Meeting of the Parliament (Hybrid)

Meeting date: Wednesday, March 10, 2021

Official Report 1371KB pdf

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University of St Andrews (Degrees in Medicine and Dentistry) Bill: Stage 3

The next item of business is a debate on motion S5M-24321, in the name of Jeane Freeman, on the University of St Andrews (Degrees in Medicine and Dentistry) Bill at stage 3.

No amendments to the bill have been lodged.

Before the debate begins, the Presiding Officer is required under standing orders to decide whether any provision of the bill relates to a protected subject matter—that is, whether it modifies the electoral system and franchise for Scottish parliamentary elections. In the Presiding Officer’s view, no provision of the bill relates to a protected subject matter, so the bill does not require a supermajority to be passed at stage 3.

I invite members who wish to contribute to the debate to press their request-to-speak buttons now.

15:22  

I am pleased to open the stage 3 debate on the University of St Andrews (Degrees in Medicine and Dentistry) Bill. The bill has reached stage 3 without amendment and with what I hope is the support of members throughout the chamber. I think that that is in no small measure thanks to thorough and careful scrutiny by the Health and Sport Committee, for which it has my thanks.

I think that this is the last time that I will have the opportunity so, for the record, I thank the members of the Health and Sport Committee, under your fair and able leadership as convener, Presiding Officer, for all the work that we have undertaken together and for their constructive engagement on and the positive contribution that they have made to critical areas in my portfolio. I also offer my thanks to the organisations and individuals who provided evidence at stage 1.

That the bill is a short and largely technical one should in no way detract from its importance. In essence, it will repeal an archaic, unfair and arguably anti-competitive prohibition that prevents the University of St Andrews from awarding medical and dentistry degrees. The prohibition was always intended to be transitional, and no other higher education institution in the United Kingdom suffers a similar prohibition. After 50 years, we are well past the time for it to be removed.

The bill will remove from one of our most valued higher education institutions a prohibition that, as I said, was never intended to remain for so long. As an additional impetus, the bill will enable the University of St Andrews to award jointly with the University of Dundee primary medical qualification degrees to Scottish graduate entry medicine programme—ScotGEM—students in advance of the first cohort graduating in 2022.

During the stage 1 debate, we heard strong support from across the chamber for ScotGEM, Scotland’s first graduate entry programme for medicine. The universities of St Andrews and Dundee have done incredible work to innovate new methods of delivering undergraduate medical education. That innovation focuses on the centrality of primary care. It inspires new interest in general practice and recognises the challenges and opportunities of remote and rural working, along with the lessons that those have for care in more urban settings.

I had the privilege of meeting and speaking to the first cohort of ScotGEM students. With other members, I have heard their strong testimony on the quality of learning and experience that they are receiving, and I have every confidence that ScotGEM will achieve its ambition of graduating passionate, skilled doctors for our national health service workforce who want to work and remain in NHS Scotland.

Removing the prohibition will create a fairer higher education sector in Scotland and across the United Kingdom, enabling all our valued higher education institutions in Scotland to maximise the options and opportunities that they offer to students.

As we recognised in the stage 1 debate, there are significant challenges to overcome in creating and growing a more sustainable medical workforce. There are also significant challenges to overcome in the higher education sector, including the constraints on immigration, the consequences of European Union exit and the potentially diminished attractiveness of studying abroad as a result of the coronavirus pandemic. Removing the prohibition is one step in providing greater flexibility to address all those challenges.

This short, technical bill has an importance and a significance that should not be underestimated. It is right and timely to remove an anomalous prohibition that disadvantages one of Scotland’s higher education institutions.

I move,

That the Parliament agrees that the University of St. Andrews (Degrees in Medicine and Dentistry) Bill be passed.

Thank you for your kind words, cabinet secretary.

15:27  

I welcome the opportunity to open for the Scottish Conservatives in the stage 3 debate on the University of St Andrews (Degrees in Medicine and Dentistry) Bill. I confirm, of course, that the Scottish Conservatives will support the bill at decision time. I thank my colleagues on the Health and Sport Committee for their work and I pay tribute to those who are stepping down after many years of service, namely yourself as convener, Presiding Officer, David Stewart and Sandra White.

In saying farewell, it is incumbent on me to pay tribute to the cabinet secretary. I think that I am right in saying that this will be the last time that she gives a speech in a debate in the chamber, although there might be statements or portfolio questions in the next few weeks. Since I have been health spokesperson, I have certainly had many jousts with Jeane Freeman in the chamber and elsewhere, and I am sure that we have a few still to come, but I have always respected her as a formidable opponent and an industrious and effective minister. I have never doubted her commitment to the NHS and her genuine motivation in what she has sought to do in government, especially during the pandemic, and I wish her all the best in her well-earned retirement.

I move on to the substance of the debate. As many noted in the stage 1 debate, the legislation intends to amend the Universities (Scotland) Act 1966 to remove the provision that prevents the University of St Andrews from awarding degrees in medicine and dentistry. The provision was only ever intended to be a temporary measure and was brought about to give effect to the separation of Queen’s College in Dundee from the University of St Andrews, so that the University of Dundee could be instituted. That purpose has long been served, and now that the University of Dundee is evidently well established as one of Scotland’s leading universities, it is right that Parliament makes this change. It is long overdue.

Given that the first set of ScotGEM’s students are due to complete their studies in 2022, it is only right that they are able to receive their degrees from both the University of St Andrews and the University of Dundee. Indeed, the British Medical Association Scotland has argued that

“for a number of ScotGEM students, this joint award was an important factor in their decision to apply and had it not been on offer, they may have applied to another institution.”

The evidence that the Health and Sport Committee took from Callum George, deputy chair of the BMA Scottish medical students committee, was pertinent in that regard.

It is clear that, with the bill, we are not only rectifying an outdated provision but ensuring that many current ScotGEM students are able to be recognised as graduates of both institutions. We are also recognising the importance of the work of both institutions.

It is important that the concerns about a full repeal, rather than a partial repeal, that the University of Dundee has highlighted are acknowledged. However, on balance, we agree with the cabinet secretary that the University of St Andrews should be able to competitively offer similar degree programmes.

We also believe that the issue should be viewed through the prism of increasing the overall number of student medical places in Scottish universities so that we can address the longer-term issues of general practitioner vacancies. We know that the current data shows that the number of GPs aged over 60 and approaching retirement is at a 10-year high.

More broadly, we believe that the Scottish National Party Government has to increase student medical places. Specifically, we hope that the bill will make the ScotGEM course even more attractive to prospective students. Given the emphasis on improving recruitment and retention in healthcare settings in rural communities, it should be the long-term ambition of any future Scottish Government to fund an increase in ScotGEM places to address the clear issues in rural recruitment.

The Scottish Conservatives support the bill. We believe that now is the right time to make the change, and we agree with others that it will be positive for students and for both universities. However, beyond the bill, we must continue to resolve the evident challenges—both short term and long term—that our NHS faces. They can be remedied only by fixing the workforce crisis and ensuring that our healthcare services can manage growing demand into the future.

15:31  

I, too, pay tribute to Jeane Freeman, given that this is the last time that she will speak in a debate in the Parliament. I am not sure that she has always welcomed my questions and interventions on the health portfolio, but I have never been in any doubt about her seriousness and earnestness in discharging her duties or about her focus on the progress in our health service that she has sought to make. She has been a thorough and an effective minister. In particular, I thank her for her very constructive direct engagement with me on attention deficit hyperactivity disorder diagnosis and treatment pathways. My only regret is that the pandemic got in the way of our seeing more immediate progress on that matter. However, I genuinely thank her for that engagement.

I turn to the University of St Andrews (Degrees in Medicine and Dentistry) Bill. I, too, am pleased to support the motion and the measure. I will try very hard not to repeat what I said in the stage 1 debate or what other members have said. It is a measure of the unanimity on the proposal that that will be somewhat of a struggle.

As Donald Cameron and the cabinet secretary have pointed out, the bill essentially seeks to address an anomaly that was created in the legislation that created the University of Dundee. That anomaly was supposed to be only temporary, but it has lasted for 50 years. The anomaly could be viewed as temporary, given that the University of St Andrews has existed for 600 years; nonetheless, it is time to remove it. No other institution has such a proscription on the granting of degrees for particular subject areas.

More important, the University of St Andrews demonstrates its ability not just in medical education but in innovation. We see both elements quite strongly in the ScotGEM programme that it has been instrumental in delivering. The bill is important in encouraging its future endeavours in that regard.

It is important to highlight the innovation in the programme. The University of St Andrews is a small university; indeed, it is among our smallest. Its location is remote, so it is perhaps unlikely for it to have the innovative outlook that it undoubtedly has. It is a research powerhouse, and the programme has been at the forefront of medical education.

The programme encourages graduates to retrain in medicine and, as I highlighted in the stage 1 debate, it is undoubtedly a valuable source of medics. People who have life experience have much to offer, and a programme such as ScotGEM will provide a valuable source of doctors for the future.

St Andrews has had to deliver its medical education in a compromised way. It has not been able to provide the clinical years of education that are required, so its students have gone to Manchester and other places for that. We lose those doctors, and Scotland cannot afford to lose doctors. We need more doctors, and we need more doctors in general practice. The programme will be very good and effective at meeting both those needs.

The ScotGEM programme focuses on community medicine in rural areas. As many as 35 per cent of the students who study the course come from a rural background. Likewise, the programme has a good track record in broadening access by recruiting students from less wealthy and less affluent backgrounds. Recruiting students with those backgrounds is to be encouraged.

We cannot ignore the context in which we find ourselves. We are in the middle of a pandemic and our health service is being stretched like it has never been stretched since its inception. We need to ensure that we have people with the training and skills to work at the front line of our health service. Therefore, we need new ways into medicine and nursing, and we need to harness and embrace all the talents and skills that we have. We need programmes such as the ScotGEM programme that is offered by the universities of St Andrews and Dundee. Giving St Andrews the ability to award medical and dentistry degrees is an important step in reinforcing those efforts, even as we recognise the role that St Andrews already plays in training medics for the future.

15:36  

I join others in paying tribute to the service of Jeane Freeman. She has been a responsive and effective minister, and she has put in quite a shift through the pandemic. She deserves a good retirement.

The legislation will remove a unique, unnecessary and unintentional prohibition—that on granting degrees in medicine by St Andrews university. Despite the restrictions, the university has worked hard to make a contribution to the NHS, through its bachelor of science in medicine qualification, through which students can transfer to other universities to graduate as doctors. As we have heard, more recently it established a medicine degree programme in partnership with the University of Dundee, from which it had separated in 1966—the event that created the need for the bill.

We know that the ScotGEM degree is designed for students who have already graduated in other subjects. It is an effective route into medicine. It focuses on primary care and on remote and rural medicine, and it is founded on community-based learning. The return to a level playing field will allow St Andrews university to contribute fully to patient care by graduating doctors and awarding degrees in an unfettered way; by retaining students in Scotland; by participating equally with other universities in medical research; by sponsoring important clinical trials; and by deepening its relationship with the NHS.

The university plays it part in Scottish life. Take the pandemic. Along with university staff, ScotGEM students have been involved in vaccination roll-out and have helped to match student volunteers with front-line workers who are in need of support. Some university medicine staff have been integral to the management of the response by Public Health Scotland and the Scottish Government.

However, that engagement is deeper and longer. As part of ScotGEM, the university has employed 37 general clinical mentors across four health boards, who provide 47 clinical sessions per week to general practice, at a time when we know that recruitment is particularly challenging. The success of the ScotGEM programme model has been recognised by NHS Education Scotland, which gave the GCM team the award of “Highly Commended” at its medical directorate awards.

The university works closely with the University of the Highlands and Islands in delivering the medicine programme. Students are currently placed in 72 general practices.

There is an optional bursary for students who choose to bond to NHS Scotland by committing to a period of one year’s service for each year for which the bursary is taken, up to a maximum of four years, and 94 per cent of students take up the bursary, which shows the commitment to Scotland of the university and the students. The ScotGEM programme illustrates that they have been bucking the trend and that it has been widening access. There are more applicants from remote and rural areas and 28 per cent of entrants to ScotGEM lived in the Scottish index of multiple deprivation bottom 40 per cent postcode areas. Traditionally, the figure was just 20 per cent. Retention of students in the first few years of the programme is 100 per cent, which is quite incredible.

I have made all those points to show that the University of St Andrews is part of Scotland. It is reaching out to all parts of society and is part of our NHS. Of course, the bill will correct an anomaly from 55 years ago, but more important is that it recognises that the University of St Andrews is committed to Scotland and to what matters.

15:40  

I welcome the opportunity to speak in this short but important stage 3 debate on the University of St Andrews (Degrees in Medicine and Dentistry) Bill. I thank the clerks and everyone else for their work on the bill, as well as committee colleagues and the cabinet secretary and her team. Jeane Freeman has demonstrated complete competence during the current parliamentary session, especially during the pandemic.

The bill, which is technical in nature, will remove the unfair and anticompetitive prohibition that prevents the University of St Andrews from awarding medicine and dentistry degrees. It is the only university in Scotland that has that prohibition. In doing that, the bill will repeal a section of the Universities (Scotland) Act 1966 that prevents the university from offering medicine and dentistry degrees. That is welcome, because it affords the University of St Andrews equality in competition and educational opportunity.

As deputy convener of the Health and Sport Committee, I was involved in scrutiny of the bill at stage 1. The committee produced a short report on the bill that contained only one recommendation, which was that we should overwhelmingly support the general principles of the bill.

During the committee’s discussion of the bill, we also considered evidence on NHS recruitment and widening access to studying medicine. The bill prompted discussion of the potential for a new medical school to be established. The Covid pandemic has prevented work on establishing a new school, so I welcome the cabinet secretary’s commitment on that. I will continue to raise awareness of the work that is being done in Dumfries and Galloway for a new medical school potentially to be sited at the Crichton campus. I ask the cabinet secretary to keep that in mind as we move forward. I am sure that her replacement will continue to work on that. I will continue to engage with Jeane Freeman’s replacement and local campaigners on that.

Our passing the bill will allow the university to award a joint degree with the University of Dundee for the purposes of the ScotGEM programme. It is Scotland’s first graduate entry programme for medicine, with a rural medicine focus, and the first cohort of students is expected to graduate in 2022. If the bill is not passed, their degrees will be awarded by the University of Dundee, despite the important work of the University of St Andrews. The timing of the bill is therefore welcome, because it will enable the University of St Andrews to award the degree jointly with the University of Dundee, as was promised to the ScotGEM students, who are very excited about the joint primary medicine qualification.

The committee heard how passionately ScotGEM students feel about their unique identity as students of both universities; I therefore encourage members to support the bill’s passage. I welcome the bill and its implications for the University of St Andrews and for ScotGEM students, many of whom are currently training across Dumfries and Galloway. I hear that they are doing a great job.

We move to closing speeches.

15:44  

I am pleased to close the debate on behalf of Scottish Labour, and to welcome the anticipated passing of the bill at decision time.

Jeane Freeman has always been a committed cabinet secretary who fights her corner. We will find agreement this afternoon, in her final debate, and I hope that she will take pride from having been part of the ScotGEM programme.

I thank the committee for its work on the bill. Stage 2 was not particularly onerous because no amendments were lodged, which is perhaps a reflection of members’ agreement on the bill’s single simple purpose.

Although the ScotGEM programme is the driver for the bill, it also addresses an anomaly from the 1960s, when the creation of the University of Dundee as a separate institution with a clinical school prevented the University of St Andrews from awarding medicine and dentistry degrees. Although the bill will remove that legal barrier, it will not result in the University of St Andrews being able to award such degrees beyond the ScotGEM programme, at this time.

The 2019 programme for government set out the intention to create a new medical school. The University of St Andrews has submitted a bid in the open competitive commissioning process. Although that process is currently suspended, the bill enables the university to compete in it, so I wish it well. That would place its academic offering on an equal footing with those of all other UK universities. Because it is the only university in Fife, that would also result in the first awards of medicine and dentistry degrees from the kingdom.

However, I appreciate that there are other matters to consider that were raised during scrutiny of the bill, and that further issues including widening access, NHS recruitment and the potential impact on the north-east must also be examined. Those issues reflect the views of Aberdeenshire health and social care partnership and the University of Dundee, both of which have expressed a preference for partial removal of the prohibition. The University of Dundee has also expressed concerns about training capacity for its students, if St Andrews were to start awarding medicine degrees, and its ability to place students in local hospitals. Those concerns are about capacity and competition in a shared geographic area with limited opportunities, so they must be resolved.

Although the purpose behind the bill is delivery of the ScotGEM programme, it will open up other opportunities for the University of St Andrews. On balance, I agree that it is appropriate that the bill will achieve that broader purpose.

I welcome the ScotGEM programme, which is innovative and is the first of its kind in the United Kingdom. I hope that it will be successful in increasing our GP workforce and could be considered for other institutions. I wish the first cohort of students, who will graduate in 2022, all the best in their future careers.

I also support the financial incentive for a commitment to NHS services. It would be interesting to know whether it is attractive to students, and to know how many of the 55 current students have taken up that offer. Retention of graduates is an issue. If this model is successful in securing commitment to the NHS, it could be considered for other professions in which we experience shortages.

We compete internationally for healthcare staff as well as for other key workers. It is also unclear what the impact of the new immigration system will be, but it will certainly have an effect on the number of European Union workers who will be able to transition seamlessly into working in the UK. We need to find ways of securing our workforce.

The challenges that health boards and integration joint boards face in recruiting and retaining GP and primary care staff are well known. In my region there has been a steady flow of retirals and resignations, and in some cases it is proving to be very difficult to replace the GP workforce. In Fife, a number of general practices operate closed lists, and some have now come under the direct control of NHS Fife. Many practices rely on locum cover and are described as being in a high-risk situation. That has also led to difficulties in delivering out-of-hours services in local hospitals, and to the recent closure of a palliative care ward because a responsible medical officer could not be identified. The impact of a shortage of GPs is therefore being felt in areas other than primary care.

Although the ScotGEM programme will not resolve all those issues, it is a positive intervention. As a member for Mid-Scotland and Fife, I am pleased to have seen the development of the course. Its focus on rural medicine and healthcare improvement is welcome. It also seeks to focus on acute care issues. I hope that, as more cohorts come through the course, the benefits can be realised across the whole of Scotland.

15:48  

I am delighted to close the debate on behalf of the Scottish Conservatives. In truth, the bill simply corrects an anomaly in the further education system, as has been the consensus among members from across the chamber who have spoken in the debate. The bill’s aim is to remove a legislative prohibition that prevents the University of St Andrews from holding qualifying examinations and awarding degrees in medicine and dentistry. The reason for taking action at this time is to allow the University of St Andrews, jointly with the University of Dundee, to award undergraduate UK primary medical qualifications to Scottish graduate entry medicine students. The first set of students is due to complete the four-year course and graduate in 2022.

As was indicated earlier, that prohibition is unfair and anti-competitive, and it no longer serves a purpose. In removing the prohibition, the bill therefore creates a fairer higher education sector, enabling all of Scotland’s institutions to maximise the options and opportunities that they offer to students.

The importance of the bill can be appreciated against the well-documented background of Scotland generally being short of clinicians: we are well over 800 GPs short, and Audit Scotland highlighted to the Health and Sport Committee that the plans put forward by the Scottish Government will still leave a significant shortfall of some 650 GPs at the end of the programme. Any step that allows for an increase in the number of those attaining a medical qualification must be welcome.

There was widespread general support for the repeal of the prohibition among the written submissions and oral evidence that were given to the committee, and one of the main reasons for that support was that the bill will bring the University of St Andrews school of medicine into line with other medical schools in Scotland, allowing the university to award the ScotGEM primary medical qualification—PMQ—jointly with the University of Dundee.

It was argued that students who enrolled on the ScotGEM programme of study were given a clear expectation that their degree would be jointly awarded by the universities of St Andrews and Dundee. For a number of students, that joint award was an important factor in their decision to apply, and it was a matter of fairness to ScotGEM students that they should receive that joint degree. The written submission from ScotGEM highlighted that the vast majority of students who responded to the survey were strongly supportive of obtaining that joint degree.

The University of Dundee supported the prohibition being removed only partially, for the purpose of ScotGEM, and remaining in place for all other degree-awarding purposes. That was on the basis that there could potentially be adverse unintended consequences to the education and training environment in Scotland. The Scottish Conservatives are supportive of the ScotGEM programme, however, and we also support the removal of the prohibition to allow the University of St Andrews to award degrees in medicine and dentistry. We recognise that the prohibition is unfair and that it was not intended to remain permanently in place. For that reason, only a partial removal of the prohibition would not be appropriate.

There was an issue of whether the University of St Andrews will compete to establish the new medical school, but that is not provided for in the bill and would not require additional legislative changes. Although discussions around proposals for that new medical school have been postponed, we think it prudent that, when they are resumed, they take into consideration the wider evidence heard by the Health and Sport Committee during scrutiny of the bill on NHS recruitment and widening access to medicine.

I thank fellow members of the Health and Sport Committee, especially those who are not returning to the Parliament, for all their work. It has been an honour to work with them under your stewardship, Presiding Officer. I also add my tribute to the cabinet secretary, Jeane Freeman, for whom I have the greatest respect. We have sat in opposition and have debated many times, but always with respect and courtesy. I wish her well.

15:53  

I will start by thanking colleagues across the chamber and those who are joining us remotely for their very kind words, which are much appreciated.

Members have made a number of important points in this relatively short debate—it has been a short debate because we are in agreement about the importance of passing the bill—and I will address a couple of those points before I make some more.

Some 94 per cent of ScotGEM students have taken the bursary. One of the innovations of the ScotGEM programme is that testing out of the offer of a bursary in return for a commitment to work with the health service in Scotland, should the student graduate. That is a really important innovation, and it has proved to be effective and to work. For a future Government, it is an innovation to which great attention should be paid if we are serious not only about widening access to higher and further education and to healthcare but about attracting more individuals to healthcare.

I have taken note of the concern that was raised primarily by the University of Dundee—although the Aberdeenshire health and social care partnership raised it, too, to some extent—at the various stages of the bill’s consideration, as has been mentioned, about the possibility of additional medical school opportunities increasing the number of medical undergraduates and the impact that that might have on training, placements and so on.

The one thing that I would say about that—and I think we are all agreed on this—is that we need an increase in medical undergraduate places, and the Government has brought that into being. There is an argument that we will need more of those places just as we may need more training places for roles in other areas of healthcare, such as nurses, allied health professionals and so on. Actually, it does not matter where we put those. If we have more places, we will still have to work through issues around clinical placement opportunities and so on.

I, too, pay a personal tribute to Jeane Freeman, whom I have always found to be responsive to any questions that I have had.

Does the cabinet secretary agree that the issue is not just about additional places but is also about increasing the diversity of opportunity for youngsters? Does she agree that one of the reasons why this is such an important bill is that it adds to that diversity, particularly in times of changing healthcare?

I absolutely agree. I think that, regardless of whether a future Government takes forward what was in this Government’s programme for government about a new medical school, there is a need to increase opportunities across our training services for all healthcare roles, to varying degrees, and, in doing so, to widen access and address some of the issues around equity.

ScotGEM is important because, apart from bringing an opportunity to ensure that there is a focus on remote and rural medicine and on general practice, it is an innovative approach that brings in graduates and delivers training in new ways, with new opportunities; that brings front-line expertise and experience into the learning; that offers new ways of designing the curriculum and harnessing practical front-line experience as part of student learning; and that does all of that while not compromising by one whit either quality or standards. I think that there is a lot in the design, the delivery and—so far—the success of ScotGEM to provide us with examples that we can learn from in other areas of medical undergraduate and postgraduate training, as well as other training and curriculum opportunities.

As colleagues have said, this is a short, technical bill, but, as I said before, we should not underestimate its importance. Members have mentioned a number of reasons why it is important, but, for me, at its core, the bill is about correcting what, by its longevity, became an injustice. Although that injustice affects an institution, in truth, it affects all of us and those we are here to represent, especially young people in relation to the richness and diversity of opportunities that we can offer them.

I am pleased that the bill has widespread support across the chamber, because it is important. In some of the areas that it seeks to address and in some of the examples that members have given, I think that it offers important pointers and learning to a future Government about how we might advance not only the number of people we bring into our health service but how we do that and how we incentivise them to repay the investment in their education and training by continuing to work for our quite marvellous NHS Scotland.

That concludes the debate on the University of St Andrews (Degrees in Medicine and Dentistry) Bill.