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Chamber and committees

Meeting date: Thursday, December 13, 2018

Meeting of the Parliament 13 December 2018

Agenda: General Question Time, First Minister’s Question Time, General Practitioner Out-of-hours Facility (St Andrews), UK Withdrawal from the European Union (Legal Continuity) (Scotland) Bill (United Kingdom Supreme Court Judgment), Demonstrating Leadership in Human Rights, Pow of Inchaffray Drainage Commission (Scotland) Bill: Final Stage, Pow of Inchaffray Drainage Commission (Scotland) Bill, Parliamentary Bureau Motions, Decision Time


General Practitioner Out-of-hours Facility (St Andrews)

The Deputy Presiding Officer (Christine Grahame)

I ask those members of the public who are leaving to do so quietly—silently, preferably—as I want to move on to the next item of business, because time is tight today.

The next item of business is a members’ business debate on motion S5M-15013, in the name of Willie Rennie, on the St Andrews general practitioner out-of-hours facility. The debate will be concluded without any question being put.

Motion debated,

That the Parliament notes the proposal by the Fife Health and Social Care Partnership to close the GP out-of-hours facility in St Andrews; further notes the reported criticism from the community regarding the consultation process; understands there has nonetheless been a large response to the consultation from people in east Fife, and that over 6,000 have signed a petition and more than 2,000 have submitted objection postcards; believes that the Dundee Kings Cross out-of-hours facility is often at capacity and consequently finds it difficult to accept patients from north Fife; understands that there is a large number of students and older people in the east Fife area; believes that GPs from the area are prepared to step up to provide a local service, and notes the calls for the St Andrews’ facility to be retained.


Willie Rennie (North East Fife) (LD)

I am grateful to the members who, in supporting my motion, have made this afternoon’s debate possible. I am also grateful to the Cabinet Secretary for Health and Sport for the interest that she has taken in the issue.

For those members who are not familiar with the situation, I should say that the Fife health and social care partnership’s proposal is to close the primary care emergency service—the general practitioner out-of-hours service—that is based at St Andrews community hospital. That is part of a wider proposal that also affects Glenrothes, where Jenny Gilruth has made a powerful case, and Dunfermline, where Shirley-Anne Somerville has expressed concerns.

The fury in St Andrews and east Fife has been extraordinary. It has inspired lots of people who are unconnected with politics to be active. Penelope Fraser from St Andrews has collected hundreds of names for my petition from right across the area. Students from the University of St Andrews have produced a special video and carried out a protest outside the hospital in Kirkcaldy. Daryl Wilson from Anstruther has produced her own special objection postcard, and more than 2,000 people have sent one to the partnership board. A group of people led by Angela Anderson have submitted a participation request under the Community Empowerment (Scotland) Act 2015. Those are just some examples of people from the community who have stepped up because they are appalled by the proposal.

The response has been overwhelming. The public meetings in Anstruther and St Andrews have been packed—in fact, one of the meetings had to be moved to a bigger venue because so many people had turned up—and 2,300 of the postcards that I mentioned have been signed. The majority of the consultation responses that the partnership received were from people in north-east Fife, and more than 6,500 people signed my petition against the closure.

I believe that the case for retaining the St Andrews facility is strong. St Andrews is a long way from Kirkcaldy, where the nearest centre would be, and some of the rural roads are particularly poor. There are lots of elderly people and young students in east Fife who do not have their own transport, and some of the people who use the facility, including students from all over the world, have special health needs. Kings Cross hospital in Dundee is often too busy to take people from north Fife; that was supposed to be a solution for the Tay Bridgehead area of Fife, but people there will also have to travel to Kirkcaldy in many instances.

Furthermore, the minor injuries unit in St Andrews is run by the primary care emergency service, so if the PCES goes, the minor injuries unit will go, too, which would be a double blow for the community.

The local GPs are prepared to provide a service. In fact, the rota at St Andrews is booked up until Christmas, and it has been for some time. A new service might be different from the one that we have been used to and it might utilise the skills of other health professionals, but a local service is possible and is required. The Lewis Ritchie report highlights the need for a multidisciplinary approach that is person centred, but there is nothing in the Ritchie report that prevents the St Andrews facility from remaining open. Indeed, I would argue that it reinforces the case for that.

There is a shortage of GPs, which is a legacy of poor workforce planning. Of course there are more GPs, but more of them are part time, which means that, in effect, there has been a cut in the number of whole-time equivalents. That is what has created the current problem. There is an issue that needs to be addressed by the Fife health and social care partnership. People in east Fife understand that, but those problems will not be solved by the closure of the St Andrews facility. As I have mentioned, the rota at St Andrews is full until Christmas. There is also no guarantee that the GPs who currently provide that service in north-east Fife would be prepared to make the long journey to Kirkcaldy to support the new service, so, if the change were to go ahead, we would end up with fewer GPs participating in the service as a whole. The recent newspaper report in The Courier on low uptake among GPs of the out-of-hours service related to Dunfermline, not St Andrews. The uptake in St Andrews is healthy, and it would be extraordinarily perverse to penalise north-east Fife for the shortages elsewhere in Fife.

There have been flaws in the consultation process, including impenetrable language, three consultations bundled into one and the ruling out of the St Andrews option from the very beginning. Despite those flaws, the officials in the Fife health and social care partnership have been responsive and sensitive throughout the process. I thank them for their professionalism even though I disagree with their recommendations.

I have heard it said that people in north-east Fife are just whingeing and that they are wealthy, so they can cope. The people who hold those views are small in number but hold senior positions, and my advice to them is to think very carefully. They have responsibilities for the whole of Fife, whether or not they like some parts of it. I was the Westminster member of Parliament for Dunfermline and West Fife before I entered the Scottish Parliament, so I understand the special needs of north-east Fife and other parts of Fife. Those needs should not be ignored.

There is a strong case for retaining the facility in St Andrews. We have the need for it, with students and elderly people. It is a long distance to Kirkcaldy, and those roads are not in good condition. There is a clear demand in north-east Fife, as demonstrated not only by the public meetings but the response to the petition, and GPs are prepared to step up to provide a service. There is a demand, there is a need and GPs are capable of providing that service. There is a way to make the facility happen, and I urge the health secretary to provide her support for it.


Jenny Gilruth (Mid Fife and Glenrothes) (SNP)

I congratulate Willie Rennie on securing today’s members’ business debate. It is not the first time that the issue has been discussed in members’ business. Although the motion focuses on St Andrews, as Willie Rennie mentioned, out-of-hours closures have affected Dunfermline and Glenrothes. For the past 223 days, our constituents have been travelling to the Victoria hospital in Kirkcaldy, which provides one GP out-of-hours service for the third largest local authority in the country.

I spoke to my colleague Stephen Gethins, the MP for North East Fife, ahead of the debate. He told me:

“The Out of Hours service must be retained at St Andrews Community Hospital.

North East Fife is a large rural area with many minor roads and remote communities like the East Neuk. Many parts of North East Fife are a significant distance from Kirkcaldy.

North East Fife has a diverse population including a higher than average elderly population and a large number of students without transport. There are real concerns about having to travel a significant distance when you are unwell”.

I agree with Stephen Gethins.

However, my concerns about the closure relate to the process as acknowledged in the motion. The service fell over almost overnight. That is not usual practice, and I am sure the cabinet secretary would agree that it is not good practice. Fife’s health and social care partnership then decided to consult retrospectively, three months after the closures had begun. It added community health and wellbeing hubs to the consultation, and then community hospital and intermediate care bed redesign—all were in the same consultation.

I know St Andrews very well, and I know my constituency. Issues of rurality in the north-east do not impact on the people whom I serve, but inequality does. Recommendation 7 of the Sir Lewis Ritchie review states:

“Quality and safety implementation and monitoring of OOH services should be assessed for their impact on health inequalities.”

No equality impact assessment took place before the closures on 9 April. I repeatedly asked the local health and social care partnership to share details of the EQIA. That did not materialise until, very quietly, in August, it was retrospectively electronically uploaded.

I encourage all members with an interest in the topic to interrogate the quality of the EQIA in its present form. Question 2 of the EQIA asks for the lead assessor’s name and contact details. The response is left blank. Age and disability are rated as “Medium Relevance”, and race, sexual orientation and religion are rated as “Low Relevance”.

Ahead of the debate, I wrote to the director of Fife’s health and social care partnership, seeking clarity. I asked who, in those categories, the partnership had spoken to. How did it identify risk? When was the work completed? Those questions have not been answered. The EQIA document, which is currently online, states that the process started on 28 March, which is four and a half days before the service apparently fell over. However, if the service had to shut on an emergency basis, how did the partnership have time to start an EQIA? The truth, of course, is that it was not conducted in March, nor was it conducted in April. As the director confirms to me in his letter, the EQIA was not approved until 14 September. It seems to me that Fife’s health and social care partnership started from a position and then worked towards it.

In my view, the consultation was flawed from the outset. Fundamentally, people did not understand what they were being asked about. Three different services were lumped together in a bid, I believe, to deliberately confuse the public. Also, the use of jargon throughout the consultation documents is excessive. The use of phrases such as “Why we need to change” suggests that the exercise was never about seeking the views of Fifers.

St Andrews residents should be commended for their organised and tenacious campaign, but people in my constituency also organised. There were stowed-out public meetings and numerous constituent complaints, all just five years after my predecessor and the former Labour MP organised to fight against the same proposal.

It should also be noted that the partnership did not conduct any transport appraisal, which means that my constituents now have to pay for taxis to access out-of-hours services if they do not have a car. If they cannot afford to pay for a taxi, they need to ask for help to do so. Dignity is at the heart of the Government’s new social security system, but where is the dignity in being forced to plead poverty just to see a doctor?

Today’s motion is focused on St Andrews and, as Stephen Gethins has argued, the best outcome in that regard is that services are retained at St Andrews community hospital. The GPs have pledged their support for retaining out-of-hours services there. However, my constituents face very different problems from those that are faced in nofrth-east Fife. Nearly one in three children in my constituency lives in poverty. In Levenmouth, we have some of the lowest car ownership levels in the country. Benefits cuts have stripped more than £1 million from the communities that I represent. Make no mistake: if the IJB votes on 20 December to permanently close the Glenrothes GP out-of-hours service, it is the poorest who will suffer.

Willie Rennie is right to bring the issue back to the chamber today. The public consultation has been opaque from the outset, and the EQIA is not worth the paper that it is written on. Our constituents deserve better in the 70th year of our national health service. The IJB will take its decision on closing GP out-of-hours services in St Andrews, Glenrothes and Dunfermline in one week’s time. Although that is ultimately a local decision, I would welcome the cabinet secretary’s views on how we can move forward.


Liz Smith (Mid Scotland and Fife) (Con)

I happen to think that this Parliament is at its best when, despite our political differences, we are able to argue forcefully when one particular issue dominates our mailbags, and this is an example of one such issue. A similar passion was evident in the previous debate in the chamber on this matter, and it is only right that we progress in that way, because this is an extremely important issue not only for St Andrews, which is the subject of Willie Rennie’s motion, but for the whole kingdom of Fife.

I thank Willie Rennie for bringing this motion to the Parliament. He has been passionate and assiduous in his advocacy of the case for keeping the St Andrews GP out-of-hours facility open. Members on the Conservative benches are fully supportive of that position.

I also pay tribute to the other members—the SNP members, the Labour members and the Green member—for their contributions to the wider debate. I know that the cabinet secretary is taking a keen interest in the matter. Like Willie Rennie, I urge her to at least put some pressure on the people who are involved in the Fife situation.

This issue is not just about the decision that the integration joint board will take on 20 December; it is about the way in which we make decisions about our local health services. That is part of a bigger picture. I have previously debated with the health secretary the structure of IJBs and the ways in which we can improve local delivery in that regard.

This must be about safe and sustainable levels of staffing. Provision must be equitable and fair across the kingdom of Fife, and we must pay heed to the advice that the clinicians give us. I know that there is a difficult balance to be struck in relation to what was termed an unsafe and unsustainable situation by Michael Kellet, who made the point that there could be improvements in delivery. However, the GPs, particularly in St Andrews, are taking a completely different position. Certainly, that was the strong message that I got at the public meeting that I attended, which was organised in the first instance by Willie Rennie. I think that it is partly because of that strong message that the campaign has had such a considerable uptake in the St Andrews community.

There are therefore a number of factors to consider. Like other members, I have heard comments about how people in St Andrews are relatively wealthy and can cope with what is proposed. Not only is that quite offensive; it is not true. There is a particularly difficult demographic in St Andrews, which has a high number of elderly people, some of whom are not particularly well off, and a large student population, so demands on services there are very different from the demands on services in other parts of Fife.

We are told that one part of the kingdom is directing operations on the matter, but I do not accept that. I think that what is happening in St Andrews is part of a much bigger picture, which we need to look at holistically, in the round. Out-of-hours care is incredibly important for a host of patients, and a town with a large population of students and retirees has a particular demographic; we must be very careful about how we respond to that.

We all know that in a health emergency it is critical that the patient receives treatment within the golden hour, as I think that health professionals call it. Travel to Kirkcaldy, Glenrothes or Dundee will be a difficult option, should the service close down.

The residents of north-east Fife were barely represented in the 2017 options appraisal workshops at which various discussions took place. I agree with Willie Rennie that some of the professionals have been listening, but I am not sure that the process has been particularly helpful to the engagement of the public. Jenny Gilruth was right to talk about the language of the consultation and the direction that it has taken in that regard.

I think that people are coming at the issue from different angles, which is not helping us to find a resolution. I am conscious that the health secretary is aware of that and is being as helpful as possible.

I reiterate my thanks to Willie Rennie and to other members, who have been honest and straightforward on a critical issue that has brought together the constituency and list members.


Claire Baker (Mid Scotland and Fife) (Lab)

I thank Willie Rennie for bringing this debate to the Parliament and for his fair analysis of the situation that we face.

It is not long since many of us were in the chamber to debate the wider closure of out-of-hours services across Fife, in the debate that Jenny Gilruth brought. St Andrews is one of three areas, alongside Glenrothes and Dunfermline, in which out-of-hours services face an extremely uncertain future. I appreciate the particular situation in St Andrews, for the reasons that Willie Rennie set out in his speech, and I welcome the opportunity to highlight it today.

Members of the Scottish Parliament were informed of the closure of the three out-of-hours sites in April. Next week, the IJB will make the decision on their future. The decision to move to contingency measures was made as a result of nursing and medical staffing difficulties, which led to concerns about clinical safety.

As we are on the brink of the decision, it is important to emphasise the consequences. The closure of the three centres was meant to be a temporary contingency measure lasting three months. However, eight months down the line, there is little confidence that the services that we once had will return.

A contingency measure might be regarded as a temporary measure until services resume, with all three out-of-hours services continuing. It is disappointing, then, that the GP situation in Fife has not improved.

I appreciate that the Scottish Government will talk about the new GP contract and the work of the University of St Andrews and the University of Dundee on the Scottish graduate entry medicine programme. Those initiatives are welcome, but there are no guarantees that they will solve the problem of out-of-hours provision. Some areas in Fife are struggling to recruit GPs to work during the day, never mind at night. In other areas, more GPs are moving from full-time to part-time provision.

A quarter of practices in Fife are full. All surgeries in Kirkcaldy, all surgeries in Lochgelly and four out of five surgeries in Dunfermline register a full practice list. Also, at least seven GP practices are experiencing long-term recruitment difficulties, and two are considered to be in a high-risk situation. All that makes the possibility of recruiting sufficient GPs to out-of-hours service work even more challenging.

This week, Information Services Division Scotland released statistics that show a small rise in the number of GPs in Fife since this time last year. However, there are still fewer GPs than there were a decade ago. At the same time, the number of people who register at a practice in Fife is increasing.

Given that Fife has fewer GPs treating more patients, there is bound to be an impact on services, and patients struggling to book appointments at their local surgeries might start heading to accident and emergency—something that out-of-hours GP services are meant to prevent. Other people might decide to ignore their symptoms, powering through until they need more urgent care.

This has the potential to put significant pressure on Victoria hospital in Kirkcaldy, which is currently the only facility in Fife with an out-of-hours service, and—as Willie Rennie highlighted—Dundee’s King’s Cross hospital out-of-hours service is often at full capacity. We need to look at how to alleviate those pressures, not exacerbate them. That is why the decision to close the St Andrews out-of-hours service is all the more perplexing.

I have attended public meetings in the area, including those organised by Willie Rennie, and I have spoken to local residents and the student representatives at the university. I know how valuable the out-of-hours service is and that the alternatives are simply unacceptable and unrealistic. The travel times are too long, the rurality of north-east Fife is challenging, and the demographics of the population demand local healthcare.

St Andrews hospital had a busy out-of-hours service and we are being told that there is a commitment from local GPs to run an out-of-hours service in St Andrews in the interests of their patients. NHS Fife makes the case that it needs to deliver for the whole of Fife and it cannot accept a solution that would serve St Andrews only. I understand its responsibility to do that—it must provide a service for the whole of Fife—but such a service must have flexibility and be able to be tailored.

I want a solution that retains all three out-of-hours services, recognises the importance of local delivery and does not risk exacerbating the health inequalities that Jenny Gilruth highlighted. However, until that can be delivered, we have to be open to alternatives. NHS Fife should be flexible about St Andrews. It has to recognise the needs of its elderly population, its rural nature, its distance from Kirkcaldy, and the student population, which includes a large number of overseas students.

Reopening St Andrews hospital would not take GP resources away from other areas of Fife. A strong case is being put forward to keep the St Andrews service running, and NHS Fife must listen.


Mark Ruskell (Mid Scotland and Fife) (Green)

I add my thanks to Willie Rennie for lodging the motion for debate. Of course, much of what we discussed back in October, in Jenny Gilruth’s members’ business debate, is relevant to the debate today, but it is good to have the opportunity to focus in particular on the situation in St Andrews and north-east Fife.

Liz Smith made the very important point, which I hope the cabinet secretary will reflect on, that there is genuine cross-party concern. We are bringing to the chamber our thoughts and concerns, what we have heard from communities and, I hope, solutions.

Following the emergency closure of their services earlier this year, residents of St Andrews and the east neuk have endured journeys of up to an hour to access primary care overnight and at weekends, with capacity issues at King’s Cross hospital in Dundee only compounding the issue. I have received reports—as, I am sure, many other members have—that patients who have had to take taxis have still not been reimbursed for those long and expensive journeys. I have also heard from students that they are relying on the good will of the university to pay for their travel costs to access the services.

The area has a unique demographic profile, as members have already mentioned. We have a significant ageing population living alongside a growing student population, which brings its own specific healthcare challenges. Young and transient populations are more vulnerable to sudden contagion incidents—not just the notorious freshers flu, but serious and sometimes life-threatening illnesses including mumps and meningitis, which require swift medical responses.

The unique demographic profile, however, also makes St Andrews an ideal place to trial new and enhanced ways to deliver out-of-hours primary care, using a mixed multidisciplinary team of advanced nurse practitioners, paramedics and pharmacists, as was recommended in the 2015 Ritchie review of primary care out-of-hours services. I have been calling for an assessment of that option for some time now. I remind colleagues that it does not have to be an all-or-nothing scenario; we could have a model that retains the important services in the communities. We can recognise the need for change, but at the same time retain a level of primary care locally by joining up with a remote working GP and an urgent care team based at the Victoria hospital.

It is clear that the consultation on the proposals has been wholly inadequate, especially given that the formal consultation began with the assumption that the services in St Andrews would close. I recognise that the initial closure earlier this year was made in emergency circumstances, but I have heard from GPs in Fife who say that they were not consulted before the closure, and were not aware of the extent of the staff crisis in out-of-hours services.

I commend the work of the royal burgh of St Andrews community council, which has sought to ensure that local people are represented better in the decision-making process through a formal participation process, and I urge the integration joint board to grant that request ahead of next week’s decisive meeting.

However, the issue is linked with the wider GP crisis that we face in Fife and across Scotland. The number of GPs in Fife has fallen since 2008, while the patient list has increased by nearly 11,000. Eighteen surgeries have stopped accepting new patients, and seven are struggling to recruit the GPs that they need to deliver a basic primary care service. When local doctors are under such immense pressure during normal surgery times, it is entirely understandable that the out-of-hours service has reached crisis point. I will be grateful to hear from the cabinet secretary in her closing speech about what is being done to address the overall GP crisis, and how the Scottish Government is planning to deliver more GPs for Fife.

I look forward to hearing the outcome of next Thursday’s IJB meeting, and I hope that the board fulfils its duty to consider all options, to consult the community properly and to ensure that it is providing the best possible care in the communities, using the full range of medical practitioners at its disposal.


Alexander Stewart (Mid Scotland and Fife) (Con)

I welcome the opportunity to take part in the debate, and I congratulate Willie Rennie on having secured it.

Here we are again, having to comment, condemn and debate yet another ill-thought-through proposal by Fife health and social care partnership on GP out-of-hours facilities in St Andrews. We have already heard that the primary care emergency services at hospitals in Glenrothes, Dunfermline and St Andrews have all faced difficulties in the past few months, since they experienced shortages back in April. The area has a large number of students, who depend on those facilities, and it also has an ageing population. That population deserves more—it deserves better facilities than it has at present.

I would also like to comment on wider effects. I lodged a motion back in April discussing and condemning Fife health and social care partnership for what it was doing. The consultation process, which was widely criticised across the community—rightly so—was completely and utterly unacceptable. We have already heard that 6,000 people have signed a petition and that more than 2,000 have submitted objection postcards. I sincerely hope that the IJB takes notice of that, although it does not appear to be doing so. We have all attended meetings across the region and communicated with the IJB, but it seems to be stuck in its ways about what it wants to achieve. As others have said, we seem to be moving towards the goal of achieving what the IJB has on paper, not what the community needs and deserves.

The whole idea was supposed to be a contingency measure to sort out the situation and deal with problems in the region. That has not happened. We seem simply to have gone through an exercise and the community feels very let down by that process. We have heard that the out-of-hours facility at King’s Cross hospital in Dundee is often at capacity, which means that there are difficulties in ensuring that people from north Fife can be looked after and supported. Otherwise, they have to go to Kirkcaldy, and we have already heard about the long distances and the difficulties that that causes.

It was only last week that GPs in the area talked about what they could do to provide a local service, and what they might be able to support. That should be taken on board but, once again, the IJB seems to be very blinkered in its attitude to the consultation. I very much hope that it will hear the views of local people that have been highlighted, and that it will look towards reinstating those vital services. I share the deep disappointment that Fife health and social care partnership seems to have a lack of respect for the community that it is supposed to represent.

We know that the previous Cabinet Secretary for Health and Sport kicked things into the long grass; that was how things were managed. I hope that the new cabinet secretary will look upon this situation and see it as urgent. As she has heard, constituency and list members from across the chamber really understand the problem; I think that she is beginning to understand it, as well.

We have a massive problem and a major concern. We have already heard acknowledgement that Fife is facing a recruitment and retention issue, so what do we have to do? We need to do more.

Alex Rowley (Mid Scotland and Fife) (Lab)

We are aware, as Claire Baker has highlighted, that the shortage of GPs in Fife is critical, and the cabinet secretary needs to look at that. Does Alexander Stewart also understand that the Fife health and social care partnership has continued to overspend its budget? I am told that its overspend may currently be running at about £8 million. Does he think that there is a financial issue that needs to be addressed, as well?

Alexander Stewart

I acknowledge that there are priority issues with the IJB, which needs to take on board what it has and what it is doing for the communities that it represents, so I very much agree with Mr Rowley on that.

As we have already heard, St Andrews is a growing location, and other areas across the region, including Glenrothes and Dunfermline, all need support mechanisms to be put in place to ensure that the public are being looked after. The situation continues to be a cause of concern, and individuals across the region have the opportunity to ensure that the necessary changes take place.

We must do all that we can to continue. Patients’ lives are at risk and the Government and the health and social care partnership have a duty of care and a responsibility to protect individuals in the region, so they must act now.


The Cabinet Secretary for Health and Sport (Jeane Freeman)

Like my colleagues, I thank Willie Rennie for bringing this matter to the chamber and I thank all the members who have contributed so far. I also thank Mr Rennie for his recognition of the professionalism of the health and social care officials and the way in which they have handled the situation, as well as his recognition that what may need to be delivered to meet the needs of citizens in Fife—not just in north-east Fife but across Fife—is not necessarily what has been in place until now. That is a welcome recognition of the fact that, as we move delivery of our health and social care services forward, what has aye been is perhaps no longer the right service to offer people.

Access to urgent primary medical services outside normal GP surgery opening hours is a fundamental part of unscheduled care in Scotland. Around 4,500 patients are seen every month by the Fife out-of-hours service, with around 20 patients being seen between midnight and 8 am every week.

The reason why we have a difficulty with GP shortages in out-of-hours services comes in part from the 2004 contract that GPs signed, which allowed them to opt out of working in the out-of-hours setting. Many of our GPs, as they approach retirement, are using that to opt out of out-of-hours services. Many have retired, and new entrants to general practice have, in the main, chosen not to work out of hours.

One thing that we have touched on in this chamber before is the new GP contract, which reflects one important element—and there are many—in Sir Lewis Ritchie’s review of out-of-hours services and care: that out-of-hours services require GP involvement. As well as introducing the important multidisciplinary team, the new GP contract brings GPs into general practice on the basis of a recognition that they are required to contribute to out-of-hours services.

In Fife, the health and social care partnership has taken a number of steps to improve sustainability and resilience. It has introduced new pay scales for GPs, to encourage the uptake of shifts as the norm, and that has steadied the service to some degree. It has moved ahead with the advanced nurse practitioner training programme, training band 5 nurses up to become band 7 advanced nurse practitioners.

Using the out-of-hours funding, the partnership has recruited a further three advanced nurse practitioners to work alongside GPs, and it has a paediatric advanced nurse practitioner. The partnership is also considering the prospect of introducing a salaried GP service as part of the overall GP provision. Tayside has successfully introduced a 65:35 salaried to sessional GP ratio, and the Fife partnership is working with Tayside to see what lessons it can learn. The partnership has also taken on a new GP clinical lead and is considering introducing a GP on-call service, which would involve GPs offering clinical advice at home.

I absolutely understand the concerns that members have expressed and the concerns of people in Fife about the current situation. I do not believe that the consultation was undertaken in such a manner in a deliberate attempt to obfuscate and make it difficult for people to be involved. However, I understand why that is the perception. The issues of out-of-hours services, intermediate care and how we configure primary care and deal with unscheduled care are not unrelated, and it makes sense to look at them in the round. However, with hindsight, we can see that because of the manner in which the consultation was undertaken—coming as it did on the back of the need to reduce out-of-hours services for reasons of clinical safety—it almost inevitably produced some of the serious perceptions that people have. I think that the chief officer in Fife and others recognise that difficulty. They recognise that, although they undertook a number of meetings, effective consultation and engagement are not just about the number of meetings; they are about how easy it is for people to participate.

Liz Smith

Will the cabinet secretary take an intervention?

Jeane Freeman

I will take the member in a second but, before I go any further, I have to say that I am not singling out Fife in that regard. That is an issue across our health service and our health and social care service. I am not being unfairly critical of people, because I think that folks do that work with the best of intentions, but we need to be smarter in understanding how it feels to be asked to participate so that we can make that engagement as genuinely productive as possible. I am looking at that issue overall, across the service.

Liz Smith

The cabinet secretary has just made some perceptive comments, and she is right that the issue applies across the country and not just in Fife. Does she acknowledge that some of the language that Jenny Gilruth referred to made it all the more difficult for members of the public to understand what was going on? Perhaps that could be considered in future discussions about changes that have to be made.

Jeane Freeman

That is absolutely correct. It is a widespread issue that has been with us for a while. It is about language and how we run consultation events. We need to involve local people in a way that is genuinely meaningful, so that they can have a say. We have to be straight with them that, actually, their having a say does not necessarily mean that we will decide to do what they want us to do, but that we will come back and explain why not. There are examples of that being done very well and examples of it not being done very well.

Ms Gilruth has raised serious issues about when the equality impact assessment was done and so on. I take the issue very seriously. I am sure that Mr Stewart has noticed that at least two members of the health team are quite short, shall we say. Long grass is not particularly attractive to me, because I would disappear inside it—I am not a fan of it. We need to try to move ahead. Notwithstanding the important points about the equality impact assessment and the transport impact assessment, the health and social care partnership undertook the process in a manner that complies with the requirements. It did the options appraisal involving members of the public, produced a consultation document and ran a number of meetings. Therefore, we should not be overly critical of the approach that it took, although we might have positive suggestions to make to it and others about the language that is used and some of the critical elements that need to be put in place.

There is now, of course, a request from St Andrews under the Community Empowerment (Scotland) Act 2015 to have recognition and participation, which was entirely within people’s rights to make, and I believe that there has been a request from Glenrothes, too. The St Andrews request was not put to the IJB; it was put, quite rightly, to NHS Fife. NHS Fife needs to look at that and consider it. It has already responded and asked for additional information. In my mind, all of that means that the IJB will not be in a position to make a decision next week, because NHS Fife has to hear, deal with and make a determination on that request in a proper and appropriate manner, without taking too long to do that.

It is also important that the discussions that have begun—I think that there have been three so far—with the GPs in St Andrews continue. As I understand it, the initial proposition from those GPs was not accepted on the basis of clinical advice. Therefore, clinicians are disagreeing with clinicians. That is not unusual; it happens. They need to work that through, because both parties genuinely want to find a resolution that is appropriate for north-east Fife.

I take Willie Rennie’s point about how accessible the service in Tayside is in practice. I welcome the fact that the University of St Andrews has acted to produce additional health facilities for students, but they do not provide out-of-hours cover, of course.

A number of issues are being moved on. I have outlined some of the remedial actions, and there are continuing discussions with GPs in north-east Fife. There is now the requirement to treat appropriately and seriously the two requests that have been received under the Community Empowerment (Scotland) Act 2015.

Willie Rennie rose—

The Deputy Presiding Officer

We are running out of time, so the exchange has to be about one minute.

Willie Rennie

I welcome the fact that the cabinet secretary has indicated that the partnership will not be in a position to make a decision next week and that further discussions can take place. That is a great opportunity, because there is a willingness to try to find a solution that works. If that is the case, that is very welcome news in east Fife. I hope that the partnership is listening to the minister’s advice.

Jeane Freeman

I was informed of the request from St Andrews only very recently. I read the letter that was received and I understand that, as of this morning, Glenrothes area residents forum, I think, made a similar request. My understanding and my reading of the letter that has gone back from NHS Fife to St Andrews is that an exchange of information needs to take place. NHS Fife needs to consider matters and look at what Glenrothes is saying to it, too. That all indicates to me that it is not possible to make a decision in a week’s time. I will discuss further with the chief officer of Fife health and social care partnership what needs to be done and what the times might be.

I remind members that, for people who have to travel for the existing provision, the out-of-hours service will offer a home visit if travel is not possible. We should ensure that residents understand that.

Finally, I assure members who have taken part in the debate and others that I will continue to keep a very close eye on the matter in order to ensure that, within the available resource for the challenges that are to be met, we reach a resolution that genuinely meets the needs of residents in north-east Fife and Fife as a whole for adequate out-of-hours services.

13:34 Meeting suspended.  


14:00 On resuming—