Meeting of the Parliament

Meeting date: Wednesday, April 24, 2019

Official Report 1201KB pdf

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General Practitioner Recruitment and Retention

The next item of business is a debate on motion S5M-17011, in the name of Alison Johnstone, on addressing Scotland’s general practitioner recruitment and retention challenges.

15:37  

Nobody in the chamber would deny that Scotland’s GPs are facing considerable pressures. Those pressures impact practitioner wellbeing and also have huge ramifications for the recruitment and retention of GPs.

The results of a survey that was commissioned by the Royal College of General Practitioners in 2018 revealed that more than a quarter of GPs in Scotland are unlikely to be working in general practice in five years’ time. Of those who reported being likely to leave general practice in the next five years, one in three said that that was because it was too stressful. Those figures are a stark warning that Scotland’s GP workforce is teetering on a cliff edge.

I recognise that the Scottish Government has taken steps to tackle low recruitment, by introducing the new GP contract and through initiatives such as the Scottish graduate entry medicine programme—or ScotGEM—and by increasing training places. I applaud those efforts, but retention must be addressed urgently. We must take care of those who are already on the front line, or we might struggle to retain our workforce.

The chair of the British Medical Association’s Scottish general practitioners committee, Dr Andrew Buist, said that the contract was aimed at making general practice more attractive, but noted:

“Of course, these deep-seated problems—such as there simply not being enough GPs—were never going to be solved in a single year.”

That poses the question of how we can make things better for GPs while changes are being implemented. I acknowledge that the expansion of practice teams is a means of lessening the GP workload, as other health professionals will now deliver aspects of patient care that were previously the responsibility of GPs, such as vaccinations and pharmacotherapy. However, it will take time to grow and develop those teams.

Extra strain is placed on GPs when patients are not informed of changes. I have previously mentioned in the chamber that 35 per cent of GPs surveyed by the RCGP spent consultation time explaining to patients why they were offered appointments with other healthcare professionals instead of with a GP. That places strain on GPs and patients, who are becoming distressed, confused and, at times, angry, as GPs have reported. I urge the Scottish Government to hold a national conversation on changes to services to relieve the burden on practice teams to deliver that message. That must be an urgent priority for the Government. I am happy to work with the cabinet secretary on the form that any such information campaign might take.

The GP contract acknowledges that speed is not the only aspect of access that matters to people, and that being able to see a practitioner of choice also matters to some groups. Therefore, it is extremely important that patients are still able to see a GP when they need to, and that the workforce is in place to enable that to happen. However, the same RCGP survey showed that, of those who were likely to be working in general practice in one year, 20 per cent expected to work reduced hours. That represents a culture change within general practice. There has been a continued decrease in the proportion of GPs working eight or more sessions per week, from 51 per cent in 2013 to 37 per cent in 2017. Given the stressful working conditions that have already been mentioned and the fact that GPs frequently report that they work 12-hour or more days, that culture change is understandable, but until an appropriate workforce is in place to support that change, patients might find that they wait longer and longer to see a doctor. It is significant that the 2017-18 health and care experience survey showed that 67 per cent of respondents highly rated the arrangements to see a doctor, compared to 81 per cent in the 2009-10 survey.

The Scottish Government has pledged to provide an extra 800 GPs over the next 10 years. I welcome that commitment, but that figure refers only to head count. The RCGP estimates that Scotland will be short of 856 whole-time equivalent GPs by 2021, so the Government’s pledge falls short of what is needed, so I urge the cabinet secretary to introduce more ambitious recruitment targets in line with the Royal College’s recommendations.

The Royal College also says that there is a serious funding deficit for general practice. General practice carries out the vast majority of patient contact within the national health service. Given that Scotland has an ageing population and that GPs are seeing patients with increasingly complex health conditions, it is perhaps surprising that the RCGP’s latest figures show that general practice receives just 7.35 per cent of Scottish NHS funding, falling well behind the average funding of general practice in the United Kingdom, which currently stands at 8.8 per cent. The RCGP, supported by the BMA, has consistently called for general practice to receive 11 per cent of the NHS budget. That would represent approximately a 1 per cent rise every year for three years.

The “National Health and Social Care Workforce Plan” states that

“the primary care workforce is uniquely placed to influence the level of demand for other care settings”

and lists cost-effectiveness as one of the many benefits of strengthening primary care.

Investment in general practice is therefore an investment in Scotland’s entire healthcare system. Investing in general practice is investing in preventative measures. Lack of access to primary care often results in patients seeking assistance at hospitals. A better-equipped, well-funded general practice would relieve some of the strain on busy accident and emergency departments and beyond.

One of the aims of health and social care integration is to shift care towards preventative and community-based services. Why, then, is proportional investment in general practice consistently below what is needed? The Royal College says that such an investment would result in an increased GP workforce, modernised, fit-for-purpose surgeries, widened access to training and improved information technology systems. Those are the resources that are needed to support integration and for GPs to continue to deliver the very best standards of care for patients in Scotland.

Funding must also be targeted to tackle health inequalities. Scotland still has among the lowest life expectancies in western Europe, and GPs have expressed concern that no extra funding has been allocated to those practices that serve the most deprived populations in Scotland. Affluent practices with the most elderly patients continue to receive the highest GP funding per patient per annum. The RCGP has called for additional GP clinical capacity, with appropriate funding, for areas of high deprivation, in recognition of the specific workload that is associated with socioeconomic deprivation and in order for community link workers to be prioritised for practices in those areas of high deprivation.

Will Alison Johnstone recognise, as the BMA does, that, with regard to how the funding is allocated, the new contract is weighted towards areas of social deprivation and those practices that care in particular for the elderly?

Ms Johnstone, please move towards closing.

I appreciate that every member of Scotland’s population has an entitlement to the very best of care, but the cabinet secretary will be aware, and I am sure that the debate will emphasise, that there are still concerns around particular areas of the contract. That concern has been expressed to me by GPs.

In conclusion, Presiding Officer, with proper funding and a bolstered workforce, general practice can make significant strides in tackling health inequalities, lessening the strain on other NHS services and continuing to provide excellent care to Scotland’s population.

I move,

That the Parliament recognises that Scotland is facing considerable challenges in recruiting and retaining GPs, with almost a quarter of GP practices reporting vacancies, leading to temporary and permanent surgery closures; notes that the number of whole time equivalent (WTE) GPs has been declining, from 3,735 in 2013 to 3,575 in 2017; agrees that WTE is a more appropriate measure than headcount in fully appreciating the recruitment and retention challenge; is concerned by warnings from the Royal College of General Practitioners (RCGP) that there will be a predicted shortfall of 856 WTE GPs in Scotland by 2021 at the same time as demand on Scotland’s healthcare system is growing; agrees that health and social care integration cannot be delivered without adequate resources and capacity in community services; welcomes Scottish Government action to improve recruitment and retention of GPs but agrees that more urgent progress is required; notes that general practice carries out the majority of patient contact in Scotland yet has received a declining share of the total NHS Scotland budget since 2005-06; notes RCGP’s call, supported by the BMA, for general practice to receive 11% of the total health budget, and calls on the Scottish Government, given the importance of general practice to tackling health inequalities and improving the health of people in Scotland, to undertake an urgent review of GP recruitment, resources and funding.

15:45  

I am grateful for the opportunity to talk about the significant progress that is being made to reform primary care and general practice and to acknowledge the challenges that we continue to face. More than 90 per cent of healthcare in Scotland starts and stays in primary care. It is a vital part of our health service, and I know that everyone in this chamber offers their thanks to the staff across the many different professions who deliver those indispensable services, day in, day out, in every community in Scotland.

We are working hard to deliver on our strong commitment to primary care, but there are challenges and I am keenly focused on them. It is important to recognise that those challenges are not only the recruitment and retention of GPs, but the recruitment and retention of the wider primary care team with all the multidisciplinary skills that patients need them to have. The guiding principle is the right one—that people should see the right healthcare professional at the right time and in a way that suits them. The new teams—including practice and district nurses, health visitors, pharmacists, allied health professionals, mental health professionals and link workers—enhance patient care, provide the support that our GPs need and deliver on that guiding principle.

The new GP contract—Scotland’s first—has been in place for one year. It is a landmark contract that was developed and negotiated in partnership with the BMA, receiving support from 71 per cent of its members. Increased business risk and workload were identified as key reasons that prevent people from wanting to be GPs and encourage them to leave the profession prematurely. Therefore, the new contract reduces risks around premises and staffing, and the creation of the multidisciplinary teams of healthcare professionals ensures that the GP’s workload is focused on those patients for whom the GP’s particular clinical skills are needed.

The new GP contract, in its widest sense and in its critical application, sits at the core of our reform of primary care. Central to the new contract is developing the leadership role of GPs locally. That includes the development of locally agreed primary care improvement plans covering all 31 integration authorities.

What does the cabinet secretary say to my constituents in Stoneyburn, who do not have a GP practice for the first time since the creation of the NHS, in 1948?

I met representatives of the community council at the start of the Easter recess and was able to assist them in making sure that some of the services that they are concerned about can be made available to them in a sustainable way. I will continue to monitor and secure that engagement for exactly those purposes.

All GPs—urban and rural—need to see the benefits of the new contract: that it brings reduced business risk, improves workload and, critically, delivers the care that a patient needs from the right health professional. The way in which services are delivered should fit local circumstances, so the scope for local flexibility in the national contract is a central aspect of the work that we have commissioned from the working group that is chaired by Professor Sir Lewis Ritchie. We have asked the working group to agree exactly what the scope for that flexibility is. The group involves the BMA, representatives of rural health boards and integration authorities and, critically, rural GPs.

We are investing substantial sums in our reforms of primary care and general practice, and we have committed to increasing annual expenditure on primary care by £500 million a year by the end of this parliamentary session, with £250 million of that increase being invested in direct support for general practice.

Although our focus is on developing the multidisciplinary teams that we need to deliver enhanced services, we also need more GPs.

Alison Johnstone rose—

I do not have time to take an intervention. I am sorry.

We have committed to recruiting at least 800 more GPs by 2028. However, we need to train, recruit and retain. Between 2015-16 and 2020-21, the Scottish Government will have increased the number of medical places in Scottish universities by 190, with the majority being focused on primary care. Those include places on ScotGEM and 60 additional places for the academic year 2019-20 at Aberdeen and Glasgow universities.

We have set up bursaries for harder-to-fill posts, in which we have seen a steady increase from 60 in 2017 to 101 in 2018. We are also taking specific steps to improve the recruitment and retention of GPs in remote and rural communities. Last April, we published the first-ever workforce plan focused on primary care. We have introduced and expanded practical services that aim to support GPs, including coaching and mentoring. We have also introduced special financial packages to encourage the relocation and retention of rural GPs, and we have developed a targeted GP recruitment marketing campaign. At the RCGP conference last year, we addressed another practical problem that it had raised with us when I launched the national GP recruitment website: GPjobs.scot. We will work to ensure that all existing vacancies are picked up and advertised there.

We are seeing early signs of success in meeting our commitment to increase the number of GPs, with the latest figures indicating a record number of GPs working in Scotland. In 2018, the GP headcount was 4,994, which was 70 more than in the year before.

I believe that all the actions that I have outlined—and the others that time prevents me from covering—are the right ones for us to take. However, I am also listening to primary care professionals, patients and members in the chamber. If more steps need to be taken to ensure that those essential services are not only protected but helped to flourish, we will take them. I know that, across the chamber, all members recognise that enhanced primary care services, with general practice at their heart, are the bedrock of the NHS.

I move amendment S5M-17011.3, to leave out from “is concerned by” to “total health budget” and insert:

“notes the aim of the Scottish Government to recruit 800 additional GPs; welcomes that funding for primary care and general practice will be increased to 11% of NHS Scotland frontline funding by the end of this parliamentary session; believes in the multidisciplinary approach that recognises the GP role as that of an expert medical generalist supported by expanded multidisciplinary teams that include practice and district nurses, health visitors, pharmacists, allied health professions, mental health professionals and link workers; understands that the GP contract, designed in partnership with the BMA, gives flexibility on aspects of delivery to reflect the needs of rural Scotland; notes that all aspects of GP support and re-imbursement will be considered in partnership with the BMA and GPs as phase 2 of the new GP contract is developed.”

There is a little time in hand for interventions, for which members will get their time back.

15:52  

I thank Alison Johnstone and the Green Party for securing this important debate.

Parliament last had the opportunity to debate the GP crisis in Scotland in November 2017, when Scottish Conservatives brought to the chamber their own motion, which called for 11 per cent of funding to go directly to general practice. Since then, we have seen no progress on that becoming reality. Over the Easter recess, I spent time in the Highlands, Moray and Aberdeenshire, where I met rural GPs. Their overwhelming message was that they feel that the new GP contract is not working for them and that their concerns have not been listened to.

I accept Miles Briggs’s point that rural GPs face particular challenges. Does he also accept that deep-end GPs, who deal with the 100 most deprived areas, also face big challenges?

Absolutely—I was just coming to that. The Government’s ability to unite both sets of doctors has been amazing, in that deep-end GPs are equally unhappy with the contract.

Despite being responsible for delivering the vast majority of patient contacts in our health service, general practice in Scotland continues to face considerable underinvestment. A fall has taken place since its 9.8 per cent share in 2005-06; the latest figures show that general practice in Scotland receives just 7.35 per cent of Scottish NHS funding, well behind general practice’s average funding across the United Kingdom, which now stands at 8.88 per cent.

We will be able to boost the GP workforce only by investing sufficiently in general practice and ensuring—as Alison Johnstone said—that manageable workloads can be put in place. A serious funding deficit exists for general practice, which the Government must recognise. Without funding, the area cannot fulfil its potential and achieve its goals, as we all want to see it do.

In the face of more than a decade of cuts in the percentage share of NHS Scotland spending that is made available to provide general practice services, the RCGP has consistently called for 11 per cent of NHS Scotland’s annual budget to be delivered for general practice. As the RCGP briefing for the debate makes clear, the funding gap in general practice is unsustainable and urgent action should be taken to preserve patient safety by resourcing general practice with 11 per cent of the budget.

There has perhaps never been a greater need for clarification of the funding for general practice in Scotland and for the roles and capacity in the wider multidisciplinary teams. There is great potential if we fund general practice properly. As the RCGP briefing points out, it would enable new roles in general practice; support for practices; teaching and training development opportunities; and digitally enabled care across our communities. We should all be looking to deliver those things.

From the outset, Scottish Conservatives have raised concerns—with both the former health secretary and the new one—about the new GP contract’s unintended consequences for rural GPs.

The truth is that when general practice works well, our national health service works well. We should all look towards that and never more so than in relation to recruitment. Over the past 12 years, SNP ministers have launched several schemes to try to recruit to general practice. In 2015, the SNP created a programme that aimed to take forward proposals to increase the number of medical students who choose to go into GP training as well as to encourage them into rural practice and economically deprived areas. However, in two years and at a cost of £2.5 million, we have seen the recruitment of only 18 GPs. That is simply not good enough and it continues to fail our communities.

Rural GPs in particular have serious concerns about the proposals for the future contract, which is something that my amendment looks towards. Phase 2 of the GP contract must be agreed across the parties and there must be an opportunity to highlight the concerns and get the contract right, especially as we face an election year. I know that the Rural GP Association of Scotland has already put the concerns to the cabinet secretary.

For some time now, it has been clear that SNP ministers have not truly understood the crisis facing general practice across Scotland, especially in our rural communities. As I said almost two years ago, it is important that we take time to get this right. Tonight, Parliament can send a united message to ministers that they need to take urgent action on general practice and funding in Scotland and to do far more than they are currently doing to prevent the crisis from growing even further. Until the Government fundamentally addresses the complaints and concerns that GPs are putting to all members of this Parliament, general practice will not be able to flourish in Scotland.

I move amendment S5M-17011.2, to insert at end:

“; and to take consideration of the concerns of rural GPs with the GP contract as well as allowing them flexibility to provide vaccination services”;

15:57  

I believe that we all appreciate the hard-working staff in our NHS, and because we appreciate them, it is incumbent on all of us to address Scotland’s GP recruitment and retention challenges. I am grateful not only to Alison Johnstone for bringing the debate to the chamber, and to the Royal College of General Practitioners and the BMA for their briefings ahead of the debate, but to the many members of the public who get in touch with me, my colleagues and us all to share their views and experiences.

It is right that we show our appreciation in debates such as this one but, at the end of the day, it is action that counts, and the role of general practice in our NHS cannot be overstated. It is on the front line of healthcare, with GPs carrying out the majority of patient contacts and acting as gatekeepers to other parts of our health service. GPs dedicate their working lives to the health and wellbeing of others. It is an admirable commitment but, with our NHS facing crisis, a challenging one, and increasingly so. GPs tell us that they are under unprecedented pressure amid GP shortages and that they face increasing levels of stress and burn-out. That should worry us all.

The evidence that GP recruitment is in crisis is clear and is mounting. There has been a failure on the Scottish Government’s part to address workforce planning properly. Steps to remedy the challenges are welcome, but we know that change will not happen overnight and, in the meantime, GPs and their patients are paying the price. In the past three years, more than 200 doctors have chosen to leave general practice due to significant workload pressures. It is a sad fact that our valued GPs feel that way and one that is difficult to accept. The bottom line is that Scotland cannot afford for it to continue.

Out-of-hours GPs provide an invaluable service in all our communities that has the potential to ease the pressure on A and E departments. Cuts to out-of-hours services and a shortage of GPs mean that more people have to take themselves to A and E, putting more pressure on the service. However, hospitals and medical centres in Glasgow were left without staff covering emergency out-of-hours GP services more than 200 times last year. Easterhouse, which has high levels of deprivation, has had a shocking 977 per cent increase in the number of shifts that were not covered. Before 2017, there were no examples of shifts that were left unstaffed in Glasgow, so those figures require further scrutiny and attention.

I am not about to disagree with Monica Lennon about the challenges that we face in our out-of-hours services, but does she recognise that it was the 2004 GP contract, not one that was negotiated by this Government, that removed the requirement on GPs to provide out-of-hours services and that means that the participation of GPs in those services is now voluntary? As GPs retire and with many of the newer GPs wanting a different kind of work-life balance, as a member said earlier, we are seeing fewer GPs volunteering for out-of-hours services, so we need to think differently about how we provide them.

I will give you your time back, Ms Lennon.

I am grateful to the cabinet secretary for that input and commentary, but I do not think that it really cuts it when we have people in Easterhouse and other deprived parts of Glasgow who are wondering why they had out-of-hours access before 2017 and now have problems with it. We have to deal with 2019 and, as we heard from Neil Findlay, the challenges that his constituents face in Stoneyburn. The GP contract that was introduced last year was meant to ensure that GP recruitment and retention problems were alleviated, but its implementation has been criticised—it has been slow, and the BMA has called for an increased pace of change.

The Scottish Government has had difficulty with regard to rural GPs. Last month, Dr Hogg, vice-chair of the Rural GP Association of Scotland, walked away from the Scottish Government’s task force due to a lack of progress, saying that it had

“fallen by the wayside”.

That is another cause for concern. I welcome some of the action that the cabinet secretary has outlined, but we need to see promises being delivered—that has not always been the case under this Administration.

The Scottish Labour Party supports the Scottish Green Party motion and we can support the Scottish Conservative Party amendment. We cannot support the Scottish Government’s amendment, because we do not believe that it adequately addresses the concerns of rural GPs, and because it fails to acknowledge the serious issues with GP recruitment.

We must value and support GPs across Scotland, because a robust, well-resourced GP service will ease pressures on other parts of the NHS and, ultimately, provide people in Scotland with a better health service. We must all value GPs and look out for their health and wellbeing; we cannot have GPs experiencing burn-out. We are highly concerned about the increasing problems with out-of-hours GP provision across Scotland and the particular challenges in our rural communities. For those reasons, we call for any review of GP resources to include a specific focus on out-of-hours coverage and rural service provision.

I move amendment S5M-17011.1, to insert at end:

“; is concerned about the increasing gaps in out-of-hours GP service provision across Scotland, given the value of this service to local communities and its importance for relieving pressures on A&E departments; acknowledges the significant challenges faced by rural GPs and their critiques of the new GP contract, as stated by Dr David Hogg when he resigned from the Scottish Government’s Remote and Rural General Practice Working Group, and believes that any review of GP resources should include a specific focus on out-of-hours coverage and rural service provision.”

16:02  

I thank the Greens for securing time for today’s debate. We do not discuss this matter enough in this place, but it is of great importance. I was appointed as my party’s health spokesperson on my second day here and within hours I became aware of the breadth and depth of the crisis. GPs are often our first port of call but so often are the last to be given consideration in this place. That has to change.

On the metrics of the crisis, by the end of this decade we may have 800 fewer GPs than we require as a country. A freedom of information request by my party has revealed the depth of the recruitment crisis. In NHS Forth Valley, a post has gone unfilled for the past few years; on Shetland, a position has been advertised eight times with only one application; and Dumfries and Galloway NHS has had a 22-month wait for a post to be filled. Those stories are replicated the country over, with many reasons for them. In my constituency, in west Edinburgh, we have not had a new doctors’ surgery established for 45 years, despite a year-on-year proliferation of new homes and populace. All the GP surgeries in my communities are on their knees; some have had to restrict their lists or close them entirely. That is down to the fact that while housing development in the constituency proliferates, no consideration is given to who will treat patients. Thousands upon thousands of new homes are on stream right now, with no thought being given to whom the patients will turn to when they fall ill.

We are not promoting general practice to our medical students as they progress through their degrees and we are not recognising the pressures on general practice that we could easily alleviate right now. I have raised time and again the fact that one quarter of all appointments made with our GPs are for an underlying mental health condition and that GPs are ill equipped, or do not have the time, to bottom out the psychological reasons for the appointments being made.

We know that there are workforce planning problems. It takes seven years to train a GP, but workforce planning cycles in Scotland happen only every five years, which, in turn, leads to a problem of attrition, where we fail to plan effectively for the cohorts of retiring GPs by backfilling them with new GPs coming up through the ranks.

I believe that retired GPs offer part of the solution. In my constituency surgery, I have visited retired GPs who said that they would be very happy to undertake one or two sessions a week if it was made easier for them to come back into general practice and keep their hand in. We need to box clever and listen to the good will of our retired general practitioners.

I commend the Government for the new contract; aspects of it have proved to be elegant and have been well received by the community. The issue around premises was a particular millstone around the necks of new entrants to general practice partnership—the idea that people would have to take on a mortgage of £80,000 just to become a partner in a GP surgery was an inhibiting factor for many; and the solution that the Government, along with the BMA and the RCGP, has offered to address that issue is very elegant. However, some issues around the contract will begin to bite only as phase 2 comes in at the start of the next parliamentary session. In particular, there are issues around financial recompense for GPs in areas of profound rurality—areas that, as I said at the beginning of my speech, are struggling to recruit GPs first and foremost.

As I said at the start, GPs are the first port of call for many of our constituents when they fall ill but, all too often, are our last consideration in the Parliament. That needs to change.

16:07  

It is clear from members’ comments in the debate that the GP crisis continues to have a big impact across Scotland. Just this week, the Dunfermline Press and West of Fife Advertiser reported on a local father who had to phone his surgery more than 100 times in one morning to get an appointment.

Of course, it is not only primary care services that have been impacted by the GP shortage: delivery of out-of-hours care has been limited by a lack of GPs and the contractual changes that have taken place over a number of years. In my region, two NHS boards—Forth Valley and Fife—have been carrying out major service changes to out-of-hours primary care. Their approaches have been very different, however, and there are serious lessons to be learned for other NHS boards.

In 2017, NHS Forth Valley implemented interim measures by concentrating its out-of-hours service in one location, at Forth Valley royal hospital in Larbert. Understandably, that caused concern and disruption for many people, especially people in rural Stirlingshire, who were facing journeys of up to 40 miles to access services.

On the back of that measure, NHS Forth Valley instigated a recruitment drive for a significant team of allied health professionals to complement and support GP provision, including the out-of-hours service. Earlier this year, 80 new advanced nurse practitioners, prescribing pharmacists, paramedics and other health professionals joined the NHS Forth Valley team—the first of more than 200 new staff who will deliver a multidisciplinary model of primary and out-of-hours care at locations across the area. I emphasise that the model continues to be led by GPs. It is important that GPs display strong leadership and are supported by those multidisciplinary teams, which they, in turn, support.

In contrast, NHS Fife implemented emergency out-of-hours provision last year, limiting services to just two locations—in Dunfermline and Kirkcaldy. That was followed by a consultation that proposed a very limited set of options and no discussion about the role of GP-led multidisciplinary teams.

It has taken two participation requests by communities under the community empowerment legislation and a whole new series of consultation workshops for a new option to be developed in Fife that uses the same multidisciplinary model that Forth Valley and other NHS boards have been adopting. The latest proposals that have come out of that participation will see the retention of an evening and weekend service at St Andrews community hospital, using a mixture of GPs and health professionals, with home visits to the most vulnerable and remote patients. Work is—I hope—on-going to design a similar model for Glenrothes.

I have serious concerns about the ability to deliver an effective multidisciplinary model with the current staffing levels in Fife. There has been no recruitment drive comparable to that in Forth Valley NHS, and there are only five urgent care practitioners and 5.4 full-time equivalent advanced nurse practitioners in the training pipeline. There are 10.5 staff for Fife, versus 300 for Forth Valley. That is a worrying difference in our workforce planning, and I am deeply concerned that it will put our GPs in Fife under further pressure. Meanwhile, what was supposed to be a temporary centralisation in Kirkcaldy has continued for more than a year, with no date set for the new model to be rolled out.

I have raised that issue in the chamber before, and was heartened by the cabinet secretary’s response that specialist funding is available for training advanced nurse practitioners and prescribing pharmacists.

As today’s motion states, we need

“an urgent review of GP recruitment, resources and funding.”

That has to include health professionals, who are so vital to delivering a successful multidisciplinary model for primary care. Multidisciplinary team models are popular: patients report high satisfaction levels, and communities such as Bridge of Earn in my region are lobbying their local health boards to have multidisciplinary health and wellbeing centres built in their communities. However, the inconsistency and lack of staff recruitment in some NHS boards needs to be addressed right now.

16:12  

I am pleased to speak in the debate as a nurse with more than 30 years’ experience, and as the deputy convener of the Health and Sport Committee.

The new GP contract for Scotland, which came into force in April 2018, aims to cut doctors’ workloads, provide a minimum income guarantee for GPs and allow general practice to become a more attractive career. The contract is still in its infancy—we are now embarking on year 2 of its implementation. In 2018-19, the Scottish Government invested more than £110 million to support the new GP contract and wider primary care reform, which was extremely welcome.

Last year, I attended the Royal College of General Practitioners’ annual conference in Glasgow, where I spoke to GPs including Dr Carey Lunan, who is the RGCP Scotland lead, and heard first hand about apprehensiveness about whether the contract will work for rural GPs. Following those conversations, and after discussions with former colleagues in the primary care sector, I wrote to all GP practices in the NHS Dumfries and Galloway area to ask for feedback on the contract and on any other issues that they wanted me to relay to the Government. I am pleased that, to date, more than six practices have responded. I am in the process of meeting them to hear their thoughts about how we can further improve the contract.

Last week, I met staff at the Charlotte medical practice in Dumfries. It was clear to me that the GPs there agree with much of what the contract has to offer, but they made clear their concerns about some of its timescales, including in respect of the length of time that it might take to integrate pharmacists into practices.

It was clear that many of the GPs whom I met at the RCGP conference and locally believe that the way to recruit GPs, particularly to rural areas such as the south-west, in my South Scotland region, is to improve road and rail transport infrastructure. I am sorry that this is Ms Harper harping on again about the A75, A76 and A77, but the GPs said that if people who have studied in the central belt and who live and have families there could have easy access to Dumfries and Stranraer—and all the places in between—by fast train or road links, they might be more inclined to work in bonnie Galloway.

I am aware that the Government is working on recruiting and, indeed, retaining our GPs. In 2018-19, it invested £7.5 million on that, which included £850,000 for remote and rural areas. For all 160 remote and rural practices, the Scottish Government has made available “golden hello” payments for GPs who are taking up their first post in a rural practice, and relocation packages of up to £5,000.

GP recruitment concerns are not unique to Scotland. However, this Government’s commitment, which includes expanding the remote and rural incentive scheme and relocation funds, should have a real impact. The investment of £7.5 million has allowed the Scottish Government to invest in the ScotGEM programme, which will benefit NHS Dumfries and Galloway in my South Scotland region and is the result of a partnership between the University of St Andrews, the University of Dundee and NHS Scotland. The course is oriented towards current NHS Scotland workforce requirements, particularly in remote and rural GP practices.

In August 2018, a total of 55 students were matriculated with St Andrews university. I am pleased that the first group of second-year students will arrive in Dumfries and Galloway in August this year. Happily, five GP practices across Dumfries and Galloway are set to take part in the pilot year of the project. I look forward to seeing its outcomes.

I thank the exceptional specialist GPs across Scotland and welcome the positive steps that are being taken by the Scottish Government to help with recruitment and retention of GPs.

16:16  

General practice is the front line of the NHS, but it has been seriously let down by the SNP. After nearly 12 years in charge of Scotland’s health service, GP recruitment and retention are only getting worse. We know that there is a longstanding problem, about which the SNP has repeatedly been warned.

Demand on the health service is growing and the role of GPs is becoming more important. As the Royal College of General Practitioners points out,

“General Practice is the frontline of the NHS ... carrying out the vast majority of patient contact”.

GPs act as gatekeepers to the entire NHS. Despite that, the Royal College of GPs has estimated that there will be a shortfall of 856 GPs by 2021. More than 500 GPs have taken early retirement since the SNP came into power, and the number of doctors in training in Scotland has sunk to a five-year low.

Will Annie Wells cite the evidence that she has for the assertion that the number of doctors in training has sunk to a five-year low? Those are not the figures that I am working with.

I will send the figures over to the health minister.

Do that.

I will.

The Scottish Government has highlighted the measures that it has taken to combat the crisis. However, although I welcome schemes such as ScotGEM, it is concerning that it has taken so many years to reach this point—even more so given that in 2008 the BMA warned of severe GP shortages.

When it comes to retention, talks about the new GP contract between the SNP Government and rural GPs have revealed on-going tensions. The contract is still widely opposed by rural doctors, who state that due to its focus on workload, it unfairly benefits practices in wealthy urban areas in which there are large elderly populations. Only last month, Dr David Hogg, the vice-chair of the Rural GP Association of Scotland, resigned from a working group that was set up by the Scottish Government because of what he sees as a failure to suggest any pragmatic and realistic proposals to counteract the impact that the contract will have on rural services.

The Scottish Conservatives have repeatedly made calls to counteract the problems that general practice is facing. We have called on the SNP to spend more of the NHS budget on the GP front line, and to meet the 11 per cent target. Our save our surgeries campaign makes clear the importance of properly funding general practice. As we have heard, in recent years, Scotland’s general practice has continued to face considerable underinvestment, having fallen from its 9.8 per cent share in 2005-06. The latest figures show that general practice in Scotland receives just 7.35 per cent of NHS funding, which is the lowest share of NHS spend in the UK.

The additional funding that we have called for would equip general practice for the future, allow surgeries to invest in improved IT systems and help GPs and patients to save time and resources. It would also allow surgery premises to modernise and become fit-for-purpose buildings that act as community hubs in which social prescribing becomes the norm.

The Scottish Conservatives have also called for more medical school places to be made available to Scotland-based students, and for GPs to be given more time for appointments—up from 10 to 15 minutes—to assist patients who have more complex needs. Those changes can be made only by properly funding general practice.

I reiterate our calls for the SNP to spend more of its NHS budget on the GP front line. At a time when demand on the health service is greater than ever, it is vital that general practice receives the correct level of funding. It acts as the gateway to the entire NHS, and it is in dire need of our support.

16:20  

General practice, and the relationship that patients have with their doctor, is key to the way our NHS operates and the trust that we place in it. People—including me—have great respect for and show great deference to their doctor, and anything that negatively impacts on general practice ripples across the rest of the NHS, resulting in more and longer delays at A and E, treatment time guarantees being breached, delayed discharges, more pressures on staff, fewer students entering general practice, greater reliance on locums, which costs the NHS more, fewer appointment times, closed lists and, ultimately, poorer patient care. All that is happening in Scotland now. General practice is therefore crucial to the wider NHS, and it is being failed by poor planning and financing and mismanagement at the governmental level.

Over the past decade, the number of people entering GP training has fallen; it is down to around 300. The Royal College of General Practitioners has said that we are 850 short.

Two years ago, I held a drop-in session for GPs in my area in the summer. I spoke to people from 14 different practices, and all of them raised with me the crisis in recruitment. The crisis is worse now than it was then. Some of them said that they were a resignation away from closure. They are long-established practices that sit in communities in which doctors are highly valued. Others were completely reliant on locum GPs just to keep the doors open.

Across Scotland, locums claim up to £1,400 a day. In Lothian, locums claim over £500 a day. Also in Lothian, around 50 practices are operating restrictions on their waiting lists. I say to the cabinet secretary that that is not good enough. A quarter of practices have reported vacancies and a third of advertised GP posts took six months to fill.

Only last week, NHS Lothian announced that, this May, nine out of 23 days cannot be covered at the St John’s hospital out-of-hours GP service because of staff shortages.

Does Neil Findlay accept that, as I said to Ms Lennon, the reason why there are those challenges in out-of-hours services is the 2004 GP contract, which was not negotiated by the SNP Government?

Come on.

It is not a matter of saying, “Come on.” That is the case. Ask the British Medical Association, the Royal College of General Practitioners and Sir Lewis Ritchie. They will all point to that and to the removal of the requirement of GPs to undertake out-of-hours services. That plus the cohort who are ageing and retiring have combined to produce the problem. Rather than rehearsing the problem, will Neil Findlay say where Labour’s solutions to it are? I am still waiting.

Mr Findlay, I will give you extra time.

The SNP has been in power since 2007, and it is getting round to addressing the problem only now. I do not think that the cabinet secretary will get away with that one.

The NHS could not staff the children’s ward at my local hospital for six years, and we are now told that it cannot staff the out-of-hours GP service. I do not know what the cabinet secretary finds amusing. There was turmoil there for six years, with three closures. The cabinet secretary should look at the record. Given the closure of the out-of-hours GP service, patients are being advised to contact NHS 24. That is not good enough. Patient care will be compromised.

On several occasions, I have raised the situation at Stoneyburn health centre. The community has had a GP since the creation of the NHS in 1948, but it no longer has one thanks to the crisis that is taking place on the Government’s watch. That must be a proud achievement for the cabinet secretary. The elderly, the unemployed, the disabled and the low paid now have to use a very poor public transport system to travel to appointments. For a young mum with two children, the minimum cost of travel is almost £7. Previously, she would have been able to walk up the street to her local surgery.

Come to a close, please.

What does the cabinet secretary say to the young mum who came to me and said that she struggled to take her children to the doctor because of the cost? That is the health service of the 19th century, not the 21st century.

16:26  

I begin by reflecting on the general state of the national health service in Scotland. I suggest that we have a health system to be proud of. Since I became an MSP in 2011, the NHS budget has gone from £10 billion to more than £13 billion. Unlike those who like to complain, particularly in the chamber, we get on with the day job and resolve issues through local health boards, not in the chamber.

Will the member take an intervention?

No, I have no time.

Like many others in the chamber, I have constituents who come to my surgeries with health inquiries, which we resolve. Yes, with any organisation there will be delays and complaints, but it is solving each and every complaint that gives me satisfaction. That is what we do for constituents.

Will the member take an intervention?

No, I do not have any time.

Our health service has to cope with many issues, too numerous to mention in the time that I have available. The health service deserves more credit than it gets, and I regularly contact my local GPs when required. I get annoyed because, time and again in the chamber, there is political criticism of our health service. Rather than trying to get resolutions at local level through the health boards, some of the main parties maximise their opportunity to take a pop at the Government or the cabinet secretary.

Will the member give way?

I have no time.

You do have time.

No, I do not have time.

It is quite clear that Mr Lyle is taking no interventions.

The SNP has the most significant investment plans for the NHS. The other parties have no answers to the recruitment and retention of GPs, which is what we are discussing today.

I value each and every one of our GPs. I had the good fortune of having a part-time job as an out-of-hours driver for NHS 24 before I became an MSP. I drove doctors, who worked at night and at weekends, to house calls and saw how they coped with the health needs of the population. I saw at first hand the work that GPs do and the work that goes on in our local hospitals.

To be clear, the SNP greatly values the contribution that GPs make to the nation’s health, and I am sure that the Government wants to ensure that GPs have the support that they need. That is why the new GP contract for Scotland, which came into force only in April 2018, helps to cut doctors’ workload, ensures a minimum income guarantee for GPs and makes general practice an even more attractive career.

In its briefing, the BMA states that there has been considerable progress over recent times. Indeed, we are now embarking on year 2 of the implementation of the new GP contract. Figures from 2018-19 show that the Scottish Government invested more than £110 million to support the new contract and wider primary care reform. Dr Andrew Buist, the chair of BMA Scotland’s Scottish general practitioners committee, has said:

“At the heart of the new GP contract introduced last year was a clear aim to make becoming a GP a more attractive career choice and encourage more people into working in this part of the profession.”

That is absolutely correct, and that commitment has been matched by the Scottish Government’s announcement that GP premises will be able to access loan funding of £50 million through the GP premises sustainability loan scheme over the next three years.

The scheme, which is in direct response to concerns raised by the BMA, aims to ease the financial burden that is associated with owning a practice and will, in turn, help improve recruitment and retention. GPs who own their premises can apply for long-term interest-free loans worth up to 20 per cent of the practice's value, thus reducing the risk of premise ownership, which has been raised by GPs as a common concern. It is all part of a move towards ensuring that GPs are no longer required to own a property. A total of 172 practices—or around 50 per cent of the total that are eligible—have successfully applied for loans, and I am delighted that a number of them are in Uddingston and Bellshill and elsewhere in Lanarkshire.

The Scottish Government has committed to recruiting 800 GPs over the next decade. By the end of this session, it will be investing an additional £500 million in primary care. I believe that the SNP Government has a record to be proud of, and the political parties opposite should stop carping from the sidelines.

We move to closing speeches. I point out that we have no spare time left.

16:31  

I, too, congratulate Alison Johnstone and the Green Party on securing this afternoon’s important debate on Scotland’s GP recruitment and retention challenges.

This has been, in my view, a well-informed and insightful debate about crucial players in the delivery of primary care—our GPs. As the BMA has rightly argued, problems with GP recruitment and retention are deep-seated, and there is no quick fix for them. According to current surveys of GPs, about one in four practices are reporting vacancies. As many members, including Neil Findlay, Miles Briggs, Monica Lennon, Alex Cole-Hamilton, Mark Ruskell and Annie Wells, have argued, increased workloads have certainly been to blame for some of the vacancies. Excessive workloads have been cited as a major reason for some either leaving the profession or—which is equally important—not entering it in the first place. In the 2018 BMA survey, over 70 per cent of GP partners said that they work substantial hours per week beyond their surgeries’ opening times.

Many members have also spoken of the risks that are associated with working as a GP, including in respect of owning the practice premises and employing staff. In fairness, I say that the GP premises sustainability fund, which is intended to make general practice more workable, is a good concept and is designed to reduce the risk to which practice partners are exposed.

Will the member give way?

I will give way very briefly, because I am quite tight for time.

Does David Stewart recognise that there is a place for the introduction of salaried GPs, as has happened in my region?

Yes. Salaried GPs are an important part of the model; indeed, I have visited some myself in Wick and Thurso.

I have no time to debate the matter now, but I have also raised at the Health and Sport Committee concerns about the 6 per cent increase this month in employer contributions to pensions. The increase, which has been caused by a technical issue—a change in the current discount rate—will hit GPs and general practices, and might result in GP staff being made redundant. The issue is, of course, reserved, but I hope that the Scottish Government will get the full funding from the UK Exchequer to deal with it. Other wider pension issues, such as the lifetime allowance, also affect retention of GPs—especially those aged over 55.

As we have heard, another key element in recruitment and retention of GPs is the effect of the new contract in remote and rural areas. As has been said—and as our amendment makes clear—Dr David Hogg, who is the vice-chairman of the Rural GP Association of Scotland, resigned last month from a Scottish Government working group, saying that rural GPs are “despondent” about the new contract. Concerns were raised about the new funding formula: it is based on the number of appointments, so it fails to recognise the challenges that are faced by rural GPs, who often have to travel much longer distances to treat patients or get to their practices.

General practice is a crucial Iinchpin of the NHS because of their delivery of services in the community and because they reduce pressure on acute and emergency services. I believe that we have a workforce crisis in the NHS. As many members including Alex Cole-Hamilton have pointed out, we are facing a shortage of 850 GPs over the next 10 years.

Out-of-hours services are vital if we are to ensure that access to urgent care in the community is there when it is needed. However, we have seen cuts in out-of-hours services across Scotland.

I will turn to the big picture. We know that the reasons for the loss of GPs are demographic changes, the demands of rural areas and the social and economic challenges of disadvantaged communities across Scotland. Although there is no quick fix, Scottish Labour supports the RCGP’s call to increase to 11 per cent the proportion of NHS spending that is allocated specifically to general practice, in order to grow and maintain the workforce and to support fully the highest possible standard of patient care. As Nye Bevan famously said—

I hope that he said it quickly.

Nye Bevan said:

“The NHS will last as long as there are folk left with the faith to fight for it.”

16:35  

I, too, thank Alison Johnstone and the Green Party for bringing the debate to the chamber and for giving us the chance to discuss an issue that the public are really concerned about. I wish that we had more time to explore the issue, because it deserves that.

The debate has been well rehearsed in Parliament, and we all know the numbers. As many members have stated, we are heading towards a shortage of more than 850 GPs. I am glad that Emma Harper is sitting down, because I want to say well done to her—it is not like me to do so—for getting the A77, the A75 and rail infrastructure into her speech. That is important, because the environment has an effect on where people work.

We have been talking about recruitment and retention, but in my view we have them the wrong way round. We should talk about retention and recruitment, because it is much more difficult to fill a bucket of water when it is full of holes. We know that more than 500 GPs have taken early retirement since 2007, and that a third of GPs are aged 50 or over, as Alison Johnstone said. It would make more sense to create an environment in which healthcare professionals can deliver the care that they are trained to deliver in the manner in which they would like to deliver it. We should be cognisant of their need to have a healthy lifestyle.

First and foremost, we should look to retain the experience that resides in our GPs while we look to backfill the shortage. That is all the more relevant given that the BMA has reported that pressure on our GPs is increasing and that their mental health is in decline. As Annie Wells mentioned, GPs need more time in which to deliver their service.

The shortage has been highlighted consistently to the Scottish Government by various experts, including the RCGP. A number of years ago—I think that it was back in 2008—the BMA said that a “workforce crisis” was imminent because too few GPs were being trained to replace those who were retiring or leaving. We should therefore not be surprised by the current situation. Meanwhile, in the time since then, the percentage of indigenous students in our medical schools has dropped dramatically. It is reasonable to assume that the place in which a qualified medic will practise is most likely to relate to the address on their Universities and Colleges Admissions Service form. We have just heard from Richard Lyle. When I was a member of the Health and Sport Committee, I used to hear him mention that young constituents of his could not access places in medical school.

The aim of having 11 per cent of the total health budget going directly to general practice should be the minimum target, especially given the drive towards community-based delivery and away from delivery in acute settings. The RCGP has expressed concerns about the lack of clarity on the Government’s commitment to invest £500 million in primary care, and has warned that

“if the long-standing underfunding and confusion that we are currently experiencing is to continue, we will keep witnessing a considerable number of general practices closing”.

Neil Findlay mentioned issues in his constituency. In East Ayrshire, the surgery in Fenwick has closed and a surgery has closed in Troon in South Ayrshire. We cannot deny that there is an issue. However, the solution is not easy, and a multifaceted response is required, including in relation to student places for Scottish students. We need to review that.

We also need a review of the GP contract, given its unpopularity in the rural GP community. We must accept that, as members including Alex Cole-Hamilton, Miles Briggs and Monica Lennon highlighted. Inevitably, technology will play a major role in the development of a solution, but that is a discussion for another time.

The Green motion sets out an obvious first step in addressing the current crisis, so we will support it.

16:39  

I thank members for their speeches. In particular, I thank Mr Whittle for his welcome recognition that this is a multifaceted issue that will require a multifaceted response.

I make it clear that I understand completely that there are key challenges to do with how phase 1 of the contract is interpreted and understood, as we address issues that some GPs in rural practices are raising with us. As I hope that I made clear in my opening speech, we will look specifically at that matter. That is what we asked the group that Sir Lewis Ritchie chairs to consider.

I hope that we will make quick progress on some of those key issues. We will then look at phase 2 of the GP contract and begin negotiations, informed by the conclusions of Sir Lewis Ritchie’s working group and discussions with the BMA about what more we might do. Of course, that work will begin shortly.

I thank Alison Johnstone, not just for bringing the debate to the Parliament but for raising the issue of the national conversation, which has been raised directly with me by the RCGP and by Emma Harper. I confirm to members that we are actively working with the RCGP on how we will take forward the national conversation, to ensure that many more of our citizens understand the positive changes that not just the GP contract but our reforms to primary care are bringing.

As a recent edition of the British Journal of General Practice reported, over a two-year period patient satisfaction has increased. That is not to deny that there are areas where there are difficulties. However, we are seeing improvements in some areas and the national conversation should help us significantly.

I do not think that there is any basis for saying that members of the Government and I do not understand the challenges that face GPs and GP practices. That is not the BMA’s view.

Although funding alone will not get us past some of those challenges or overcome the time that it takes to train, produce and recruit GPs, I hope that members accept that the Government’s commitment to increasing investment in primary care by £500 million over this parliamentary session will take spending in primary care to at least £1.28 billion, which is 11 per cent of the front-line NHS budget, and that, by 2021, more than half of front-line NHS spending will be in community health services.

Of the £500 million that the cabinet secretary talked about, £250 million will be spent on direct support for general practice. May we have some clarity on what the other £250 million will be spent on?

The rest of the funding goes to all the other areas of primary care that I talked about—the other healthcare disciplines that are required to create a multidisciplinary team, such as allied health professionals, mental health services, health visitors and district nurses, all of whom combine to create the important multidisciplinary team that is a core part of primary care reform.

There are undoubtedly challenges with out-of-hours care. There is no use in any member of this Parliament rehearsing those challenges for me; I understand them very well indeed. We are trying to address them in the context of the new GP contract.

Will the cabinet secretary take an intervention?

The minister must close in a minute.

I would like to be able to address those challenges on the basis of the work that we are undertaking and additional ideas that come forward from colleagues across the Parliament.

I am happy to take an intervention from Neil Findlay.

No. You are closing, cabinet secretary.

Oh, I am closing, so I am not happy—

I am not happy, either.

I will make two quick points.

I am grateful to Emma Harper and look forward to receiving detail about the practices that she is engaged with.

Mark Ruskell made a strong point when he compared NHS Forth Valley and NHS Fife. I will look further at the matter that he raised. The recent review of integration authorities commits us and the Convention of Scottish Local Authorities to work actively in the next 12 months to improve consistency.

There are challenges, but we have made significant progress, including on our commitment to increase GP numbers by 800. I hope that members recognise that.

There are issues for us to address in some of our GP practices in remote and rural areas, but the principle, in the contract, of addressing workload is the right one. However, it is clear that no services should transfer out of a GP practice unless it is safe for them to do so, and that the locality decisions are the most important decisions.

You must close. I call Alison Johnstone to wind up the debate.

16:45  

I thank all members for their contributions to today’s debate. I also thank the RCGP and the BMA for their briefings, and the GPs from across Scotland who have contacted me after learning about this afternoon’s debate.

The cabinet secretary has confirmed that she understands the issues. She spoke about our rehearsing those issues in the chamber, but I think that it is important that GPs know that this Parliament is listening to them.

Will the member take an intervention?

Very briefly.

I return to the point that I was going to raise with the cabinet secretary. Does Alison Johnstone agree that it is the duty of members of this Parliament to raise those issues time and again, whether the cabinet secretary likes it or not?

I agree whole-heartedly that that is our duty.

Monica Lennon and Miles Briggs raised concerns regarding the impact of the GP contract on particular GP groups, as did Emma Harper, and their engagement and action on behalf of GPs is welcome.

Annie Wells spoke of the role of the GP as a gatekeeper, and Neil Findlay spoke about the knock-on impact of insufficient numbers of GPs across the NHS. He also spoke of the many closures in the Lothian region that both he and I represent, but the issue clearly applies Scotland-wide.

I think that it is fair to say that Richard Lyle left us in no doubt that he is a loyal member of the governing party. I do not want to waste time, but Emma Harper and Brian Whittle are becoming known as the A75 appreciation society in the chamber. However, I really do thank all members for their contributions to the debate.

In my colleague Ross Greer’s region, Bargarran medical practice in Erskine was left with no permanent GPs after the lead doctor resigned because recruitment issues had made his position unsustainable. He was the fourth GP to quit the practice in 18 months. In the chamber today, we have heard about similar cases across Scotland. The number of GP practices in Scotland has decreased by 8 per cent since 2008, and we all know the impact that that is having on patients. Will a departing GP be replaced? Who will patients be seen by the next time that they make an appointment? Will the practice have to close altogether? Has it already closed?

The RCGP tells us that

“Patients who receive continuity in general practice have better healthcare outcomes, higher satisfaction rates and the healthcare they receive is more cost-effective”

because they have built a trusted relationship.

The RCGP acknowledges that new methods of working, including multidisciplinary teams, are part of the solution for falling levels of continuity for those who need it most, but we need those methods to be successfully implemented as well as significant investment to produce more GPs.

My point is that the expansion of the multidisciplinary team is welcome, but it is vital that GPs are available to work alongside other health practitioners. That is the holistic, person-centred care that Scotland’s people deserve.

We have also heard about rural GPs’ concerns over the contract. The Rural GP Association believes that the contract fails to take into account the workload of and services provided by GPs in rural settings. A survey of the association’s members showed that 82 per cent believed that the outlook for rural healthcare was worse under the contract, and a third reported that they anticipated that services would need to be curtailed. Concerns have also been raised in the media about the change in the way in which vaccinations are delivered in rural areas, which might lead to a fall in immunisation as patients make longer journeys to attend special clinics, rather than their local surgery. That is the epitome of the fragmentation of care that might occur.

Rural practices clearly operate differently from those in urban centres. I appreciate that the cabinet secretary has said that she is in talks with the BMA about how to take account of those concerns in phase 2 of the GP contract, but 98 per cent of Scotland is considered rural, and a fifth of its population lives in a rural area, so the matter is urgent.

As I have previously discussed in the chamber, there was once fierce competition for GP positions and several applicants for each post, but now there are practices with no permanent GPs, and the increased number of training places are not being filled. We need to make general practice in Scotland an attractive career that appeals to people, and one to which GPs who have taken career breaks will return.

The health and care experience survey that I mentioned earlier reported that 83 per cent of people gave the overall care that was provided by their GP practice a positive rating. The service that is provided in our GP practices remains outstanding, and I am sure that members have no doubt at all that that is down to the efforts of our fantastic practice teams. We should therefore make every effort to promote the fact that general practice in Scotland is a challenging, competitive, worthwhile and rewarding career that will offer the opportunity to deliver excellence every day.

However, we live in a modern world in which people desire more flexibility in their working patterns. General practice is not immune to that. There is an increasing number of GPs who do not work full weeks, and although practices have worked on a small-business model since the 1960s, that might be the preference of many GPs, because more and more of them do not want to be partners. New ways of working could make being a GP a more attractive career to a greater number of people. We should take care to promote the many different forms that working in a GP practice can take.

Working with and listening to Scotland’s health professionals will enable us to develop and deliver a healthcare model that will better support those who work in the NHS and will help them to keep our growing and ageing population well. We need to listen to GPs when they tell us what will improve conditions and patient care, including the need for at least 11 per cent of NHS funding to be allocated to general practice, the need for sufficient numbers to secure enough whole-time equivalent GPs, the need for targeted funding and the need for a national conversation. Those are all calls that are coming from the front line, and I sincerely hope that the cabinet secretary will heed those messages and implement a review of GP recruitment, resources and funding as soon as possible.