Meeting of the Parliament

Meeting date: Thursday, October 6, 2016

Official Report 944KB pdf

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Island Health Boards

The next item of business is a members’ business debate on motion S5M-01639, in the name of Liam McArthur, on island health boards. The debate will be concluded without any question being put.

Motion debated,

That the Parliament considers local NHS boards to be key in delivering frontline services across Scotland’s distinct communities; believes that a one-size-fits-all approach rarely works, particularly in delivering health care in Orkney and Shetland where, more often than not, island communities require different solutions to the central belt; acknowledges that the nature of delivering health and care services in rural and remote island communities inevitably requires additional resources; recognises that decisions about how those services are most effectively delivered are best made locally; considers therefore that concerns that the Scottish Government’s intention to “examine the number, structure and regulation of health boards” could lead to the amalgamation of NHS boards to the detriment of providing the best possible health care in the islands, and notes calls for the Scottish Government to undertake to protect island health boards, including NHS Orkney and NHS Shetland, in its forthcoming review.

12:46  

I thank colleagues for the cross-party support that has allowed the debate on island health boards to take place. I look forward to hearing the contributions of those who participate, including the minister.

I was slightly surprised that no Scottish National Party MSP felt able to support my motion, even though it says nothing that is unduly controversial. In the Cabinet Secretary for Health and Sport’s recent response to me and my colleague, Tavish Scott, she reasonably accepted many of the same points. She acknowledged the

“unique nature of the islands”,

that NHS Orkney and NHS Shetland are

“very distinct communities”

and that the

“respective NHS services are experienced in the demands of serving those populations”.

As I set out why our island health boards deserve protection, I am encouraged by what appears to be a decent amount of common ground between me and the health secretary.

Nevertheless, the First Minister’s intention, as set out in her programme for government, to

“examine the number”

and

“structure ... of health boards”

has had alarm bells ringing in Orkney and Shetland. From my conversations with those who are directly employed in delivering health and care services in Orkney, as well as with the many members of the public who have been in touch with me in recent days, there can be no doubting the strength of feeling or the determination to resist any dilution of local control.

Some of those concerns will not be confined to the island communities that Tavish Scott and I represent, because all the evidence shows that large-scale structural changes inevitably distract attention from the day-to-day business of delivering services. Those changes can affect morale and organisations’ ability to recruit and retain staff, and the savings that are often used to justify them invariably prove elusive, if not illusory. Anyone who doubts that need only look at what has happened since the Government decided to create a single, centralised police force. Five years on, surely only Kenny MacAskill believes that that has been a success or that it has delivered what was promised.

A review of how health boards are performing is prudent. Given the crises in many areas of health and care provision, a review is perhaps overdue, but I caution against believing that structural reform is the answer to the maiden’s prayer. Certainly for rural and island areas, such reviews tend to signal a retrenchment of services and decision making into the centre. That matters, not least to those who rely on those key services. At NHS Orkney’s annual general meeting earlier this week, the local patient group voiced its opposition to NHS Orkney being subsumed within a larger board that serves a wider geographic area. Preserving NHS Orkney’s identity is important as that identity shapes the ethos, priorities and approach of the organisation.

Little wonder that there is such anxiety in the islands at what might be lost in any move to centralise services and decision making. Bringing together different boards with different identities—or even different priorities—offers no guarantee or much likelihood that island needs would be effectively heard, understood or—far less—met. Moreover, it would remove the ability to be nimble in responding to local needs, to develop services that best suit island circumstances in conjunction with communities and to enhance the skills of staff in ways that ensure both quality and breadth of provision.

This is not an isolationist approach. Island health boards already work collaboratively with counterparts on the mainland. NHS Grampian is the obvious example with respect to the northern isles, but there may be opportunities in the future to work with others in providing specialist treatment that it would be impractical to deliver in an island setting.

Here again, though, I sound a note of caution. If the Government plans to merge mainland health boards, it must take account of the impact on all patients. For example, recent problems that affected the oncology department at Aberdeen royal infirmary meant that some Orkney and Shetland cancer patients were offered treatment in Dundee and Glasgow. Although the treatment might have been exceptionally good, if they are to go outwith Aberdeen, isles patients face more complex travel arrangements and limited access to the support structure that CLAN Cancer Support and the Red Cross provide in the north-east.

Far from the services that are available in the islands being reduced, I want them to be increased. That ambition is shared by NHS Orkney, staff, patients and local communities, which see it as crucial to their efforts to attract and retain people and effectively serve their populations. The recent decision to locate a computed tomography scanner in Orkney is a case in point. I know from speaking to the staff involved that it has already made a big difference in terms of early diagnosis, allowing more effective treatment and improving and in some cases saving lives, which justifies the long, hard-fought campaign.

More is possible. Telehealth opens up opportunities to increase the availability of treatment in Orkney, as it reduces the need for patients to travel south or even to travel within Orkney. For those who live in the smaller isles, the option of a consultation in their local surgery, supported by their general practitioner or nurse, may appeal a great deal more than getting on a boat or a plane and travelling into Kirkwall, particularly during the winter months. Such an approach can therefore help to improve patient care, reduce travel and accommodation costs, unlock economies of scale and open up more interesting career paths for those who work in health and care services in our islands.

That point is important given the challenges that are faced in recruiting and retaining staff in remote and rural settings. The Royal College of Surgeons of Edinburgh shone a light on that in its report last week. There are no easy solutions, but we need to do more to give those who are in training a taste of what island working has to offer. We need to develop a workforce that is comfortable across a range of general skills rather than training ever more specialists, and we must ensure that more isles students can access Scottish medical schools. Widening access needs to be about rurality and not just about poverty. At the same time, there is no escaping the fact that financial incentives will play a part in the equation as well.

Delivering good-quality health and care services in our islands to a population that is living longer but with more complex conditions presents enormous challenges, and meeting them is beyond the gift of any health minister. We also need decent transport links, for example, including reliable air services—I note that the Minister for Transport and the Islands is by Maureen Watt’s side, which is helpful—together with good mobile and broadband coverage, the need for which is routinely and compellingly raised by GPs and nurses throughout my constituency. Those factors and others fundamentally affect the way in which health and care services are delivered in Orkney and, in turn, that has a fundamental bearing on the economic wellbeing and sustainability of the islands that I represent.

My plea to the minister today is to ensure that the review—it would help to hear a little more about the timeframe and the process that are involved—protects island health boards and recognises their unique status and the risks that are inherent in submerging them in larger, less responsive or less accountable set-ups. Failure to do that would drive a coach and horses through the Government’s commitment to island proofing. More important, it would undermine the ability of health and care provision to be tailored to the specific needs of our island communities. That cannot and must not be allowed to happen.

12:54  

I thank Liam McArthur for bringing the debate to the chamber. I commend him for his efforts not just in highlighting concerns about health services in his Orkney constituency but in acting as a champion for the islands. I signed his motion and I support the principles that it sets out.

As an MSP for the Highlands and Islands, I share the concerns that Liam McArthur has raised about the SNP’s manifesto commitment to review

“The number, structure and regulation of health boards”.

In particular, I am concerned about how that might affect the health boards that cover my region.

The needs of people in rural and remote areas of Scotland are vastly different from those of people who live in more densely populated areas, so a very different approach is required to the provision of healthcare services. That is even more the case in island constituencies such as Orkney and Shetland, but it is also the case in the Western Isles and in the many smaller islands in Argyll and Bute.

I spoke on this very matter here in Parliament at a recent meeting, hosted by Kate Forbes, with the Royal College of Surgeons of Edinburgh, which has just launched its report, to which Liam McArthur referred, on the delivery of care in rural surgery. The RCS notes that there is a clear difference between the provision of healthcare services in urban Scotland and that in rural Scotland.

The president of the RCS made a particular point in the foreword to the report that

“‘one size does not fit all’ when it comes to service delivery in these challenging environments and ... the needs and provision will vary depending upon the speciality and the region.”

That statement is poignant in the context of the discussion because, time and again when it comes to the organisation of our public services, we have seen an increasing drive to centralise services by the SNP Government. We have seen it with our fire services, following amalgamation. We have seen it with our police, with the creation of a single force—we all know of the many problems that have been reported in that. We are now seeing it even in education, in the proposals that John Swinney announced a few weeks ago to create regional education boards, which will take powers away from local councils and centralise them in a larger body.

Recent history serves as a powerful reminder of the dangers of overhasty, top-down centralisation. At a time when health boards are still adjusting to the huge reorganisation that the recent integration of health and social care has caused, there are many valid concerns about committing to further reorganisation unless it can clearly be shown to be in patients’ best interests.

The Conservatives are sceptical about the possible creation of health superboards that would be run on a regional basis—if that turned out to be the case. l say “if” because all of us here are somewhat shooting in the dark, as we do not know what the proposals are. There might be elements that we can support, and we will of course hold off from expressing a concluded view until something concrete has been put on the table.

Like Liam McArthur, I acknowledge that there is already joint working and collaboration across health boards. However, it is vital that we know what the Government’s proposals are as soon as possible, not simply so that we as elected representatives can be made aware but, more important, so that the public—the patients—can be consulted in a meaningful way and have their say.

I will finish with a question to the minister that repeats a call that I made in early July for clarity on the proposals. Will she give clear details today of the Scottish Government’s plans for the organisational structure of NHS boards? If she is unable to do that today, will she tell us when that announcement will come?

12:58  

First, I declare an interest in that I am a pharmacist registered with the General Pharmaceutical Council and, until my election in May, I was employed by NHS Highland.

I am grateful to Liam McArthur for the opportunity to speak in the debate. I represent the Highlands and Islands region, which covers nearly half the landmass of Scotland and is served by six health boards. I take the opportunity first to acknowledge the aspects of the motion that I believe that we can all agree on. Like Mr McArthur, I believe that island communities often require different solutions from those for the central belt. However, I would go further and suggest that many communities require their own solutions. It is clear that providing health and care services in remote communities requires a higher per capita investment, and I recognise that decisions about how those services are most effectively delivered are best made locally.

Unfortunately, I cannot in all conscience agree that the potential amalgamation of NHS boards would be to the detriment of the best possible healthcare in the islands. As a health professional, I was encouraged to ask regularly whether the way in which we had always done things was necessarily the best way. Innovation and change are vital to improving healthcare. We should always be looking for ways to improve how public services are provided. Whatever the financial constraints are, our focus must be on patient outcomes and quality of care. Governance and quality must not get lost during reorganisation.

Bigger health boards could be just as capable of reflecting the needs of a community as smaller boards are. The key to success is for the individuals on the ground, in the small local operating units, to be empowered to deliver local solutions.

I absolutely understand that people in the northern isles might be frightened that they will lose their voice. I assure them that people all over the Highlands share the same concern. We know very well that one size does not fit all. In fact, NHS Highland provides an example of a large health board area that covers remote and urban areas and island and mainland areas. For health and social care integration, it operates different models to suit local needs; it has a lead agency model in one part of its area and an integration joint board model in Argyll and Bute.

If there is to be a change, it is vital that the engagement and consultation process enables us to make an informed decision. People must have the opportunity for discussion and a chance to identify any benefits as well as risks. Some things are already done well Scotland wide—for example, NHS National Procurement uses combined buying power to get the best deal on buying drugs, and the savings go right back into patient care.

I have heard from people who work in island health boards that it can be difficult for the smaller health boards to compete with larger, better-resourced ones to attract certain skilled staff. It is probably easier to conduct research and develop specialist knowledge and expertise in the large centres. Having fewer health board areas might encourage the sharing of that precious resource or at least remove the barriers to staff in remote areas tapping into it. Duplication of effort might also be reduced. Could having fewer health board areas reduce unnecessary variation in practice and outcomes? Might it improve the quality of care? False boundaries are an issue, and the proposed change could see them disappear.

The most important question in the debate is: how can we best deliver high-quality care to communities? We have to answer that question by looking at the evidence and consulting widely. I hope that that is exactly what the review will do.

13:02  

I congratulate Liam McArthur on securing the debate.

When examining health board structures, we need to make sure that they are fit for purpose. Service delivery must be at the forefront of decision making, and the structure must be that which best delivers that service.

Our islands are unique. People who live and work on the mainland think that weather can be disruptive, but they do not recognise the challenges that it places on island life. Although island life is wonderful in many ways, people on our islands cannot plan in the way that those on the mainland take for granted. It is normal to have plans disrupted because of weather, so the provision of services on an island must have at its heart the determination that systems will work in spite of the weather. We do not expect a lesser service; we simply expect services to be delivered differently, dependent on the local circumstances.

Our island health boards are crucial, given their knowledge and understanding of local conditions, and they can plan services to fit their unique local circumstances. That is not to say that they do not need support. Let us take the patient transport budget that was rolled up into this year’s settlement for NHS Highland. I find that worrying because, due to the size of their populations, our island health boards’ budgets are small, which means that they do not have the economies of scale that will enable them to absorb the changes.

I believe that the funds that were transferred to meet the costs were insufficient and that cuts will have to be made. Those cuts must not have a detrimental effect on patients. However, as I speak to people about transport, I am staggered by the number who have been taken off island for routine check-ups that they felt were unnecessary and disruptive to their lives. They felt that the check-ups could have been carried out locally through videolinks. The patients of island health boards need to be able to request and receive consultations via telehealth.

I know that island health boards have such technology and expertise because they use it interisland, but some clinicians on the mainland appear to be reticent about embracing the technology. It would not augur well if the health boards that will not embrace the technology were put in charge of delivering services to the islands. If they had the technology, using it would provide better services that are patient centred, which is why the island health boards use it in responding to the needs of people who live not on a main island but on small islands that surround it.

If the health boards that understand such challenges were to disappear, we would lose that knowledge and patients would be worse off. What we need from the larger health boards is a better understanding of the needs of remote and rural communities—they need to fit telehealth facilities into their consulting rooms—and what we need from the Government is better broadband in our remote rural and island communities so that they can access those services. It is not just mainland health boards that have to change but services such as the Scottish Ambulance Service, which operates a model for urban areas that simply does not work in rural areas either as an emergency service or as a patient transport system.

We need change, but the change must be of the mindset rather than of the structure. We need to protect local knowledge and support the island health boards to deliver for their patients.

13:06  

I, too, thank Liam McArthur for bringing this very important debate to the chamber. The motion talks about distinct communities, and my colleague Rhoda Grant talked about changing the mindset. If members were to read the “Scottish Government Urban Rural Classification”—if they had nothing better to do—they would see that there are various classifications, all of which are fixated on centres of population. The classification of “remote rural” is somewhere

“with a drive time of over 30 minutes to a settlement of 10,000 or more”.

That is challenging, because we are talking about communities that might be classed as being beyond “very remote rural” because they are significantly impeded by geography.

The motion also talks about a one-size-fits-all approach not working, and I agree with that, although there are some exceptions that members have previously alluded to—for example, standards of care and terms and conditions for staff, which should be protected however the administrative arrangements are configured. Nevertheless, there are challenges associated with that, too. In the previous session, I wrote to the Cabinet Secretary for Health and Sport about the challenges that are faced in delivery of training to people in social care on Orkney’s small islands. Of course, there is an assessment of needs, but there must be a practical approach to how that is delivered that bears in mind—quite literally—time and tide. I have no doubt that such approaches are best determined locally.

Island communities require different solutions and although impact assessments inform a lot of our decision making in this building, it is hard to change mindsets—it is a two-way thing: urban-rural, rural-urban—and I do not think that there is a clear understanding of some of the practical implications. The solutions come from communities. For example, I commend the new and innovative model of care on the small islands in the NHS Highland area. Called the nuka model of health and care services, it was created and is managed and owned by Alaskan native people, and it has enabled the islands of Eigg and Muck to come up with their own solutions to problems as well as delivering jobs there.

Another phrase in the motion—“inevitably requires additional resources”—is important because, as has been said, there are additional travel costs and other costs associated with travel. When Highlands and Islands Enterprise had the budget for training, it took cognisance of the actual costs. However, when Skills Development Scotland took over that budget, it moved to one-size-fits-all delivery of training per capita, which has impacted desperately on some of the small providers; indeed, Argyll Training went out of business just last Friday. All decisions are best made locally and on an informed basis.

A colleague mentioned NHS Highland. I can stand at the north end of that board’s catchment area and look over to Liam McArthur’s constituency in Orkney and I can stand at the southern end and look over to Glasgow. It is a ridiculous size—it covers an area the size of Belgium and Wales, with Argyll and Bute added on. It is not the model that we should be looking at, and it is certainly not the one that I am promoting.

Integration of health and social care is a factor, too, but I do not know whether that factor has prompted some of the Scottish Government’s proposals. My party and I suggest that there should be more rather than fewer local management decisions. There is no doubt that collaboration will continue, but not every health board could or should have every specialism.

As we have heard from Mr McArthur, the scanner in Orkney has made a difference. Telehealth and the information technology infrastructure that underpins it are important.

The NHS is a shared resource and a valued public service and it should be managed locally. For the good folk of Orkney, that should be from within the islands by NHS Orkney.

13:10  

I welcome the opportunity to contribute to today’s debate and congratulate Liam McArthur on securing Parliamentary time for an important subject for Orkney and all our island health boards.

As a member for the Highlands and Islands region, which covers an area with the same land mass as Belgium, I know that a one-size-fits-all model will never work for an area with such diverse and distinctive communities. The healthcare that is provided in Kirkwall can never be the same as that which is provided in Keith. Liam McArthur alluded to that, and I was encouraged when he said that the Cabinet Secretary for Health and Sport’s letter also accepted the distinctive challenges in the very different communities within the same region.

The signs are that the Scottish National Party is, despite having its fingers burned by many other mergers, moving on with further centralisation of services. As my colleague Donald Cameron mentioned, anyone who followed the merger of Scotland’s previous eight police forces into the national Police Scotland could not have failed to witness the havoc that that merger has caused. Jobs have been lost, staff morale is at an all-time low and—despite crime figures falling—public confidence that communities are safer is also falling. The chief constable stated recently that it will take a two-year to three-year adjustment period to balance the force’s finances. I put that point to the First Minister last week. She was, as usual, quite dismissive about it. However, communities in Orkney, Shetland and the Western Isles will have looked at that centralisation of services and will be worried that a similar approach is being proposed for their local health services.

When I listen to Maree Todd, a back-bench SNP MSP, I worry—

Maree Todd rose—

I will give way in a second. I worry that Maree Todd does not recognise the failure of the mergers and just assumes that similar problems would not happen were the islands’ health boards merged and made bigger.

I give way to Maree Todd.

I will allow you the time back, Mr Ross.

Will Douglas Ross acknowledge that people in Moray, which is in his region, have raised concerns with him and with me about the false boundaries that are caused by the health board areas? People in Moray who may live closer to Raigmore hospital then they do to Aberdeen royal infirmary are forced, because of the area that NHS Grampian covers, to travel to ARI. Will he at least acknowledge that it is worth looking at mergers as a potential solution to some boundary issues?

I am not sure that Maree Todd made the point very well for her own argument. People in Moray are saying to me that because they live between Aberdeen and Inverness, the service that they get from the NHS is not as good as the service that people who live closer to those places get. A person who lives in Moray should not just have to put up with services being lost. We should look at delivering services locally, which is exactly what we are discussing in the debate, and not merging them into far bigger functions, because places such as Moray would get lost and forgotten about, which is a serious concern in our area.

NHS Orkney serves a population of approximately 21,500 people. Its challenges are well known. The 620 staff who are employed by NHS Orkney do a fantastic job and the Scottish Conservatives commend them for the role that they play across the Orkney Islands. When presenting the NHS Orkney annual review earlier this week—which Liam McArthur mentioned—Cathie Cowan took the opportunity to acknowledge the efforts that are made in Orkney, in particular to recruit and retain staff on the isles. They are a key asset and they will be troubled, I think, by some of the Scottish Government’s proposals.

I hope to meet the board chief executive, Cathie Cowan; I have met the board chairman, Ian Kinniburgh. I know how passionate they are about delivering the best possible care as locally as possible. Consequently, it is difficult to hear some of the examples given about people having to go as far as Dundee to get vital treatment.

I have always found that the best decisions are made locally and with the full involvement of the people who will be affected by them. Although there are no firm proposals on the table, there is a clear statement from the minority—I focus on the fact that it is a minority—Scottish Government that it will

“examine the number, structure and regulation of health boards”.

As a Scottish Conservative MSP for the Highlands and Islands, I urge the Scottish Government to consult fully on its plans. It is worrying that the Royal College of Nursing noted in its briefing for the debate that there has been

“little or no engagement on the government’s stated intention”.

The briefing also suggests that that could lead

“to a perception that change is being introduced by stealth, by a government talking behind closed doors.”

That cannot be allowed.

I welcome the debate, which allows us the opportunity to debate openly in Parliament, and I will listen carefully and with great interest to the Scottish Government’s response.

13:15  

As other colleagues have, I thank Liam McArthur for bringing the debate to Parliament.

I will briefly concentrate on the care that medical staff bring to the islands. In particular, I thank staff at the Gilbert Bain hospital and throughout the NHS for the care that they gave my father recently. We sometimes take it for granted, but the professionalism of our staff is worthy of mention in a debate about process and structure.

It would be helpful for the minister to be clear with Parliament about what is going on. In today’s Press and Journal, the Cabinet Secretary for Health and Sport is quoted as saying that the Government’s objective is to

“reduce bureaucracy and remove … barriers to effective patient care.”

I hope that, in her closing speech, the minister will be able to say exactly what those bureaucratic bits and the barriers are. When I ask the health service in Shetland to detail them, it would be interesting to compare the notes that the minister clearly has that illustrate why the need for change is so great. Of course it is right to remove barriers to patient care and to reduce bureaucracy, but instead of just the language of that, let us have some concrete examples from the minister that illustrate why the Government is taking that approach.

As other members do, I, too, hope that the minister will in her closing speech commit to bringing the Government’s proposals to Parliament. We know that any changes to the structure of health boards and the geographic coverage of our territorial health boards can be made by ministerial direction. However, I hope that, instead, the minister will confirm that, if the Government concludes its plan to introduce proposals to Parliament, it will do so through primary legislation so that they are fully and properly scrutinised and consulted on.

I will make a couple of points on the general issues that have been raised well by members from all parties. The first concerns the integration of health and social care. As Audit Scotland has made very clear, integration is challenging, to put it mildly. It is challenging throughout Scotland but, as Douglas Ross said, it is certainly challenging in areas where boundaries are not coterminous. Therefore, it is beyond belief that anyone would propose merging the island health boards—whether in the Western Isles or the northern isles—with mainland health boards, thereby making the situation for those integration joint boards even more challenging. I hope that the minister will, based on that argument alone, recognise the importance of maintaining the geographic consistency of the boards that are being worked on.

That is not to say that the merger of health and social care is not difficult, because it certainly is. That is best illustrated by the report in last week’s Shetland Times that the integration joint board in Shetland decided not to close a ward in the Gilbert Bain hospital in Lerwick not least because of the argument that was made by one of its councillor members, who pointed out that there is only one intermediate care team, whereas four would be needed to deliver care, were that ward to close. That is an example of the importance of the accountability of our local health services to sensible arguments about the geography that we all face. It is the principal argument for not making a change to the island health boards.

The second argument is that, as we have seen time and again in Scotland, the management tier in a structural reform concentrates, through no fault of its own, not on the service—in this case, patient care—but on its own jobs and the future of its organisation. That will surely happen. We need look no further than Police Scotland for the way in which chief constables throughout Scotland had to deal with the consequences of the merger for their staff. I hope that the Government at least recognises that point and will be prepared to respond to it.

The essential point to bear in mind when it comes to designing healthcare in local areas is that it should be designed around the expertise of those who are involved in the service. I know that recruitment challenges are faced not just in Orkney and Shetland, but right across the Highlands and Islands, as many people have said in recent days—not the least of them being David Alston of NHS Highland. I suggest that the one thing that will not help us with those challenges is another process of structural reform. It seems that there are some very good arguments for not proceeding with such reform; I hope that the minister is listening.

13:20  

I welcome Liam McArthur’s motion and the opportunity to discuss the points that are raised in it. The Government has placed the needs and aspirations of our island communities at the very centre of our agenda, and will continue to do so. I welcome the opportunity to talk about how we are delivering on that commitment.

The review of health boards’ structures and functions and their relationships with local authorities has not yet begun, but I reassure members that the final proposals will ensure that the unique needs of our islands are reflected. Parliament does not yet have a timetable for introduction of the legislation; the Cabinet is still in discussion on the initial papers. It will be brought forward in the normal way and will, of course, go out to consultation of all those who wish to be involved in the process.

We are committed to services being delivered locally where possible, and we know that our islands’ healthcare services are experienced in serving the unique needs of their populations. The NHS staff on the islands should rightly be proud of their delivery of those excellent services. As Rhoda Grant and others have said, healthcare professionals know their populations and their needs. That is precisely our direction of travel.

NHS Orkney and NHS Shetland are both developing new models of care so that services can be delivered locally for patients who would previously have had to travel to the mainland. For example, NHS Shetland has successfully worked with the Golden Jubilee national hospital to provide a shared pathway for patients who undergo joint replacement in Glasgow. That means that much of the pre-assessment and post-operative follow-up for those patients is provided in Shetland by local physiotherapists and nursing staff using telehealth techniques. I take on board Rhoda Grant’s point that telehealth is sometimes restricted by the lack of availability of broadband services. That is why we need to continue with the work that we are doing through the digital Scotland programme to upgrade broadband provision. NHS Shetland is now also working with NHS Grampian to use the approach that is being followed with the Golden Jubilee hospital in other parts of the orthopaedic pathway.

NHS Orkney is increasing provision of locally delivered services, including enhanced chemotherapy and gynaecology. Liam McArthur mentioned the £200,000 of funding for the acquisition of a CT scanner, which has enabled 800 scans—for which patients previously had to travel to the mainland—to be carried out in Orkney. That is an example of newly available local delivery.

Does the minister accept that there has always been such cross-border collaboration on specialist treatment? That does not require any alteration of the administrative structures, which should be local.

Yes, I accept that. As someone from the NHS Grampian area, I know about the CLAN Cancer Support services, on whose delivery we have worked with local people. I recognise the huge contribution that is made by the islands to the services that are provided at Aberdeen royal infirmary. However, local delivery of such services is possible only if we have the workforce to support it; we recognise the challenges of recruiting staff in the unique areas that we are discussing.

We also know that island boards are leading the way in designing models of care that maximise the contribution of the whole healthcare team. As I was saying before John Finnie intervened, there is more, not less, that we can deliver locally, and that is the direction of travel.

In Shetland, the largest GP practice has improved access to the healthcare centre by successfully introducing an advanced practice skills mix to its primary care team, which now includes GPs, advanced nurse practitioners, practice nurses and a pharmacist.

We seek to work more effectively for patients not only in the health service. Through health and social care integration, we have continued to build on the islands’ long history of joint working across the public sector. That has empowered communities in the islands to develop and shape their health and social care services, and it allows them to control how best to use resources, based on their detailed understanding of the needs of their populations. Local people are developing local solutions. That is community empowerment and devolution to communities, not the centralisation that Liam McArthur and Donald Cameron tried to assert it is.

I really could not disagree with any of what Maureen Watt said, but what she describes has gone on for some time, as John Finnie illustrated. The island boards have demonstrated their willingness to work collaboratively within themselves and between themselves and larger health boards. The concern is that a merger of island health boards into a larger health board area would dilute the voice of the island health boards, which can currently stand alone and make representations as they see fit.

There are no firm proposals on the table yet, so Liam McArthur is just surmising that that will happen.

In reply to Liam McArthur and Tavish Scott, as the Cabinet Secretary for Health and Sport has said, we want to reduce

“unnecessary backroom duplication”

and remove structural

“impediments to better care.”—[Official Report, 7 June 2016; c 10.]

Given that we now have integration joint boards, do we still need to have the health boards, as well, or do we need a structure that reflects the change that has taken place?

We are supporting improvements through substantial financial investment across Orkney and Shetland. Resource budgets have increased by 15.5 per cent in real terms between 2010-11 and 2016-17. The uplifts for both boards for this financial year include £1 million for social care as part of the health and social care integration agenda.

We are making significant infrastructure investments, including more than £60 million in the new state-of-the-art Balfour hospital. That will support a range of first-class primary care, emergency and elective diagnostic, out-patient, day case and in-patient services. That is all to reduce the amount of time that folk need to travel to the mainland.

I say to Douglas Ross that I, as a Keith quine, would expect patients in Keith and Kirkwall to get the same high standard of care, however differently it might be delivered.

Someone made a point about artificial boundaries. That is exactly the situation that people in Moray find themselves in. They may want to go to Inverness, but a service being delivered at Dr Gray’s hospital instead of their having to go to Raigmore hospital is better. We have to remove the artificial boundaries that currently exist.

The commitment of the Government has been seen with the appointment of the Minister for Transport and the Islands, who is here with me. We have said that we will in the future island-proof everything that we do.

In conclusion, it is right and proper for the Government to review the existing structures to support improvements in patient care. We will continue to identify specific solutions for our island communities to help them to continue to flourish and prosper in the years ahead. That will be not just for the benefit of Orkney, Shetland and the Western Isles, but for all of Scotland’s 93 island communities.

13:28 Meeting suspended.  

14:30 On resuming—