 2020-21, the controlled intake for medicine grew by 22 per cent. It further increased to 1,117 in 2021-22. Our modelling shows that we need to increase that number, as Liz Smith said, which is why the 2021 programme for government commits to increasing undergraduate numbers by 100 each year during the current parliamentary session. That will allow us to increase numbers to ensure that we have sufficient supply with a degree of headroom, but in a planned fashion.

If we were to go down the route that Dr Gulhane and the Conservatives suggest, my concern would be that we would have no idea of how many students to expect until they matriculated each year, and we could find that we did not have the clinical capacity to train them. Even if we were able to train them, we might find that there was no job for them as a qualified doctor at the end of the day. That would lead to a real danger of creating medical unemployment.

Secondly, our planned increases have allowed us to focus undergraduate education on areas of known NHS patient need. For example, we know that, in the future, we will need more doctors working in community settings to care for our ageing population. That is why we commissioned Scotland’s first graduate medical entry programme, with its focus on producing GPs and on remote and rural placements, and GP track courses at the University of Glasgow and the University of Aberdeen. If we had no control over places, that would limit our ability to commission our medical schools to adopt new and innovative approaches to respond to the long-term policy drivers.

My third point is one that I wanted to make in my attempted intervention on Dr Gulhane. Our planned expansion has allowed us to focus on opportunities for Scottish students from all sectors of society. The 50 ring-fenced widening access places that were introduced in 2016, and which have been maintained annually thereafter, were increased to 60 in 2021. This year, all those places have been filled by students from some of the most deprived backgrounds in Scotland. We probably all welcome that.

We have also set up two pre-medicine entry courses at Glasgow and Aberdeen universities, which are aimed at potential applicants from less socially advantaged backgrounds who might have narrowly missed the grades that are required in order to study medicine.

We have also widened access to medicine in the widest possible sense. The University of Edinburgh course for graduate health professionals is a unique route for experienced healthcare professionals to use to study to become a doctor. That HCP-med programme is specifically designed for healthcare professionals who live and work in Scotland. If we were to have no control at all over numbers, widening access students would be the first to lose out. If we were to have a free-for-all, those who have traditionally been furthest away from gaining entry to medical school would be the ones who would lose out.

I understand that I am probably fairly short of time, Presiding Officer. It is important to have a mixed economy of medicine graduates for many other reasons. We are delighted to have people from across the UK and international students who want to study to become doctors here, too.

For all the reasons that I have highlighted, including—crucially—my point that if we remove the cap, we will remove the ring-fenced places that are designed to widen access, as well as the fact that all UK nations set controlled intakes for medical undergraduate places, I ask Parliament to reject the motion and to support our current process of planned expansion to meet the future medical workforce needs of the NHS in Scotland.

I move amendment S6M-02139.2, to leave out from “calls” to end and insert:

“welcomes the sustained increases in medical undergraduate places at Scottish universities; notes that the level of new domestic training places for medicine is proportionately higher in Scotland than anywhere else in the UK; further notes that, this year, the Scottish Government fully funded all places for Scottish domiciled students holding an offer from a Scottish medical school, where they met the terms of their conditional offer; recognises that the Programme for Government sets out steps to substantially increase training places further; believes that widening access to medicine is essential, and supports doubling the number of widening access places to help create a more diverse medical workforce.”

16:47  

I have much sympathy with the intention that underlies the Conservative motion, so we will support it at decision time, but I am genuinely concerned about the practical implementation of lifting the cap on medical training places. I also think that restricting the proposed measure to front-line staff could result in an unfortunate focus on some parts of the NHS and not others where there are critical shortages, too.

I thought that the SNP amendment was a tad self-congratulatory, considering that the SNP has been in charge for the past 14 years. I cannot help recollecting that we were discussing workforce planning 10 years ago, when I was last Scottish Labour’s shadow health secretary. It is beyond depressing that nothing much has changed in that period. There is no getting away from the fact that it is the SNP that has presided over historic workforce planning failures across our NHS.

The problems are not new—they pre-date the pandemic—but they have absolutely been exacerbated by the pandemic. I well remember Nicola Sturgeon cutting the number of nursing places when she was health secretary, despite warnings from me and the Royal College of Nursing about the consequences of so doing. In fact, during her tenure in that role, she presided over some of the smallest intakes of medical students in the past 14 years.

To deliver on removing the cap on funded places, there will require to be additional investment in our medical schools across the country and in the capacity to deliver foundation places to all graduates on completing their degree.

I am not sure that the Conservatives have done their sums on that or that they have any idea what that would cost. Where would they set the bar? Should everyone who applies be given a place? Last year, 9,530 people applied to study medicine in Scottish universities and 1,290 were given a place. I am sure that the Conservative proposition is not that all 9,530 people should be offered a place, so a limit would probably need to be set. Understanding that is critical.

Who are regarded as front-line staff? We know that there is a shortage of accident and emergency consultants, a shortage of nurses and a shortage of GPs, but what about consultants in neurology, vascular surgery or psychiatry, or allied health professionals in physiotherapy, diagnostic radio therapy or occupational therapy? There needs to be an expansion in their training places, too.

There is no doubt that there are acute shortages across the NHS. Just listening to the evidence that was presented to the Health, Social Care and Sport Committee should leave no one in any doubt about that. John Thomson of the Royal College of Emergency Medicine told us that there was a shortfall of 130 A and E consultants. The BMA told us that the vacancy rate for consultants stood at 15.2 per cent, which was more than double the official Scottish Government figure. Dr Lewis Morrison told us that doctors were

“washed out, physically and mentally”,

and Margo Cranmer of Unison said that nurses were “stressed and exhausted”. A paramedic whistleblower said that they were “exhausted, undervalued and overwhelmed”. All of that is before we reach peak winter pressure.

We need to urgently address workforce planning, but that will not alleviate the pressure on the NHS right now. It takes a long time to train those people for those roles.

Scottish Labour has put forward a series of suggestions about what we think needs to be done now. Let us start with a working time review for every member of staff who is planning to retire early and offering them flexible working so that we do not lose their skills from our NHS. Let us ask the hundreds of staff who have left the NHS recently to come back to help their community, especially over this winter. Let us give staff better facilities in the workplace, such as hot meals, rest spaces and access to mental health support. I know that the Government has made money available but, in some areas, improvement is far too slow and too patchy.

Will the member take an intervention?

I am afraid that I do not have time.

Let us also ensure that a long-term pay deal is in place that addresses low pay in the health and social care sector to stop the haemorrhage of staff. It should not escape our notice that, for the first time in its more than 100-year history, RCN members in Scotland have voted to take selective industrial action. There is a real urgency to improve pay in social care by paying staff £15 per hour.

Scottish Labour supports increasing the number of places for Scotland-domiciled students on medical and nursing courses, doubling the number of widening access to medicine places and increasing student intakes for key health professional roles.

The problems with workforce planning are manifest, and the time for talking has long gone. We need urgent action now, and the Government must listen to the royal colleges, the trade unions and the workforce if we are not to have a crisis each and every winter from now on.

I move amendment S6M-02139.1, to insert at end:

“; recognises that the Scottish Government has presided over historic workforce planning failures across the NHS, with warnings of shortages and staff burnout long before the pandemic; considers that, as well as recruitment, there is an immediate need to improve retention of staff, following reports that many are planning to leave their profession; calls on the Scottish Government to ensure that basic facilities, such as hot meals and rest spaces, are available to all staff, and to improve access to specialised mental health support for the workforce, and recommends that the Scottish Government offers a working time review to every staff member considering retirement, thereby offering more flexible working arrangements, and calls on the expertise of retired nurses and medical professionals willing to return to the NHS to increase workforce capacity over winter.”

16:53  

I thank Dr Sandesh Gulhane for securing time for this important debate. It is dispiriting that, once again, it is Opposition time that has been given over to the workforce crisis in our health service, particularly after the warnings that were given to the Scottish Parliament’s Health, Social Care and Sport Committee this week. Nonetheless, I congratulate Dr Sandesh Gulhane and assure him of the support of the Liberal Democrats at decision time, notwithstanding the caveats that Jackie Baillie rightly raised about the complete removal of the cap. However, I support his intent. Likewise, we will support Labour’s amendment.

A person’s decision to dedicate their life to joining the medical front line is a noble one, but it can also feel like a thankless one. As the past 19 months have highlighted, if they make that decision, they choose a career that is defined by self-sacrifice and perseverance in incredibly demanding circumstances. People who enter the profession do so because they care passionately about serving our sick and our vulnerable. There is no higher calling in our society. We are very fortunate to have so many such people in Scotland, but evidence shows that we are losing them. We cannot afford to do so in the current context.

This May, the BMA released a report that said that 15 per cent of consultant roles in Scotland could lie vacant. To put that into perspective, that is an entire large hospital’s complement of consultancies, should we not fill them.

At the Health, Social Care and Sport Committee last week, the Royal College of General Practitioners told us that there is an enormous strain on the workforce. As a result, individuals are having to choose between sacrificing their profession or sacrificing their wellbeing. At the same committee meeting, the Royal College of Nursing told us that nurses in Scotland face a similar struggle, which has led to a significant issue of retention in the nursing workforce.

That is just not acceptable. No one should have to choose between their profession and their mental health. As a result of that choice and other factors, front-line medical professionals are choosing not to work in Scotland and are instead deciding to work south of the border or abroad, or they are giving up their professions entirely. We must do more to prevent that, given how much we have invested in those individuals.

A key part of the solution lies in planning for our workforce. As we are being told, the Scottish Government’s workforce strategy is not equipped to deal with the crisis that our NHS is experiencing. Members should remember that this is the same Government that delivered its integrated workforce plan a whole year late. That is why the Scottish Liberal Democrats have called for the presentation of an annual workforce report to debate in this Parliament, which would include a study of reasons why newly qualified staff leave NHS Scotland to work elsewhere.

Moreover, we need to look at the way that we deal with people who work in our NHS—the way that they suffer burn-out and the way that we are not supporting them with their mental ill health. We need to do that from the very start of their career in the NHS. Currently, just over half of medical students at our universities are Scottish. We must ensure that Scots who wish to train and work on the NHS front line are equipped and incentivised to do so.

It should be no surprise that there are severe burn-out and mental stress issues, which may be off-putting. Among ambulance staff alone, mental health absences are up 300 per cent since 2017 according to a freedom of information response that was received by the Scottish Liberal Democrats. That is why we have called for a substantive mental health package for front-line staff to help to deal with the crisis.

The crisis is one that has grown under a complacent SNP Government. Perhaps we should not be surprised. After all, it is the same Government that is led by a First Minister who, in her tenure as health secretary, cut 300 student nurse places, claiming that it was the sensible way forward. That was not a sensible way forward, and we are reaping the rewards of that whirlwind now. Restricting training places, neglecting strategy and not providing staff with adequate support is not a sensible way forward in anybody’s book.

The NHS is one of the most vital services—if not the most vital service—in our country. The people in it provide a service that we could not do without. Front-line staff deserve from this Parliament the same unwavering care, effort and support that they have continually shown to our country.

16:58  

We have all witnessed the impact that a front-line medical staff shortage has had on our NHS. Shortages put pressure on our heroic NHS staff, who work tirelessly to ensure that we can receive treatment whenever it is required. The problem is that a shortage of NHS staff creates waiting lists, waiting times and backlogs for many people who are in urgent need of care or treatment. As we have heard in this chamber, people are waiting too long for an ambulance, too long to be triaged at A and E and too long to see their GP.

Our NHS was under pressure long before the pandemic, but it is now at breaking point. We need a solution to the staffing crisis, and we need it now.

If we look in more depth at the shortage of NHS staff, we see that the Scottish Government has presided over an increasing shortfall. Members do not need to take my word on it. When NHS Lanarkshire front-line staff were interviewed by STV, one emergency medicine consultant said:

“From a nursing point of view, the military support is helping as it gets the basic stuff done, like the observations and bloods and initial assessments, but they can only do certain things—we don’t have more doctors. My colleagues and I don’t want to think about winter, as we know it will be worse than it is at the moment. We need a break and we won’t get one. We will cope because there is no other way.”

Health professionals are on the front line and, for them to be able to do their job, there need to be enough of them to cope with the demand of patients.

Staff shortages are not the fault of our NHS; they are the fault of the people who manage and oversee the internal structure of our healthcare service. They are the fault of the Scottish Government, which has not addressed long-standing issues.

The SNP has repeatedly been warned about the increasing shortfall in NHS nurses, doctors and ambulance crew. Despite recent funding commitments from the Scottish Government, more action is needed. As Sandesh Gulhane asked, where is the plan?

Since 2016, the Scottish Conservatives have repeatedly called on the Scottish Government to remove the cap on funded places for front-line medical students. I am therefore pleased to support the motion, which calls on the Scottish Government to do just that, to respond to concerns that emerged during the pandemic and to tackle issues that have existed for years.

It is not just the Scottish Conservatives who have called for the cap to be removed. The Royal College of Physicians and Surgeons of Glasgow has also called on the Scottish Government to remove the cap on medical school places in Scotland.

The reason is clear. The past two years have presented an unlikely opportunity to create more spaces for students to take their rightful places on medical university courses after exam results were revised due to the exam fiasco that the SNP created. The upgrading of thousands of exam results has led to calls to increase places at Scottish medical schools, to accommodate the students who meet the entry requirements.

I acknowledge that the Scottish Government has increased the number of medical school places, but that is not enough. By further increasing the number of medical students that our universities can accommodate, and by looking at the shortfall in positions across Scotland, we can start to address the issues that all health boards are experiencing.

I want to thank our NHS staff for their dedication and hard work, especially during the peak of the pandemic. They need more support—and by “more support” I mean more colleagues. There is a staffing crisis across our NHS, which is directly impacting our NHS. The best and quickest way to create an opportunity to have more NHS staff is to remove the cap and allow more students to study and gain the qualifications that they need to advance their medical careers.

I join my colleagues in calling for the cap to be removed, to support students and to alleviate the staffing pressures that our NHS has experienced for years.

17:02  

I am grateful for the opportunity to speak in the debate. It is important that we set the context for the debate. Staffing levels in NHS Scotland are at an all-time high, after nine consecutive years of growth. As the cabinet secretary said, the Scottish Government has fully funded all places for Scotland-domiciled students who met the terms of their conditional offers from Scottish medical schools, and NHS staff numbers increased by 25,000 between 2006 and 2021. Last year alone, there was 3.6 per cent growth, with more than 5,000 more staff.

There is no doubt that there has been a rise in demand for services in response to the Covid-19 pandemic. The Scottish Government is investing in several ways to address the issue. It has established the national centre for workforce supply, with investment of £11 million. One of the centre’s areas of focus will be to offer boards expert advice in relation to labour market intelligence and to help to co-ordinate recruitment programmes.

That work needs to go hand in hand with social work recruitment. There is no doubt that Brexit has had a massive impact in that regard. In my constituency, staff have moved between the NHS and the care sector during the pandemic.

It is important to note that investment in medical and nursing education has been sustained during the pandemic. A record number commenced training in 2021: 4,206 people started nursing training and 1,138 people started in medicine. The numbers will rise further in the autumn. In addition, during the pandemic, work was undertaken with national bodies to ensure that as many former doctors, nurses and allied health professionals as possible who wanted to return to work could do so.

The Scottish Government has record staffing levels and the best-paid staff in the UK, having recently given staff a 3 per cent pay rise.

The proposed significant expansion in the number of trainee doctors underlines the Scottish Government’s commitment to support the NHS, not only in response to the pandemic but as we look beyond it and build resilience for the long term.

In addition, £32 million has been committed for a further 139 trainee doctor posts to support NHS services. In psychiatry, five posts will be recruited for a 2022 start, which will provide much-needed support for the delivery of mental health services in NHS Scotland. There will be a further 22 medical specialties that will benefit from the creation of additional training places, including clinical radiology, anaesthetics, clinical oncology, medical oncology, geriatric medicine and infectious diseases, along with neurology and respiratory medicine. The majority of those trainee doctor places will commence in August 2022.

Since 2014, 574 trainee expansion posts have been created in a wide range of specialties, 100 of which have been in general practice. The Scottish shape of training transition group, which is responsible for deciding on the number of trainee posts and the medical specialties in which they will be created, will be undertaking a similar process for 2023.

I want to touch on the Labour amendment, which mentions staff burn-out. That is an important issue. The Scottish Government is committed to safeguarding the mental wellbeing of the workforce and has committed an additional support package of £4 million for staff wellbeing. Having led a members’ business debate on mental health recently, I am aware that workers in health, social and social work experience higher levels of mental health problems than those in other groups, and that that has been exacerbated by the Covid-19 pandemic. The additional funding will focus on the physical and mental needs of staff and will, of course, include provision for hot drinks, food and other measures to aid rest and recuperation.

Importantly, another £5 million has been committed to the establishment of a health and social care mental health network to enhance existing wellbeing and mental health provision, including the national wellbeing hub and the 24/7 national wellbeing helpline.

In conclusion, the level of new domestic training places for medicine is proportionately higher in Scotland than the level anywhere else in the UK and, with the measures that have been highlighted, that will continue to be the case. I urge members to support the Scottish Government amendment.

17:06  

For me and most of my constituents, this is a simple issue. It is about doing what is right to help an NHS that is struggling to keep its head above water and it is about making sure that we have well-trained and well-looked-after staff who are supported to give the best care in the world. I do not want this to become a party-political issue—I do not think that the issue would benefit from that—but the Scottish Government must step up.

I worry that, going into winter, we will see a repeat of the capacity crisis that we have seen year after year in Scotland and elsewhere. That is undoubtedly exacerbated by the Scottish Government’s failure to properly engage in serious workforce planning. That is not a new problem, nor is it, as some spin would have us believe, a problem that is caused solely by Covid. Warnings were in place long ago, and many of my colleagues who sat in the previous session of Parliament will make the same points that I will make today.

As Jackie Baillie indicated, Labour members will support the motion on removing the cap. We must remove that cap on funded places for front-line medical students, but we cannot do so without additional investment for our first-rate medical schools and the capacity to deliver foundation places to all graduates on the completion of their degrees. That is basic common sense, and I believe that it is achievable with the correct political will.

The problem is generally applicable across the medical fields, as Jackie Baillie indicated. I have repeatedly raised issues in the Parliament around the need to increase the number of trained pharmacists in Scotland. Without moving away from the purpose of this debate, I want to make that point again. There is a staff shortage emergency in the NHS in Scotland, and we have to be honest about that.

Beyond the vital need to get more high-quality front-line staff into our NHS, we need to take care to look after those who are already putting in incredible shifts day after day. Margo Cranmer, the chair of Unison’s nursing sector committee, has described Scotland’s nursing team as “stressed and exhausted”—that has already been mentioned, but I thought that it was worth stating that again. She went on to say:

“Substantial investment in extra staff and changes to their working lives are essential.”

Staff retention is nowhere near where we need it to be, and I view maintaining a satisfied workforce as a top priority for any service that wants to tackle the challenges that lie ahead. I do not think that, in all honesty, we can say that that is where we are in Scotland at the moment.

We have all spoken to constituents and representatives of medical NHS staff who have no end of stories about the strain and pressure that they are under. I want to give them something to hold on to, not just a few headlines or motions of thanks. Therefore, as well as lifting the cap, let us get a long-term pay deal that seriously reflects what health groups and trade unions are asking for, and offer a working-time review to every staff member considering retirement, which will give us the opportunity to offer more flexible working arrangements and retain staff for longer. Staff are fed up with being a secondary consideration.

At the heart of all this is low pay, which is a mistake that the Government makes again and again. We are supposed to be designing a transformational national care service, but the Government has still not committed to a wage of £15 an hour for social care workers. The NHS recovery plan that was presented to Parliament a few weeks ago was equally full—

Will the member take an intervention?

Very briefly; the member is closing.

Can the member tell me briefly how much a wage of £15 an hour for social care workers would cost and where in the health budget she would take the money from?

This is what the Government does time and again. It tries to move the debate away from what we know will solve many of those problems. The trade unions tell us that offering that wage to staff would have a positive result.

As the colder nights approach, we may be in serious difficulty no matter what, but if we start the work now and the Government delivers for NHS staff, we can return to this place in the months and years to come with a sense of achievement.

Thank you, Ms Mochan.

It starts with pay, wellbeing measures and workforce planning, not spin.

17:11  

Standing in the Scottish Parliament, we are fortunate that we get to experience visceral reminders of the rich history of our country. Since the 18th century, Scotland has produced some of the greatest thinkers, writers, scientists and physicians that the world has ever seen—a formidable reputation that defines us to this day.

Such a reputation does not emerge through chance; rather, there is an undeniable relationship between the level of talent that we have and the established focus on education that has shaped the country for hundreds of years. Here in Edinburgh, we have the oldest medical school in the United Kingdom, and in my Glasgow Kelvin constituency, the University of Glasgow’s school of medicine boasts incredible contributions from an impressive history of alumni that dates back to the 17th century.

Medical students face incredible challenges, navigating a notoriously competitive field of study while enduring the additional pressures of the pandemic, so I thank the students who volunteered to help the NHS during this time of crisis. There are now more than 21,500 extra NHS staff since the SNP Government came to office, including more doctors, qualified nurses and midwives, and the number of GPs working in Scotland has increased by nearly 12 per cent since 2006. It is our duty to ensure that those numbers continue to rise and that our NHS workforce is as strong as possible.

Remaining mindful of that goal, I am delighted that the number of medical places in Scottish universities has increased in recent years. The University of Glasgow has spoken positively about the upward trend in Scottish medical students, which was achieved by converting 100 former home-nations places into Scots places over a several-year glide path, in line with Scottish Government policy.

Our Government has shown that it is committed to improving the lives and working experiences of junior doctors up and down the country. That commitment is evidenced by a willingness to engage with external stakeholders about goals to implement a 48-hour working week, the £32 million pledge that will create additional trainee posts and the further £4 million for NHS staff support and wellbeing. Only by investing in the mental and physical health of our workers can we expect to retain our new recruits, build long-term resilience and maintain high standards of care across the NHS.

There is no question but that recent disruptions have created ineluctable vacancies and gaps in the current system.

Does the member acknowledge that there were staffing problems before Covid and that it is not just Covid that has caused those problems?

I acknowledge that having free tuition in this country is the best way of widening that access and addressing any shortfalls in staffing, which we are making great progress on.

Although certain things have been outwith our control, we can influence the way in which we value our healthcare workers. An immense burden has been placed on their shoulders and, as we brace for winter, we assure Scottish medical students that there will always be a place for them and they will always be fully supported in achieving their goals and reaching their full potential, not least because of free tuition in Scotland.

17:15  

Our NHS is under pressure like never before, and it is increasingly clear that the SNP has no positive ideas for how to turn things around. All that it offers the people of Scotland, and our hard-working NHS staff, is more excuses.

The SNP does not want to admit that removing the cap on funded places for key NHS roles is the right thing to do. The current crisis in the Scottish NHS is, in large part, down to the lack of GPs, doctors, nurses and paramedics—and the list goes on. The problem stems from Nicola Sturgeon’s decision a decade ago, when she was health secretary, to cut the number of funded training places at Scottish universities. When this Scottish Parliament first sat in 1999, more than 60 per cent of medical places were filled by Scotland-domiciled students. That figure has dropped by around 10 per cent as a result of the decisions that have been taken in this chamber.

We cannot continue with a policy that is holding back our NHS. After having 14 years in which to sort things out, the SNP has failed. We know that the applicants are still there and are still applying, that Scottish universities are filling their funding places and could fill more with suitably qualified young Scottish people, and that the widening access places could and would be maintained. It would, therefore, surely be worth giving that suggestion more than a cursory glance.

As Paul McLennan outlined, there is a wide and diverse range of new training places, which conflicts with the cabinet secretary’s statement about the threat of a lack of training places for graduates of our medical and nursing schools. Would it not be a more desirable problem to have too many graduates, rather than the workforce crisis that we currently face? Surely our universities are better placed to meet and plan for the longer-term workforce needs.

At the Health, Social Care and Sport Committee earlier this month, the vice-president of the Royal College of Emergency Medicine stated that the training scheme had nationally determined numbers and was six years out of date, and that one in five consultants was considering early retirement and one in two was seeking to reduce their hours. He went on to say that, right now, we have one A and E consultant for every 6,500 patients, when it should be one for every 4,000; we are 130 whole-time-equivalent emergency medicine consultants short; and GPs are already facing unprecedented demand. Andrew Buist from the BMA translated those figures to say that, right now, there are 250 whole-time-equivalent GP vacancies in Scotland.

We cannot keep on letting the problems get worse. The SNP’s incremental increases in funding for places simply do not meet the scale of the challenge that we face. I urge members on all sides of the chamber to ask themselves whether we are doing enough to protect and future proof our NHS.

We cannot keep on doing the same thing and hoping that the staffing shortages will sort themselves out. We need a bold new approach. Is the SNP Government ready to admit that it has got it wrong? For a nationalist Government, which claims to care about Scotland, to be overseeing a system in which we are turning away bright young Scots who want to be the nurses, doctors and paramedics of the future is nothing short of shameful. By keeping the funding cap in place, we are selling Scotland short. We have the talent—let us do something about it and support the motion from Dr Gulhane today.

17:19  

The pandemic has been an extremely difficult time for all those who are learning and working in the NHS, and I, too, express my sincere thanks to them for their efforts.

We know that the NHS workforce was under pressure before Covid and that the pandemic has intensified that pressure, and it is vital that every avenue is explored in efforts to ensure that our NHS has the staffing levels that it needs. However, it is also important that any decisions are made with a view to the long-term impact.

In its statement about today’s debate, the BMA said about the Conservative motion:

“Simply taking steps such as these without a proper, strategic long-term plan for our whole workforce could potentially be counterproductive.”

Right now, we have staff shortages in the NHS, and the staff who are in post have experienced huge increases in their workload. That means that the number of clinicians who are available to engage in teaching and training is reduced. Any move to increase medical student places must take account of that, or we risk piling even more pressure on existing staff and creating bigger class sizes with fewer teachers, which, as the BMA has warned, could affect the learning experience.

In the wake of the pandemic, proper workforce planning will be essential if we are to secure the sustainability of the NHS, but that must be long-term strategic planning that anticipates how the decisions that we make now will affect the workforce in future generations. The BMA has also warned that, if the Conservatives are proposing that we lift the cap on Scottish students without increasing student numbers overall,

“there are issues around how that is done fairly and appropriately.”

Increasing student numbers is, of course, an important part of long-term workforce planning, but we must also look to the short term. We need to retain the staff who are in place now, but that will become increasingly difficult while the pressures on the NHS continue to increase. Staff are exhausted. They are worn down and burned out. Mental health support will play a key role in supporting the workforce, and I have heard positive feedback about the national wellbeing hub, although it is only part of the picture.

Fundamentally, we need to improve working conditions for staff and ensure that they feel valued and that their contribution is recognised. I have been dismayed by some of the questions that have been asked in Parliament about why GPs are “not seeing patients” or when GP practices can “reopen”. GP practices are open and GPs are seeing patients. General practices in Scotland deal with more than half a million appointments every week. There are, of course, on-going issues with waits for appointments, and I do not want to minimise the distress that that is causing to patients. People are waiting for far too long, which is unacceptable, but that is due to the immense pressure that is being placed on GP services and it is not because their doors are shut to the public. We do GPs a disservice by pretending otherwise, and that will certainly not help retention.

I turn to widening access. I welcome the Scottish Government’s commitment to doubling the number of widening access places to help to create a more diverse medical workforce. The NHS needs to reflect the diversity of Scotland, and there is evidence that a diverse workforce can improve the quality of care. Widening access is essential from a social justice perspective, but it also has numerous benefits for the NHS and patient care.

We know that students from the poorest 40 per cent of neighbourhoods are less likely to study medicine, or the other professional courses such as law, veterinary medicine and architecture. People who are care experienced, young carers and asylum seekers might also be less likely to study medicine. That means that we are missing out a significant pool of people who could go on to become excellent clinicians. That is to our and the health service’s detriment, and it needs to change.

17:23  

Presiding Officer,

“We need a recruitment and retention strategy with real teeth because it is evident the one in place by Labour ministers is totally ineffective and is putting our NHS at breaking point.”

That was said by a Conservative member of the Senedd in Wales. I do not believe the statement, and nor is it true of the NHS in Scotland. I could also make a point about the vacancy rate for nurses and midwives in Scotland, which is 7.1 per cent. That is not good enough and it is a significant issue, but the rate is 10.3 per cent in England. That is not to remotely pass the buck in relation to the significant and major issues in Scotland, but they should be placed in context.

I agree with many of the matters that Jackie Baillie raised. I absolutely agree that pressures on staffing existed before the pandemic, but that was not just in Scotland but across the UK. That can be true at the same time as we have record levels of investment in the NHS by the Scottish Government and record staffing numbers, with numbers up by 21 per cent over the SNP’s time in office. Action was being taken to tackle the pressures prior to the pandemic, with the expansion of medical, nursing and midwifery training places, as well as an increase in levels of postgraduate specialist medical training.

As part of the NHS recovery plan, there is a commitment to grow the number of undergraduate medical training places by 100 per annum over this session of the Parliament, as well as an ambitious plan to double the numbers of people training from the poorest backgrounds.

That puts into perspective the calls from the Conservatives to remove the cap on funded training places. Action has already been taken—the action of a costed plan to increase those places. However, I would welcome additional information from the Scottish Government on the creation of a national centre for workforce supply and what its relationship will be with more general workforce planning—there surely must be a connection—including in ensuring a sufficient supply of places at medical schools and across other disciplines. Those things have to talk to each other, because that is important.

By the end of this year, the Scottish Government will publish a national workforce strategy that supports the delivery of its Covid recovery plan with more details and key workforce targets. Will the national centre for workforce supply feed continuously into any revisions of those targets? Will the strategy have specific targets on recruitment and retention that we can monitor? Will it feed into the assumptions on training places over the years? It is right that all that should be scrutinised.

I return to Jackie Baillie’s amendment, which references various important matters other than training places, such as recruitment and retention of staff across the NHS, as well as the idea of targeting potential NHS returners. I agree with that absolutely. I contend that much of that work is already happening but it is right that we do more where we can and monitor its success.

I wanted to say more but, in the time that I have left, I will talk about people who are already qualified to work in our NHS. I refer to people such as the nurses whom I met at an event in the Parliament a few weeks ago who were trained in Scotland but are not allowed to work in the NHS because of their asylum status. That is scandalous, against their human rights and an act of self-harm against Scotland and its NHS. Someone who is about to graduate in another medical discipline—they are not a medic and I do not want to mention their discipline—contacted me the other day to say that, because of their asylum status, they will not be able to take up paid employment in the NHS.

There are things that we can do in the Parliament to improve the situation, but surely to goodness there are also things that we can do in the UK to allow everyone who is qualified to work in our NHS to take up employment and do so.

17:27  

As has been said throughout the debate, although the chronic shortages of staff in our NHS have been exacerbated by the pandemic, they were not caused by it. The crisis is 14 years in the making.

As my colleague Jackie Baillie forensically set out, the Government has presided over historic failures in workforce planning. It was warned time and again. Further to that, for far too long, there has been underinvestment in higher education, which trains our NHS staff of the future.

The funding that is awarded for Scottish students comes nowhere near meeting the cost of training them. We welcome today’s call for a significant increase in funded places for front-line medical staff, but there is a worrying lack of understanding from the Tories on the practical constraints on that. Jackie Baillie set out that there were 9,530 applicants last year and 1,290 students were admitted, and she asked a reasonable question about where the bar would be set.

The Cabinet Secretary for Health and Social Care and Paul McLennan fell into some of the same patterns by hailing the number of people admitted who met the entry requirements while seemingly unaware that those entry requirements are, in significant part, set to limit entrants based on the number of funded places that the Government supplies.

I welcome the broad agreement among members of all parties who have spoken about the fact that much more can be done to recruit young and older Scots. It would be good to hear more about how that can develop, so that we can increase the number of Scotland-domiciled people who are involved in our NHS. However, we currently have acute shortages in a range of areas. Those are in not only—to name but a few—vascular surgery, neurology, internal medicine and mental health, which Alex Cole-Hamilton highlighted, but nurses and, crucially, GPs.

Therefore, when the health secretary made a trip to my Lochee ward to glumly announce a national scheme for new GP surgery buildings—

I was not glum.

The photo that I saw was pretty glum.

It was not only the risible figure of £7 million that attracted ridicule but, crucially, the fact that there are no GPs to go into those fantasy buildings.

Will the member take an intervention?

I will do so in a while, if the minister will bear with me.

Long-term cuts that are made to training places have real-world consequences, and not just for those young people who hope for a lifelong productive career in medicine and care. Let us take the breast cancer care crisis in my home city of Dundee. From this SNP Government, we get denials and a Deputy First Minister burying his head in the sand—“Crisis, what crisis?” was the headline. Instead, Labour is listening to those who know what they are talking about, such as the workers in the service, the patients who require care and the tragically bereaved families. They know that one clinician cannot do the work that was previously done by three specialists. On the same visit, the health secretary—and I think that this is why he looked glum—told people in Dundee and across Tayside that there is a “full service”, but that is utter fantasy. The perverse situation is that the SNP says that the cause of the crisis—which we are, at the same time, to believe does not exist—is national staff shortages in those specialist positions. Who is in charge of training those people and providing those skills? The Government says that it takes years, but the SNP has had 14 years.

Carol Mochan touched on a relevant point in relation to that issue. As well as recruiting more, we should be retaining and valuing the workforce that we already have. If only the SNP Government and NHS Tayside management would listen to that point on retaining the specialist breast cancer staff in Tayside, we would not have a crisis in that service in my constituency.

As many members have said, NHS staff are doing tireless work, performing miracles every day under the harshest pressure and without the support that they need from the SNP Government. That is important, because the lack of planning and specialist staff means that services come under increased pressure and, for too many, those services cease to exist. The consequences are life threatening, and the population is reaping what the SNP sows.

17:31  

I will try to address some of the points that members of the Opposition and my colleagues on the back benches have raised. It has been a good and interesting debate, and we have managed to get into a bit of the detail of the Tory motion and the consequences that it would have, but the issue could do with further debate, and I am happy to engage in that debate with Dr Gulhane or health spokespeople across the chamber.

Jackie Baillie made a very good speech; she can put that in a leaflet if she wishes.

No.

She has declined my offer; I am not sure why. [Laughter.]

Jackie Baillie, Michael Marra and a couple of other members did well to focus on the pragmatic and practical challenges with the Tories’ proposal. It is very clear that the Tories have not thought through the proposal in any great detail. For example, they are not able to answer questions about how many places the universities would have to take on or how much that would cost. Have they spoken to medical schools about whether they have the teaching staff in place? Have they spoken to NHS boards about the number of trainees that they have in place and whether they have the capacity to train an uncontrolled expansion of medical students? They have clearly not had those conversations, or else they would have gone into that detail. Jackie Baillie and other members went into those practical and pragmatic issues in relation to the cap. Somewhat strangely and bizarrely, Jackie Baillie said that she will still support the Tory motion, despite, rightly, poking holes all the way through it.

Although they have not thought the practical consequences through, does the cabinet secretary not agree that the intention behind the Tories’ motion is valuable?

That is why am delighted that we committed to increase medical graduate places by 100 per year and that those places were filled. Every Scotland-domiciled student who met the conditions of their offer was offered a place in a Scottish university, so I am delighted about that.

Although many of the suggestions in the Labour amendment are very good, of course, I cannot support it, because I do not agree with its inaccurate preamble.

How is it inaccurate?

I will come to why it is inaccurate.

As I mentioned in my opening remarks, if we look at our workforce statistics, we see that we have an excellent record on NHS staffing and that is why we have record numbers working in our NHS under this SNP Government.

Will the cabinet secretary take an intervention?

I will not give way, at this stage.

Since we came to power, there has been a 20 per cent increase in our staffing. There has been a more than 11 per cent increase in the number of qualified nurses and midwives and a 58 per cent—almost 60 per cent—increase in the number of medical and dental consultants.

When I look at the figures across the UK, I note that we have 94 GPs per 100,000 in Scotland, compared with 76 per 100,000 in England and 75 per 100,000 in Labour-controlled Wales.

I cannot speak much to Alex Cole-Hamilton’s speech. It is a shame that he was not in the chamber, as I would have been able to intervene during his contribution, which was riddled with inaccuracies.

Meghan Gallacher asked when our workforce plan will be published, and I can tell her that it will be published later this year. I thought that she and Dr Gulhane perhaps portrayed something inaccurately: they both seemed to suggest that the Royal College of Physicians and Surgeons of Glasgow said that the cap should be removed in perpetuity. That is not my understanding of the royal college’s statement; rather, my understanding is that it had asked for the cap to be removed in 2020 due to the increase in applications caused by the exam situation. We did remove the cap in 2020 to deal with the additional applications. However, if I have that wrong, I am happy to correct the record.

Carol Mochan has regularly stood up here, quite rightly, to remind every single one of us, including those of us in government, that the wellbeing of our staff is crucial. That is why I am delighted that we have invested £12 million in the wellbeing of staff.

With regard to Carol Mochan’s call for £15 an hour for social care workers, I asked a reasonable question about how much that would cost. She seemed to say that that is immaterial, but that is not correct. In government, I am afraid that we have to consider such matters. However, if, as part of the budget negotiations—which we are undoubtedly about to enter into—her party wishes to make such a proposal, it will have to demonstrate where the money will come from.

I know that I need to conclude, so I will end by saying that I understand that there are challenges, which have undoubtedly been exacerbated by the pandemic, but I am proud of this SNP-led Government’s record on NHS staffing. Staffing is at record levels, and has been growing for nine consecutive years. I do not doubt that it will grow for a 10th year in a row.

17:37  

I am grateful for the opportunity to close the debate for the Scottish Conservatives, especially given the urgent need for action.

I express my sympathy to those who have been directly affected by the NHS crisis, and offer my gratitude to the NHS staff who are working under extreme pressures to keep us all safe.

Today, members have heard my colleagues call for action from the Scottish Government on removing the cap on funded places for front-line medical students. Members have heard from my colleague Dr Sandesh Gulhane, who is a practising doctor who, alongside his colleagues, faces those challenges day in and day out. He could not have been more accurate with his comments. A distracted Government that focuses more on ideological and constitutional obsessions is no friend of the NHS.

I echo what Dr Gulhane said—we urgently require strategic workforce planning to ensure that the NHS is prepared for the future. That is why it is important that the SNP listens to medical staff on the ground, such as Dr Gulhane.

My colleague, Meghan Gallacher, referred to NHS Lanarkshire, whose staff have said that they

“don’t want to think about winter, as we know it will be worse than it is at the moment”.

That is not all. My colleague, Sue Webber, highlighted the lacklustre increase in funded training places, which will not scratch the surface of the problems that we are facing.

I will pick up on a few of the other contributions from around the chamber.

Will the member give way?

I do not have enough time. I am sorry.

It was great to hear all the statistics from the cabinet secretary, but we need the plans to translate into change and delivery for those on the ground, but not only for the short term; we must have a long-term strategic plan that works.

I welcome the removal of the cap for a year, but why just a year? Why not just remove it?

Will the member take an intervention?

I will not at the moment. I need to make some headway.

I thank Jackie Bailie for drawing attention to the SNP’s planning failures, and for highlighting the need to improve infrastructure to support current staff.

I agree with Alex Cole-Hamilton that we are losing people from the medical profession and that much more must be done about that. I also agree with him that the Government’s workforce strategy is not equipped to deal with the NHS crisis.

Today, we have heard from members from all parties; I will refer to some of them. SNP members Paul McLennan, Kaukab Stewart and Bob Doris basically said that action is being taken and that nothing is wrong. Kaukab Stewart was right to say that we have great talent in Scotland—but let us keep it here.

Carol Mochan talked about the NHS keeping its head above water and said that nursing staff are “stressed and exhausted”. Gillian Mackay said that we need to have in place a proper workforce plan.

Our priority must be to ensure that we are able to provide the best standard of care for patients. We can do that only by improving the conditions on the ground and ensuring that the NHS and its workforce are prepared for the future. We do not need more sticking plasters from the SNP.

Every day, we read more reports that there are not enough doctors to keep up with demand, and that the chronic shortage of front-line staff is threatening the health sector’s recovery. Why has not the Scottish Government scrapped the cap already? There is something amiss about that.

Will the member give way? I can explain.

Not yet.

Let me highlight some figures, just in case the SNP has forgotten them. First, 55 percent of surveyed Scottish Ambulance Service staff have witnessed adverse clinical events—that is, patients dying or becoming seriously ill—because of long waiting times. Secondly, 42 percent of GP practices are reporting that demand is substantially exceeding capacity. Last but not least are the figures on waiting times. The SNP Government is still failing to get to grips with the unacceptable strain on Scotland’s accident and emergency wards.

I highlight and make clear that we are not blaming NHS staff in any way. The failure lies solely with the SNP Scottish Government’s leadership.

I now want to talk about a personal experience. My son is studying medicine at the University of Dundee. However, that might not have been the case because he was denied a place at first, but was fortunate enough to be accepted in the second round. Many of his friends, who are also successful students, were not as lucky, so we lost that talent to universities outside Scotland. That is exactly the brain drain that my colleagues speak of.

Staff are working tirelessly and people’s lives are at risk, but there is a cap on the number of people who can train in the very services that this country so desperately needs. Our motion today calls on the Scottish Government to remove completely the cap on funded places for front-line medical students. The reality is that, without urgent action, the situation will only get worse.

I urge all parties to vote for our motion today. I support the Conservative motion in Dr Sandesh Gulhane’s name.

On a point of order, Presiding Officer. I apologise—I did not declare my interest as a practising doctor.

Thank you, Dr Gulhane.

Just to be clear, I note that that concludes the debate on funded places for front-line medical students.