Health Committee

Reshaping the NHS in Scotland?

Monday 11 April 2005

[THE DEPUTY PRESIDING OFFICER opened the meeting at 10:36]

The Deputy Presiding Officer (Murray Tosh): Good morning. I am Murray Tosh MSP. As one of the Scottish Parliament's Deputy Presiding Officers, I will chair this morning's session. The afternoon session will be chaired by my DPO colleague, Trish Godman MSP.

I warmly welcome you to this Health Committee event. It is a first for the Scottish Parliament in that this is the first time our new debating chamber has been opened up for this kind of public debate. I am delighted to be able to welcome health professionals, representatives of local campaigns, patients, professionals and members of the public from across Scotland.

We will follow the basic outlines of parliamentary procedure, although the debate will be quite informal in many ways. The debate is an opportunity for delegates to contribute, so I will not apply the rules too severely. I warn you that I will call "One minute" when the person who is speaking reaches one minute from the end of their allocated time. Do not be put off by that—it is simply a guide to let you know that your time is coming to an end.

As you will be aware, members of the Health Committee and other MSPs are present today. This event is important for them because it is part of the Scottish Parliament's work of scrutiny. The Parliament was founded on certain core principles, which include openness, accessibility and participation, so today's event is quite essential to that process. The chamber was designed by Enric Miralles to encourage informed conversation rather than simply confrontational debates. We also have confrontational debates, but we like to have some conversation in the chamber.

I thank you for attending and hope that you will have an interesting and meaningful exchange of views. The Health Committee's convener, Roseanna Cunningham, will outline the context for the debate.

10:38

Roseanna Cunningham (Perth) (SNP): Good morning, everybody. I am not used to sitting up here at the podium and none of you is used to sitting down there, so I guess that we are all in a position that is slightly different from normal.

I suppose that my opening remarks might be characterised as being a word from your sponsors, because today's event is brought to you courtesy of the Scottish Parliament's Health Committee, of which I am convener. On the Health Committee's behalf, I thank you for coming here and welcome you all.

The Scottish Parliament's committee system has often been described as Parliament's real triumph. Certainly, work in committees is among the most rewarding work that any MSP does. The Health Committee is made up of four Labour members, two SNP members, one Conservative, one Liberal Democrat and one independent. We work very well together and only rarely do party politics come into our work, which means that we get a high degree of agreement across the board. That was certainly the case during the work we did that has given rise to today's debate.

All members of the committee are present—you will hear from a few of us at the end of the morning and at the end of the afternoon, but you will be pleased to know that we, the politicians, will not take a front seat in today's debate, but are here primarily to listen.

Setting up an event such as this is rather like deciding to hold a party—one makes all the preparations and then sits waiting anxiously to see whether anybody will actually turn up on the day. It is plain from the response to invitations that this is one party that no one wanted to miss. The chamber is full of eminent surgeons, people from the health boards, national health service staff and—more crucially—local campaigners and other members of the public who entered the ballot to participate. We might ask them at the end whether they think that they were lucky or unlucky to win that ballot.

We are geographically well represented today; I understand that folk from as far afield as Benbecula and Thurso are here. I am well aware that some of you have given up considerable time to be here and that you have made a considerable effort to travel to join the debate, which in itself is an important aspect of today's debate.

The background to the event is the Health Committee's work in recent months. Last year, we began an inquiry into workforce planning in the NHS, but it did not take us long to realise that pressures on the workforce were linked closely to the changes that were taking place in the NHS in Scotland. As many of those changes have provoked public opposition and anger, our inquiry was expanded to bring such matters into that wider remit. I know that all participants have received a copy of the Health Committee's report, so perhaps you will want to say something about it during the debate. For good or for ill, please do not hold back.

While we were doing our work, it became impossible to ignore the widespread feeling that there had been an across-the-board failure to consult effectively on all the various changes that were being made in delivery of NHS services to both urban and rural communities. If consultations took place at all—whether of patients or the public—they were seen as having been either cosmetic or unsatisfactory in other ways. Equally important, we saw that some of the changes were taking place piecemeal throughout the country and that it was difficult to discern any Scotland-wide strategic planning in any of it. That is why we decided to hold a major public debate and why you are all here today.

We have invited representatives of all those who have an interest in the future of the NHS—patients, professionals, academics and members of the public—to debate the subject. We hope that all shades of opinion will be represented and that the debate will range over all areas of concern.

While work was ongoing in the committee, in response to some of the public anger the Scottish Executive separately appointed Professor David Kerr to examine various changes that had already been made and suggest what the future shape of the NHS should be. While the matter is being deliberated, a moratorium has been put in place that blocks any major new changes. Two members of the Kerr group are here today. I hope that they will listen to what is said and that they will incorporate today's debate into their deliberations, as we on the Health Committee will incorporate their report into ours. We anticipate the Kerr report's being published later this spring.

I will say a brief word about the structure of today's event. We will focus this morning on how best to reshape the NHS to meet patients' needs. This afternoon, we hope to discuss possible solutions to some of the problems that face us. We have kept the two motions relatively general so that no one need feel constrained that the points that they might wish to make are not relevant; everything is relevant today. The structure is formal because a group of 110 people or so is rather too large to manage informally. You will hear from a number of different individuals and, other than opening speeches, everyone will have to keep to the same short speech time that is normally allocated to MSPs in parliamentary debates. Perhaps participants will go away feeling a bit sorrier for us than you did before today, but perhaps not.

We will start with Richard Norris, who is the newly appointed director of the new Scottish Health Council, which has just been set up. His speaking in today's debate might be Richard's first major duty. We will then hear from Professor Sir John Temple, who has undertaken a lot of work on

workforce planning and the NHS for the Executive and others. I am glad that he will be free to speak personally today as well as in his capacity as an expert.

You have heard enough from me, so I will sit down among you near one of my local campaigners. I want all delegates to contribute to the debate in the morning and in the afternoon, and I hope that you have fun as well. It is your day, so I really hope that you make your voices heard.

The Deputy Presiding Officer: Roseanna Cunningham said that she does not normally get to speak from the Presiding Officer's desk and now she is about to sit where the First Minister usually sits. She does not get to sit there very often either. Perhaps one day—who knows?

We will now start the debate on how the NHS in Scotland can be reshaped better to meet patients' needs. I will call Richard Norris and Professor Sir John Temple who will each have eight minutes to speak. When I call Richard Norris, I will be grateful if other delegates who wish to speak would press their request-to-speak buttons at that point. That does not mean that you cannot do so later, but it allows us better to work out the sequence of speakers.

10:45

Mr Richard Norris (Scottish Health Council): I thank the Health Committee for staging today's debate and for opening up the Scottish Parliament to participation by people who have an interest in the future of the NHS. A debate such as this represents a step forward.

As the Health Committee said in its report:

"The enormous public reaction to the wave of proposed changes to the provision of NHS services in Scotland has signalled clearly the lack of public debate that there has been on this topic—one crucial to the future well-being of the nation."

It is good that we are having that debate today.

As has already been mentioned, the Scottish Health Council is a new organisation whose task is to develop and monitor patient-focus and public-involvement activities in the NHS in Scotland. I emphasise for two reasons that I do not speak today as some sort of representative of patients or the public. The first is that we are a new organisation—we have existed for only one week. Secondly it is not in any event our function to be representative. As we will hear today, patients and the public are perfectly capable of speaking for themselves. The Scottish Health Council has not been set up to be a patients' voice, but to ensure that health boards become better at listening and responding to the views of their patients and communities.

I am not an expert on workforce planning issues, although I will pick out some salient points from the Health Committee's recent report, which I very much welcome. The report states:

"It is also important that workforce planning in future is driven primarily by patients' needs and the desire for good health outcomes, rather than an over-concern for traditional roles or professional structures. It can be argued that this has not always been the case in the past."

The report makes the point that there has been significant and substantial additional funding. I note the Health Committee's concerns that the

"additional resources may be absorbed by the NHS without a direct impact on the improvement of patient care."

That concern is widely shared.

Among the issues with which the report deals is increasing specialisation and the centralisation that seems to go with it, which is at the heart of much of the recent controversy over health board plans. The committee has argued that centralisation of services is not always sensible or in patients' best interests and it refers to a "fault line" that has appeared, with the public on one side and health boards and professionals on the other.

The report notes that

"health boards have frequently failed to convince the people they serve of the reasons for proposed changes."

It also notes that professionals do not always agree either, and that support for centralisation is not universal from that quarter.

We learn from the report that although there might well be evidence to support the argument that increased specialisation leads to better outcomes for patients in respect of particular procedures, witnesses were unable to provide evidence to support specialisation across the board.

It is clear that everyone wants better outcomes for patients and that the person who has the strongest interest in all that is, after all, the patient. However, it seems that there have, in many areas of Scotland, been genuine disagreements about how to achieve that. There is nothing wrong with disagreement; in fact, it can be quite healthy. In an age when commentators describe the growing problem of apathy and disengagement with the public realm—falling turnouts at elections, for example—perhaps we should be pleased that issues about delivery of NHS services are so important to people, rather than see it as a problem. However, if there is disagreement, people need to be treated like grown-ups. They need to be given all the appropriate information, treated with respect and trusted with openness; we have already heard it mentioned that there has been a feeling that consultation has sometimes been too cosmetic.

Health boards need to present all the options for public consideration and not to be premature in ruling out options. One member of the public commented about a recent health board consultation by saying that when the option that one is in favour of has been ruled out before consultation begins, you cannot really talk about that option. There is deep cynicism about health boards and plans for centralisation and about the sometimes belated attempts to engage the public. Although disagreement is healthy, that situation clearly is not.

In its report, the Health Committee has called for a public debate and we know that the public are keen to take part in that debate, not just from the turnout today but from a survey that was conducted in 2004 on public attitudes to the NHS in Scotland. That survey was carried out on behalf of the Scottish Executive by NOP and the University of York and found very high satisfaction levels in respect of individual NHS services; for example, 90 per cent of users were very or fairly satisfied with each of the eight services that were covered in the survey. However, when it came to public involvement, most people felt that the public has either very little influence or no influence at all over how the NHS is run. That figure has risen from 57 per cent in 2000 to 73 per cent now: people are not happy about the level of public involvement. In the same survey, 86 per cent of people thought that members of the public should have either a great deal of influence or some influence over the way in which the NHS is run. The fact that is revealed by that research is that the vast majority of the public consider that they do not have enough influence or say in how the NHS is run.

I return to evaluation of a consultation that I mentioned earlier, which was evaluation of one health board's consultation of the local public. Seventy-five per cent of people who were asked about that consultation felt that their views had had no impact on direction of clinical strategy. That report also quoted a member of the public as saying:

"I do not sense that the consultation made any difference. Any concessions made by the Board were due to the negative media coverage."

Sometimes we hear that the most vocal and active of campaigning groups or special interests are unrepresentative. That may be true, but that is why it is important that the NHS get better at true public involvement that gives everyone the opportunity to have their voice heard and listened to by health boards. One of the important points is that we need a proper and informed debate, but when health boards appear to be pushing through change against the views of the communities that they serve there is a cost, which is the loss of trust and good will. I appreciate that health boards and

health services face a challenging agenda; given the difficult decisions that need to be made, it may be impossible for boards to make those decisions with the full support of the communities that will be affected. However, it is important that the process by which such decisions are made is seen to be legitimate, and that the public have confidence that decision makers in the health service really are trying to do their best for them.

We hear a lot these days about the evidence base—evidence-based medicine and evidence-based policy. Indeed, the role of the Scottish Health Council will be to produce evidence-based standards for public consultation and patient focus. Sometimes, however, the question that needs to be asked is: Whose evidence? Do we treat the views of patients and the public as being as much a part of the evidence base as the results of clinical trials or economic studies? Until now, that does not appear to have been the case.

There will, in the coming years, be many challenges in reshaping the NHS and not just in relation to centralisation. What the Health Committee refers to as the "fault line" will continue to be a big problem unless it can be demonstrated that all the evidence is being weighed fairly. It is about treating every view with respect. The re-establishment of trust and good faith is the single most important outcome for which we need to aim, not just today but in discussions in the future.

10:53

Professor Sir John Temple: I am pleased to be here to talk about the issues. Many people will know that, during my time in Scotland, I was responsible for the production of two reports for the Minister for Health and Community Care, on the future of the medical workforce in Scotland and how that relates to health care delivery. I must say that it was the medical workforce that we examined: that was not to dismiss all the other people who provide health care, but we had a focused view, so that was what we did.

In "Future Practice: A Review of the Scottish Medical Workforce", which came out in June 2002, and in "Securing Future Practice: Shaping the New Medical Workforce for Scotland", which came out in July 2004, we tried to give clear messages. I am not going to repeat those messages in detail, but I will pick out a few issues. I am speaking today in a personal capacity. I was chair of the short life working group and I am chairman of the Specialist Training Authority of the medical royal colleges, which oversees all training of all hospital doctors. I will give today my distillate of where I think things are going.

There are five pressures for change from which we cannot get away and which we must

recognise. First is demography, then technological advances in medicine, which is allied to increasing public expectation—those two cannot be separated. We have already heard from Richard Norris about specialisation; I have a specific interest in the training requirement for that. Fourthly, there is globalisation of the workforce, which is with us. Finally, there are the working time regulations and the new contracts, which affect the way in which people in health care are allowed to work. I shall deal briefly with each of those factors.

The demography of Scotland is not new and neither is the centripetal flow from without into the centre of Scotland. Those factors were present more than 100 years ago and have remained with us since. They are not new, and neither is the migration of people out of Scotland, although there is perhaps a difference now in that, in previous years, much of the emigration involved trained and professional people. Now, younger people in Scotland tend to leave. That is a problem. There are people coming back into Scotland, but they are not in that age group and they are not those sorts of people. They tend to be much older people who are coming back for lifestyle-change reasons. That trend, particularly in the more remote and peripheral parts of Scotland—and even in some of the more urban areas—is leading to what we now recognise is an increasingly aging population, which is also reducing at the same time. That brings its own special health care needs, all of which has been well reported.

That there is an issue in respect of technology and public expectation is irrefutable. Of course we want technology and we want new advances. In our lifetimes in the profession, we have all seen enormous changes, as we should. Such advances raise public expectation, which is also as it should be. Those two are inextricably linked; who would not want coronary artery by-pass surgery if they have myocardial problems, or would not want a knee replacement to be done by somebody who is good at doing knee replacements? The knee is the most commonly replaced joint in the United Kingdom at present and we have to accept such facts.

On specialisation and training requirements, the public expect—they are quite right—well-trained professionals to deal with them when they are ill. Many of the training reforms came about when we did not have restrictions on how doctors and other personnel worked. We have restrictions now and we also have contractual issues because of the new contracts, which has led to a shift in emphasis. The royal colleges in particular have been blamed for specialisation, but they were merely responding to public desire and to service needs at the time. I must point out that the colleges have changed their emphasis over the

past three to four years because of the impact of the working time regulations. We now have good examples of changes from more specialism to what I would call more generalism. The paediatric world has changed, general medicine is changing and even my discipline in surgery is changing. Urology is now dealing with general urologists and office urologists and is starting to train for them.

Those are all steps in the right direction, but we must remember that the standards that are required and the regulations that are necessary for education and training are not devolved matters; they are reserved matters for the whole United Kingdom so that we can have a flow of professionals across borders, particularly the border between England and Scotland.

That brings me to globalisation of the workforce. Free movement is the very basis of the European Union. We cannot deny that and we will not change that, but we must recognise—I come from England—that we have a predatory neighbour down south, which has been recruiting worldwide as well as UK-wide for the past four or five years. Some of that has been at Scotland's expense and Scotland has perhaps not responded sufficiently. Some solutions to that problem were suggested in "Securing Future Practice: Shaping the New Medical Workforce for Scotland", which was published in July last year.

The final pressure is from the European working time regulations and the new contracts. Those are the very reasons why the professions—my profession in particular—need to change how they work and approach their tasks. Why? It is because we no longer have the opportunity to have as many doctors as we want whenever we want them. First, such numbers do not exist and, secondly, those that do are restricted as to when they are allowed to work.

What do we need to do? I have said it before and I have no hesitation in saying it again in this chamber that the first thing to change is the way in which Scotland's NHS is organised at present. In my view, it is not sustainable to have 15 regional health boards for 5 million people because the situation becomes extremely territorial. England has 13 strategic health authorities for 55 million people. An area that I know extremely well—the west midlands, where I come from and where I still live—has three strategic health authorities for 5 million people. It also has about the same number of hospitals and so on as Scotland, although dispersal is of course slightly different.

In Scotland, we need what I have called a macro health economy that can plan. However, that is not enough; that economy has also to be responsible for service delivery, which would allow us to pool and redirect resources so that we could provide

safe, appropriate and sustainable health care that meets patient and service needs.

Equity of access to health care is a basic tenet of the national health service. Of course everyone wants local services; I believe that we can have local services, but they must be safe and they must be deliverable. I would put those two requirements together and use the word "appropriate". The services have to be appropriate for the health service that we are trying to run today.

We will have to consider the services of communities—any community. Communities will have different patterns and different requirements. We will then have to consider the work that is to be done, which I would separate into two parts. There is what I would call the elective work or the cold work, much of which is minor and will be carried out at extremely local level, as it should be. However, some work is more major. Many people—although not yet all—understand that they may need to travel for a major event, a specialised event or a once-in-a-lifetime event, but we are talking about only a very small percentage of patients and an even smaller percentage of the population. That small percentage of people must understand why they might need to travel for a major event—whatever it may be—and then return, via step-down facilities, to their own community.

As we all know, the real difficulty lies in what we have called 24/7/52 delivery, which is the round-the-clock delivery of emergency and urgent patient care. There are three scenarios: in the community there is primary care; in the hospital, there is secondary care, which is a very full service at present, but there is also something between those that has not really been developed except in one or two places, although we can find some very good exemplars in Scotland.

The working time regulations have made the matter crucial—it has to be addressed. There are not enough personnel to staff around the clock everything that we staff just now and if there were, they would have to have enough to do. We cannot pay people full-time to work part-time, and their roles have to be challenging and fulfilling. There must be enough of what we call medical patient throughput to maintain and advance skills. When that is sustainable, we will have an all-singing, all-dancing secondary and primary care service. When it is not sustainable, we will have to consider other ways of delivering health care that is regarded as safe.

We need protocol-driven health care. People who initially receive and deal with patients must be able to stabilise them and, only when necessary, to transfer them. For such transfers, we need to ensure that the transfer facilities are up to the job.

The ambulance service here and everywhere else does an amazing job. However, we do not use air ambulances enough; we should remember that the first air ambulance in Scotland started in the 1930s and not the 1990s. In addition, as I have often said, we do not use water transport enough in certain situations. Those problems can be solved, but there are different ways of providing care in different places.

I am not suggesting that we should close anything. I have never suggested that here, in England or even in Iceland, where I have spoken on such issues. However, we should look into what we do and we should consider service redesign, reorganisation or re-engineering. I do not mind what we call it because we all know what we are talking about, which is using facilities in a different way, as we have to do.

We are all members of the public and occasionally we are all patients—although we hope not too frequently. As we have already heard, the public need to understand the issues. How can we ask people to take ideas on board if we have not put our message across clearly? We have to use words that people understand rather than our jargon—I hope that I have not used too much jargon this morning. Today is about getting the message across. We have heard that the public are often involved late, so we should involve them earlier.

I remind delegates that a Highlands and Islands health board was set up in 1913 for very good reasons. It was a forerunner of the national health service in 1948. It was well-organised and well-planned and it delivered a good service. It had no difficulty in recruiting staff, in enhancing team working or in providing a good safe service. It was innovative. We need to be innovative again. That is possible, but it is time we got on with some things. We have had reports lying around for nearly three years, but we still do not seem to have gone very far forwards.

Those are my views; I thank you for listening.

The Deputy Presiding Officer: We come now to open debate. I ask for speeches of about four minutes. If speakers are timing themselves, they will find that the upper of the two digital displays over to my left, or the one on the left of the two digital displays over to my right, will show the time that they have taken. Unfortunately, because of a triumph by our design team, there is no clock that you can see without twisting your head one way or the other.

11:06

Ms Margaret Hinds (Health Service Forum South East): There is deep dissatisfaction with health provision across Scotland. That

dissatisfaction has brought hospital campaign groups together under a single confederation—the Scottish health campaigns network.

Over the past 14 years, hospital provision in Glasgow has been reduced to unacceptable levels. Greater Glasgow NHS Board has inundated the city with consultation documents and meetings. The health service forum south east responded, attended and read, and it produced petitions ranging from 72,000 to 235,000 signatures, but it was all to no avail.

Greater Glasgow NHS Board is not alone in its determination to close hospitals and reduce services. The number of hospital closures and reductions in services across the country is unacceptable. The latest disaster—which we must take very serious account of—is the recent report of the increase in the number of infant deaths in Inverclyde since the closure of the Rankin hospital. That sort of thing could happen in Caithness. When I lived in Caithness 25 years ago, we fought hard to get a decent maternity service, but where are we now? We are going back 25 years. It is incredible and very wrong.

The introduction of trusts with their marketplace economy—and the resultant dominance of the accountants and the administrators—has accelerated the downward spiral in the NHS. We are convinced that outbreaks of winter vomiting bug and the more serious MRSA are due in part to the outsourcing of catering, cleaning and laundering. An even more important factor is the striving to achieve 98 per cent bed usage. That is intolerable; it is incredible and it should never have happened. In Scandinavia, when a patient goes home from hospital, their bed is completely decontaminated. The whole job can take something like 24 hours. What happens in our hospitals? We have hot bedding. We know perfectly well what that is. People come in and say, "What bed are you in? Oh, that's great. I can move into it as soon as you go home." That must be wrong in a hospital. MRSA and sickness bugs prove that it is wrong. That is sheer common sense.

The Victoria infirmary in Glasgow lost 25 per cent of its most qualified nurses to NHS 24. Operations were stopped in the infirmary not because we did not have consultants or theatres but because we had no nurses, as many had been taken to NHS 24.

We are now faced with the next catastrophe: a stand-alone ambulatory care and diagnostic unit. ACADs are perfectly acceptable as part of an acute hospital, but stand-alone ACADs are totally unacceptable. We consider it intolerable and unacceptable—on the ground not just of health, although that is most important, but of transport—to deal with 400,000 patient episodes in the

Victoria infirmary, which is a considerable distance away from the nearest acute hospital.

I ask people to visit our web page, where they will see that we have produced "Keeping the Scottish NHS Local", which follows what was in the English Department of Health's document "Keeping the NHS Local: A New Direction of Travel". The DOH has proved, as have we, that the way we are going is wrong. People want safe local hospitals. We are not saying that we do not want specialisation. We are perfectly willing to accept it. For example, it is acceptable that the Southern general hospital has a spinal injury unit. However, we have to examine the whole issue and keep local hospitals, which is what people want.

On behalf of the forum I thank the Presiding Officer for the opportunity to speak to this meeting and to air our views. The forum's website is www.healthforumglasgow.org. Please read it.

The Deputy Presiding Officer: I should explain that when delegates appear on my screen they appear as the MSP whose card they have. I will not be doing this for everyone, but I cannot resist introducing Jim Devine from Unison with the intelligence that he appears on my screen as Miss Annabel Goldie.

11:12

Mr Jim Devine (Unison): That has possibly not done me any favours.

I was born in the national health service, I had the great honour to work in the national health service and I have the privilege to represent nearly one in two health service workers in Scotland. I also hope to die in the national health service, although not as early as some might wish, and certainly not with the intervention of some new Labour groupies.

It is worth reminding ourselves what is happening today in the Scottish health service. More than 100,000 people are receiving health care—they are visiting their general practitioners, they are being operated on, their babies are being delivered or they are being visited by district nurses. The service is provided free at the time of need. It is interesting that Richard Norris mentioned patient satisfaction levels of 95 to 98 per cent for people who are admitted to and treated in NHS hospitals. This debate is important, but we have to be careful that we do not talk ourselves out of the NHS.

Reference was made to money. We have great concerns about how the money in our national health service has been spent. The drugs bill has doubled in real terms in seven years. We are paying 32 different prices for cornflakes in the

Scottish health service as a result of the internal market and that can be extended to beds, bandages and breakages. Just down the road we have Edinburgh royal infirmary, which should be called Edinburgh royal bank infirmary, because it cost £185 million to build but Scottish taxpayers will pay back £1.2 billion. At the end of 30 years, we will not own one blade of grass. An examination of expenditure in the Scottish health service shows that it is a cash cow for the private sector.

The status quo is not an option. It is not easy to come here and say that, or to say that to local campaigners and our members. We have made a significant contribution to David Kerr's report. We have set out patient and client-centred criteria that should be used in service change. We have not gone for a trade union argument, because not only do our members use the national health service, but their families use it.

Unison asks for only three things. First, the Parliament must mature. We need our elected representatives to examine the Scottish health service through the eyes of Scotland, not from the point of view of 129 separate patches. Secondly, we must be given one target, such as an 18-week target for the time between someone being seen by their GP and their commencing treatment. We should not be given a dozen different priorities a week. Thirdly, as Roseanna Cunningham referred to, it is nonsense that we have one group looking at the workforce, another group examining service delivery and another group looking at education and training. Those three groups must be brought together.

11:16

Mr Ken Barr (Cowal Against the Cuts in Health Services): I praise the Health Committee on the excellence of its second report, on workforce planning. Were the Executive to implement the many improvements to health provisions that are suggested in the report, there would be little need for our organisation to exist. However, I will raise three points of particular concern to our area of Cowal in Argyllshire.

First, paragraph 164 of the report states that the committee

"welcomes the common sense attitude of the Executive in agreeing to postpone future decisions on service restructuring until"

after Professor Kerr reports. Nobody appears to have told Argyll and Clyde NHS Board, which has continued with its decimation of our services under the banner of "new, improved", which is a term borrowed from junk food manufacturers. One example of the new, improved service is the downgrading of maternity care, with the closure of

the obstetrics department at Inverclyde royal hospital and the relocation of the service to Paisley, where I am told that expectant mothers in the early stages of their confinement have had to wait in corridors or wheelchairs for beds, and mothers who have had their babies have been discharged prematurely to make way for others. That is not to mention the tripling of infant mortality that has been mentioned.

Secondly, the lack of ambulance cover in Cowal is totally unacceptable. Our group, along with the local community council and others, warned that it was unsafe and that deaths would occur. On Friday 11 March, a man of 47 collapsed in the main street in Dunoon and the emergency services were called. The police arrived within minutes and attempted manual resuscitation, with the help of the nearest doctor, who attended with oxygen, as his surgery did not have a defibrillator, although the surgery 400yd further away did have a defibrillator. An ambulance arrived 45 minutes later, by which time the man had died. I understand that the ambulance had come from Arrochar, which is 39 miles away, because our single ambulance was otherwise occupied. Despite Argyll and Clyde NHS Board's repeated promises since last year that we would have a second ambulance by 1 February, we still do not have it. We are told that crews are being trained, but the board has used that excuse for weeks.

A lady with cancer in Tighnabruaich who was undergoing chemotherapy became ill. She was shaking and nauseous. Her husband contacted his local surgery. As it was shortly after hours, he was told to contact NHS 24, which he did twice, 45 minutes apart, but his wife's condition deteriorated. To cut a long story short, NHS 24's answer to that emergency situation was a wait of two hours for a doctor to attend, one hour for the ambulance to arrive, and another two hours to get to the Beatson oncology centre.

In exasperation, the husband called the local doctor, who arrived within minutes and tried to organise her quick transfer to Glasgow. The air ambulance could not come, because the helipad at Tighnabruaich does not have landing lights. An ambulance transfer to Glasgow was unacceptable to the patient, who did not feel up to it. Eventually, an ambulance to Dunoon and a helicopter transfer from there to Glasgow were arranged. The patient eventually arrived at the Beatson at 1.30 am the next day. Incidentally, the local Tighnabruaich doctor was on NHS 24 call for his area that night, but he was never contacted by NHS 24, a fact that he made known to the NHS in no uncertain terms.

There is the case of a 14-month-old toddler with a high temperature and a rash, whose mother was informed by an NHS 24 telephone receptionist that someone would call back; someone did, 15 hours later—what if it had been meningitis?

Thirdly, there is the proposed closure of five hospitals—two mental health hospitals, two for people with learning disabilities and one for the elderly—which is being slowly implemented ward by ward without adequate care in the community being in place. I could say more, but I am not here to be negative.

All helicopter landing pads must be equipped with landing lights. Rural taxi firms or local volunteers should be provided with large estate cars or people carriers that can meet the medical team at the helipad, uplift them and their stretcher, and take them to the patient's home. The patient can be readied and transported to the helicopter, rather than having to wait for an ambulance to become free then travel for an hour or more to perform the transfer. Information on the location of life-saving equipment should be given to all emergency services, with a list of those trained in its use.

On NHS 24, the call centres should be disbanded and the service made more local by using receptionists and trained nurses in local hospitals, where they will assess and triage as at present but with local knowledge. Moreover, surgeries should programme their telephones to divert automatically to the local service.

On training, I have advocated at several meetings that full loans, including a living allowance, should be made to young people wishing to become doctors. The thought of years of training with no money coming in but with ever-rising debts must be a significant deterrent to capable young people from lower-income families. The loan could be repaid by the recipient in one of two ways: over a period of years, with interest; or by their agreeing to work exclusively in the NHS in Scotland for a period of, say, 10 to 15 years after graduation.

Finally, there is no support in Cowal or Bute, or even Paisley, for our use of Paisley's Royal Alexandra hospital—a hospital that is already at full stretch. Travelling to Paisley makes no sense to people in Cowal or Bute. Argyll and Clyde NHS Board is unsustainable. The £40 million deficit is unrepayable. If we are to maintain a service fit for one of the richest countries in the world, the deficit must be written off and a total rethink on the restructuring of the board should be undertaken. There is a need for a fully functional hub-and-spoke model, with Inverclyde royal hospital as the hub, and the smaller hospitals in Argyll and Bute as the spokes. As Professor Kerr said to me in Glasgow before the public meeting, we should

"Take the doctors to the patients, not the patients to the doctors."

In other words, we should share consultants among the hospitals.

Everyone I have spoken to expects centres of excellence for cancer, transplant surgery, heart bypasses and implants, and neurosurgery. In the case of lesser procedures, general surgeons—such as Dr Sedgwick in Fort William—should be placed in local hospitals. A much increased use of telemedicine must be the way forward. I could say much more, but I am out of time.

11:22

Ms Helen McDade: I thank the Health Committee for carrying out the review and inviting members of the public to the debate. The committee is to be congratulated on taking an innovative step.

However, for the Scottish Parliament to review the workforce rather than to take a strategic overview of the heath needs of the population is perhaps to put the cart before the horse. The two are not necessarily the same thing. Many groups, such as the chronically ill and people with developmental conditions, do not fit into the present structure of the NHS. Thousands of people who are significantly affected by ill health receive very little care from any aspect of the NHS. One example is a little girl in Glasgow who for years has been unable to get out of her bedroom. She is cared for by her mother, lives in a darkened, soundproof room, and has received practically no medical care. She is not an unusual example. For someone who does not belong to a priority group for the NHS and the Scottish Parliament, it is a very different world. I feel as if I live in a parallel universe to the one that Professor Temple and Jim Devine described, which bears no relation to the one occupied by those of us with chronically ill family members.

Tens of thousands of chronically ill people have signed petitions to the Parliament—the position of such people is an example of unmet need. Health professionals know about the patients who come through their door, but they do not know about sufferers who are nobody's patients. Richard Norris mentioned the high level of satisfaction on the part of those who are seen in clinics. I am sure that that is true, but there are many people out there who are not being seen much by anybody. If the review looks only at how to improve current services, it will miss a huge area of need and those badly neglected groups will still be out there. Such groups have no champions in the current hierarchy. Indeed, in some areas, doctors who have championed those groups have been forced out for speaking up.

The Health Committee, having rightly identified that specialisation is an area of contention, has perhaps missed the area that I am talking about, which is the groups that do not fit into any particular box. The old joke about a specialist

knowing more and more about less and less seems apt when we consider someone who has a lot of things wrong with them and who does not fit into a specialist box. Another problem with specialisation is that if there are a lot of psychiatrists but few neurologists, for example, the medical profession will tend to view matters through psychiatric spectacles. That is what is happening. Because of the deficiency in many areas of specialisation, such as neurology and immunology, people are sometimes forced in one direction, in tandem with medical research. When pharmaceutical companies pay for research, they choose the type of research. We get drug-based long-term treatment, not cheap cures or investigation into nutrition and toxicity.

Many chronically ill people would suggest that complementary medicine is another area that should be brought into the NHS, yet Glasgow homoeopathic hospital is under threat. Is that due to patient dissatisfaction or lack of powerful medical lobbying? Ironically, many chronically ill people end up becoming a high priority, as a result of exacerbation, by becoming an emergency or because they get to the stage where they are suicidal, and—bingo—they have become a high priority for the Scottish Parliament, the Scottish Executive Health Department and the NHS. Ignoring the chronically ill may save the NHS money in the short term because it is not speaking to them and not looking at them, but it will cost us all a hell of a lot more in future.

11:26

Mr Jim MacLeod (Inverclyde Council on Disability): Most people in Scotland appreciate that the world has changed since the inception of the NHS in 1948 and that the health service in this country must also change. However, it must and should change for the better. The big question that must be asked is whether more centralisation of health services in Scotland is a good thing. If it is a good thing, who is it good for: the Scottish Executive; the UK Government; health professionals; or the public who depend on the NHS? Most people would agree that not all NHS services can be delivered locally. Specialist services such as cancer services, most heart surgery and neurosurgery are delivered by hospitals in cities such as Glasgow and Edinburgh. Most people agree that that is the best way to continue. However, many other forms of medicine should continue to be delivered locally in hospitals throughout Scotland.

All of us taking part in the debate will be aware of drivers—such as the European working time directive, the new deal for junior doctors and recruitment problems—that are being used to attempt to force through change, but we should

not forget that those issues did not turn up yesterday. We have known about the working time directive for more than 10 years, yet until now the Scottish Office, the Scottish Executive and the health boards have done very little to try to address the issues. In Inverclyde, where I come from, our local hospital—like many others in Scotland I am sure—has lost many of its local services in recent years: in-patient ear, nose and throat services; in-patient dermatology; in-patient gynaecology; in-patient paediatrics; and consultant-led maternity services. The loss 18 months ago of our consultant-led maternity service to Paisley's Royal Alexandra hospital has already been mentioned this morning. A sad and disturbing statistic emerged last week, which is that since the loss of that service the number of infant stillbirths has increased threefold. That is a tragedy for every one of the families to whom that has occurred. Although an investigation will need to take place, we cannot help wondering what part the loss of the consultant-led maternity service has played in it all.

In Inverclyde, there is a great mistrust of the local health board and what the Scottish Executive is or is not doing about our health service. To date, 55,000 people have signed petitions to save our local health services in Inverclyde. Many people are suspicious that it is all about money and cutting costs. They see any further erosion of our health services and cuts that are proposed by our local health board in accident and emergency, coronary care and laboratory services as leading to the end of our local hospital. If we are to lose even more health services, people will not want to stay, or indeed come to live, in areas such as Inverclyde, which already has its fair share of problems such as poor health, unemployment and lack of job prospects. People need assurances that if and when they fall ill, they will be treated quickly and safely in a local setting. Unfortunately, Inverclyde has an unenviable health record—only Glasgow's is worse in Scotland. The last thing we need is to lose our local hospital. If more services go, it becomes even more unsustainable.

In reshaping the NHS to meet patients' needs better we should become more patient focused. We do not need statistics that are engineered to get the results that health boards require to support their arguments for more centralisation. We should be aware of the transport difficulties that patients and visitors will face as a result of more centralisation, particularly disabled and elderly people and people who live in poverty. We need to be aware that more people may move away from areas where few or no local health services are delivered. We must also be aware of the impact of further centralisation. Will risk assessments be carried out? We also need our health planners to come up with improved

strategies that will help to retain the local delivery of health services.

The Scottish Executive and the health boards must consider all the options—they must look at health matters with peripheral vision and be innovative, not insular. We should not be scared to look outside our country at nations that may already be solving or have solved the problems with which we are now faced.

11:31

Dr Danny McGuigan (Business Development Centre): I have delivered training and development, mentoring and coaching and stress-auditing services for the NHS in Scotland for more than 10 years.

How should the NHS in Scotland be reshaped to meet patient needs better? Professor Sir John Temple mentioned that we need well-trained professionals; I add that we need well-trained managers and leaders. Professor Temple also mentioned challenging and fulfilling roles and the fact that younger people are leaving Scotland. I was delighted that Richard Norris spoke about trust and good faith, because the NHS in Scotland should be a great place to work. Friendships and high performance can make it a great place to work but, in my experience, for some—perhaps for many—the NHS in Scotland is not a great place to work because staff are exhausted, demotivated and de-energised. They tell me that they feel that way because they are unhappy with the prevailing culture and with media negativity.

The most widely accepted definition of the term "culture" is that it is "the way we do things round here". To be honest, I cannot make any sense of, or find any pattern in, the way in which the NHS in Scotland does things—it seems incoherent. I have identified several problems, which people might find strange. They are the uncomplicated but daunting problems of the outdated and misleading definitions and understandings of what it means to be a professional, a leader or a manager. Those bureaucratic, outdated and archaic ways of managing and leading need to change, because they squeeze out and discourage friendship at work, which is my principal interest.

I have come across attitudes, decision-making processes and behaviour in the NHS in Scotland that add up to and point to an unhealthy culture. In a study that I carried out in one division of the NHS, staff described to me the way in which they experience the culture as follows:

"Disciplining friends is too difficult so don't make friends at work, make acquaintances ... Friendship gets in the way of decision-making, do as I say ... Friendship and feelings have no place in the NHS"

and, in any case,

"You are here to work not make friends."

In that organisation, 19 members of staff needed immediate help for stress-related reasons.

The chief executive responded immediately with a culture-change programme through which members of staff were encouraged to communicate and develop relationships that had previously been denied them. After two years, a further audit discovered that no members of staff needed professional support. When asked what made the difference, staff reported that it was freedom to make friends at work openly and to nourish those friendships. They reported that trust was blossoming and that conflict was being navigated more robustly and quickly. In short, leaders and managers modernised and the staff followed their example.

The European Commission's European network for workplace health promotion has just published on its internet site one of my articles, which is entitled "The power of friendship and leadership for wellbeing and work/life balance". Our European partners are well disposed to and are promoting the concept of friendship for health and high performance. The top leaders in the NHS today need to find a way of determining a leadership or management style that respects the power of friendship to produce well-being and high performance at work. That would carry moral authority and energise staff willingly to take on even more responsibility. I appeal to all the delegates—and to Mr Kevin Woods, the new chief executive of the NHS in Scotland—to take a serious look at that proposition. People might wonder how that could be done, but that would take at least another four minutes to discuss.

11:36

Professor George Irving (Ayrshire and Arran NHS Board): I will comment on something that I have heard and on something that I have not heard so far. We are in danger of polarising the centralisation versus localisation debate and thinking that centralisation is bad and localisation must be good. With respect, that is an oversimplification. The main issue is access. In NHS Ayrshire and Arran, we have found that people accept centralised specialist units, provided that we can arrange easy and convenient access to them. I agree entirely with Professor Temple's point that there are many reports on that, but little action.

If access is the main issue, the onus is on the NHS to ensure that people can get to facilities that have been centralised for valid purposes. NHS Ayrshire and Arran has appointed a transport co-ordinator to link with our local authority partners, voluntary organisations, community transport

schemes and the Strathclyde Passenger Transport Executive. A range of unused facilities are available to us for patient and relative transport, but that third element in the debate is often ignored.

I will comment on something that, regrettably, has not been discussed, although it has been touched on. Paragraph 18 of the Health Committee's report talks about more flexible working. Again, the focus is on professionals, which is a word that we have heard a lot this morning. The recommendation is for a dilution in medical dominance, to which none of us objects, and an increasing role for allied health professionals such as nurse consultants and endoscopists and occupational therapists. However, a wider range of people are involved. We heard talk of chronic patients, but we have heard nothing much yet about unpaid carers, who are the real caring service.

The caring services that the NHS and local government provide in Scotland involve about 350,000 carers, while it is estimated that there are 600,000 unpaid carers in Scotland today—many of them will be in the chamber. That equates to one in six households. Those people are unsupported, untrained and unidentified. We know that 93 per cent of unpaid carers undertake medical tasks, but that only 30 per cent of them have ever received training. It is estimated that unpaid carers save the NHS and local government £3.4 billion per annum in caring services. They are the fourth and major caring partner, but what, if anything, do we do for them?

The committee's report does not refer to the interesting fact that the NHS has required the implementation of carer strategies that acknowledge that largest caring partner. I am pleased to note that the Royal College of Psychiatrists now requires psychiatrists to undertake carer-awareness training as part of undergraduate and postgraduate qualifications. Inter-professional education, which is referred to in the report, must also involve raising awareness of unpaid carers and working with them. For example, some initiatives are under way at Glasgow Caledonian University's combined school of health and social care linking all these forms—the eight professions and unpaid carers—into one combined service on the understanding that those who train together will work together and remove the boundaries that we have heard so much about this morning. My plea is to reconsider what centralisation and localisation really mean, and to consider unpaid carers and what they contribute.

11:40

Mr John MacPherson (Killin Community Council): I thank the Health Committee for inviting

us lay persons to today's debate. I am a member of the public, an ex-patient, and the current chairman of the community council of Killin, which is situated in rural north-west Stirlingshire at the west end of Loch Tay. I have authority to speak on health-related issues for all the community councils from Callander in the south to Tyndrum in the north. That is a sizeable rural area. The distance from Callander to Tyndrum is approximately 40 miles and the area has a population of about 5,000, which increases greatly in the summer because of tourists, hillwalkers, fishers and so on.

Until 25 years ago, the areas of Killin and Strathfillan—that is Tyndrum, Crianlarich and Killin—were served by one local lady doctor who ably and conscientiously served the community 24 hours a day, or 24/7 as they say nowadays, and who was much respected by all. Since her retirement, the area has had much the same population and three doctors who provided 24-hour cover until NHS 24 took over. However, since the inception of NHS 24, the nearest out-of-hours doctor is based in Stirling, which means a journey of anything up to one and a half hours to see patients. There is also no local out-of-hours nursing or midwifery cover in our area.

Added to that is the problem of ambulance cover. Although I appreciate that that service is separate from health boards, it has a bearing on wider health care provision in rural areas. Prior to NHS 24 becoming operational, there was a double-crewed, full-time ambulance based in Callander with another double-crewed, part-time ambulance based in Killin. Both vehicles were available on an on-call basis 24 hours a day. Since the implementation of NHS 24, the cover for a 24-hour period consists of one full-time, double-crewed ambulance and one rapid response vehicle manned by one paramedic. That vehicle is, of course, unable to transport patients. Although that means an end to call-out duties for the crews, it represents a loss of one crew member and one double-crewed ambulance. The current service has to cover the area that I have already described.

I am well aware that several other rural areas in the country have similar, if not worse, concerns. Our area is fortunate in that Forth Valley NHS Board, NHS 24, the Scottish Ambulance Service, our local MPs and MSPs, local general practitioners and community leaders all meet frequently to discuss the problems. Although we do not want to alarm our communities, we are of the opinion that the current service is unacceptable, unsafe and a recipe for possible tragedy.

It is very easy to find fault with the service but I will briefly offer two or three possible points for

consideration. It must be remembered that providing cover in a rural area is different from providing it in an urban area. I make the plea that issues of time and distance be taken into consideration in the review that is now taking place. It must also be remembered that although rural dwellers might not add up to as many votes in an election, they pay the same for health care as their urban neighbours. Consideration should be given to placing primary first-response health care closer to the customer. It should be worth considering whether that would be more cost effective. It seems ludicrous that several qualified doctors with a wealth of local knowledge reside in our communities, but we have to wait for up to one and a half hours to get attention. Setting up cottage-type hospitals or clinics in rural areas should also be considered where there is no such provision at present, such as in the rural areas covered by Forth Valley NHS Board.

In order to encourage people to come into rural areas, we require to demonstrate that we have a robust and safe medical service. A number of people have already said to me that they would like to live in our area but have doubts about the available medical cover. That is relevant to people with young families and the elderly.

11:45

Mr George Bruce (North Action Group/Caithness and Northern Sutherland Health Forum): To me there are two important words in this morning's motion: "patients" and "Scotland". Scotland stretches from John O'Groats to the Borders, Buchan Ness to Ardnamurchan, plus the three island communities. It is not only made up of the cities and the central belt. The NHS in Scotland needs policies and structures that are tailored to the needs of individual areas rather than to the country as a whole.

For example, if it is suited at all, NHS 24 is more suited to urban than rural areas. We would possibly get better policies and more appropriate structures that fit the requirements of individual areas and their populations if the committees that were making recommendations and drawing up policies had a reasonable number of members from outwith the cities and urban areas. For instance, there is only one person with a rural address on the Kerr committee. In a country as diverse as Scotland, one size does not fit all, and that should be recognised by the policy makers.

Some months ago, a report in The Herald showed that a majority of Scots prefer to have general hospitals close by as opposed to having distant centres of excellence that are quite good if a patient lives beside them. In our area, people expect to have to travel more than 100 miles for neurosurgery or cancer treatment, but they do not

expect to have to travel for maternity care and dentistry. Indeed, in many cases, people are making a round trip of more than 200 miles for a short appointment with a consultant or a visit to a dentist who, at the moment, has to be private. That also used to be true for renal dialysis but that situation has now improved.

Appropriate policies and models of service in remote and rural areas are essential for the health of the local residents and, in the longer term, for the existence of a sustainable rural economy. If we continue with centralisation policies, there will be another Highland clearance. Although there might well be good arguments for the centralisation of some services, that does not go for all services. That is also true for specialisation. Centralisation can work against rural areas. Paragraph 142 of the committee's report clearly states:

"The most contentious centralisation proposals have been for core services such as accident and emergency and consultant led maternity and obstetric services".

The public has made it clear that it expects such services to be provided in local hospitals. My group, which is fighting for the retention of a consultant-led maternity service in Caithness, was born out of such expectations. Various reviews have taken place over the years and the latest one recommended a midwife-led unit, subject to certain conditions. That report led to overwhelming local opposition on the grounds of geography and safety. More than 2,000 out of a population of 7,500 marched in protest. That is the equivalent of 120,000 taking to the streets in Edinburgh or 162,000 in Glasgow. We have the support of local GPs and midwives and have received more than £8,000 in contributions to a fighting fund. At last, the NHS board has set up a maternity action team to look into the matter and it has involved members of the local action group, other service users, members of the hospital staff and GPs. That is a model that I believe should be used in the reshaping of health services in Scotland. Service users should have an input and be listened to at the early stages of any changes. The formation of so many action groups throughout Scotland and the umbrella organisation, the Scottish Health Campaigns Network, is testimony to the need for a change in approach in the NHS.

11:49

Robert Cumming (North Glasgow Monitoring Group): Arguably, the fundamental starting point for reshaping the future of the NHS in Scotland is the issue of medical manpower. I congratulate the Health Committee on the production and publication of its excellent document on workforce planning. Paragraph 8 of that document states that the lack of cohesive planning was due to the competitive nature of trusts. That might be true but

there are lessons to be learned from two previous attempts to deal with manpower planning in Scotland. One of those attempts was in the 1960s, following the Wright report, and the other was in the late 1980s and the 1990s, following the Shaw report. They foundered on two accounts. They failed first on political grounds, because there was inadequate finance to deal with some of the recommendations and, secondly, on professional grounds because universities exerted undue influence over where trainees were located—indeed, it was political and medical suicide to take a middle-grade post outwith a teaching centre, as that would ensure that one's chances of becoming a consultant disappeared down the tubes.

I am glad to hear that there is recognition from the royal colleges that generalism is coming to the fore. It should be recognised that most of the initial acute medical encounters between the public and the medical profession come into that generalist category. Accreditation and maintenance of standards is essential, but I know that super-specialisation has led to problems of recognition because people's training was not sufficiently general and the operation of the rotation system depended on general hospitals maintaining a teaching hospital. It is vital that generalist skills are not lost.

It was a great pity that the European working time directive was not anticipated earlier. For years, post-graduate education committees endeavoured to suggest to the then Scottish home and health department that increased manpower was required, but to no avail. We are now faced with a crisis to which the centralisation of resources, with its supposed economies of scale, is being promulgated as the solution. Regrettably, I see no evidence that some of the current planning is other than crisis management, with paper exercises that take little account of the clinical and practical realities.

In Glasgow, we have been waiting for a number of years for a report on the number of acute beds. We still do not know how many there are and the publication of that information has been repeatedly postponed. As one manager said to me recently, the debate is not a clinical one, it is about processes.

Much is made of the services that the new ambulatory care and diagnostic service will provide, particularly in relation to modern diagnostic techniques, such as magnetic resonance imaging. However, although finance might be available for the purchase of the equipment, there are major staffing problems that require to be addressed now, as those units are due to come on stream in 2008. By its own admission, north Glasgow division has a waiting list of approximately 52 weeks for a routine MRI

scan. The president of the Royal College of Radiologists told me recently that there was a shortage of radiographers and radiologists at the local level and throughout the United Kingdom. Glossy brochures might look good, but what about the reality?

There is a credibility mountain for the Executive and health boards to climb in order to gain the trust of the general public. The electorate of Strathkelvin and Bearsden were the first in Scotland to show their concern about the likely loss of a quality hospital service to their community. When they elected Jean Turner as their MSP, they showed that they were unconvinced that Greater Glasgow NHS Board had the answer to the problem. The group in Belford hospital in Fort William has shown that local acute services can be provided. Hopefully, the forthcoming Kerr report will take account of the concerns of local communities.

11:53

Ms Susan Aitken (Scottish NHS Confederation): I represent the Scottish NHS Confederation, which is the independent representative body for NHS boards in Scotland. I congratulate the Health Committee on today's fantastic initiative, which I hope will be the first of many such events in the chamber.

The subject of today's debate is the question of how the NHS in Scotland can be reshaped better to meet patients' needs. However, from the perspective of people inside the NHS, it sometimes feels as if the question should be whether the NHS in Scotland should be reshaped better to meet patients' needs. It seems that we face a paradox in which everyone agrees that something needs to change but, at the same time, there is still a huge resistance to change. All of us who are interested in the future of Scotland's health services and who want to see our NHS deliver the highest possible quality of safe and effective care to the whole population have to open our minds and our imaginations to the question of what our services will look like in years to come, what shapes and forms they will take and what the different points at which patients and communities interact with them will be.

The Health Committee's report, which prompted this debate, is an excellent starting point for thinking about the way ahead. It contains many valuable insights into the problems and issues that are facing us and embraces great solutions, such as new ways of working with staff in flexible roles. However, even that report often finds itself stuck in old ways of thinking and uses old language to talk about services. For example, it is dominated by discussion of acute services in large acute hospitals and barely mentions services delivered in primary care and at a community level.

The future of the NHS depends on all of us working towards a health service that ensures that fewer of us need to be treated in large, acute hospitals because the range of health care settings will be wider and will use the technologies that are available to meet patients' needs in the most convenient and appropriate ways. We need a health service in which the skills of all the members of the health and care team are maximised and treated with equal value and that, perhaps above all, does not merely treat ill health but promotes the health and well-being of the population. For example, people with long-term chronic illnesses, about whom we heard earlier, are not well served by a debate that focuses simply on acute hospitals and uses the term "health services" to talk about what is, in fact, a small number of acute hospitals and tertiary services. Health services are far wider than many of the issues that have been addressed today.

At the same time, we need to be realistic and honest about what it is possible for the NHS to deliver within the resources that are available to it. In a way, it has become taboo for NHS boards to admit that they are taking financial considerations into account in relation to service change. However, the NHS has a duty to deliver value for public money and to strive to strike a financial balance. The NHS should be able to be honest about that. There will always be limits to the resources available and the challenge is to maximise the return from those resources for patients and the public. If a service can be delivered in a new way that is just as clinically effective but more fiscally effective or which uses the skills of staff more efficiently, boards have a responsibility to examine that option.

The shape of services and the ways in which they are delivered will change as the years go by. It is essential to emphasise that the fact that a service has changed does not mean that it will be a lesser service. Different does not necessarily mean downgraded. I want to make it absolutely clear that a nurse-led, therapist-led or midwife-led service is not a downgraded service. In fact, it will often be a more appropriate and faster service for the patients who use it.

I make a plea to the people who usually sit in this chamber, our elected representatives, to be a bit more careful about the language that they use when they are talking about service change and the various roles of NHS staff. Scrutiny and questioning of what we do in the NHS are vital and welcome. However, in the day-to-day knockabout of party politics, it is too easy to fuel the genuine public concerns and fears about the future of services or to resist necessary long-term change in the interests of short-term electoral gain. The difficult thing—and the thing that requires real leadership in the NHS and the Parliament—is to

create a compelling vision of where we are taking our health services and other public services that will convince and engage the public and bring them with us on the journey of change. As Richard Norris said earlier, the NHS has a huge responsibility and a duty to gain the trust of the public with regard to that journey. However, we cannot do that alone; our elected representatives must support us in that task as well as holding us to account.

11:58

Miss Isabella Mooney (Glasgow Homoeopathic Hospital): I thank the Parliament for letting me be here today to have my say. I am an in-patient at the Glasgow homeopathic hospital, the in-patient bed facility of which is currently under review by Greater Glasgow NHS Board and might be closed. In April last year, the health board produced a press release headed "Challenge to deliver modernising agenda". It stated that the health board would deliver that agenda by

"identifying things that happen today that are not representing good value to patients and taxpayers alike."

My concern is not only for myself, but for the many who cannot be here to have their say. I believe that the in-patient bed facility in the Glasgow homeopathic hospital represents exceptional value not only to the patients who use it, but to the NHS and taxpayers, as it results in noted reductions in in-patients having costly medication, visiting their GPs, being referred to specialists and consultants and having costly investigations and surgery. That alone represents good value, saves time and frees up precious time. The exceptional value is reserved for the patient, who has access to an award-winning hospital that is the envy of the other homoeopathic hospitals in the country. It is not only surgical skills and technology that save lives.

The patients who attend the in-patient unit suffer a wide range of complex chronic illnesses, disability, emotional trauma, terminal illness and chronic pain. The commonality of the patients is the fact that they have all been down the conventional medical route and experienced the accompanying emotional rollercoaster ride. After many years of being on that emotional rollercoaster, people hear the words, "We can do no more. Take these pills and go away."

I have a degenerative bone disease that has no cure. I was referred to the homoeopathic hospital by a specialist consultant from Bristol, and I remember the words, "last resort." From the moment that I entered the hospital building, I knew that it was something different. Many of the in-patients' testimonies against the proposed closure of beds use words such as "sanctuary" and

"haven". Those are powerful words to describe a hospital.

In its approach to treating patients, the hospital treats the whole person—the body and the mind. It works. I do not know the science; I just know that the approach works. I have the same bone disease that I have always had. That will not change, but I have changed and how I cope with my condition has changed. The transformation in me is nothing short of a miracle, but that is just my opinion and that of my family and friends.

If Greater Glasgow NHS Board continues with its proposal to axe those vital beds, with the loss of a unique and pioneering model of homoeopathic and integrative care, along with the team, the skill base and the experience, that will be nothing less than short-sightedness and bad money management. That would not represent good value for patients or taxpayers.

12:02

Ms Margaret Smith (Stracathro Hospital Campaign): I am an old granny from north Angus. I am so old that I was a member of the first delegation to present a petition to the Health and Community Care Committee, in November 1999, when we were very concerned about the proposal to close without any public consultation our county hospital in Angus. In 2001, after enormous upheaval in Tayside, we eventually won our campaign. I pay tribute to our new chairman of Tayside NHS Board, Peter Bates, who is here today, and to our new chief executive of Tayside's acute services division, Gerry Marr, who has started a new fashion: listening to the public.

Stracathro hospital is now a diagnostic treatment centre with excellent facilities such as computed tomography and magnetic resonance scanners, a stroke rehabilitation unit, a return to much of the elective orthopaedic surgery for which we were renowned and a superb multiskilled staff, who manage to keep our theatres free from MRSA infection. We are delighted that medical students are to return to Stracathro for part of their training.

In 1999, two reasons were given for the need to close Stracathro. One was the new, stricter clinical governance guidelines following the Bristol scandal and the other was the effect of European directives on junior doctors' hours. Now, we have the huge impact of the new consultant contract, the new GP contract and NHS 24. I emphasise the important point that the consequences of contracts and guidelines never seem to be properly assessed before implementation.

We were told that, because of clinical governance, all unplanned admissions to Stracathro had to stop. That meant that every old soul had to be rushed to Dundee when, often, they

simply needed observation and short-term nursing skill. The Health Committee's report mentions boundaries. People who lived 10 minutes away from Stracathro, just across our boundary with the Mearns, had to go to Aberdeen. Mike Rumbles knows all about that. No one thought about the increased and unsustainable pressures that the receiving hospitals would face, about the increased cost of occupying expensive, high-tech beds or about what being so far away would mean for a whole family. Staff, too, were removed to Dundee, many of whom we lost from the NHS at that time.

The threat to close Stracathro resulted in the departure of some consultants who have proved difficult to replace, particularly in radiology and care of the elderly. We heard about that this morning. The consultants who remain cope magnificently, but the new consultant contract means that they find it increasingly difficult to schedule their work. On the other hand, it is interesting to note that our new-style hospital has attracted nurses, therapists and scarce radiographers, of whom I am delighted to say that we have a full complement.

What can we do about our consultants? I am glad that suggestions are creeping in about the return of the generalist. In our discussions with the Royal College of Physicians of Edinburgh and the Royal College of Surgeons of Edinburgh, we get the impression that things have changed. We would like a new breed that could straddle the great divide between hospital and community services, but how do we attract the new generalists and put their career paths at the top of the tree? That is the $1 million question. Telemedicine and the hub-and-spoke approach that Sir David Carter advocated in 1998 but which our board ignored might provide some answers.

I am grateful to the committee for giving us all the opportunity to make our case.

12:06

Ms Sandra Casey (Belford Action Group): I am in a position today—standing among delegates—in which I did not expect to find myself. I am one of the ordinary people who, through the Public Petitions Committee process and the Belford action group, can participate today.

I ask Mr Norris how we move away from the proposition that groups such as the Belford action group centre on only a few people. My group came to the Parliament on the back of a meeting that was attended by a vast number of people on a cold November night. I was privileged to be involved with MSPs who put us on the path to the Public Petitions Committee and the Health Committee, and we are here today. The people of

Scotland should be well proud of this institution and of the fact that when ordinary people sign a piece of paper on the street and ask me whether it will make a difference, I can look them in the eye and say, "Yes, this can make and is making a difference."

I say to Professor Temple that people understand the choices that are available. In the past, a community was not built around a hospital that was planted there. Hospitals grew from communities' needs. Each hospital—bar a few recent units—has been formed and has grown and developed around communities' needs.

Historically, the central belt was our industrial engine-room, with the population to support it and the hospitals. However, rural and remote communities contribute much to the nation's economic well-being and also need people to survive and to support them. Industries such as fishing, crofting and farming are suffering the same fate as did our industrial heartland. Delegates' distant cousins have rallied, risen to the challenge, persevered and diversified, predominantly into tourism, call centres and specialist food and clothing production. If their medical support is stripped away and if the 24/7, 52-weeks-a-year, consultant-led acute services are removed, the outdoor and high-risk adventurers and our much-valued grey tourists will think again about travelling to the unspoilt regions, which can start as close to Glasgow as Loch Lomond.

Many speakers have talked about the depopulation of Scotland. To say that we could experience another Highland clearance is not an overstatement. I have spoken to many of the people who have moved into my area. One couple's family were concerned that they should have hospital facilities close at hand as they entered their more senior years. People make choices. People go to the Highlands now to holiday, to live and to bring employment. I urge everyone here please to take cognisance of the call of ordinary people not to strip us of hope—we need hope. We do not want a Scotland in which we must think twice about where we will stay or travel, but that is now the reality of life.

I make a plea to the health boards: the people want to be heard. We realise that they are flesh and blood, that they have our concerns at heart and that they are not divorced from us, but I ask them to give us a mechanism whereby we can impact on them.

12:10

Ms Shirley Rogers (Scottish Ambulance Service): It is a privilege to be invited to contribute to this public debate. I speak for the Scottish

Ambulance Service, which is a special health board with a national remit but which delivers a service in a variety of local permutations. The service employs 3,700 people and undertakes approximately 3 million patient journeys every year. We provide paramedic and transport services to all Scotland's communities. That means that we provide accident and emergency care, which accounts for about half a million journeys per year; high-dependency care for patients who are transferring between hospitals or between home and hospital; and non-emergency care for patients visiting clinics.

In addition, we are slowly extending our services as budgets allow. We are now working in some primary care centres and out-of-hours centres. We are extending our range of services into offering people treatment at home, where that is appropriate, so that they do not always need to be taken to hospital. We are working hard to grow closer links with regional health boards to improve clinical care and with local authority workforces. Local authorities can help us to improve non-emergency services to the public and we can help them to improve public access to their health facilities. We think that we would all find it easier to meet public demand if we worked more closely together.

Top-class health care needs to be developed and delivered locally as well as nationally. The Scottish Ambulance Service is well placed to help to deliver that; we believe that we are part of the solution and not part of the problem. However, we think that any strategic framework needs to accommodate the following. First, we need more ways to bring medical services to the patient. Secondly, we need improvements to transport for patients who need medical care during journeys to hospital or between care facilities. One aspect of finding a balance between centralisation and specialism is the fact that patients' journey times can be extended significantly. Thirdly, we need an effective network of community transport for patients and for those who travel to visit their family and friends, because hospitals can be quite lonely places if one does not get visitors and one is a long way from home.

As a result of those beliefs, the service is pursuing the following ambitions. We are helping paramedics to extend their skills to improve the medical resources that are provided to patients locally. By working more closely with GPs and other care providers, we can help to improve the evidence that underpins decisions to admit patients to hospital and try to improve emergency response times in life-threatening cases. We also want to develop a specialist service for the transfer of high-dependency patients between hospitals, working closely with the specialists on whom patients rely. We want to develop clear guidelines

for primary care providers about when ambulance support for patient journeys is appropriate and what kind of support is needed. At present, we find that many providers are not fully aware of the range of transport options that we offer. Finally, we want to improve the way in which we and other transport providers share the responsibility for supporting public access to NHS facilities. That includes encouraging the development of community transport initiatives for patients and their families.

The Scottish Ambulance Service is a small but crucial part of NHS services in Scotland. I could go on for hours about the services that we provide or could provide, but I hope that in the short time that is available I have given a flavour of the contribution that we can make to a health service that delivers top-class services at the local, as well as the national, level.

The Deputy Presiding Officer: There is just enough time to squeeze in Dr Mike Kay, who is in seat 16.

12:14

Dr Mike Kay (Insch Hospital Action Group): I am from Insch in Aberdeenshire and I speak for the Insch hospital action group.

I commend the Executive for trying to tackle the health issues that are caused by poverty and poor housing, particularly in the inner cities. That is exactly the correct tack. I want to throw in a point in reply to Dr Danny McGuigan—[Interruption.]

The Deputy Presiding Officer: Dr Kay, you must speak into the microphone. As soon as you turn your head away, the sound vanishes.

Dr Kay: Dr McGuigan's point about the health of staff in the NHS in Scotland is vital. So many problems arise because of petty squabbling between management and various groups: doctors, nurses and others. If his points were taken up, there would be a significant improvement.

I am a GP of 23 years' standing and I am in total agreement with Richard Norris and Ms Hinds regarding the necessity to carry out—and to take good heed of—consultation with local people. Over and over again, health boards formulate a plan and push it through in spite of poor consultation and a lack of evidence for their plans. I will use my local community hospital in Insch as an example. It provides GP acute services, in particular the treatment of illness in the elderly and rehabilitation services. It is highly valued by patients and it is safe, effective and inexpensive. It works well for staff and patients and it should be a model for all communities, such as that of the gentleman from the Trossachs, yet it has had an

axe hanging over its head for many years. I call on the Executive to support fully the maintenance of safe and deliverable services in community hospitals and other local facilities.

The Deputy Presiding Officer: One of the things that I have to do on a regular basis is to express regrets to the people whom I have not called in the course of a debate. I have never had as many as 19 people still on my request list. I can say only that I am sorry but there just is not the time to call them. I do not know who you are, because you are down as Ross Finnie, Rhona Brankin, Frank McAveety and so on.

Janis Hughes will sum up the debate for the Health Committee.

12:16

Janis Hughes (Glasgow Rutherglen) (Lab): Never before in the chamber have I had such an onerous task to perform. I reiterate the welcome that my colleague Roseanna Cunningham gave earlier.

When we are elected as politicians, one of the things that we are most nervous about is making our first speech in the chamber. The people who spoke this morning put some of us in the shade with the speeches that they made, given that this is the first time—I presume—that they have spoken in such austere surroundings. Doing so must have been quite onerous. I congratulate everyone who contributed and commiserate with those who did not manage to speak in the debate.

As we have heard, we are here to discuss the Health Committee's inquiry into workforce planning. All members of the committee felt strongly about the issue because of local interests, but we are also concerned on a pan-Scotland basis about many of the issues that have been raised today. To inform the inquiry, the committee went to various areas of Scotland. Members visited areas that are not similar to the areas that they represent; I represent an urban constituency, so I visited a rural area in the Western Isles with some colleagues. It was an interesting experience and I certainly learned a lot about the way in which some of the issues affect rural areas in particular.

An event that came about after we started our inquiry was the formation of Professor Kerr's group to consider workforce planning on behalf of the Executive. The committee agreed to continue its inquiry with a view to feeding in our report and the outcome of today's discussions to Professor Kerr's report, so that we can help to inform his inquiry with some of the issues that we have unearthed.

During the debate, different views have been expressed from various areas throughout

Scotland. Richard Norris, who spoke first, told us about his new organisation. One of the important points that emerged from his speech is that health boards in Scotland have not always persuaded the public about the need for change. In relation to the changes that were going to happen in health provision, we missed an opportunity early on to educate the public about the need for change. Today, we have talked about some of the reasons, including the European working time directive and the many other pieces of legislation that have necessitated change. People now know about the European working time directive, about junior doctors' hours and about consultant and GP contracts, but they did not necessarily know about those things before changes were suggested in their areas. Therefore, they were not in full possession of the facts to inform their views on the proposed changes. An opportunity was missed in that regard and, as a result, we are kind of back-pedalling, which sometimes makes the need for change difficult to accept.

The committee took extensive evidence during its inquiry from Sir John Temple, who this morning went over some of the issues that were raised, particularly with regard to training requirements. He talked about specialisation, which we have highlighted in our report, particularly with regard to whether it is right for everybody, every area and everything. The jury is still out on that. The committee accepted that we needed to take further evidence on the need for specialisation in many areas, although I think that in some areas specialisation is generally acceptable. Sir John Temple talked about the reserved element of training requirements, which are not fully within the power of the Scottish Executive or the Scottish Parliament.

Sir John Temple mentioned the critical mass argument, which is important. In considering the need or wish for specialisation, we have to accept that health professionals must gain enough experience in certain tasks and certain areas to allow them to continually update their skills. It is important that such experience is provided on an on-going basis for training purposes.

We heard from Margaret Hinds, who I know well from a campaign group in Glasgow and who talked about the need for campaign groups and why they have come about. Margaret also said that 25 per cent of nurses from the Victoria infirmary in Glasgow—my local hospital—went to NHS 24. We have to accept that, as we heard from other contributors, nurses, as well as other health professionals and other staff in the health service, need on-going professional development and often feel a need to diversify. NHS 24 provided that facility. There was obviously a concern in some areas about nurses leaving the acute side of the NHS and going to NHS 24.

However, we must accept that when people choose to diversify and move to a different area to work, it is necessary for their on-going professional development.

Margaret Hinds said that people want local hospitals. I accept that there is an argument that people are used to local hospitals and know that they provide a good service, but we must balance that with the issues that we have discussed, such as critical mass and specialisation, which, as I said, is acceptable in certain areas.

Jim Devine talked about 100,000 people receiving health care. It is important to remember that a fair number of our constituents write to us with complaints about the NHS, but we forget about the people who every hour of every day go through the NHS and have good experiences of it. It is all too easy to focus on the negative; we must remember that the majority of people have a positive experience of the NHS.

We heard from Ken Barr about a number of issues that are of concern locally, including NHS 24.

Helen McDade made pertinent points about the unmet need of people with chronic illness. If we streamline and improve the current services—that is the focus of the committee's inquiry—we will be able to address areas of unmet need. In many areas we are firefighting and cannot address such issues. I agree with Helen McDade that treating chronic illness in a reactive way is not cost effective or value for money for the NHS; that issue must be considered seriously.

Jim MacLeod talked about the working time directive and the fact that we have known about it for many years; the committee acknowledges that in its report. The directive was first considered in 1996 and successive Governments have ignored it, which is a problem and explains why we are where we are today.

Danny McGuigan made an important point about managers, not just health professionals, being well trained. He said that health professionals often say that the NHS is not a good place to work, that it is demotivating and that the prevailing culture is often negative. I worked in the NHS for 20 years before I was elected and I totally accept that that is often the case. Negative media pressure has a large part to play in that. I have not worked in the NHS since the advent of the Scottish Parliament, but I know that it must be demotivating for staff to see some of the negative headlines that often greet us in the local papers.

George Irving from NHS Ayrshire and Arran said that people from his area accept centralisation if access is provided, which is an important point. People are concerned about local facilities going. They accept that what they will get instead will be

better, but they are concerned that they might have to travel further to get it. Access to the facilities is of most concern to them, and that must be taken on board.

John MacPherson raised local, particularly rural, issues. He mentioned GP cover and how it has changed. It is important to understand that the provision of local GPs did not change because of NHS 24, but NHS 24 came about because of a need and desire for change from general practitioners, who now have a new contract and do not therefore have the onerous out-of-hours work that they once had.

George Bruce said that facilities should be tailored to individual areas and that one size does not fit all, which is absolutely right. I visited the Western Isles and I saw that what works in Glasgow would not work there.

Robert Cumming from the north Glasgow monitoring group mentioned the important issue of generalism. We learned that there is a great need for generalists, particularly in the Western Isles. The problem is that nowadays doctors want to specialise and become proficient in a particular area. There is a great need for generalists and we must consider innovative ways of attracting doctors to become generalists. That was one of the issues that were close to Professor Temple's heart. I hope that we see the picture improve in the future.

Susan Aitken talked about the focus being very much on acute care. That is absolutely right, but we need to focus also on primary and community care. Susan also talked about value for money. That argument is strong, but she also made the important point that the fact that services are being led by nurses or health professionals other than doctors does not necessarily mean downgrading. That perception often leads to the demotivation of health professionals; they feel that they are being devalued because people think that they should be seen by a doctor, which is not always the case.

Isabella Mooney made a moving speech, representing patients from the homoeopathic hospital in Glasgow. She came back to the value-for-money argument about the treatment that she is receiving and its cost effectiveness for the NHS. I do not mean to talk about Isabella Mooney in particular saving the NHS money, but it is important to say that the service that she is getting will, in the long term, prove to be cost effective for the NHS. I thank Isabella for her contribution.

Ms Margaret Smith talked about the petition that was lodged with the Parliament in 1999, which demonstrates the value of the Public Petitions Committee and how it works in practice. She also mentioned telemedicine, which has been useful in rural areas and which I would like to see being

developed further, because it is a vital part of the service that is provided in rural communities.

Sandra Casey, too, mentioned a petition and talked about how petitions can make a difference. She will be able to tell people locally how the Scottish Parliament can make a difference, because of the system that we have here; it is important to bear it in mind that hospitals grow out of the needs of communities.

Shirley Rogers from the Scottish Ambulance Service told us about the excellent work that the service is doing and, more important, how it is working proactively with all its partners to improve access for communities, particularly in the light of changes.

There is no doubt that many external factors have contributed to the need for change—the reason why we are here today. The generalisation versus specialisation argument goes on. There are training issues and the critical mass argument is important. On centralisation, we heard today that in some areas, such as cancer services and head-injury services, there is no argument about having regional facilities. However, there is still concern in some areas that centralisation is happening because it is necessary. We are crisis managing the health service and centralising services because of that, rather than considering whether better services will be provided. One size does not fit all—that is clear. Strategic planning is necessary, and I welcome the minister's commitment to introducing the national workforce plan in the spring.

Something that has not been mentioned so far is public health and health promotion. It is very important that we consider preventing illness in the first place. What has come across clearly is the fact that health boards and politicians need to listen to the public and to balance the views of the public against the need to provide services.

I thank everyone for their speeches this morning and I look forward to this afternoon's debate.

The Deputy Presiding Officer: That concludes this morning's session. We now go to lunch and I suspend the meeting until 2pm prompt.

12:30

Meeting suspended.

14:00

On resuming—

The Deputy Presiding Officer (Trish Godman): Good afternoon. Welcome to this afternoon's session. My name is Trish Godman and I am the other Deputy Presiding Officer. I have a cold, so I am afraid that you will have to put up with my rather hoarse voice.

I remind you of the text of the motion that we are debating. It states:

"Despite the many pressures, difficulties and expectations facing the NHS in Scotland, solutions to these problems are possible and should include: listening to the views of local patients; adopting new ways of working and new technologies; pursuing creative, flexible approaches; improving workforce planning; and by these means the NHS in Scotland will be improved and enhanced."

Before we move on to the debate, I ask Roseanna Cunningham, the convener of the Health Committee, to set the scene.

14:01

Roseanna Cunningham: Good afternoon, ladies and gentlemen. I hope that you had a break over lunch and that your brains are now regeared for the afternoon session.

The morning's debate was supposed to be about things that are going wrong or about which people are unhappy. We heard about the problems that face the NHS both at a national level and in local areas. I am pleased that so many members of the public spoke this morning. I know that that can be a daunting prospect for folk who are not accustomed to the kind of formality to which we are accustomed in the chamber. We heard from many people, and everything that they had to say was very important.

Before I say anything further about this afternoon's debate, I encourage people to consider making interventions. Many people who wished to speak were not taken this morning, and I suspect that it is inevitable that many people will be disappointed because they will not have the opportunity to make a speech this afternoon. However, it is perfectly legitimate for people to make interventions, as well as entire speeches. I know that doing so may seem a bit scary, but in some ways it is easier than making a four or five-minute speech.

This morning Professor George Irving raised the issue of care in Scotland. The Health Committee intends to hold an inquiry into care, which will start this year. I hope that Professor Irving will contribute to the inquiry when it is set up.

I hope that this afternoon we will be able to get around to discussing some possible solutions to the difficulties that we all see facing the NHS in Scotland. As some people said this morning, it is always easy to criticise. Sometimes it is harder to agree on solutions. However, I hope that we will hear about some possible solutions, and not just from the professionals. Patients' representatives and others should also get in on the act. There is no monopoly on wisdom in Scotland, especially in this area. The most successful responses to difficulties in providing services have been

characterised by the involvement of local people in contributing to solutions.

We will kick off with three different perspectives. First, we will hear from George Venters, who is the chair of the Scottish health campaigns network. His perspective is coloured by the work of the many local campaign groups that have sprung up around the country over the past few years. We have heard from some of those groups this morning. Some of the groups go back four, five or six years. Some have been more successful than others but, either way, they have a wealth of experience—good and bad—from all the work that they have done. Much of the anger over changes to service delivery has come from such groups. Spread across the country, they are a testament to the strength of feeling that exists about the continuing changes to the health service.

Secondly, we will hear from Christine Lenihan, who is the chair of NHS 24. Every MSP's postbag is a testament to the fact that that organisation is not without its teething problems or its critics. Indeed, I would not rule out the Health Committee taking a closer look at it in the future, which may or may not be welcome news to Christine. However, whatever we think of NHS 24, it is the new kid on the block and is doing things in new ways. Christine will talk about NHS 24, but she will also talk about other changes that may help us to move forward.

Finally, we will hear from David Sedgwick, who is a consultant surgeon at the Belford hospital in Fort William. With the Belford action group—which I understand is more colloquially known as TBAG—he has been at the forefront of devising creative solutions to some of the difficulties inherent in delivering NHS services in remote and rural areas. The committee was very impressed by some of the evidence of the innovative thinking that is emanating from the north-west of Scotland, and the experience that David offers will have value for the whole country.

I hope that these speeches will prompt to their feet other participants who have been able to tackle local difficulties. We should not assume that a local solution is only that or that everyone knows about it anyway. In my experience, that is simply not the case, and good practice does not always seem to translate across the various internal and invisible boundaries that we seem to have built for ourselves in Scotland's NHS. This afternoon should be about breaking down some of those boundaries.

The Deputy Presiding Officer: As Roseanna Cunningham said, the first speech this afternoon is from George Venters. However, before I ask him to speak, I invite anyone who wishes to speak this afternoon to press their request-to-speak buttons now. When I move to the open debate, I intend to

start with five-minute speeches; however, depending on the number of people who press their request-to-speak buttons, I might move to four-minute speeches. I shall certainly tell you before I do so.

As Roseanna Cunningham also pointed out, it is appropriate for people to intervene as long as they do not make a speech. People should either ask a question or make a comment. In any case, people should keep their remarks short, otherwise I will tell them that they are not keeping them short enough.

14:06

Dr George Venters (Scottish Health Campaigns Network): Good afternoon. It is an honour and a privilege to open this afternoon's debate on looking for solutions. It is a privilege to speak on behalf of the health service, because I have worked in it now for 45-odd years and because it shows society at its best. For example, it shows that we care for and about people, and I have found those with whom I have worked, particularly at the sharp end of the service, to be caring, committed and competent people who are trying to do a good job. Unfortunately, as we have heard this morning, they are not always able to do so, because the resources are not necessarily available to them.

Although we have already rehearsed them, I will summarise the problems that have led to the unavailability of resources. First, suitably trained staff must be available. We agree that we are really toiling for staff in all domains. Another fundamental problem for the Scottish health service that has not been so consistently picked up is the lack of strategic thinking and planning.

We are also having problems with the capacity of existing services. As everyone knows, because of limited capacity, queues are building up in almost every part of the health service. Over many years, there have been reductions in the available facilities in hospitals and health services, and that continuing process has led communities to raise their voices in defence of those services and to point out the depredations that are diminishing them.

There is a lack of accountability by the health service to the communities that it serves. Although I have worked in a health board for more than 30 years, I did not realise that its primary accountability is to the Scottish Executive. Indeed, the public themselves do not know that. They think that the health board is accountable to them and expect it to make decisions and consult on their behalf. Clearly, the current structure is not set up in that way. We also fundamentally lack people, places and equipment to provide the kind of

service that we want. As Professor Sir John Temple pointed out earlier, we are all striving for effective and safe local services.

We must really move towards strategic solutions to the basic problems of planning. Wherever we go in Scotland, communities are encountering the same problems, although the instances or flavour of the difficulties in meeting our needs might be different.

I do not think that the problems that have been outlined are insuperable. There is enough wit, imagination and initiative in Scotland to bring about improvement. The contribution that has been made by the different groups that make up today's confederation demonstrates the public's willingness to take up cudgels and fight on behalf of services for the community. Again, that reflects Scotland's caring nature; ours is a caring community that cares about people. The stout-hearted and willing people who work on communities' behalf are not often acknowledged, but they should be. I pay tribute to the people with whom I have worked over the years.

I ask the Health Committee to pick up on the availability of strategic planning. It is good that it has produced a report that shows the way ahead on strategic thinking. I heard Roseanna Cunningham say that the committee was surprised that initiatives were incoherent and inchoate. People string together a set of bright ideas and soundbites and call that a plan, but it is not. In the past—I can remember back a long time in the health service—planning took place. However, over the past 20 years, planning has disappeared; it has started to re-emerge only now. Unfortunately, finance drives most of the boards' agendas.

In the past, we used to define what we thought the public would need over a period of time. That was easy enough to do; it was not rocket science. Our analysis was based on patterns of illness in the population, how the population was aging and what its structure would be in a decade or two. That enabled us to work out the health service's future workload and it took into account the pace of clinical change. We could anticipate that the diseases of decrepitude would be the fundamental problem that would confront the health service. Given that everyone was getting older and that the health service and doctors would be able to do ever more for ever more patients, we knew that those were the conditions with which we would have to deal. We could predict what we would be likely to face. Fundamental strategic planning for the Scottish health service disappeared about 20 years ago and we have been trying to catch up ever since.

I make a plea to bring analysis back into the planning process. That would be great, because

too often a string of bright ideas and soundbites is presented as a plan. I commend to everyone the work of the south-east Glasgow health forum, which has produced a highly competent, articulate and well-written plan for hospitals in the south-east of Glasgow. That shows that planning can be done. It is just unfortunate that it is being done not by the health board but by a voluntary organisation.

What can we do about improving the health service, to which everyone is committed? We must start with the politicians. I am glad that the Health Committee works well together and provides a congenial environment in which to work. Unfortunately, the political parties do not seem to be addressing the agenda in that way. We must all work together to sort that out and to make the necessary changes. People inhabit silos—they inhabit them in political parties and in Scottish health service departments. As Roseanna Cunningham said, we must start to break down the walls and barriers.

The Deputy Presiding Officer: You have one minute left.

Dr Venters: I could run through a list of potential solutions, but to some extent David Sedgwick will deal with that when he discusses the Belford solution. We must learn from others. The philosophy of keeping health services local governs thinking in England. We must engage the people to a much greater extent. They must be involved in health service planning from the outset. We may need to have direct elections to health boards to ensure that there is a degree of local accountability in relation to the plans that are being thrust upon us.

The initiatives on training generalists are great, but much more comprehensive integrated workforce planning initiatives are going on. For example, in the south-east of Scotland, what I call the Alan Penman plan is working by empowering the public, bringing people into training and education in the health service at very basic levels, including through a sort of health academy, to the level of professionals. That plan is sustainable and can recruit people over a long period of time.

We have to build for the long term. The service that we are designing is for our children and our grandchildren, which means that we have to think about how we can improve the situation in the long term.

Although telemedicine and technology have a lot to offer, telemedicine is not new. I refer to the Inverclyde agenda and the increase in perinatal mortality that has taken place and note that we established a telemedicine service in Lothian that ran for 22 years and which dealt with people in Wester Hailes who were similarly disadvantaged.

The Deputy Presiding Officer: You must wind up now, Mr Venters.

Dr Venters: Okay.

What we need is a new enlightenment for Scotland:

"That Sense and Worth, o'er a' the earth
Shall bear the gree, and a' that."

We have to move our focus to build better societies, where our enemies are poverty, deprivation, inequality and lack of opportunity. Bettering our health service is the best place to start that work.

14:16

Ms Christine Lenihan (NHS 24): I am pleased to have the opportunity to contribute to the debate. I commend the Health Committee for instituting it: for all of us to be gathered in the chamber today is an innovation in itself.

The committee's findings provide a thought-provoking basis from which to consider the future. One underlying element of the future was well-woven into the contributions that we heard this morning, when the committee convener spoke about the linkage between the changes that are taking place in workforce planning. The deputy convener spoke about the context within which every health board in Scotland is redesigning their models of care—which, for NHS 24, are the models of out-of-hours care—to support the key drivers of the changing environment in which we live. The wise granny on my right, Margaret Smith, spoke about the consequences of change and how we communicate them.

Given that background of the constant nature of change as the world in which we live changes, I want to share one or two experiences that illustrate that change. As the convener mentioned, I will talk about NHS 24 and future possibilities. Before I take delegates to Clydebank, however, I want to take everyone briefly to California where—

Mike Rumbles (West Aberdeenshire and Kincardine) (LD): Will Ms Lenihan give way?

Ms Lenihan: I am very short of time.

The Deputy Presiding Officer: If you wish to take the intervention, I will allow time for it.

Ms Lenihan: Okay. Thank you.

Mike Rumbles: My intervention concerns people's experience of NHS 24. Do you agree that it is simply not acceptable for patients to have to wait for 16 minutes for a telephone call to be answered or for two or three hours before their call is returned?

Ms Lenihan: If I may, I will answer my colleague in two ways. It is important to understand that the

NHS 24 service is being redesigned in order to meet the needs of the substantially changed environment in which we live. I am thinking in particular of the new general practitioner contract and the new out-of-hours arrangements. Every health board and the Scottish Ambulance Service are working together to provide the kind of services that we want patients to have.

My colleague will also be well aware that we have welcomed the First Minister's review of NHS 24, which will help the organisation continually to improve its service and to ensure that the potential of the new digital communications platform for Scotland can bring the benefit of access to services for patients. That is particularly the case in remote and rural areas as well as in urban areas. We are well aware of some of the aspects of NHS 24's performance, which we are in the process of improving.

Let me now take delegates to California. I had a stimulating conversation with a colleague in California who told me that his son, of whom he is particularly proud, is what in the United States of America is called a family practitioner, which is our equivalent of a GP. When he told me how well his son was doing with a practice of 26 staff, I told him that I was surprised to hear that, as I had understood that North America suffered from shortages of doctors that were similar to ours in Scotland. "Oh no," he told me, "He's the only doctor in the practice." The other 26 people supported the doctor to provide patients with the services that they need to improve their health. He told me how the team worked. It was supported and enabled with all kinds of new technology—not just the communications technology that I mentioned earlier but new kinds of medical technology such as imaging and diagnostics. In that one practice, patients were cared for by technicians, carers, nurse practitioners, physician assistants and many other people with different skills.

The practice was in a predominantly elderly community. The patient experience in interacting with the family doctor service was that they would sometimes be seen for an hour or an hour and a half. They might be seen and cared for by six or seven different skilled professionals in the team. The system was very popular with patients and it enabled the doctor to see far more patients than one might have imagined, because everyone else in the team ensured that the doctor did those things that only a doctor can. That seemed rather a creative approach. Care was designed around the needs of older people, who could participate and were encouraged to be involved in the process of maintaining their own health.

Returning to Clydebank, let me tell a story. I was with a visitor at NHS 24's Clyde contact centre one

Monday holiday when the centre was receiving hundreds of calls an hour, and we spoke to one of our team leaders, Kate, during our walkabout. She told us that one of our call handlers had come to her during a break to explain that he had taken a call from Fred, who was an 83-year-old who lived in a high-rise flat in Glasgow's east end. Fred's wife Molly had run out of her eye-drops. The weather had been unexpectedly warm that weekend and her spare supplies had been used up. Molly was distressed and in pain. At 83 years of age, Fred had walked a mile to the nearest chemist shop only to find it closed and then had to walk a mile back again. Public holidays do not mean much when you are 83.

Fred then telephoned NHS 24. He explained the situation to the call handler and asked where he might find a chemist shop that was open. Our database indicated that Boots in Argyle Street in central Glasgow was the nearest available chemist. Having passed the information to Fred and finished the call, the call handler logged off the system and spoke to the team leader, Kate, who is a nurse. "Isn't there anything we can do to help?" he asked. Kate was able to establish that Fred's GP was in his surgery that day because a nurse team member had spoken to him about another patient that morning. Kate called the GP and explained the story to him. The GP knew Fred and Molly. He made out the eye-drops prescription and offered to phone the details into Boots.

At the same time, another team member was in contact with the Scottish Ambulance Service patient transport service. From her conversations with the service, she understood that not only would an ambulance be in the centre of Glasgow but the same ambulance would practically pass the door of Fred's house. The ambulance people agreed that they would pop into Boots to pick up the prescription. The next thing that Fred knew, without any expectation, was a knock on his door. When he opened the door, a young man said, "Hello, I'm David from the patient transport service. We were talking to NHS 24. They told us that Molly had run out of her eye-drops. We were just passing." The interesting thing is that it was a young call handler—a non-clinical person—whose initiative and compassion reminded us what we are all here to do.

For me, the common elements to those two stories are creativity, compassion and the use of new technology. New technology allows us to do many other things. The digital doctor and the cyber nurse might be a little further away, but our telemedicine and telecommunications capacities could provide tremendous support for people with long-term conditions such as diabetes, asthma and lung and heart disease.

NHS 24 online, which is under development, could provide a new kind of access to high-quality

information for people in Scotland. I believe that the powerful combination of those new technologies with the greatest assets that we have—the compassion and creativity of our staff—will help us towards an information health care age for the people of Scotland.

14:25

Mr David Sedgwick (Belford Hospital): I am grateful for the opportunity to speak here. I am one of the general surgeons who are left in Scotland. I work at the Belford hospital in Fort William and am a member of the Viking surgeons club, a group that is interested in general surgery in remote areas.

I would like to present some of the ideas that we as a team have been developing over the past two years in the west Highlands. Everyone here will be aware of the drivers for change in acute health care that we have heard about this morning. All of those drivers have a greater impact on the district general hospitals and on the smaller hospitals in Scotland. The issues that have been discussed, particularly super-specialisation, will lead inevitably to increased centralisation of services in Scotland, which could reduce acute hospital services to only three or four major urban hospitals. However, we must take into account the geography of Scotland, where at least a fifth of the population lives in rural communities. There is a problem with transporting inadequately resuscitated and unstable patients over large distances and it is not acceptable to expect emergency cases to travel for three or four hours before they are seen and stabilised by an appropriate hospital consultant.

The Belford was faced with the serious threat of downgrading the hospital to a day or community hospital, which would have forced some of the people of Lochaber to travel for up to three hours to access acute hospital services. That situation would have been replicated in the other five remote area hospitals in the Highlands and Islands. However, all those hospitals exist for a reason, which is to serve local people and the significant numbers of visitors who come to those areas.

The west Highland solutions group, which was set up to tackle the problem, defined rural general hospitals as being a suitable answer. They are 24/7 consultant-led hospitals that provide accident and emergency care locally, in-patient medical and surgical care with appropriate supporting services, and a wide range of specialist out-patient clinics with visiting consultants. Teams in rural general hospitals do not work in isolation but should, with the bigger units, be part of established managed clinical networks—a sort of buddy system. Managed clinical networks are

becoming more formalised, with executive committees mapping out patient pathways, applying national standards for care and co-ordinating collection of audit data.

Successful working in such networks requires video-conferencing links to enable clinicians and specialist nurses to discuss management of each case. Joint operating takes place between surgeons from the rural general hospital and the tertiary centre in either hospital, depending on the complexity of the procedure or on how fit the patient is. That has been happening regularly for eight years between consultants from Raigmore hospital and the Belford hospital in urology and colorectal surgery. Joint clinics have taken place in medical practice for conditions such as diabetes. The consultants in the hospitals need to have the honesty and humility to refer patients on as appropriate. Consultants in bigger hospitals also need to appreciate the skills and facilities in the rural general hospitals, so that appropriate cases can be managed locally in those hospitals.

One advantage of rural general hospitals is that they allow generalists both to work alongside super-specialists and to keep up their skills. I assure Professor Temple that there is enough work for the generalists to do in the hospitals that are run by rural general consultants. They may also want to travel, if necessary, to the bigger units in the city centres to help out with waiting lists and problems there. A rural general hospital also enables patients to have procedures and follow-up treatment closer to home, and it removes the potential distress that is caused by long or difficult journeys to and from treatment and through people being separated from the emotional support of their families.

A third advantage of the rural general hospital is that it gives a full-time consultant presence to manage emergencies. If patients need to be transferred to a bigger unit, it is important that the patient is first well resuscitated and stabilised. Patients do not get better in helicopters or ambulances; they stay the same or get worse.

Fourthly, networking between GPs and the rural general hospital is a hallmark of the sort of hospitals that we work in. It would be lost in centralisation.

Finally, the rural surgeon is also well trained for providing a visiting surgical service to hospitals that are even more remote. For example, Belford consultants visit Broadford and Portree hospitals, and Oban consultants visit Campbeltown.

I point out that a three-month audit at the Belford showed that if our hospital were downgraded, there would be a fourfold increase in the number of emergency patients who would be transferred to the bigger hospitals. A significant number of

elective operations would also be transferred. I wonder what effect that would have on waiting list targets. It is therefore vital that generalists are given specific training for those posts. Otherwise, there will be serious knock-on effects in the bigger city-centre units.

Training posts in rural medicine and surgery have been established in the north of Scotland postgraduate deanery; the first surgeon to complete the scheme was appointed to the hospital in Lerwick in Shetland last September. However, the royal colleges and the training authorities must encourage medical graduates to consider working as generalists in district general or rural general hospitals. Students are now enjoying attachments in rural general hospitals so that they can experience that type of medical practice. However, they need to see a definite pathway through training if succession planning is to be successful.

A strategy for recruitment of consultants and other staff to remote area hospitals is also imperative. The strategy should highlight aspects of working in rural general hospitals and the quality of life in the Highlands and Islands. Important features would include the fact that it is a beautiful place to live and work, that crime rates are low, that there is more autonomy and job satisfaction, that there is a wide range of general medical and surgical patients, that there are good schools for children's education and that there is easy access to many outdoor activities. There is also easy access to work, without the traffic jams that are prevalent in the cities. The attractions of working in rural areas are covered by our website and in a CD-ROM that is being produced in conjunction with Highland Council and the enterprise and health boards.

People who live and work outside the city centres do not expect specialists of every variety to be on their doorsteps. They know that they will have to travel long distances to access certain treatments. However, they need appropriate acute medical and surgical services within reasonable distance. With thought and forward planning, it is possible to establish a robust network of rural general hospitals that are staffed by trained generalists so that it does not become a health risk for people to live, or for GPs to practise, more than 100 miles from a city.

Thank you for listening.

The Deputy Presiding Officer: We now move to open debate. A considerable number of people wish to speak, so I start by asking for speeches of four minutes. I may reduce that to three minutes because my objective is to ensure that all of you, if possible, get a chance to say something. I think that that is the mood of the day.

14:33

Brendan Rooney (Cambuslang and Rutherglen Healthy Living Initiative): I, too, applaud and thank the Health Committee for facilitating this event for all of us today.

I am the director of a healthy living initiative in the Cambuslang and Rutherglen area of South Lanarkshire; and for 24 years I have been a volunteer in a wide variety of health-related activities in my community. I am also currently undergoing a variety of in-patient and out-patient care. I therefore have a reasonable insight into the health service, and have some reasonable comments to make.

My points—and what I hope is a solution—relate to both of today's motions and to point 19 on page 3 of the committee's report, where the committee states:

"It is also important that workforce planning in future is driven primarily by patients' needs and the desire for good health outcomes".

That sentence, in essence, is my main point.

In terms of this afternoon's motion, I will comment mainly on

"listening to the views of local patients".

However, I acknowledge the complexity of the other issues in the motion, and in the committee's report, but I am sorry that I will not offer any particular solutions on those today.

We and the committee are doing something fundamental today, which relates to revisiting the values and possibly the culture of the NHS. Dr McGuigan talked this morning about trust. Partnership seems to be very much to the fore.

There are two areas in terms of values that I would like the forum to consider. First is the consistency of patient and public involvement and engagement. In my experience, consistency is lacking. The attempt to bridge the dialogue gap and to share information and communication up the way, down the way and across the way is a massive part of my day-to-day job. Just because I am a local person and a member of a local group does not mean that I am always right. Just because I am a professional—I am a health professional and a member of a health professional group—does not mean that I am always right. My experience tells me that there are, as in any good debate, three sides to the story—both sides, and somewhere in the middle. We need consistent public involvement. There are good examples the length and breadth of the country of good and consistent public involvement, so we need to learn from that and to use it. I urge the Health Committee to take that on board.

Secondly, in relation to values, Janis Hughes in her summary this morning touched on the idea of

a health-promoting health service. I am surprised that we have not heard about the massive change that is going on right now in the NHS through community health partnership developments. A health-promoting health service and public involvement are mentioned consistently in all directives and principles of community health partnerships.

Someone this morning mentioned the horse and the cart. A consistent approach to patient involvement and public involvement and to a health-promoting health service should be the horse that pulls the cart. That should be the main driver in improving the NHS and in making the rhetoric real.

14:37

Ms Kathryn Davie (Hands Off Perth Royal Infirmary): I am here today thanks to Roseanna Cunningham, whom I met through my being a campaigner for Perth royal infirmary. I welcome this public debate and hope to see a similar level of importance being given to public opinion in the future. It is extremely difficult to achieve open and honest debate of this nature, particularly in situations where health professionals' jobs are potentially at risk. I am sure that many people are afraid to speak out, which is unjust.

I agree with Professor Sir John Temple that Scotland is overrepresented in terms of the number of health boards we have, but I stress that, whatever structure evolves in the future, public consultation must be got right. I would welcome the Health Committee's consideration of democratically elected health board members.

As a campaigner from Tayside, I was amazed and somewhat insulted a few months ago to hear the consultation process that was conducted last year by Tayside NHS Board being vigorously praised in Parliament and held up as a model for all Scotland. To people like me who are outside the establishment, it was clear that what took place in respect of Perth royal infirmary was a series of public relations events to enable the health board to tick the right boxes and subsequently to implement its long-planned reduction in Perth royal infirmary's service provision, ignoring strong public protest. Planned spend of £28 million at Perth royal infirmary has already been reduced to £21 million, but we are assured that all the promised benefits can still be achieved. I hope that that will be the case.

To remove on a piecemeal basis consultant-led maternity care, overnight paediatric care and special-care baby unit provision from a growing Scottish city that is bucking the national trend in birth rates makes no patient-centred sense at all. The knock-on effect of disfranchising the public

who care deeply about the NHS can be directly seen in the numbers who turn out—or, more significantly, who do not turn out—to exercise their right to vote at local and national elections.

14:39

Ms Pat Dawson (Royal College of Nursing Scotland): The Royal College of Nursing Scotland is greatly honoured to be here today. We have heard many quality contributions, to which I hope I will add.

This morning, speakers emphasised why listening to patients is essential. If I had to make a couple of personal comments about the debate, they would be to ask whether Parliament is convinced that our laws ensure that the public voice is heard and acted upon, and whether it is possible to call for a review if the public or others disagree with the outcome of health board planning processes. What are people's rights to appeal decisions? In guidance from the 1970s, such rights of appeal in respect of service change existed. Do they still exist?

Secondly, should Parliament consider making explicit a bill of rights for patients? Currently, rights range across many laws. Is it time the Health Committee examined gaps in the legislation and where it needs to be strengthened so that the public realises that its voice is protected in law? Despite what has been said this morning, not all patients have a voice, a group or someone who can represent them and make laws that safeguard their rights.

In thinking about solutions, one of the key elements is getting the right numbers of staff. One finding from a recent survey of more than 35,500 Royal College of Nursing members in Scotland showed that some 40 per cent—more than 5,000 of those who responded—work more than six hours extra a week. The NHS used about 1,300 full-time equivalent agency staff nurses last year. Vacancies are rising in Scotland, but the nursing workforce here has the lowest growth of all four UK countries and no growth target. We need to improve our planning processes—of which, interestingly, nursing has one of the more developed—to ensure that national targets deliver local needs. For example, we cannot keep increasing the student nurse intake throughout Scotland equally in all nursing schools. We need to target action in the Lothians and Glasgow where turnover and vacancies are highest and, like medicine, we need targeted local approaches in rural areas.

We need to be brave, ladies and gentlemen, and to keep nursing intakes high, because we are not yet seeing the signs of complete recovery. Much has been achieved, but nurses want to see action

on their workload—it is their single most important concern. Remember: a busy nurse does not have time for patients, which is why the Royal College of Nursing in Scotland is calling for a statutory basis for appropriate locally determined staffing levels.

The Irish Nurses Organisation's president said:

"International research shows that the ratio of nurse to patient is critical in determining patient outcomes. In 2002, the University of Pennsylvania shocked us all when it revealed that the number of patients a nurse cares for is a determining factor in life and death outcomes. Research revealed across acute medical and surgical units that the optimum workload for a nurse was four patients and that increasing that to eight patients was associated with a 31% increase in mortality."

Furthermore, she went on to say that

"The Australian Nursing Federation has been operating staff/patient ratios mandated through legislation since 2001. These ratios have been credited with drawing almost 4,000 nurses back into the workforce".

Similar negotiations are ongoing in New Zealand.

The INO's president posed the question that I would pose today, when she said that we must ask ourselves:

"Do we stay with the system, which uses the top down approach of staffing levels and is different in every region and nearly every hospital?"

Alternatively—to paraphrase her words—should we go for the bottom-up approach, in which discretion about staffing is taken away from budgets and administrators and is instead research-based, mandated through legislation and adapted to the Scottish system?

14:43

Mr Malcolm May: I thank Parliament for the opportunity to speak here today as a member of the public. I am involved in the public participation exercise in Dundee to encourage consultation and to involve the public. I am tempted to invite quite a number of this morning's speakers to relocate to the Tay estuary. It is not that we enjoy the best services, but the services in Dundee are certainly very good. I thought that that invitation might have been received as a joke, but no one is laughing—[Laughter.]

As a member of the public, reading the Health Committee's report I am concerned about the overwhelming nature of the problems and how those problems are to be dealt with. I am glad that the debate has moved on to that this afternoon. The committee's report identifies the need for greater flexibility and more multidisciplinary working. Those things are already happening—I have experienced them through my involvement with various working and planning groups in Dundee—although they must be progressed and continued.

The problem is how to involve the public in consultations. For the past two years, I have been involved in exercises in community centres and at events such as the Dundee flower show—which, by the way, is well worth a visit—to try to let the public have their say about the health service. The issue is how we talk to members of the public on the street or at a stall about strategic planning, given that—as we have been told today—the health service has only just got round to doing that.

Another issue is jargon. It took me several months to work out that MCNs are not a new form of nurse. When I began to understand the concept of managed clinical networks, which Mr Sedgwick talked about, it seemed to me that they represent a positive and important way forward.

Consultation is vital, but it is not simple. It is difficult and challenging to involve the public when they do not immediately have sores that have been rubbed, so to speak. Today's event is a good way at least to make a start, to get ideas talked about and to encourage the public to take their thoughts to their local health service.

14:47

Professor Sir John Arbuthnott (Greater Glasgow NHS Board): As chairman of Greater Glasgow NHS Board, it is my pleasure to be here today. I have greatly enjoyed the speeches, some of which—as we would expect—have been hard hitting. That is a result of our task, which is to describe personally what we and our groups feel about the health service. I inform delegates that I, as a health board chair, am listening to their comments. I welcome the Health Committee's report, which makes a good deal of progress.

We have heard a wide range of views, but there is one issue on which we are all agreed; we all want to work for a safe and high-quality health service for patients that is delivered fairly throughout Scotland. As I worked for four years on the distribution of health resources and the "Fair Shares for All" report, I know a little about the feelings of people in the various regions.

Mike Rumbles: Does Professor Arbuthnott agree that not all NHS boards have a fair share of the NHS budget? For instance, Grampian NHS Board has to manage on only 90 per cent of what it should have per head of population. Is not it time for Professor Arbuthnott's formula to be reformed?

Professor Arbuthnott: I hope that you will not count the time that I take to answer that against my contribution to the debate, Presiding Officer.

My answer to that question is twofold. First, the formula, as it was introduced, has been challenged—I can go on holiday to some places in

Scotland, but not to others. Secondly, I am pleased to tell the questioner—although I think that he knows this—that a successor committee has been appointed that will consider questions of fairness.

My point is that we want to strive for a fair and high-quality health service throughout Scotland, which is why I welcome the new Scottish Health Council. I welcome the council's involvement in assessing patient-focused public involvement in our health board and in others. We will collaborate fully with it. We must work towards closing the credibility gap that has been referred to time and again—I say that on behalf of health boards.

Glasgow faces huge challenges but I will not bore the delegates with them; they know most of them. Within the city itself, 70 per cent of the population is in the top category of deprivation.

The Deputy Presiding Officer: Sir John, someone would like to intervene. Will you take the intervention?

Sir John Arbuthnott: Certainly.

Mr Ernie Walker: I was intrigued by what Sir John said about improving care. Has he though about amalgamating his health board with Lothian NHS Board?

Sir John Arbuthnott: We have been talking to all the senior people at the highest possible level in Lothian NHS Board about the way in which the two largest health boards in west and east central Scotland can collaborate to the benefit of those regions and the regions between them. However we have not yet got to the point of writing our conclusions, although I welcome the question.

I mentioned the deprived population in Glasgow. I also mention the 20,000 children whose parents or guardians are drug addicts, and the 5,000 children who live in official poverty. Those are staggering figures in a modern society.

We have old hospitals that have to be remodelled to take care of modern requirements, and there are many other challenges, but I would like this afternoon's debate to concentrate on the opportunities, which include the fact that we have new ways of working with staff, we have dealt with major contract negotiations and we are now in a position to get the benefit from that for staff, the health boards and patients. I am sure that we will get better performance.

We are moving to single-system working, which is complex but which will give us more efficient approaches to issues such as dealing with hospital-acquired infections—as a microbiologist, I have a special interest in that. I also echo the view that sometime this afternoon we must return to the role of community health partnerships. In Glasgow, nine of those partnerships will return

discussions on social benefits and health care to the people and the communities through partly elected boards. That must be seen as an advantage and as a reversal of what is perceived as a move towards centralisation.

14:52

Mr David Wishart (Local Health Concern, Dunfermline): I am chairman of Local Health Concern and, at the outset, I say that I do not speak from any political platform. However, I do speak with 25 years of experience of working in and with the health service in Scotland.

In the restricted time allowed, I wish to ask the Health Committee to address the basic problem of chronic mismanagement and waste in the Scottish national health service, which has resulted in, among other things, treatment rates falling behind those in England for the first time on record, despite a massive extra financial investment. The only solution that the Executive seems to have is the panacea for all NHS ills: to throw yet more money into the NHS pot. In 2002-03, the NHS cost Scotland's taxpayers £7 billion. This year it will be £8.7 billion and by 2007 the cost will be £10 billion.

It is my opinion that that level of expenditure should be quite sufficient to provide the people of Scotland with a good quality health service. More money is really not the answer. The solution lies in much more efficient management and control of existing resources. As Dr Venters has already said, there is a lack of strategic planning, co-operation and forward thinking. Someone once said in this chamber that it takes a special kind of incompetence to spend so much money and treat fewer patients in increased waiting times.

Where is that incompetence? A good place to start might be with excessive health board administration. The following figures were given in parliamentary answers to MSPs. In April 1999, £280 million was spent on administration. Four years later that had risen to £365 million—£1 million every day being spent on the administration of NHS Scotland—and that figure continues to rise. We now have more than 1,700 senior managers and 26,000 admin staff presiding over a health service that, since 1999, has probably shown no significant improvement in hospital cleanliness, waiting times or other standards of care.

We must look to the health boards to bear much of the responsibility for that. I entirely agree with Professor Temple regarding the unsustainable number of health boards that we have. Health boards in Scotland are insular, introspective, self-centred and apparently unaccountable. When he was the Minister for Health and Community Care, Malcolm Chisholm was quoted as saying that he

had no control over them. I wonder whether his successor is of the same opinion. If so, it is high time that he did something about the situation.

The composition of health board membership requires urgent consideration. There is nowhere near the necessary level of experience, expertise or competence that is required to run a modern, highly complex health service in this country. Cross-board planning is sporadic and nearly always reactive rather than proactive. There is evidence of serious internal disagreement over financial arrangements for the provision of cross-board services and each health board is intensely jealous of its status, structure and importance. In addition, practically every health board in Scotland is top heavy in terms of management and administration, to the obvious detriment of medical and nursing staff provision and, ultimately, patient care.

The proportion of health service money being spent on administration is now quite unacceptable and must be constrained and brought under strict Government control. The Executive must take serious and immediate steps to root out that obscene waste of precious resources and I hope that, when Professor Kerr reports on the future of NHS Scotland, he will emphasise and endorse such urgent action.

14:56

Mr John Morrice (Inverclyde Royal Hospital): I am one of those dinosaurs who has provided a general surgical service, combined with a specialised interest, to a local district general hospital for 25 years. I am glad to hear that we are about to be reborn.

This morning, we have heard a fair amount about centralisation versus local delivery. In that regard, I compliment David Sedgwick on his speech, which was outstanding.

The community that I serve is a mixture of rural and socially deprived areas. Although it is accepted that neurosurgery, cardiac surgery and so on should be delivered in large, central units, it is unfortunate that cancer surgery has also been added to that group. We must stop ourselves extrapolating some of the major tertiary specialties to core services. I emphasise that a great deal of cancer surgery and other surgical procedures can and should be provided in district general hospitals, as long as entire teams of appropriate people are in place—I am not suggesting that single experts should have all the responsibility.

I would like sound a note of caution. Experts and so-called ultra-specialists must resist the temptation to ask local people whether they would like their surgery or treatment carried out locally or by an expert. We have to break down the idea that

a 400-bed district general hospital does not have a critical mass. As David Sedgwick said, such hospitals are busy places and provide care to a high level.

What is the way forward? It might be easier to see the way forward in relation to a hospital such as the Belford, which serves a remote area, than in relation to Inverclyde hospital, which is only 20 or 25 miles downriver from Glasgow. However, as with many issues, perhaps we have to turn the clock back a bit. Earlier, Mrs Smith from Perth—who referred to herself as Granny Smith—mentioned Sir David Carter's report, which was produced in 1999 and introduced the concept of managed clinical networks as a way of integrating care across hospital boundaries. We need to convince clinicians—who must take some blame for building ivory towers for themselves—that they should be thinking beyond their local hospital boundaries. I would like the way forward to be promotion of the idea that clinical networking in its practical sense—not just paying lip service to it—and not hospital centralisation is the most efficient and possibly the most cost-effective way to provide better health care.

15:00

Mr Edward Harkins: I am grateful for the opportunity to speak. I am a resident of Rutherglen in Lanarkshire and, unfortunately, I am of an age at which I require the help of the NHS more than I did before.

First, I congratulate the Health Committee on making today's innovative civic engagement event possible. I endorse fully Richard Norris's remarks about the need for more engagement between the NHS and the public that is based on trust and respect for alternative views and evidence.

I will comment on how we can move forward from the Health Committee's timely report. The report makes welcome, explicit and repeated references to the need for a future NHS to attend to patients' needs and demands. However, like the NHS, the report continues the focus on patients only as sources of need, demand and possibly even trouble. We should go further in our thinking and perceive patients and the wider public as working partners in the delivery and development of the NHS. That means engagement with the public at the earliest possible stages and at the highest strategic level. George Venters made good remarks about the need for strategic planning in the NHS.

That engagement means more than belated and purposeless consultation exercises. As has been said, real engagement is not easy, least of all for patients and the public, who find themselves participating in often difficult and even distressing

fundamental decision making. However, such consultation can be achieved. Scotland has a great success story called the community-based housing association movement, through which ordinary lay members of the public showed what can be done when the public are invited in and respected as an equally contributing partner.

A practical and more local example of the potential for partnership between the NHS, the public and other agencies comes from my locality of Rutherglen and Cambuslang, where the local MSP, Janis Hughes, is supporting a community transport initiative. The intention is to use collaboration and partnership between the public, the NHS and other agencies to deliver and realise some of the intended benefits of the controversial reorganisation of greater Glasgow hospitals. The initiative will bring together local community players and the more centralised decision makers along with non-health sector agencies. That will benefit everyone, not least patients.

I do not have sufficient time to cover the other similar point that I would like to make. The report speaks extensively of the need for future recruitment for the NHS workforce. The difficulty is that a bit of an internal focus is taken. Paragraph 44 of the report refers to

"the very substantial change factors which are at work within the health sector."

Considering non-health sectors is of paramount importance. For example, in the emerging community planning environment, other public service delivery agencies will determine some aspects of the service that the NHS must deliver.

Finally, we must be aware that sectors outwith the health care sector will be competing for the best highly skilled professional staff and willing voluntary civic participants.

The Deputy Presiding Officer: I am afraid that I will have to ask for three-minute speeches.

15:04

Mr Robert Hosie: I am grateful for the opportunity to speak. I represent two groups from Inverurie in Aberdeenshire: the doctor-patient participation group and Grampian Cardiac Rehabilitation Association. I speak principally not as a health professional, because I have been involved in the activity only for a few years—at the most, eight years—since I had a cardiac bypass operation. I speak as a professional engineer and a retired academic.

Several potential solutions have been mentioned and need further development. Funding is the key issue. We all have a wish list, but the pot is limited. I was delighted to hear from Sir John Arbuthnott that there is likely to be a review of the Arbuthnott

formula. As an engineer, I would like to see the details of the formula; I have not found them yet, though I have tried. Additional funding is available from the lottery, but at the moment only 3.7 per cent of lottery funding is allocated to health. Why should that be, when health is such a prime concern in our existence? Surely that figure should be boosted. The Government should try to influence the lottery fund to allocate a greater proportion to health activities. We in Scotland have a fairly good sense of value for money; our feeling is that if we are given the money, we should get good value for it.

The Deputy Presiding Officer: One minute.

Mr Hosie: There are issues about new and developing technologies. There need to be better links between medical and research staff in the health professions and the professional engineering institutions, such as the Institution of Electrical Engineers, the Institution of Mechanical Engineers and the British Computer Society, because communications and the new and developing technologies are key issues.

Another important issue is the use of portable intravenous injection units. Three years ago, I was on vacation in Calgary for eight days and I experienced walking about with a portable unit strapped to my tummy. That unit was a portable bed. The four hospitals in Calgary each have 50 of those units. That represents 200 beds, and is an effective way of preventing bed blocking.

I turn to distance learning and diagnostics. It is assumed that medicine needs to involve face-to-face contact. That is correct, but we have already had an instance of videoconferencing. Why cannot NHS 24 think about using more videoconferencing? Why can we not think in terms of using local health centres seven days a week, 24 hours a day, as a contact point for NHS 24?

We need to use the services of the voluntary bodies. It is estimated that in London the voluntary bodies contribute 200 million hours per annum, which is equivalent to a £500 million subsidy to the NHS. That is only £2.50 per hour, and many of the people who volunteer are worth a lot more than that.

The Deputy Presiding Officer: I must ask you to finish now, Mr Hosie.

Mr Hosie: Thank you very much indeed.

The Deputy Presiding Officer: I am sorry about that.

I will have to keep speeches to a strict three minutes. I extend the debate by 10 minutes, but I have to tell you that at least 15 people will not be called. I am very sorry, but you are obviously all very keen to contribute this afternoon. I am doing the best that I can, but I will have to keep you to a tight three minutes.

15:08

Dr David Love (British Medical Association Scottish Council): Thank you, Deputy Presiding Officer, for the invitation to contribute. I am deputy chairman of the Scottish council of the British Medical Association and joint chairman of the Scottish General Practitioners Committee.

I hope that we will come up with some ideas to achieve the right solutions for the NHS in Scotland. I am aware that, today, there has been a slight preoccupation with the delivery of hospital services. Of course, hospital services are not the NHS in Scotland. I am surprised that no one has trotted out the old cliché—I will do it now—that 90 per cent of care is provided to the people of Scotland in the community by general practitioners and community-based health care professionals.

Mr Sedgwick: GPs need a supportive hospital structure to be able to function normally in their neighbourhoods. Susan Taylor, who was chair of one of the GP groups and who works in Lochaline, could not continue to practice in her area without a hospital structure nearby. We can put out the figure that 90 per cent of all the activity in the health service goes on in general practice, but the activity needs to be taken as a whole. We should say not just that all the activity goes on in general practice, but that it goes on in hospitals too. It is about the two working together in co-operation, rather than working against each other.

Dr Love: Thank you. That is precisely what I was coming on to say. If we are to get the right solutions, we have to look at the NHS as a whole, not just in silos. Of course hospitals could not survive and function without general practice and general practice and patients could not survive without good hospital services. What I am saying is that we need to consider the services that patients receive. We seem to be preoccupied about the buildings in which they are getting them. Let us focus on the patients. In recent years we have changed patient care dramatically; services that used to be provided in hospital are now provided in general practice, which is a good thing. That does not mean that hospitals are twiddling their thumbs; they still have lots to do and are extremely busy.

The Deputy Presiding Officer: Mr Love, there is another intervention if you wish to take it.

Dr Love: As long as I get extra time.

Mrs Janice Johnson (Skin Care Campaign Scotland): Patients with chronic skin conditions such as psoriasis and eczema are short-changed because they do not happen to fit into GP or hospital targets.

Dr Love: It is not the medical profession that sets targets; it tends to be the politicians. Our aim

is to give patients with all sorts of diseases equally high quality care and equal priority. That includes patients with psoriasis.

We need to consider the whole NHS. If we are to achieve solutions we have to decide where patients are best treated. If we are going to deliver the best possible services for patients we really have to exploit the full potential of general practitioners and primary health care teams.

The final point that I want to make is about workforce planning, which is of course important. Workforce planning has been sadly lacking in the past and it is needed urgently. I make a plea for workforce action. We know now that we are heading for serious shortages of doctors in a few years' time. We know now that we are not training enough general practitioners to maintain current numbers, far less expand them. That is my final plea. Those shortages are not mysteries or unknowns; we know about them as we speak and yet all we seem to be doing is planning. Planning must be converted into action.

15:13

Dr Brian Durward (Glasgow Caledonian University): Thank you for the opportunity to contribute. As dean of the school of health and social care at Glasgow Caledonian University I am responsible for providing some of the allied health professionals and social workers that can contribute to the new ways of working that sit behind the motion that we are addressing.

People who apply to become students in the university do so not mainly for financial reasons but because of a high vocational motivation to enter the health and social care field. It is fair to say that in considering a job in that field, they are after not just a job but a career.

One of the striking things about the second report and the debate today is the lack of reference to joint future working and the fact that we should be considering cross-sector working and developing new activities and ways of supporting patient care.

Mr Bill Skelly (North Glasgow Community Health and Social Care Partnership): Given that we are bringing people into a new organisation with health and social care working together, I emphasise for the dean a point that an old professor of mine once made: structures are easy, but cultures are more difficult. I ask him to bear that in mind when bringing in the new cohorts of professionals into the health and social care partnerships.

Brian Durward: Thank you, yes. Somebody has described the health professions as a set of competing tribes. It is interesting to reflect on the

fact that we have structures such as the professional advisory structure in the Scottish Executive, which perhaps reinforces the competing tribal nature of the professions. Within education, we have a responsibility to try to break down that idea of competition. Sometimes we knock that idea out of health professionals, but when they go out into health and social care settings it gets knocked back in again. That is worth reflecting on.

In terms of solutions, in order to prepare graduates who are capable of supporting activities such as podiatric surgery or radiography-led breast screening services, some of which have received very positive feedback, there is a need to secure even distribution of funding for professional development; to consider the issue of developing careers, not just providing jobs; and to consider seriously the professional advisory structure that might facilitate joint future working.

15:16

Ms Catherine Hughes: I contribute to the debate from several different aspects: as a carer for my dad, who was diagnosed with Crohn's disease when I was just six weeks old; as a former nurse; and as a patient who would be considered a frequent service user. As an in-patient, I have spent more than a year in hospital as a result of my health care needs and I feel that I can contribute positively to finding solutions. I have been asked to speak to you by several different organisations that have a vested interest in the health of our nation and the role of the NHS in the provision of care for those who have illness and chronic disease. We must address Scotland's reputation as the sick man of Europe and look for the solutions through health promotion.

I was going to take you on a journey to a hospital that is considered a centre of excellence, but Isabella Mooney eloquently took us there earlier. For those who have access to a computer, more information can be found and a virtual tour of the hospital can be taken at the www.ghh.info website. Information about the academic departments can be found at www.adhom.com.

More investment is needed nationally in chronic disease management to prevent the revolving door syndrome as, in their quest for health, patients will not stop placing demands on the finite services that are provided by the NHS. Patients require, on diagnosis, counselling on how to manage a lifetime of health care needs and chronic disease management courses to teach them the skills that they will have to call on to manage their condition effectively. That will mean the training of more specialist nurses in chronic disease care, and patients need to know that they can afford the maintenance medication that they

will require to comply with their doctor's orders. The conditions that are exempt from prescription charging criteria need to be re-evaluated, as patients are often on multiple prescriptions for their complex conditions and do not know whether they can afford them.

The National Association for Colitis and Crohn's Disease—NACC—has further information on the prescription issue. This is NACC's 25^th anniversary year and awareness of the disease, which affects one in 500 of the population, is the priority. NACC has a membership of 30,000, with groups across the country. More information is available at www.nacc.org.uk.

The views of the Royal College of Nursing's work-injured nurses group—RCN WING—must be considered, as it proposes a solution in utilising the skills of a group of nurses who can still make a positive contribution to addressing the current recruitment crisis. I have also carried out research on the immediate influence of the media on the recruitment of nurses. The media have a positive role to play in encouraging people to enter a profession that is both valuable and rewarding.

I hope that Glasgow homeopathic hospital receives the necessary funding for the expansion of the holistic and integrative care model throughout the health service as well as recognition for the valuable service that it provides. That must be seen as a possible solution to the problems that we currently face. Greater Glasgow NHS Board will make its decision on the plight of the hospital tomorrow.

I thank you for listening and for giving me the opportunity to share my experiences and views with you.

15:19

Ms Kim Hartley (Allied Health Professions Forum Scotland): Hello, Scotland, from all your 13,000 health professionals. I am a speech and language therapist and today I am representing the Allied Health Professions Forum Scotland.

Health is a multidisciplinary, multi-agency, multiperson pursuit. It involves not just professionals but, as we heard earlier, patients, carers, their dependants, employers and the whole community. On their journey from health to illness to full recovery, no patient is cared for by one professional group or even two. Take the example of a man who has had a stroke which, sadly, is an experience through which one adult in three in Scotland goes. To help such a man get from the moment at which he has his stroke back to being a husband, a dad or a granddad—back to walking, talking, providing for his family and socialising—he will need the services of not only nurses and doctors but many allied health professionals,

including speech therapists, physiotherapists, occupational therapists, prosthetists and orthotists, podiatrists and dieticians. They represent only some of the 13 allied health professions that are potentially involved in delivering health care in Scotland.

Workforce planning and the other solutions that we seek this afternoon must be multidisciplinary. We do an enormous injustice to Scotland's people if we talk only about doctors and nurses. The Health Committee's report talks about how change factors are impacting on doctors and nurses. The same can be said for all the allied health professions and, in some respects, it is even more the case for them, but I do not have time to go into the examples. Workforce planning must manage the impact of change factors across the multidisciplinary team.

As several delegates have said, we need a whole-systems approach to solutions; the problem will not be solved by using a medical model that is delivered solely by doctors and nurses in acute hospitals. Because quality health care can be delivered only through multidisciplinary team work, any planning must achieve balance across the multidisciplinary team, which includes increasing staff numbers across that team. More doctors should mean better health outcomes for patients, but more doctors making more referrals to the same number of allied health professionals means that the patients' experience turns into the series of frustrating waiting lists with which the people of Scotland are far too familiar. Imbalance within the multidisciplinary team means that a man who has had a stroke will be less likely to be able to walk, talk, provide for his family and enjoy a good quality of life for the rest of his life.

Allied health professionals are extremely concerned that current planning will inevitably lead towards an exacerbation of the huge waiting-list problems in their professions. They need to be involved in health service planning, which needs to be multidisciplinary, whole-system planning. We need to stop looking through the narrow pinhole of the medical model of doctors and nurses and, instead, manage the change factors across the team and create balanced, viable clinical teams. For those approaches to work, a cultural shift among providers is needed so that we begin to consider who is doing the planning and who knows best about what can be managed by whom and about who can refer to, and take referrals from, whom.

A cultural shift in public perception is also vital. A service does not have to be provided by a doctor to be good; sometimes, it is definitely not good if provided by a doctor, as some evidence shows. We must stop viewing allied health professional-led services as downgrades and the public needs

to develop knowledge of and confidence in the regulatory bodies that oversee the allied health professions and the contribution that allied health professionals make.

15:24

Ms Lesley Crawford: Lack of beds has been a problem for years. It has been made particularly acute over the past 25 years by a policy of curtailing bed numbers, closing wards and closing smaller, second-in-line hospitals. We must stop that stressful policy, which has a knock-on effect on admissions to accident and emergency departments, on patients' satisfaction with their care when they get to and beyond those departments, on the morale of staff who search for beds, on waiting lists, which get longer, on the cancellation of operations and treatments, on the turnover of nursing staff in particular and on general hygiene in hospitals, which perhaps has contributed to the rise in serious infections. One wonders whether a bed can be properly cleaned if it is occupied by one patient minutes after another has left it. No wonder we have big problems with infection. I make a plea for no more bed closures and for some beds to be reopened as soon as we get more staff.

15:25

Mr Malcolm Allan (Scottish Health Campaigns Network): When the previous chief executive of NHS Scotland retired and moved on, his post was advertised. The remit was to provide the right treatment, at the right time and in the right place. We must ask ourselves who defines the right time and place. At present, it appears to be the members of the 15 health boards in Scotland. Given that there is little meaningful consultation with local communities or those who practise in the NHS, it is hardly surprising that there has been a wave of public protest.

Let us cut to the possible solutions. So far, it has not been suggested that we might utilise the professional skills of refugees, following reinstatement of training. There is anecdotal evidence of physicians and nurses being employed in care homes as unskilled personnel. Similarly, can we utilise the abilities of specialists from non-European Union countries by amending the registration procedures?

Let us consider the use of mobile units for diagnostic procedures—for example, for cataracts diagnosis and endoscopies. That would be similar to the X-ray campaigns of the 1950s, which some people may remember. South of the border, there are diagnostic and treatment centres—DTCs. Those are a short-term solution, but it would not surprise us if Andy Kerr were already considering establishing such centres. Twenty DTCs are in

place in England, some under the NHS and some managed privately. It is planned that 80 will be rolled out by the end of this year. If I were waiting for a hip replacement, I would jump at the thought—although it might be more of a hop or a skip. In the short term, DTCs would cut waiting lists. There are advantages and significant disadvantages to such centres, but the principle must be considered.

Let us look at the medium term. Let us implement the Calman report's recommendation that we increase the annual intake of medical students by 100. We should consider providing a financial incentive to medical undergraduates, in return for a commitment to practise in Scotland for an agreed time. As we have heard, we should invest in information technology.

We are well aware of all the health initiatives that the Executive has put in place. Mr McConnell and his team are to be commended for their courage in addressing smoking in Scotland. However, there are other health issues that must be addressed, such as poor diet and lack of exercise. Sometimes I wonder whether the Executive is pushing at a door that is not closed but that has gey stiff hinges. Could we encourage individuals to get out the oilcan, lubricate the hinges, swing open the door and embrace initiatives? Perhaps there is something in the psyche of the Scottish establishment that is resistant to doing that. There is a feeling that initiatives are being imposed on people. It would be awfully nice if the Scottish establishment could join in and welcome them.

The expression "the sick man of Europe" has been used. Let us emphasise the fact that two groups in the country offer improvements in health care. The health providers are giving health care, but let us encourage people to take more responsibility for their health. Thank you for your attention.

The Deputy Presiding Officer: Before we move to wind-up speeches, I apologise to those people whom I have been unable to call. I regret that, but I have done my best in the limited time that was available.

15:29

Shona Robison (Dundee East) (SNP): In winding up, I will do a bit of a double act with my colleague Nanette Milne.

All in all, the debate has been good. However, if we had had it six years ago when the Parliament was first set up, we might have been able to avoid some of the mistakes that have been made and some of the pain that has been caused over the years. That said, we are now at a crossroads and have the opportunity to stand back and think about

the type of health service that we want for the 5 million people who live in rural, semi-rural and urban Scotland.

Before I touch on some of the many solutions outlined in this afternoon's speeches, I should say that I have been struck by how some solutions such as those introduced at Belford hospital have come from the bottom up. People have simply said, "Enough's enough; let's get together and see what can be done," and have come up with proposals in spite of what is happening at health board level or, indeed, at Scottish Executive Health Department level. It is worth bearing it in mind that such an approach has been the most successful one and every tribute should be paid to people at the Belford and elsewhere who have come up with such innovative solutions. I should also point out that there has been most success where staff have been prepared to break down silos and to work together to achieve those aims.

We also heard that there must be more strategic planning instead of having the piecemeal, crisis-driven decisions that health boards have made over the past few years. That is right but, as other delegates pointed out, such planning must be translated into action that must be taken sooner rather than later. We must train staff to meet the health service's needs, instead of doing things the other way round.

Some have said that politicians need to work together. Although we must be honest and realistic and acknowledge that that might not always happen, the fact that the Health Committee has produced the workforce planning report and initiated this debate perhaps sends a message that we can work together in certain circumstances. Indeed, that can happen to good effect. For example, through working together, the members of the Health Committee basically brought about the formation of the expert group under David Kerr, which will report in the next few months.

Some delegates mentioned that a change of direction is required in Scotland along the lines of the approach taken in England, where services have been kept local. The model of a rural general hospital that is emerging at the Belford could happen elsewhere, but it needs the backing of and resources from the Health Department.

We should consider managed clinical networks as a way forward and, in order to benefit patients, we need more of a two-way process between bigger teaching hospitals and smaller general hospitals. Medical graduates should be encouraged to work in our smaller hospitals and might need incentives to do so. Indeed, as far as quality-of-life issues are concerned, we should be promoting rural areas to ensure that people work there.

One very important point is that we need more and more effective public consultation. Although elected health boards might represent one way forward, delegates have pointed out that consultation is never easy and that we need to avoid the jargon that can put people off. One thing is for sure: the process of consultation needs to be improved, because if we do not rebuild trust between the public and the health boards that deliver services, we will get nowhere. As a result, we must take a radical look at how we rebuild that trust.

At this point, I will hand over to Nanette Milne.

15:34

Mrs Nanette Milne (North East Scotland) (Con): As the new girl on the block in the Health Committee, I was not directly involved in the workforce planning report. However, like most people in the chamber, I found it extremely interesting.

Today's morning and afternoon sessions have been interesting and full, and I want to pick up on some individual comments that were made this afternoon.

George Venters highlighted the need for strategic planning. When I joined the health service in 1965, workforce planning was an issue—as George Venters said, people would look a decade ahead. That has not been happening recently and all the pressures on the service that have arisen in recent years have meant that there is now an acute need for workforce planning, whereas before it was just something that was dealt with in the course of time.

George Venters also argued that we need to keep health services local, whenever that is possible. I am a great fan of community hospitals, which I think are extremely important, and I would like them to be kept, as they have a major part to play in our health service. However, as we have heard today, everyone accepts the need for more specialist hospitals. Not every patient can be treated for everything at or near home, especially in rural areas. We must have a combination of local facilities and more specialist, tertiary facilities.

I was fascinated to hear about the Californian experiences that Christine Lenihan described. The family doctor service that she spoke about is a service that many people would dream about. The idea that caring and compassionate people should work inside the health service—in NHS 24—alongside health service professionals is extremely important.

The solutions that David Sedgwick has come up with for the Belford hospital represent a

tremendous example of the way ahead for the whole country. In his intervention on Dr Love, he talked about the need to combine general practice with hospital services and said that it was important in planning ahead to consider the activity of the whole of the NHS as a single entity.

He said that colleges need actively to encourage medical people to train to work in rural general hospitals. That would encourage people into the periphery as well as into the teaching hospitals. Many of us who have worked in the medical profession realise that personal experiences are often more satisfying in a smaller community in which one deals with people in the round rather than treats a highly specific aspect of their health, as the specialist hospitals do.

The Deputy Presiding Officer: You have one minute left.

Mrs Milne: I will not have time to make all the points that I intended to make.

As David Wishart said, chronic mismanagement and waste in the NHS must be tackled. The fact that health boards have been planning in a reactive way must be examined soon.

It was said that people should not have to choose between local treatment and expert treatment. Expert treatment can be provided locally—for example, many patients have their cancers dealt with highly effectively in smaller hospitals.

Patients and the public should work together with the health service; it is important that they should have input into the planning and running of the health service. In the Parliament, we hear ad nauseam about consultation. I agree that it can be meaningless, as many delegates have said, so we must consult and listen to the public in a meaningful way. I hope that today's consultation, which has involved listening to people here in the chamber, will contribute significantly to forward planning in the health service.

As has been said, technology is vital. We all know how advanced technology is. Techniques such as videoconferencing are crucial to planning. Other important issues include cross-sectoral working, even distribution of funding for medical development and the role of allied health professionals. Without the work that AHPs do, the service would fall flat on its face. It is time that podiatrists, speech therapists and all the other much-needed specialist AHPs received more recognition.

I have run out of time; in four minutes—eight minutes, if I include Shona Robison's time—it is impossible to sum up everything that has been discussed this afternoon, but I am sure that all the points that have been made will be noted. All the

speeches will be on the public record and I hope that they will make a significant contribution to the development of workforce planning.

15:39

Professor Gillian Needham (Advisory Group on the National Framework for Service Change): It is my privilege, as one of two members of the national framework advisory group—or the Kerr group, as everyone is calling it today—first to give a big thanks to the Health Committee for ensuring that we were in the body of the Parliament today to hear the contributions that have been made. I promise everyone that we have listened. Indeed, what I heard has gone not just into my head but into the copious notes that I have made today. I will ensure, as will my colleague Peter Bates, that what we heard goes back to the group.

I say to Margaret Smith that it important to understand that public consultation is not simply a new fashion. Public consultation has been a valued part of the Kerr group process. John Winton is sitting next to me, and it has been good today to see some well-kent faces from the process that our group has gone through.

We know, as we heard today, that the status quo is not an option—Jim Devine was one of those who said so—and our group has been considering the evidence around the drivers for the change that will have to happen. I say to Susan Aitken and Kim Hartley that different does not mean downgraded—that argument was well made again today.

The Kerr group wants health planning to be visibly driven by patients' needs. When we deliver our report, we hope that what is billed as a plan will be turned into action, as we think that that is important.

Again, on behalf of the Kerr group, I thank the committee for allowing us the privilege of being in the chamber today.

15:41

Roseanna Cunningham: On behalf of the Health Committee, I give a huge thank you to everyone who has attended and contributed to the debate. By my count, 16 people contributed in this morning's session and 18 people did so this afternoon. That is a pretty splendid number of contributions. I also thank members of the public who sat through today's proceedings. That such a great number of people did so is an important part of the process.

I hope that everyone has enjoyed the day and that we will all go away from the debate with a sense of having got something out of it. Certainly,

the members of the Health Committee have been given a lot to think about and we will consider carefully and take forward everything that was said. I learned a new phrase today, which is "hot bedding". I realise that more than one use may be made of the term in future.

I was particularly pleased to hear Gillian Needham's comments from the perspective of the Kerr group. I very much hope that some of the messages that were articulated today will find their way into the Kerr report. As I said this morning, the report is expected to be published later in the spring.

I will not sum up all the contributions to the debate but will make one or two responses to what was said. I say to Dr Love that the Health Committee may yet turn its attention to GPs and that, when that happens, he might not find it much fun. Clearly, what David Wishart said about chronic mismanagement struck a chord with a great number of people in the chamber. That is an issue on which the committee needs to reflect.

There was some real passion in the debate, including the excellent contribution that Isabella Mooney made this morning on behalf of the Glasgow homeopathic hospital. [Applause.] I was struck by Sandra Casey's reminder that communities do not grow up around hospitals but that hospitals come to communities.

David Sedgwick of the Belford hospital threw down a real challenge to the royal colleges. Another direct challenge was made by Pat Dawson of RCN Scotland. Constructive input was made to the debate from right across the chamber.

All delegates will receive a copy of the report of the day's proceedings. Today's debate was recorded and, if delegates visit the Parliament's website tomorrow, they will find the debate in the Holyrood live archive. People will be able to watch themselves if they want to; no doubt, that will be the point at which some people will wish that they had said something or at which those who spoke will wish that they had said something different. If so, all that I can say is, "Welcome to the club." Some delegates got a much easier time from the Presiding Officers than any member of the Scottish Parliament would.

Today's debate is unique. It is the first time that the Parliament has attempted to conduct a debate of this sort in the chamber, involving ordinary members of the public as well as professionals and members of interest groups.

The Parliament is keen to find out what delegates thought of the debate. We want to know whether there was anything that worked particularly well, anything that could have been organised differently or any lessons that can be drawn from the experience. If anyone wanted to

speak but could not, I ask them to use the space in the evaluation questionnaire to set down an outline of what they would have said had they been called.

If you fill in the evaluation questionnaire now, you can leave it in the box at the rear door. Alternatively, you can fill it in later and return it in the prepaid envelope that has been provided. Either way, please take five minutes to fill it in. Your responses will be used to guide the next such event—I hope that there will be others.

I thank you again and wish you a safe journey home. Please return your badges, in case the security staff rugby tackle you on the way out.

The Deputy Presiding Officer: I, too, will take a minute to thank all the delegates for coming along to today's event.

I am not a member of the Health Committee, but I have learned some things this afternoon. I have seen the parliamentary chamber being used, as it should be, to invite the public to come to the Parliament and enjoy it—this is your Parliament.

Despite its problems, I still think that we have a national health service of which we can be proud. The service could be better, as I have learned this afternoon, and all of you are keen to improve it. I am sure that we will see some improvements when we hold our next such event.

I am off to find out what "hot bedding" means—it sounds really interesting.

I thank you for attending.

Meeting closed at 15:46.