Primary Health Care

– in the Scottish Parliament at 9:30 am on 25th April 2002.

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Photo of George Reid George Reid Scottish National Party 9:30 am, 25th April 2002

Good morning. The first item of business is a debate on motion S1M-3022, in the name of Malcolm Chisholm, on modernising primary health care in the national health service to improve health, and three amendments to that motion. Members who wish to contribute to the debate should press their request-to-speak buttons now. I call Malcolm Chisholm to speak to and move the motion.

Photo of Malcolm Chisholm Malcolm Chisholm Labour

Our agenda of investment and reform is a collaborative venture that involves patients and front-line staff wherever they are based. Our focus is the patient and their journey within and across care sectors. Integrated care and single-system working will be required ever-increasingly. In that context, I have a passionate commitment to primary care, which is at the heart of my vision for the future of health care in Scotland.

Our test for new and existing NHS services will be this:

"If it can be done in primary care, it should be done in primary care."

We want people to have ready access to the most appropriate member of the primary care team for such services. We want the services to be part of an integrated, joined-up health and social care system that is designed to meet the needs and wishes of patients. We want primary care teams to drive reform of the NHS, so that people will receive the services that they need, in the right place and at the right time.

Ninety per cent of patient contacts with the NHS begin and end with primary care, which is the gatekeeper to most other parts of the NHS. People value the services that they receive and the staff who provide them. We want to ensure that we continue to develop and enhance those services through our reforms. However, sustainable change will be possible only with the continued support, dedication and hard work of the people who work day in and day out in primary care, caring for patients and working with communities. I thank those staff and pay tribute to all that they are doing and will do in leading change. It is critical that we work in partnership with front-line staff to achieve the level and pace of change that we need to deliver our vision.

Primary care is also a key element in our health improvement and public health agenda for tackling inequalities and raising the health status of individuals and communities. Primary care must be an integral part of the wider drive for social justice, and primary care teams must work with other agencies and local communities.

This summer's decisions on the near 50 per cent increase in health spending that was announced after last week's budget will link investment to evidence of right-place, right-time care and intervention. Nowhere will that be more important than in primary care. The potential is huge for improvements in the experience of patients and the effectiveness of the NHS. That is why we intend to back local primary care teams in taking a central role in leading reform in the NHS. Those professionals—general practitioners, nurses, pharmacists, dentists, health visitors and others—see patients most often and know best their needs. They must be the leaders of change who drive forward the development of care and the redesign of services around the needs of patients.

The transformation in services has begun. However, to speed up the pace of change, we must give front-line health professionals access to the investment and support that they need. That is why we have announced some £30 million of dedicated additional resources for local services, which will be spent through primary care teams on extra staff and equipment. That is also why I support further devolution of funding and decision making to local primary care teams and why I urge all those who work in primary care to play a full and active part in the high-level review of NHS management and decision making that is now under way. A key part of the review's remit is to focus on the developing role of local health care co-operatives in our unified health care system.

In view of comments that were made on the radio this morning, I want to make it absolutely clear that this announcement has nothing to do with GP fundholding. GP fundholding was bureaucratic and competitive and it institutionalised inequity. We will therefore reject the Conservative amendment.

Of course, we want to give choice to patients—we made that clear last week. Patients and GPs can, for example, express a preference for a hospital that can offer a shorter waiting time. Such referrals can take place without GPs' requiring funds to purchase secondary care. The money can simply be transferred. I await with interest the SNP's position on that. If the SNP amendment refers to the devolution of power and resources to local health care co-operatives in our sense, I could accept it. However, if it means LHCCs holding funds for commissioning secondary care, I will not support it because it would set up unnecessary bureaucracy.

Photo of Ben Wallace Ben Wallace Conservative

I am grateful for the minister's comments on our amendment. He will know that the amendment uses the words of Alan Milburn, not those of the Scottish Conservative party.

The minister says that the Executive will devolve financial control to PCTs. What is the difference between fundholding and commissioning care at PCT, practice or LHCC level on behalf of the patient?

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I do not know what Iain Duncan Smith or Liam Fox would think about it, but time and again the Conservatives talk to me about Alan Milburn. They often misrepresent him and that does not win them the argument. Last week, Alan Milburn said that to move patients around the system more easily we must get away from the bureaucracy of contracts. That is my position. We do not need to get involved in that situation. We want more resources in primary care so that professionals in that sector can develop services and lead change.

Improvements for patients are at the heart of this programme of reform. By October, there will be a clear timetable in every NHS board area for the delivery of 48-hour maximum waits to see the right member of the primary care team. Patients throughout the country will also have access to a wider range of services—including minor surgery—close to home. There will be a major drive to cut the bureaucratic NHS paper chase between primary and acute care, through investment in information technology and a new contract between the NHS and GPs. Those measures will reduce delays for patients and increase the amount of quality time that local health professionals are able to spend with patients. We will invest £50 million over the next three years to step up the use of information technology in the NHS, and this year we have added another £2 million to slash the 10 million pieces of paper that slow down the organisation of primary care.

Photo of Tommy Sheridan Tommy Sheridan SSP

On the time limit for an appointment with the appropriate primary care professional, where does physiotherapy fit into the Executive's plan? Constituents who come to see me and who are trying to get physiotherapy appointments often complain that the difficulty is in having to go to a GP simply to get an appointment, rather than go directly to a physiotherapist. Does the minister plan to expand physiotherapy and make it an integral part of primary care?

Photo of Malcolm Chisholm Malcolm Chisholm Labour

Tommy Sheridan has highlighted another part of the primary care reform agenda. Sometimes, people must go through too many stages before they reach the appropriate professional. Physiotherapy is an area in which that happens; optometry is another. Waiting times for treatment for eye conditions has been dealt with by cutting out some of those stages. The general point that Tommy Sheridan makes is absolutely valid.

We also want to take steps to ensure that best practice becomes common practice throughout Scotland. There will be a major drive to encourage collaboration in primary care—for example, by funding more locum covers—so that professionals in one part of the country can share experiences systematically with those in other areas. The need for best practice to become common practice runs through the recent report of the primary care modernisation group, which is aptly entitled "Making the Connections: Developing Best Practice into Common Practice". The report identifies specific priorities for action, including improving access to services, better chronic disease management in the community and improved mental health services in primary care. I support those priorities, which are at the heart of our immediate reform agenda.

I referred to dedicated additional resources of £30 million to primary care teams. LHCCs are currently investing that money in a range of services for patients. I had intended to speak at greater length about our continuing investment but, as time is passing so quickly, I will refer only briefly to the £30 million tranche and to the £48 million for 100 high-quality modern premises projects throughout Scotland, many of which will bring primary care professionals from different agencies together to provide one-stop services. An excellent example of that is at Dalmellington in Ayrshire, which I was pleased to visit recently. We will perhaps hear more about it from someone from Ayrshire later.

There is also £18.5 million being invested in personal medical services to enable GPs and their teams to focus on the clinical needs of their patients through more flexible ways of providing existing and additional services and through the best use of professional skills. Examples include improved chronic disease management, improved mental health services and improved services for specific groups such as homeless people and people who have learning disabilities.

I do not want people to think that all this is just a shake-up of primary care. We are stepping up the pace of change and we are taking those who work in primary care with us. They are already signed up to the agenda and are delivering it throughout Scotland.

Additional investment is not just about providing more of the same, but about doing things differently. It is about ensuring that primary care can drive change and it is about working with front-line staff and with patients to redesign services to provide more comprehensive and better co-ordinated care to individuals and communities.

Service redesign, new technologies, greater flexibilities in the roles and responsibilities of different staff groups, and the stripping out of bureaucracy can all create scope to increase the proportion of time that health professionals spend with patients. Much of the redesign work to date has focused on the interface between primary care and specialist services. For example, in Dumfries and Galloway, a managed clinical coronary heart disease—CHD—network has been developed, which provides care pathways for all health professionals. It identifies what is required at each stage of a patient's care and ensures a uniform approach. That CHD network has been driven by primary care—the project manager is a GP and all the LHCCs in the area have been enthusiastic supporters, as have individual practices. That is a concrete example of what we mean when we talk about redesigning services across primary and secondary care.

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I had better keep going because time is passing at an alarming speed. Other examples include cancer care, stroke care, services for the elderly and mental health services. NHS Greater Glasgow, in recognising that mild to moderate mental illness is the biggest reason why patients present for primary care, has developed a framework for primary care mental health services. That framework will be provided by a range of agencies and co-ordinated through LHCCs. Such developments will be key to the development of services in primary care, especially in the care of mild to moderate mental health problems.

We intend to build on the excellent work that is taking place throughout Scotland and to share the innovative work and learning that is emerging from the redesign projects by putting in place a national collaborative improvement programme. That programme will help to create the infrastructure and the resources that will support the wider implementation of best practice. The first programme of work, supported by the primary care modernisation group and the Scottish diabetes group, will tackle demand and management of access within primary care and will support the implementation of aspects of the Scottish diabetes framework.

A number of other measures can help to improve access to primary care—I will mention just three. The introduction of NHS 24—which will commence this spring in the north of Scotland—will become an important gateway to the NHS. It will provide quality-assured nurse telephone advice and an authoritative source of health care information. Where appropriate, it will direct referral to primary care professionals, accident and emergency services or the ambulance service.

The development of nurse triage and nurse practitioner services in general practice, as the first point of contact for urgent problems, will ensure that patients get to see the most appropriate member of the primary care team. That will deal effectively with minor illnesses and injuries.

Expansion in the scope of nurse prescribing in order to provide more accessible patient-centred services will also be an important development. Specially trained nurses will be able to prescribe from a range of products. That will support their growing role in treating minor illnesses and injuries, and will enable them further to develop their role as the first point of access for patients.

We also aim to maximise the expertise of pharmacists who, of all health professionals, have the widest knowledge of the science and use of medicines. At present, only doctors can change a patient's dosage. In conjunction with the Department of Health, we plan to introduce pharmacist prescribing to allow pharmacists to adjust doses in repeat prescriptions. That will help to prevent medicine-related hospital admissions, provide greater convenience for patients and their families and reduce GPs' work loads.

So many things are happening in primary care that I will simply mention in passing the joint future agenda—we have discussed it on many occasions. I would also like to highlight the provision of intensive home care and of rapid response teams to prevent admission to hospital and to facilitate discharge from secondary care.

I have made general reference to local health care co-operatives, but I highlight the recent appointment of public health practitioners, who will provide a vital resource for LHCCs. Public health practitioners will act as linchpins for actions to improve the health of local populations, as catalysts for change and as links to other agencies and communities. Everything will be done in collaboration with patients and front-line staff. There is public involvement in primary care, but I apologise for not having the time to go into it in detail. I assure members that public involvement is of fundamental importance to us.

I will move on to discuss the work force. Recruitment and retention is crucial to the development of primary care. We have agreed incentive packages for GPs, such as the £5,000 that is available to a new GP on joining the NHS and the further £5,000 on average to every new GP who joins a practice in a deprived, remote or rural area. We are piloting the World Health Organisation's family health nurse model in some of our remotest communities. The family health nurse will be a generalist community nurse who will focus particularly on the health needs of families and the communities that they live in. I look forward to visiting some of those people in the Highlands in the first half of May.

I am well aware that, in some remote and rural parts of Scotland, there are difficulties in recruiting and retaining dentists to provide NHS services. I am pleased to announce today an initial package of measures to help address this situation—which we have agreed with the profession—worth about £1 million. That package includes: funding to support a vocational training place for every dentistry graduate in Scotland; allowances of £3,000 to each newly qualified dentist who takes up their training year in a remote and rural area; allowances of £5,000 over two years to vocational training dentists who have completed their training and who commit themselves to the NHS; and allowances of £10,000 over two years to those who take up similar positions in remote and rural areas. Mary Mulligan will announce the details of that in a little while.

The new GP contract will also address recruitment and retention. The contract is fundamental to ensuring that general practice is effective, responsive and that it provides high-quality services that are free from the bureaucracy of the current system. The framework for the new contract was agreed last week between the NHS Confederation in Scotland and the UK general practitioners committee. The health ministers for all four countries have agreed to the principles that underlie the framework. I am confident that it will provide the foundations for a better deal for patients, GPs and the NHS in Scotland.

For remote and rural areas, the work of RARARI—the remote and rural access resource initiative—is examining innovative solutions to the problems of recruitment and retention of staff.

An important report on medical work force planning will come soon from Professor John Temple. Professor Gillian Needham has also produced a report—"Planning Together"—on work force planning more generally. On the back of those reports, we will produce an action plan on work force planning and development.

Research is important in order to evaluate what is happening and to establish best practice. We promised in 1998 to double our investment in primary care research over five years. By the end of last year, we had already met that target and investment continues to grow. One of our significant new investments has been in the Scottish School of Primary Care, which considers the full range of clinical and academic primary care disciplines to improve the evidence base for primary care and to support reform. I look forward to addressing its conference tomorrow and to going into some of the issues in more detail.

I apologise for having to omit some issues. Although it is impossible in 20 minutes to go through the whole primary care reform agenda, I hope that I have managed to outline the direction of travel. I also hope, in speeches over the next month or so, to give further indications of where we see the direction of reform going in the next few months and years.

The advantage of the funding that was announced last week is that it will allow us to make steady and sustained progress on our programme, which is practical and concentrates on delivering improvements in communities. Within the next year, I expect tangible progress in at least three key, but not exclusive, areas: the round-the-clock NHS 24 telephone advice line; the work that is being done to develop health improvement champions in every community; and the development of bigger roles for nurses, pharmacists and others in managing chronic disease.

Above all, we must ensure that extra health resources are used as effectively as possible. Resources must be spent where they are needed most and where they can do most good. That will allow us to move closer to achieving right-place, right-time and right-quality care and intervention for all patients, which I am sure we all want.

I move,

That the Parliament applauds the vital contribution to healthcare and health improvement made by primary care teams across Scotland and supports further investment and reform to improve access and redesign services round the needs of patients.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party 9:51 am, 25th April 2002

The Scottish National Party is committed to developing and improving primary care. We support and endorse the report of the primary care modernisation group. I agree strongly with the central premise on which the report is based, which the minister cited this morning. It is that:

"If it can be done in primary care, it should be done in primary care."

Primary care is rooted in local communities. When people are sick, they want to be treated in their own communities, close to their homes and as quickly and conveniently as possible. Primary care also has a huge role to play in the promotion of public health. With the exception of those who face medical emergencies, it is the first—perhaps the only—and certainly the most regular contact that people have with the NHS. No one is better placed than are those in primary care to disseminate messages and advice about how to stay healthy.

Professionals who work in primary care already cater for the overwhelming majority of patient needs, with 90 per cent of all patient contact with the NHS beginning and ending in primary care. It is vital that those people are recognised properly and valued for the enormous contribution that they make to the national health service. However, they could do much more if they were empowered to do so.

The drive to improve and modernise primary care must have two express objectives. First, it must enable those who work in primary care to maximise and improve what they are able to do for patients in the primary care sector. To that end, the intention to put extra money into the management of chronic disease in primary care, which was a particular focus of the primary care modernisation group report, is welcome. However, there must be a second crucial objective, which is to make primary care the engine room of change for the whole NHS. That would allow primary care to influence, on behalf of patients, the range and quality of services that are provided in the hospital sector. In that respect, Government thinking has a lot of catching up to do.

I want to look briefly at some of the challenges that we must face if we are to meet those objectives. First, if we are to maximise what can be done in primary care, we must address the under-capacity that exists in that sector, as in the hospital sector. As the minister said, recruitment and retention of staff is a major problem.

Since 1997, the number of GP consultations has almost doubled as the shift from acute to primary care has accelerated. However, the number of GPs has risen by only 3 per cent and the number of practice nurses has risen by a similar—extremely small—amount. There is an increasing number of GP vacancies, particularly in rural areas. In places such as Helmsdale, it has proved to be impossible to attract a GP. Newspapers at the weekend carried the story of a Highland GP who resigned from the NHS because of pressure of work and lack of support. It is unfortunate that he is not alone.

The story is the same in nursing. The highest nursing vacancy rates are among health visitors, community and mental health nurses and nurses who work with older people. There are also problems in the recruitment of pharmacists and pharmacy staff.

There is no single answer to those problems, but a range of things can and should be done to aid the recruitment process. Work loads—particularly GPs' work loads—must be addressed not only for doctors' sakes, because there is a recurring plea from patients for more time with their general practitioners. I hope that the solution will be provided, at least in part, by the proposed new GP contract. It is crucial that we also make full use of the skills of all members of primary care teams in delivering health care. I will return to that point.

Professionals believe that better training opportunities and support for continuing professional development are essential if the NHS is to attract staff. That issue is important also for patients. The National Asthma Campaign prepared a briefing for today's debate, which says that one in five nurses who run asthma clinics do not have an appropriate qualification. That fact, together with other training issues, must be addressed.

On pay, I hope that members will not disagree that there is a need to increase general pay levels in the NHS. We should also be willing to use pay as an incentive to attract staff to parts of the country or to specialties in which there are shortages. The golden hello scheme to attract GPs to rural and remote areas, which was announced toward the end of last year, might help, but an initial payment of £5,000 might not be enough to overcome the considerable disincentives to working in those areas. Those disincentives include professional and social isolation, long hours and no out-of-hours cover. We should be prepared to consider additional financial incentives to attract and retain staff in areas in which there are shortages.

I mentioned the need to involve fully all members of primary care teams in delivery of patient care. Although GPs are important, there is increasing acknowledgement among MSPs and the general public that primary care does not begin and end with them. A range of professionals can be found in primary care teams and all their skills must be utilised at the right times and in the right ways. That will ensure the best patient care.

Good work is under way to foster genuine multi-professional working in primary care. Examples of positive moves in the right direction include the pharmacy strategy and the piloting of nurse and pharmacist prescribing. However, many primary care professionals continue to feel undervalued and underutilised. The primary care modernisation group report highlighted the fact that community pharmacists—who dispense 125,000 prescriptions every week—represent "significant untapped potential".

The primary care modernisation group's report also states that direct access to physiotherapists can lead to a reduction in tertiary referrals and the number and cost of prescriptions and X-rays. It can also lead to a reduction in waiting times. However, patients can still often access physiotherapy only through a GP and waiting times are still measured in weeks rather than days.

The report talks a great deal about reducing the role of the GP as the "gatekeeper" of the NHS and about ensuring direct access to the relevant member of the primary care team. However, more needs to be done to make that a reality. One way in which to do so might be to make more use of nurse triage services in general practice and another might be to put nurses more into the primary care front line.

There might also be a case for more radical change. One of the debates that will take place this week at the Royal College of Nursing congress in Harrogate is entitled "Do patients need to register with a GP?". That question raises the possibility of a move away from the GP-list system to one in which patients can register with the primary care provider of their choice. If there is a genuine desire to put patients at the heart of primary care, that idea and others are worthy of consideration. That is also the case if the Government's pledge that there will be

"access to a member of the primary care team within 48 hours" is to become a reality. Better access for patients dictates that more investment than has previously been made available must be made if we are to improve primary care premises.

I turn to the second objective in the modernisation of primary care, which is to empower those in primary care to be the levers of change in the NHS. It is welcome and right that we will give more money to LHCCs so that they can provide more primary care services, but LHCCs need more than money. They need the power to spend money, not only to improve primary care, but to influence the range and quality of hospital services that are available to patients in their areas. LHCCs are closest to patients—they have the best understanding of local communities and they should be able to ensure that local needs are catered for.

Malcolm Chisholm says that he wants to devolve resources and decision making to LHCCs, but he is not clear about what he means by that. In my view, that measure will necessitate giving LHCCs the power directly to commission services from the secondary sector.

Photo of Malcolm Chisholm Malcolm Chisholm Labour

With respect, I think that I was clear about that issue. The GP and the patient will decide together, using the waiting times database, whether the patient should go to another hospital. The transfer of money can take place without the GP having the bureaucracy of holding funds. The objective can be realised without that bureaucracy. I share the objective that patients, with the guidance of their GPs, should have the choice to be treated somewhere else. The funds for secondary care do not have to be in the hands of GPs to achieve that objective.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

The problem is that many people in the front line in primary care would disagree with that. They say that they are in practice denied that power. I will come to the database in a moment. Primary care professionals require commissioning powers if they are to influence the shape of services, which would allow the professionals to ensure that services reflect the needs of communities. Those powers would also have the advantage—which the minister mentioned, but which many people including patients and professionals in primary care do not believe exists—of enabling primary care professionals to help drive up standards in hospitals on behalf of their patients.

Much was made last week of the fact that waiting times for all hospitals are to be published on a database—which the minister mentioned—for patients to scrutinise. I am all for that, because patients in Scotland have far too little access to information about the performance of the NHS. It is vital that we have stringently monitored and rigorous national standards, and that results are published for public consumption. The implication and logical conclusion of that is that patients will be able to use the information to influence how and where they want to be treated. The minister claims that that happens at present, but that is not the experience of those in the front line. Unless those who refer patients to hospitals have the power and financial muscle to effect decisions on behalf of patients, the minister's claims are no more than rhetoric.

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I will be brief. Currently, patients and those who refer them do not have the information and that is why the database is crucial. When the information is available, there will be nothing in the system to stop referrals.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

That is how the Scottish Executive analyses the situation, but the British Medical Association analyses it differently. The BMA thinks that to give patients choice, LHCCs require commissioning power to provide the muscle. That is a difference of opinion, but in this case, the Scottish Executive is wrong and those who are in the front line of delivering primary care are right. The Scottish Executive would do well to listen to them.

If patients have genuine power to choose through primary care, they will become a powerful lever for change in the system. I do not agree with everything that Alan Milburn says and does—or even the majority of it—but he is right to seek to devolve 75 per cent of the NHS budget to primary care organisations and to put them in the driving seat of commissioning services. We should aim for that not—as the Tories want—in order to open up the health service to private providers to make profits from patients, but to ensure that patients have access to the best available care in the NHS, and to ensure that there are incentives for those who provide care to do so to the highest possible standards.

A move in that direction would have implications for primary care trusts and for LHCCs; primary care trusts would become redundant and should be abolished in order to reduce the bureaucracy to which the minister referred in his opening remarks.

At present, the structure of LHCCs is not prescribed. The diversity and ability of LHCCs to reflect local circumstances are thought by some people to be strengths. However, if LHCCs are to become budget-holding and commissioning organisations, they must be expected to meet certain standards. For example, they must include all professional interests in primary care—some groups, such as pharmacists, currently feel excluded—and they must represent patients' interests. LHCCs must become more accountable to the public and to patients. I believe that LHCCs have enormous potential to turn the power structure of the NHS on its head and to put power in the hands of the people who count—the patients.

Although the debate is about primary care, patient experience in the acute sector remains crucial. The shift of emphasis from acute care to primary care is right; I do not know of anyone who disagrees with that. However, as I have said repeatedly, that shift must not be used as an excuse to cut capacity in the acute sector to the point at which the sector cannot cope. The biggest frustration for many people who work in primary care is not the inadequacy of the service, but the delays and inconveniences that are experienced when a patient is referred to hospital. Waiting lists are up and waiting times are growing, which are sure signs that the acute sector is not coping, despite the best efforts of those who work in it. The reason is lack of capacity. There are 700 fewer acute beds now than there were in 1999 and staff shortages are crippling the service. Development and improvement of primary care are essential, but they must not be at the expense of the acute sector.

The debate is important. There are many challenges in primary care, but there might also be many exciting opportunities if we are all prepared to forget our hang-ups and to grasp those opportunities in the interests of patients.

I move amendment S1M-3022.2, to insert at end:

"including greater devolution of power and resources to local health care co-operatives to support and empower primary care teams."

Photo of Mary Scanlon Mary Scanlon Conservative 10:06 am, 25th April 2002

The debate is interesting. I cannot quite make up my mind whether Malcolm Chisholm wants to admit that he has gone back to GP fundholding, devolved budgets and choice through additional information. At the end of the day, that is what we are going back to. The minister would gain more respect if he said, "We have got it wrong for five years."

Photo of Malcolm Chisholm Malcolm Chisholm Labour

This is the first time that we have had a discussion on the issue. I welcome the discussion. We must be absolutely clear that when we talk about devolving funds and decision making, we do not mean holding funds for secondary care. We believe that patient choice can be delivered without GPs having the bureaucracy of holding funds for secondary care. In the interests of the debate, Mary Scanlon should be clear about where we agree and where we disagree.

Photo of Mary Scanlon Mary Scanlon Conservative

I am pleased that the minister agrees with some of what I said.

The minister said that he is passionately committed to primary care. GPs in the Highlands are so passionate about his commitment to primary care that 10 per cent of them have walked out in recent years. None of them says that they need a golden hello payment or an extra few quid a year. Those have never been reasons for leaving. I value the primary care modernisation group report and the fact that the minister intends to listen to GPs, but if he thinks the matter is simply about golden hello payments, he has missed the mark.

I welcome the minister's endorsement of best practice becoming common practice and of the excellent work that is done in Dumfries and Galloway's managed clinical network for heart disease. My colleague David Mundell lodged a motion on that topic. He visited GPs and others who are involved and brought the matter to my attention. Many Conservative and SNP members have signed the motion, but not one member of the Labour party has done so. When we find excellent practice, which is endorsed in the modernisation group report, the minister should be big enough to ask his party members to support it.

One aspect that was missing from the minister's comments on one-stop shops in primary care was the voluntary sector, which has an enormous role. This week, I spoke to a representative of the Church of Scotland. Its work on drug problems and alcoholism—from detoxification and rehabilitation through to rehousing and support accommodation—should be welcomed. I hope that the minister will find a place in the new structure for the excellent work of the voluntary sector.

Before I begin the main part of my speech, I will deal with the joint future group. At yesterday's meeting of the Health and Community Care Committee, we were told that Edinburgh alone has 527 blocked beds, which has an obvious impact on the acute sector, patients and the primary sector. Although the minister talks about joint futures, joint working and partnership, we must consider the reality that, of Scotland's 3,000 blocked beds, 527 are in this city.

I am pleased that we are debating primary care. As a member for the Highlands, I can certainly confirm that primary care is in crisis. The Executive's reforms of the past five years have created the crisis. Dr Murray of Lochcarron described the provision of health care in rural areas as being in a state of "near collapse". It is now impossible to register as an NHS patient with a dentist in Inverness and in most parts of the Highlands but, on the east coast of Caithness and Sutherland, it is becoming almost as difficult to access a local doctor. With 139 vacancies for dentists in Scotland and more than one third of GPs in their 50s, manpower planning is in serious crisis.

Like the SNP, we would support more nurse-led care, but those nurses must be appropriately trained for the responsibilities that they undertake. According to the National Asthma Campaign, 20 per cent of nurses who currently run asthma clinics do not have the appropriate qualifications. At yesterday's RCN conference, we heard via videolink that many nurses have difficulties in accessing training funds. If we expect nurses to do more, we must give them the support and training.

In the Highlands, many people with epilepsy have never seen a specialist and have never been given an accurate diagnosis. Many of them have been on the same medication for years, despite the new and more effective drugs that are now available. I agree that we should bring primary care into the health care team because it has an enormous role to play, but we need to ensure that budgets are available for training. We must also ensure that accurate diagnoses are carried out, in particular for neurological problems, before embarking on continuing care.

We support the placing of chronic disease management of diabetes, asthma, epilepsy and mental health within primary care, but we do so only with the proviso that there must be proper support. According to the RCN, fewer than four in 10 nurses feel that their employer enables them to keep pace with developments related to their job. Physicians and consultants have in many cases accessed the training fund, but I hope that equal access to training will be allowed to nurses.

On the radio this morning, the health minister said that things that could be done in primary care should be done in primary care, but the minister should acknowledge the truth that, under GP fundholding, things were increasingly being done in primary care. I hope that the devolution of budgets to the LHCCs will enable and empower them to utilise the skills and experience of the primary care teams.

The minister also mentioned that no new money would be made available for primary care this year and that he has set out the direction. By the time the minister decides to allocate extra funds to GPs in primary care, it might just be too late.

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I am sure that Mary Scanlon does not need reminding that no new money has been allocated over and above what has already been announced, which is an increase in excess of 7 per cent. Historically, that increase is extremely high.

Photo of Mary Scanlon Mary Scanlon Conservative

We need only look at the figures to see what is happening. The proof of the pudding will be when GPs and others stop walking away from the health minister. What will the minister do to encourage GPs who have walked away from the profession back into the fold, to deliver the health care for which they were trained?

Last week, Dr Joiner resigned, citing a long list of reasons for dissatisfaction. Let me read from the letter that he sent to his patients:

"I find the administration increasingly difficult to work with and the demands of the new financial bosses completely unacceptable. The reasons that I have decided to resign are common to several senior doctors in Scotland—especially in the Highlands: being single-handed, onerous out of hours responsibility and the administrative demands of our bosses."

The problems are not all about pay and Dr Joiner is not alone. In the past six months, 10 per cent of GPs in remote and rural areas have resigned. There is a great deal of frustration in their cries for help. For example, Dr Macleod of Glencoe and Ballachulish paid £20,000 of his own money to employ an associate GP, but that was not accepted by Highland NHS Board because it did not fit into the favoured new PMS model, which does not encourage that kind of approach. I believe that we should listen to Highland doctors such as Dr Macleod, who know exactly what their patients need, what doctors need and how to work together to provide the best level of care.

The problems in the Highlands are critical— [Interruption.]

Photo of George Reid George Reid Scottish National Party

Order. I will not allow the private dialogues that are taking place behind the member who is making her speech.

Photo of Mary Scanlon Mary Scanlon Conservative

Mike Rumbles could not behave if he tried, but we have got used to that.

The Highlands did well out of the Arbuthnott formula, which provided additional funding to reduce inequalities in, and increase access to, health care. However, the opposite of that has happened. Many communities rightly fear the loss of their local doctor. I appreciate what the minister said about physiotherapists, ambulance teams, podiatrists and district nurses but, at the moment, Highland communities cannot see that any acceptable substitute is in place. People see that they are losing their contact with the NHS and that nothing else appropriate is being put in its place. It is not surprising that people will be canvassing the Health and Community Care Committee when it visits Inverness next week.

It is not surprising that people are worried. Waiting lists are up by 10,000 since 1999. Waiting times are up. There is a record number of blocked beds. Those things are not the responsibility of GPs but, as GPs have the only open door in the NHS, they usually find that they are the focus of people's anger and frustration. Less than 7 per cent of health spend goes to GP services. Despite the fact that 90 per cent of patient contact with the NHS occurs at the GP surgery, over the past five years the number of consultant posts has increased by 19 per cent while the number of GP posts has increased by 3 per cent.

The absence of primary care commissioning in Scotland needs to be addressed. Fundholding is needed to support local decision making and to ensure more empowerment, so that the NHS is more responsive to patients' needs.

I realise that my time is almost up, but I am pleased that Labour has reversed some of its dogma. I am pleased that it has gone back to some basic Tory principles. The Executive has not quite got there yet, but I welcome the U-turn. How will the Executive reverse the damage that has been done in the past five years?

Let me use my last few seconds to talk about primary care teams. A few weekends ago, I went out with the police in Inverness. During the evening, there was a problem at accident and emergency, when the staff could not cope with a patient. The police were called and the suicidal patient was locked in the cells. The police phoned the primary care mental health team but got no co-operation, despite there having been an attempted suicide a couple of days earlier. I was shocked that the police had to charge an attempted suicide victim with breach of the peace in order to keep the person in the cells. There was no hope of a call-out from a GP to treat a prisoner in the police cells.

Any new initiative must include not only the primary care team but the voluntary sector and the police, who often become the dumping ground for many of the NHS's problems.

I move amendment S1M-3022.3, to leave out from "applauds" to end and insert:

"notes that in order to improve primary care local health care co-operatives should be free to purchase care from the most appropriate provider, be it public, private or voluntary, and the incentives gained by the purchasing of such services should be used to underpin patient choice; further urges the Scottish Executive to continue to use private providers where they can supplement the capacity of the NHS and provide value for money, and asks the Scottish Executive to make available to patients information on alternative providers and on waiting lists and times to allow patients to exercise real choice."

Photo of Tommy Sheridan Tommy Sheridan SSP 10:19 am, 25th April 2002

The Minister for Health and Community Care said that his speech was a statement on the direction of travel in which the NHS is moving and the direction of the reform that is under way. I am also looking for a statement that the rot is going to stop, and that more public money in the national health service will not lead to higher profits for the private sector.

This morning, I am looking for the Scottish Executive to make a clear statement that it will not go down the same road as England and Wales and open up a vista of even greater opportunity for the private sector by increasing the devolution of power to GPs and allowing them to access private sector health. I am looking to the Deputy Minister for Health and Community Care to state clearly in his summing-up speech that the private sector has no role whatever as an aid to the public health service and that it is, in fact, a parasitic disease for the public health sector.

I will turn in a moment to the specifics of primary care, which is of course linked to secondary care and other parts of the sector, but I will say first how appalled I was—as I am sure other socialists or former socialists were—to hear an advert for Health Care International on Radio Clyde yesterday. It paraded the fact that people waiting for a hip-joint replacement operation would have to wait no longer, as they could get it done in weeks for under £6,000 if they went to HCI. The other part of the advert involved the actor telling their friend that they were waiting for a magnetic resonance imaging—MRI—scan, to which the reply was that they could get it done with HCI in a matter of days instead of months.

I hope that the deputy minister, when he sums up, will take the opportunity to state clearly that extra funds for the national health service will be for public services within the NHS and will not be directed to open up any more private profit bonanzas.

Photo of David Davidson David Davidson Conservative

Is Tommy Sheridan proposing that we nationalise all the services provided by community pharmacies, dentists and everyone else? They are all private sector contractors.

Photo of Tommy Sheridan Tommy Sheridan SSP

The member will be aware of my position in relation to pharmacies and the pharmaceutical industry. GlaxoSmithKline announced its profits only last week. It is now making £6 million a day in profit from our health service. It is not beyond the vision of the people of Scotland to invest instead in a publicly owned pharmaceutical industry in which research and advancement are based on treating people and providing cures instead of trying to extract as much profit as possible.

Photo of Hugh Henry Hugh Henry Labour

I will attempt to answer some of the questions put by Tommy Sheridan, but it would help me in trying to frame those answers if he could indicate exactly what he means in his amendment. Is he proposing that we end the self-employment of GPs? Is he proposing that the 60 per cent of GPs who operate from privately owned and leased premises should no longer do so?

Photo of Tommy Sheridan Tommy Sheridan SSP

I am specifically proposing a number of things, to which I hope the minister will reply. One of them is that we end the moonlighting of consultants, which has a direct effect on the primary care sector. GPs have told us that the problem with referrals to consultants, in particular with 12-month waiting lists to see consultants, is that it adds to their GP surgery list, as people have to return for repeat visits after they have been referred. Let us end the scandal of consultants working in the private sector to the detriment of the public health sector. That is what I would like the Executive to do.

I also want the deputy minister to refer to the problem in primary care and to expand on what Mr Chisholm said at the start of the debate. I do not know where one aspect of primary care—physiotherapy—will fit in. The difficulty with physiotherapy is that some individuals have to wait up to two weeks to get their GP appointment. They might be looking for an appointment because of a torn ligament or muscle, which needs to be cared for within a couple of days if they are involved in sport—which we should be encouraging. The difficulty is that they cannot get direct referrals to physiotherapy services, which are lacking, as is integration across the country. That encourages use of the private sector in physiotherapy, particularly for sports injuries, which is a part of the industry that is booming.

I would like the deputy minister to refer to the fact that, by employing the private finance initiative over the past five years, we are leading a decline in the quality and number of staff and a decline in patient care. Every single determinant of satisfaction in our health service depends on the quality of staff. The difficulty with PFI funding is that it reduces the number of staff and the number of beds, which returns pressure to the GPs and the primary health sector. I am looking to the deputy minister to make a vision statement.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

Where is all the money for those plans to come from? I am still waiting for Tommy Sheridan to respond to my last intervention on him, when he promised that he was going to connect everybody in rural Scotland to the mains water supply and the public sewerage system. Where will the money come from?

Photo of Tommy Sheridan Tommy Sheridan SSP

Last week, the Chancellor of the Exchequer announced a 1 per cent rise in national insurance contributions to generate £8 billion across the country. If he had instead abolished the upper earnings limit on national insurance and had put an extra 10p on contributions from those on a salary of £50,000 a year and a further 10p on contributions from those on £100,000, which would still be under Thatcher's taxation levels for the wealthy, we could have generated double that amount—approaching £16 billion extra. There is not a problem with money.

I am looking to the deputy minister to rule out any further use of the private sector and to recognise that, from primary health care through to secondary health care, the private sector is not part of the solution but a big part of the problem, because it is siphoning away public funds, which should be used for public health services.

I move amendment S1M-3022.1, to insert at end:

", however, believes that the use of the private health care sector by the NHS in Scotland is divisive and counterproductive and should not be part of the Executive's strategy."

Photo of Margaret Smith Margaret Smith Liberal Democrat 10:27 am, 25th April 2002

I am not quite sure how to follow that. We often get fantasy politics from Tommy Sheridan; this morning we got fantasy pharmaceuticals. The idea that the country and the Parliament could run their own nationalised pharmaceutical industry absolutely defies belief. Presumably Tommy has absolutely no idea about the number of drugs that go no further than research and development because, after clinical trials or whatever, companies find that they cannot take them further. As Mary Scanlon has mentioned, it can cost £500 million to develop one drug, and companies have only 10 years in which to make that pay. As members can imagine, if we opted out of the pharmaceutical systems of the world and had our own nationalised pharmaceutical industry—

Photo of Margaret Smith Margaret Smith Liberal Democrat

Tommy has had enough of a chance.

The drugs companies would come back at us for doing as Tommy suggests, and the cost of existing drugs would go through the roof. The current 10 per cent inflation in the drugs budget would pale into insignificance next to what we would have to deal with.

I welcome the debate, which is intended to allow us to reiterate our support for primary care services, and in particular for the primary care teams, who deliver 90 per cent of Scotland's health care against the background of a continuing shift in work load from the secondary care sector to the primary and community care systems. Those teams are making connections with patients and with other professions in the health and social care sectors every day. It is essential that we support the primary care sector, not least because patients, as they remind us time and again, want to access services close to their homes and within their own communities.

I reiterate the point that was made in the report of the primary care modernisation group, "Making the Connections: Developing Best Practice into Common Practice", which states:

"If it can be done in primary care then it should be done in primary care."

The modern primary care team is at the heart of the delivery of quality patient care and of the Executive's drive to modernise the service for the benefit of patients. That is acknowledged in the primary care modernisation group's report and is recognised in the on-going investment that we are putting into the sector.

I welcome the minister's announcement of the extra money to recruit dentists in rural areas and for chronic disease management. In the past three days, I and many other MSPs have been involved with the Parkinson's Disease Society, Epilepsy Action Scotland and the Multiple Sclerosis Society. I am sure that any further investment in chronic disease and condition management will be welcomed by those groups.

I welcome the commitment to take forward a national collaborative programme, which will ensure that best practice is spread throughout the system, and the expansion of the use of nurses and community pharmacists in relation to prescribing. Community pharmacists play an important role in health care because they, more than anybody, have an open door and allow people to access good-quality professional judgment and experience. The Wanless report suggested that using pharmacists properly could free up between 1 per cent and 2 per cent of GPs' time. We should examine all of the ways in which we can do that and make the best use of redesigning the service to deliver a better service for the patient. The main areas that we must think about are best practice, best value and the best interests of the patient.

Tommy Sheridan talked about the private sector, but what we have is a hybrid system, even though that might not be the system that we would choose if we were starting with a blank sheet of paper. Just as many of us complain about issues relating to what consultants do with their time or are concerned about the fact that GPs are independent contractors and we do not have total control of them in the NHS, the point that Hugh Henry made is continually worth making: those GPs are responsible for the funding of an awful lot of the capital investment and infrastructure in the primary care system in the country. When I spent some time in Argyll, I found out a lot about the problems with GP recruitment and retention and with accessing funds to improve the infrastructure. Within our hybrid system, we work quite constructively with elements of the private sector. We owe it to the patients of Scotland to try to ensure that we use the capacity and services of the private sector to deliver best practice and the best possible quality services.

Over the past few years, there has been a lot of innovation at the primary care level. In the past few days, many of us have learned a lot about the role of nurses, their increasing specialisation and the greater use of nurse-led clinics. With regard to the joint future agenda, a real shake-up is coming in primary care's relationship to the social care agenda and work force. As I have said, we can also improve the way in which we use community pharmacists.

The Executive has supported the sector with £30 million investment over three years, with the money being spent in agreement with and through the local health care co-operatives. The minister has made clear the fact that we are trying to empower the primary care sector, LHCCs and so on, to increase choice, while reducing bureaucracy and not reopening the internal market. I believe that Nicola Sturgeon quoted the BMA, but I point out that the BMA's briefing paper said that the last thing that the organisation wanted was another shake-up of the health system in Scotland. In the past two or three years, LHCCs have developed from a system that started without total prescriptive direction and have blossomed in certain parts of Scotland. However, the situation is still patchy and we must invest further in them while empowering them. LHCCs must also be accountable. It is right that we use LHCCs as an important lever in the process of redesigning services, but we should not do that in a vacuum; it is critical that we take forward the accountability agenda in relation to them.

We must examine the premises in the sector. The minister mentioned that, last year, £48 million had been invested in projects in 100 premises. It is important not only that patients are treated in decent premises but that our primary care teams work in decent premises.

The fact that the GPs contract has been agreed is to be welcomed. We hear that there will be more flexibility. We have to accept that, as well as the changes across the NHS work force, there are changes in the GP work force, particularly in relation to the rising number of women who are becoming GPs. Therefore, it is important that contracts are flexible and that various types of contracts, such as PMS contracts, can be used.

The role of primary care professionals in the areas of social inclusion and the prevention of ill health has been mentioned. I was pleased to see that the primary care modernisation report said that that would be the next part of the agenda to be addressed. The recent appointment of public health practitioners is a welcome move in that direction. We must ask whom the average member of the population is most likely to listen to for general health advice. Probably, it will be their GP, practice nurse or a public health practitioner who works at a local level, rather than a consultant whom they see for perhaps five minutes once a year.

"Our National Health" set a target that stated that patients should be able to access a member of the primary care team in no more than 48 hours. I welcome the minister's announcement that that will have been achieved by October.

I welcome the progress that has been made in relation to NHS 24. Not only does that show flexibility in the reorganisation of services, to ensure that patients can access them easily; it shows that staff are responding with flexibility to the suggestion that they might be able to work part time to provide a service. The unanswered question relates to the impact that that might have on other front-line services, which some of those same people might provide. We have to watch that.

Last week, we heard the welcome announcement of extra investment in the health service, which will allow good progress to be made. However, no matter what we want to do with the money, we will come up against the issue of work force planning. The minister stated that two reports are currently being undertaken on that issue and we must take them seriously. In the next 10 years, we will lose about 25 per cent of the nursing work force. We have problems with vacancies in community nursing, with the recruitment of community pharmacists and dentists and with rural GPs. I tend to agree with what Mary Scanlon said about the issue being to do not only with money. The golden hello and the on-going work of the remote and rural areas resource initiative are welcome, as they show that the Executive intends to take the issue seriously. However, we must address the other problems that rural GPs and other primary care professionals have to deal with, such as long hours, professional isolation and the lack of out-of-hours cover.

There are human problems as well. It was brought home to me on a visit to Islay that someone who has gone to the island to work in the community hospital or with the primary care team may have no trouble getting a house to live in in the winter, but faces difficulties in the tourist season. We have to consider the possibility of being a little bit more flexible about that.

Another important issue is the information technology agenda, but I do not have time to cover that today—it might be worthy of an entire debate on its own.

I close by saying that I welcome the primary care modernisation report.

Photo of Janis Hughes Janis Hughes Labour 10:40 am, 25th April 2002

I declare an interest, as I am a member of Unison.

I firmly believe in a modernising agenda for the NHS. Often, other members do not demonstrate the same vision. I have said many times that we should not dwell in the past but should look forward to the future. However, on this occasion, it is worth reflecting briefly on how things used to be in the NHS.

Primary care is a relatively new term for what used to be just the family doctor, who was often based in small, inadequate premises—in Glasgow, they were usually up a close—with a small back-up team of district nurses based in a nearby clinic. Even the most minor investigations necessitated a visit to the local hospital. That often meant that patients chose to bypass their GP completely and go straight to casualty, which had consequences for work loads and waiting times there.

I am pleased to say that we have moved on a long way since those days. Now, the majority of patient care happens in the community through primary health care teams. In fact, more than 90 per cent of all patient care begins and ends in the primary care setting, with 87 per cent of cases being dealt with entirely in that setting. Those statistics serve to demonstrate the valuable role that the primary care team plays in the wider health service. Whether contact is made with a dentist, a nurse, a pharmacist, a doctor, a dietician or a physiotherapist, primary and community care services are an essential part of a seamless NHS.

We have heard a bit this morning about the primary care modernisation group. When it reported earlier this year, it identified various priorities to speed up access to a wider range of services. I particularly welcome the suggestion that we tackle chronic disease management by providing more services in the community. It is always difficult to get the balance right when targeting resources. That has been topical recently in light of the budget announcement. However, I believe that chronic disease management needs to be addressed and, although I welcome the investment in personal medical services to assist that, I hope that the minister will bear it in mind in his future budget considerations.

Perhaps the group's most far-reaching recommendation, which the minister has already mentioned, is that the role of LHCCs should be expanded to allow them to have a greater responsibility for the provision and planning of services. Camglen LHCC in my constituency provides an excellent service, which is centred on the new Rutherglen primary care centre. It provides a wide-ranging package of facilities, including maternity care, physiotherapy, podiatry, oral health and day care for people with mental health problems.

That range of facilities means that local people can have a large majority of their health care needs catered for at a very local level. No one wants to be admitted to hospital unless it is absolutely necessary. Those primary care facilities mean that many fewer patients will require admission.

Primary care is not just about treatment; it is also about prevention. The primary care sector has a vital role to play in public health. Encouragement for healthier lifestyles and help with dependency problems can also be provided because of the wide range of disciplines in the primary care team that I have already mentioned.

I will examine for a moment the amendment in Mary Scanlon's name. She and her colleagues yet again demonstrate selective amnesia. Her comments about GP fundholding just serve to remind us all how divisive and destructive that Conservative policy was. I am sure that Mary Scanlon's colleagues will remind her of that. Labour members would not support any moves to take us back down that road. I have faith that the minister has no intention of doing that.

It is right and proper that we acknowledge the vital contribution that primary care teams make. Meeting the needs of patients by providing local access to health care is vital, and I am happy to support the motion.

Photo of Adam Ingram Adam Ingram Scottish National Party 10:44 am, 25th April 2002

I will focus on the delivery of mental health services in the primary care sector. It is significant that the primary care modernisation group's first report has highlighted the need for better provision for sufferers of mental health problems such as anxiety and depression. Thirty per cent of all GP consultations arise from people seeking help with mental health problems. What is more, recently published survey results show rising trends in the incidence of depression among all age groups. Even children under the age of four are being treated for depression. However, the most heavily affected group is women in the 25 to 44 age range, with a staggering annual figure of nearly 100,000 of the 700,000 Scottish women in that age group seeking treatment for depression from GPs.

We clearly need to improve our understanding of why so many people are suffering from poor mental health, so that the root causes of that modern disease can be tackled. We need to review a wide range of policies, not just in health care, to relieve the stresses with which so many of our fellow citizens struggle to cope. Lifting more families out of poverty and providing much better child care facilities for working mothers are two areas for action.

However, that is not the whole story. On a recent visit to a suicide prevention centre in Glasgow, I was told that the dangerous increase in the incidence of suicide and self-harm among young people is born out of a perceived failure to live up to their own expectations of what they can achieve in life and to what they feel are their families' expectations. That applies to upwardly mobile social groups in particular. We need culture change.

On the deficiencies in treatment of mental distress of that nature in the NHS, drug therapy is too often the first and last resort of GPs. There has been a huge rise in the prescribing of antidepressants over the past few years, with reports suggesting that the prescription rate for antidepressants is much higher in Scotland than in England. Mental health problems that are not severe and enduring can be dealt with in a variety of ways: medication, specialist treatment, counselling and other forms of psycho-social intervention. However, widespread uncertainty exists among GPs over what kind of interventions are appropriate and effective.

We need better models of care. We need better training for GPs and nurses in the area of mental health. We also need much improved availability of specialist services. For example, waiting times of more than a year are the norm for people who are referred to clinical psychologists. Above all, what people really need to overcome mental health problems is someone to listen to them and to give them time, which is precisely what hard-pressed GPs are finding increasingly difficult. Practical help and information to alleviate the conditions that contribute to health problems are also badly needed.

In that regard, the way forward has already been signposted by the Health Education Board for Scotland's 1998 study "Mental health and primary care: a needs assessment". It highlighted the need to recruit other members of the primary care team to deal with patients with such problems. Health visitors and practice nurses, for example, can be as effective therapists as the doctor—if not more so for patients with poor mental health who do not want to bother the doctor. Training is therefore a major priority.

The main message is that attitudinal change is needed. We must view the patient as a whole person who needs a combination of help, not all of it of a medical nature. We need much better partnership working between primary care professionals, the voluntary sector and other agencies, such as social work and the police, as Mary Scanlon said.

Urgent ministerial action is now required to give substance to the lip service that has all too often been paid to mental health as a national clinical priority. A mental health task force, along the lines of those that have been established for cancer and coronary heart disease, needs to be set up. It is high time that mental health lost the tag of the Cinderella of the NHS.

Photo of Murray Tosh Murray Tosh Conservative

Margaret Jamieson will inject some humour into the debate.

Photo of Margaret Jamieson Margaret Jamieson Labour 10:50 am, 25th April 2002

Like my colleague Janis Hughes, I declare an interest as a member of the public sector trade union Unison.

For the vast majority of the population of Scotland, primary care is the general practitioner. However, as we know, primary care is much more than GPs. It is the full breadth of services: podiatrists, dentists, opticians, speech and language therapists, occupational therapists, community midwives, district nurses, health visitors, community psychiatric nurses, community pharmacists, community dieticians and social workers.

In East Ayrshire, we have developed the primary care team to include police and ambulance services and the full range of local government services. That was achieved by thinking about citizens rather than about bureaucratic boundaries—the aim was to create a true one-stop shop. We hope that all obstacles to pursuing that model throughout Ayrshire and Arran, and beyond, will be removed.

It would be remiss of me if I did not advise members that the driving forces of East Ayrshire's out-of-the-box approach to local delivery are two forceful and committed women: Fiona Lees, the deputy chief executive of East Ayrshire Council; and Heather Knox, the director of estates of Ayrshire and Arran Primary Care NHS Trust. The East Ayrshire scheme provides true local delivery and empowerment. No barriers exist to providing quality throughcare, irrespective of the patient's underlying problem.

I am delighted that the minister has highlighted investment in personal medical services, because the innovation in Ayrshire would not have been possible if GPs had continued to operate as independent contractors. PMS is a vehicle that will assist in the retention and recruitment of GPs, particularly in rural and semi-rural areas. It will facilitate part-time working for those wishing to return to work, to undertake work in the acute sector or to undertake further study. Family-friendly policies that provide for a decent work-life balance are within reach from those involved in PMS. PMS will also impact on the level of quality services that are available to patients in communities.

Improvements in health will be achieved much more quickly under the community ownership model that I have described. Citizens of Scotland care about their health and have the opportunity to improve it at a local level. The Labour party has made that possible by abandoning the Tory approach of fundholder ownership for one of community ownership.

The amendment in the name of Mary Scanlon demonstrates a total lack of understanding of how the practice and delivery of health care has changed. The purchaser-provider system did not deliver for patients. Our approach includes patients and communities as equal partners in primary care.

The amendment in the name of Nicola Sturgeon fails to recognise what happens below the level of the local health care co-operative. It is unfortunate that the member is not in the chamber, because I suggest that she should get out more. She should return to her native Ayrshire to find out what can be delivered when communities, rather than GPs, take ownership of primary health care. Perhaps Shona Robison will advise Nicola Sturgeon of that.

The devolution of ideas is allowing patient-focused services to be designed that meet the needs of patients. That proves that partnership works. I hope that Mary Scanlon and her Tory colleagues will advise Liam Fox of the fact that the national health service in Scotland is working and that it is delivering for patients—not just for GPs. I support the motion.

Photo of David Davidson David Davidson Conservative 10:55 am, 25th April 2002

I declare an interest as a registered pharmacist.

I love conversions, and this morning we have seen a wonderful and extremely welcome conversion by the Minister for Health and Community Care. He has realised that the only way in which to deliver primary care is to decentralise decision making. We agree. I hope that the SNP and the Liberals will join us in that realisation, as the minister has.

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I assure David Davidson that I have taken a great interest in these matters since the mid-1990s. I have believed what I stated today since I was Opposition health spokesperson at Westminster in 1996.

Photo of David Davidson David Davidson Conservative

I accept what the minister says, although my background in health care dates back a little further than that.

Today's debate is about semantics. Whatever term the minister uses—whether it be commissioning, contracting or purchasing—he has adopted Conservative common sense by empowering those working in primary care to deliver what the people want, away from a central control model. I know how hard it is, particularly for those whom Tommy Sheridan would describe as former socialists, to give up their Soviet-style approach to health care. However, the Scottish patient and the Scottish health worker have no time for all the initiatives and overloads that are being imposed from the centre. As others have said, we need to free up health workers so that they can do their professional job.

I agree with the minister's statement that primary care is where the health journey commences. However, I would have liked the minister and others—particularly the SNP and our friend Mr Sheridan, the only socialist in the chamber—to accept that in most countries with the high health spending to which we aspire the total health spend includes private sector money, regardless of the colour of the Government in those countries.

Photo of Tommy Sheridan Tommy Sheridan SSP

I am sure that, as a pharmacist, David Davidson will recognise the magnificent developments that have been made in Cuba, which does not purchase any private health care but still makes breakthroughs with international vaccines, such as that for meningitis.

Photo of David Davidson David Davidson Conservative

Tommy Sheridan is not talking about the aspect of pharmaceutical services on which I want to focus. I have gone past Cuba in a boat, but unlike the member I have never had the privilege of landing there.

This morning the minister did not give us the full story. Most certainly, Nicola Sturgeon did not give us the answer. I am talking about the interconnection between primary and secondary care. The minister does not want to have contracts. Nowadays, all that is needed is electronic transfer and a modern accounting process to ensure that resources are allocated as intended. How would the SNP model work? Nicola Sturgeon seemed to be going down the road of simply purchasing services and pulling in people from the secondary care sector. Would the SNP model involve consultants working as liaison officers on primary care teams or providing triage services to those teams? I do not know. It would be nice for the people of Scotland to know exactly what the SNP intends.

Most GPs, all community pharmacists, and most dentists and chiropodists are self-employed. We must get away from the myth that every health professional is an NHS employee. We must bury that and get on with delivering health care, regardless of where it comes from.

The minister spoke about invasive procedures being done locally. In the north-east we have a community hospitals model. In his winding-up speech, will the minister tell us how that system will benefit from his plans? How will it be utilised more effectively to meet the needs of people in rural areas, in particular?

Several speakers mentioned GP recruitment. That is not just about salaries. I have regular meetings with the local medical committee, which tells me that it is fed up of being squeezed to get 2 litres out of the 1 litre that it has to offer. GPs tell me that they run a business, because that is how the accounting works. They find that it is not worth while for them to invest in premises, and they have withdrawn some of the additional services that they provide. The burden of providing those services has been shifted on to secondary care. How will the minister reverse that trend and give GPs the freedom to do the jobs that they most want to do?

To a large extent, this debate is about access to primary care, yet we have assets available that are underused. I will provide members with an example from the pharmaceutical sector. There is a huge public resource cost in training pharmacists, and pharmacists have skills that are rarely utilised to the full. There is enormous potential for pharmacists to take an even greater load from GPs than that suggested in "Making the Connections". As Margaret Smith said, pharmacists are accessible and can easily operate triage in the community. However, we require a modern referral system, in which proper pieces of paper are used to pass people on to the GP surgery, and patients are not just slotted in at the bottom of the queue at the overworked practice next door.

I welcome the minister's comments on prescribing rights, but there is more to it than that. What about the pharmacy services that are not easily accessed if one does not have the money? Will we reach the stage at which some of the over-the-counter medicines that are available only from a pharmacy, under the control and recognition of a pharmacist, are included in the prescribing regime that the minister suggested? The minister should consider some of our poorer communities, where the pharmacy is the first port of call for many. I welcome the talk on television this morning about the pharmacy becoming the local point of contact for health information. That is fine, but there is a shortage of pharmacists. The schools of pharmacy in Scotland are very good, but they need resources to be able to provide the correct level of courses, such as the add-ons and the continuing professional development courses that go on throughout a pharmacist's life.

I will touch on an area about which I have great concern. Susan Deacon's pharmacy plan was welcome, but it contained no real commitment to supporting pharmacists to build premises that can deliver a modern pharmaceutical service. The long, thin, old-fashioned shop unit is not effective, as one cannot fit in proper consulting rooms or laboratory space. What are we going to do to solve that problem, which exists in many parts of Scotland?

Photo of Murray Tosh Murray Tosh Conservative

You were advised that you could speak for five minutes, but you have had more than seven minutes. It is time to wind up, Mr Davidson.

Photo of David Davidson David Davidson Conservative

I will wind up, Presiding Officer.

We must take a simple look at accessing all the professions allied to medicine who are based in the community. PAMs are underused and the changes in the registration rules must be examined carefully so that we do not lose them.

The minister must put a lot more detail on to the back of what he has said this morning. As far as the SNP is concerned, we do not know where its members are going, apart from the fact that they are at the crossroads and look as if they are coming our way.

Photo of Murray Tosh Murray Tosh Conservative

I hope that the official reporters caught that.

Photo of Elaine Thomson Elaine Thomson Labour 11:03 am, 25th April 2002

So far this morning, we have heard a lot of the usual carping and whingeing from the Opposition, rather than a welcome for the many positive announcements that the minister made, not to mention the unprecedented announcements in the recent budget, which will increase health spending in Scotland by 50 per cent. Those announcements are recognised as significant by health professionals and others throughout Scotland.

Labour's extremely ambitious vision for the NHS in Scotland is to provide the highest-quality public service possible and to have the most modern health service in Europe. If we are to resolve Scotland's health problems, we will have to go much further than dealing with only acute services. Investment in primary health care and in health education is essential. As previous speakers have said, primary health care is the first point of contact for nine out of 10 people. For many communities where there is a lethal combination of poverty and poor health, health inequalities are very real and improving primary care will make a difference.

I welcome the investment of £30 million in better GP premises and improved access to GPs. I also welcome the increased impact that is being made by specialist nurse practitioners. At the Healthy Hoose in my constituency, the nurse practitioners provide health care to a community which, for many years, has not had good access to GP services and which has some of the worst health in Aberdeen.

Photo of Elaine Thomson Elaine Thomson Labour

No. I have quite a lot to say and I would like to get on with it.

Health investment, combined with reform and modernisation, will improve access to services. Initiatives such as the introduction of NHS 24, the better prioritisation of ambulance calls, the extension of prescribing powers and better staff training and retention, combined with unprecedented levels of extra funding, will make a real difference.

I recently spoke to a constituent in Aberdeen who had an injury to her arm that had become further infected due to lack of care. Her wound needed to be dressed daily by the nurse in her GP practice, but that treatment could not be provided outwith the hours of 9 to 5. She was a sole businesswoman and was not prepared to close down her business to get the medical care that she needed. Therefore, I was pleased to hear the minister talk about all the actions that will improve access to the NHS. We must recognise that lifestyles and working patterns have changed.

Aberdeen has seen the introduction of what I believe will be a groundbreaking service in the form of NHS 24, which will play a significant part in creating better linkages and a seamless service between the different sectors in the health service. Increasingly, when patients call their GP out of hours, they will be rerouted via NHS 24. That service will also be multichannel, with health information being available on the web, for example.

The investment in NHS 24, which is expected to be around £30 million a year, will include considerable investment in high technology, with the aim of integrating many NHS services in Scotland. I recently spoke to the Scottish Ambulance Service in Aberdeen, which told me that an impact of the introduction of NHS 24 would be a reduction in the number of unnecessary emergency calls. Therefore, NHS 24 will enable the Ambulance Service to provide a better service.

Finally, I will talk a little about citizens advice bureaux which, in Aberdeen and Grampian—as in other parts of Scotland—provide a valuable service by offering helpful and essential advice about benefits to acute and primary care patients who are facing difficult times in their lives. A recent report from the University of Aberdeen clearly recognised the value of that service. However, the funding of the service varies in different parts of Scotland—indeed, in Grampian, the service is not funded particularly well, despite the recognition of the value that the service provides there. I ask the minister to consider how that service can be better supported throughout Scotland.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat 11:07 am, 25th April 2002

The real problem with having only a few minutes to speak in a debate on a subject such as primary health care is that there are so many areas to cover. I make no apology for highlighting just one primary care issue—rural dentists. My involvement with the issue was sparked by the closure of the Alford dental practice in my constituency. I first raised the matter in the Parliament back in September 2000 and it was the subject of my members' business debate in November 2000. I have taken every opportunity to highlight the difficulties that my constituents face in accessing NHS dental services, so I am delighted that the minister has been able to announce £1 million of financial aid to be directed specifically at helping to solve those problems in remote and rural areas of Scotland.

The minister will be aware of the British Dental Association's recommendation that there should be a dentist for every 2,000 people. In Aberdeenshire, the ratio is one dentist for every 5,000 people. In September 2001, I asked Susan Deacon—then Minister for Health and Community Care—a parliamentary question on what steps she was taking to improve dental services in Grampian. I called for special golden hello payments to be made in order to attract dentists to rural Scotland. It is great to see that the Scottish Executive is not only listening but taking action. Unlike Mary Scanlon, I believe that the measures that were announced today will be of real, practical help and assistance.

I identified three major factors that underpin the problems of dental provision in the north-east. The first is that there are simply not enough dentists working in the region to serve the population. The strenuous efforts that have been made, particularly by the health board and individual businesses, to recruit dentists from elsewhere in the UK have not proved successful. That means that we need radical initiatives, such as those that the minister announced today, which will go some distance towards helping to solve the problem. I congratulate the Executive on those initiatives.

The second problem is waiting times for out-patients at Aberdeen royal infirmary. All members would agree that waiting four years for treatment—even if the treatment is non-urgent—is not acceptable. Although lives might not be at stake, patients' quality of life is important. That issue needs to be addressed—specialist consultants must be attracted to Aberdeen royal infirmary. I am glad that we have the opportunity to address such issues.

The third problem is that my constituents have great difficulty in accessing NHS provision. In October 2000, I surveyed every dental practice in West Aberdeenshire and Kincardine and found that 50 per cent of the practices did not accept any new non-exempt NHS patients. It is no wonder that the Scottish Executive's figures show that 51 per cent of adults and 25 per cent of children are not even registered with an NHS dentist. It is impossible for any non-exempt new patient to access NHS treatment along the entire length of the 60-mile Dee valley corridor in my constituency, which runs from the boundaries of the city of Aberdeen to the village of Braemar in the Highlands. The problem is not new, as I encountered it in 1994 when I came to live in Aberdeenshire on leaving the Army. I am one of the many people in rural Scotland who cannot access NHS dental care. I have a salary that allows me to go private, but I would prefer to use the NHS dental system.

Tommy Sheridan's speech was extremely uninformed; it was an outrageous contribution to the debate. I respect his political views, but they are extreme. Where will the money come from to nationalise pharmacists, community pharmacists, dentists, chiropodists and so on, which is what his amendment suggests should happen? He seems to hold the view that it is better to spend money on buying out those businesses than on delivering care to people through the NHS, which is what is important.

I congratulate the minister on addressing the problems relating to dental treatment in rural Scotland. The Scottish Executive's dental action plan recognises that greater health gain is more likely if resources are targeted at tackling the inequalities in dental health and access to dental services that have been identified. The minister has announced a welcome investment in tackling the problems of access to NHS dentistry throughout rural Scotland. I congratulate the minister on listening and on taking action.

Photo of Brian Fitzpatrick Brian Fitzpatrick Labour 11:12 am, 25th April 2002

Our chancellor's budget booster for Scotland's national health service means that we have a new opportunity for dramatic reform in our health services and for sustained and rising investment in resources and staff. As the Executive's motion outlines, we have a responsibility to deliver sustained and necessary improvements in health outcomes in our country. We are in a better position than we have ever been to meet those demands.

I listened with real concern to what Nicola Sturgeon said about the SNP's policy on the abolition of primary care trusts. In light of what she said, it seems that instead of considering devolution to LHCCs, the SNP has in mind divorcing LHCCs from the local primary care trust. The SNP seems ready to abandon the joint future agenda. Labour members are keenly aware that improvements in health outcomes in Scotland turn on linking health services with social work and housing and on fostering and maintaining discussion and co-operation among all the service providers and partners.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

Does Brian Fitzpatrick agree that that is exactly what LHCCs should be about?

Photo of Brian Fitzpatrick Brian Fitzpatrick Labour

The problem with Ms Sturgeon's proposal is that we are already making progress with LHCCs. Ms Sturgeon should acknowledge that we must make progress with all the partners in LHCCs—LHCCs comprise not just GP practices, but other partners. If we are to do that, we must reject the SNP and Conservative amendments. Because of the need for partnership working across the health service and between the health service and other services that serve health service users, I welcome the proposals for an integrated health and social care centre at Southbank in Kirkintilloch in my constituency.

I am interested—I am sure that ministers are, too—in ensuring that all the partners in LHCCs are given proper regard. Crudely speaking, there is a need to facilitate clout in their interactions with the secondary and tertiary sectors. Let us not dismantle simply in order to reinvent such connections.

I urge ministers to integrate primary and secondary care more closely and to challenge all those who are involved in the provision and the receipt of services to break down the barriers. Ministers will be aware of the progress that is being made on the walk-in, walk-out hospital at Stobhill campus, which is in the constituency of my colleague Paul Martin. That hospital serves many of my constituents and many constituents of other MSPs. We have managed to secure a doubling of the investment for that site—it has risen from £30 million to £60 million. A new hospital about the size of the new Hairmyres hospital is planned. The project has been the subject of some controversy.

Ministers know that Paul Martin and I remain concerned about bed capacity and modelling across the Greater Glasgow NHS Board area. We are also anxious for urgent progress to be made on the new facility, which will extend the boundaries of how we deliver health care. I am particularly keen that the greatly increased capacity of the new facility be fully utilised by all the health service professionals. I trust that ministers and health officials will work closely with the primary sector to facilitate direct access to tests and investigations.

New facilities such as the walk-in, walk-out hospital at Stobhill offer a not-to-be-missed opportunity to build in access from the outset. I will listen with interest to what ministers say about securing systems that are capable of communicating in the way that GP practitioners liaise with hospitals.

I am conscious that I am seated beside my sisters, Presiding Officer, but with your permission I will mention some men's health issues—that was not meant to be a slur on Ken Macintosh, who has joined me. This year's men and health week is scheduled for the week beginning 10 June, which is much earlier than usual. The Parliament has previously debated the specific needs of men in relation to access to health services. The principal aim of that week is to obtain the commitment of individuals and organisations to action on men's health issues. I recently underwent a health MOT, which was organised by Greater Glasgow NHS Board. I am pleased to say that I was reassured by that health MOT. We need more early interventions in relation to men's health issues. I make a partisan call for ministers to examine urgently that issue in the context of primary services.

Photo of Colin Campbell Colin Campbell Scottish National Party 11:18 am, 25th April 2002

Brian Fitzpatrick's contribution was unexpectedly loyal to the Labour party.

Nicola Sturgeon referred to the acute sector, which cannot be separated from the primary sector. I will refer to what I regard as the most fundamental aspect of health care—encouraging lifestyles that will help people to avoid medical conditions by being attentive to diet and exercise, by having positive attitudes about themselves and by avoiding excessive use of tobacco and alcohol. Such encouragement is a broad issue and is not the exclusive preserve of the medical profession. Health education in schools or community health projects is part of that process. Every adult who has any influence over a child has a responsibility, because health care is about not just the rights that we should have, but the responsibilities that responsible adults can exercise.

The first aim must be to reduce the number of people who need primary care as a result of damaging lifestyles. That is a medium-term objective, which will do nothing to diminish current demand for primary health care. I note that 20 per cent of adults who are registered with doctors visited their doctor three to five times last year, and 13 per cent went more than six times. I have been lucky enough not to have had to visit the doctor very often. I hope that when I need primary care, it will be speedy, understanding and efficient. That is not always the case now. A colleague in Port Glasgow told me yesterday that it can take up to a week to see a GP. The 48-hour target must be met as a matter of priority.

A GP whom I met recently made it abundantly clear that he could offer each patient only half the time that he felt they ought to have when they came into his surgery. He felt that that was unfair on him and on his patients. In saying that, he was mirroring the experience of patients. Many patients feel that they are being processed too hastily. Shortage of time might drive a doctor to medicate rather than to communicate, or to delegate to a specialist rather than to investigate further there and then. That then burdens the acute sector and increases waiting times, which none of us wants to happen. There might be cases in which all that is required is reassurance rather than a prescription, but time for dialogue is strictly limited.

My extended family's recent experience is with visiting midwives, who will soon be replaced by health visitors. That brings me to nursing. Nurses are vital assets in the primary care partnership. RCN Scotland desperately wants people to have access within 48 hours. We all agree on that laudable aim. However, there are not enough staff to achieve that. Telling nurses that they are appreciated and valued is no substitute for an adequate salary. Until that issue is addressed, the flight of nurses from the NHS will continue. We welcome any addition to their numbers, but it takes time to train medical staff and there is no quick fix.

As for dentists, my routine appointments have been postponed for two months because my dentist is ill. That causes no great harm for someone at my stage of life, but it could have a detrimental effect on someone who does not have my enthusiasm for dentists. I declare an interest here—I married a dentist.

I was interested to hear the minister talking about public health practitioners. I should declare another interest—my late father was a deputy medical officer of health in Paisley when that office had overall responsibility for the public health of the entire town. I get the feeling that what goes around comes around.

I endorse the motion and I endorse the SNP amendment.

Photo of Bill Butler Bill Butler Labour 11:22 am, 25th April 2002

As all members have said today, no one can doubt the importance of primary care teams. As has been mentioned, more than 90 per cent of patient contact starts and finishes in primary care.

The Executive's motion is clear in its acknowledgement of the central part that primary care teams play in the national drive towards a modern, improved and integrated health care system. The motion's intent is to acknowledge that further investment should build on the strengths of primary care and work to address any weaknesses and that we should conserve what works and reform what does not.

Mary Scanlon thinks that that sounds too much like the Tamworth manifesto, but it is just common sense. I was amused—but not distressed in any way—when she claimed that the Executive's strategy is to go back to Conservative principles. She should be embarrassed and distressed about the only principle that seems to come from the Conservatives' masters south of the border. That principle was enunciated by Liam Fox, who said:

"We have got a problem in this country where the NHS and health care have been synonymous. We're here to break that."

Nothing could be clearer. Although I accept that Mary Scanlon and other Conservatives support a type of national health service, they must be concerned when they hear such reactionary twaddle coming from south of the border.

Photo of Mary Scanlon Mary Scanlon Conservative

Does the member understand devolution, particularly in relation to health policy? Any decisions on Conservative health policy in Scotland are made by Scottish Conservatives. I realise that that is quite difficult for the member to understand.

Photo of Bill Butler Bill Butler Labour

Not at all. I have always supported devolution and I welcome the fact that the Conservative party in Scotland now pursues that policy.

We can all sign up to the main priorities that are outlined in the primary care modernisation group's report. Those priorities have commanded and will command the chamber's approval and they will command the public's approval. Action taken in the next three years on the main areas outlined in the report will, if successful, make for easier and faster access to a more extensive range of services.

I especially welcome the report's recommendation that the role of local health care co-operatives should be enlarged to take greater responsibility for the provision and planning of services. As a member of the Co-operative Party as well as of the Labour party, I commend that. Sharing skills across disciplines and in partnership with social care providers is a worthwhile objective. It is sensible and progressive and it will lead to more comprehensive localised services. Local health co-ops are fundamental to the coalition's aim of providing a truly responsive local health service.

Investment is also important. The Executive's investment of just under £33 million in the improvement of local health services' buildings and infrastructure will lend itself to the development of services redesigned

"round the needs of patients", as the motion has it. That sum will benefit 74 GP surgeries and health centres across Scotland, mainly in rural areas and in areas of economic deprivation. That is to be welcomed.

As has been said, there are proposals to give patients quicker access to medicines by extending the prescribing powers of pharmacists and nurses. Most people would agree that that is a sensible measure. It will mean that, after initial diagnosis, patients can have their medicines prescribed by their local pharmacists or practice nurses. That will free up GPs to concentrate on clinical care.

The practical reforms emanating from the Executive will improve the service that is provided. They will lead to greater accessibility because they will fit the service to the needs of patients in a more precise and sensitive fashion. I also commend the Executive's initiative to provide, for the first time, GPs with the option of becoming permanent, salaried NHS employees rather than independent contractors. I hope that that option proves popular.

The redesign of primary care services is vital to a more responsive, localised and patient-centred NHS. The extra moneys that are being channelled in will, if applied sensitively and thoughtfully, lead to primary care services fit to meet the demands of 21st century Scotland. I commend both the motion and the coalition's strategy to the chamber.

Photo of David Mundell David Mundell Conservative 11:28 am, 25th April 2002

Malcolm Chisholm tells us that just because Alan Milburn says something in England, that does not mean that it has to be followed in Scotland. However, Bill Butler comes out with the usual quotes from Tories in England. The point keeps having to be made, as the Labour party wants to face both ways: the Scottish Conservatives have accepted the devolution settlement and have rearranged our activities accordingly.

Photo of David Mundell David Mundell Conservative

I will come back to Bill Butler in a minute.

Conservative health policy for Scotland is determined by Conservatives in Scotland. Let us be quite clear on that.

Photo of Hugh Henry Hugh Henry Labour

Will David Mundell explain the consequences of following the Tory policies in England, which would severely reduce expenditure on the NHS and privatise much of the service? There would be consequential implications for Scotland under the Barnett formula on how money is allocated to Scotland. If public spending on the NHS in England is reduced under that Tory policy, how will we be able to spend in Scotland?

Photo of David Mundell David Mundell Conservative

As the minister well knows, the complicated network between the parts of the UK is still evolving. Many of the issues that will flow from devolution will be put to the test only when the governing parties in Scotland and Westminster are different. Many things that can be finessed at the moment will have to be resolved. As for the Conservatives, if Hugh Henry reads his press cuttings correctly, he will find that the Conservative health policy at the UK and England levels is still being determined—none of the statements that have been presented as fact is fact, because the policy is still evolving.

Photo of David Mundell David Mundell Conservative

No, because I want to move on to specifically Scottish issues.

We agree with Liam Fox that the health service is not working. It is not serving the people of Scotland as it should. Although we hear today about additional money for recruitment, which I welcome, I do not take Mr Rumbles's simplistic view that the money will automatically solve the recruitment problem.

Photo of David Mundell David Mundell Conservative

I am going to explain why I take that view, so I will not take Mr Rumbles's intervention.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

I never suggested that the money would solve the problem.

Photo of David Mundell David Mundell Conservative

The recruitment problem cannot easily be solved by golden hellos. The experience of the dental service in Dumfries and Galloway is that people come in, take their golden hello, then say goodbye. One reason for that is that we have a complicated labour market. One of the greatest difficulties facing rural areas is that the modern family unit is looking for two incomes. When such family units come to an area, they are looking for an income not just for the practitioner, but for the spouse as well. If, as in Dumfries and Galloway, we have a labour market that does not allow that to happen with ease, it is extremely difficult to attract people into that labour market. Therefore, in addition to money, we need to perform a much more complex analysis of recruitment. The situation applies not just to dentists—as in Mr Rumbles's area, we only have half the dentists that we need—but to physiotherapists, GPs and specialists.

Photo of David Mundell David Mundell Conservative

We are also faced with the fact that because of the peace process in Ireland—no one would want it otherwise—fewer people want to leave Northern Ireland to come to our area to provide services. The recruitment issue is serious and requires serious analysis.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

Oh, do not play that game, for goodness' sake.

Photo of Murray Tosh Murray Tosh Conservative

Order. The member is not giving way; he is in his last minute. I invite the member to conclude his speech. Let us move on.

Photo of David Mundell David Mundell Conservative

I am grateful that the Minister for Health and Community Care mentioned Dumfries and Galloway in his opening remarks. Perhaps now some of his Labour colleagues will sign my motion praising the managed clinical network in Dumfries and Galloway, as such issues should not be petty party-political ones. If we see something that is successful in the health service, we should praise it.

A lot of good things are going on in Dumfries and Galloway, which highlights one of the points that we wish the minister to grasp from this morning's debate: there is no one-size-fits-all solution to the problems of the health service, because different solutions are required in different areas. I hope that the minister will look favourably on the proposals in Dumfries and Galloway for integration in the health service—with NHS trusts and Dumfries and Galloway NHS Board working closely with the local council on their coterminous boundaries—because that is a positive way forward towards delivering the health services that people want. However, let us be clear that there is no one easy answer. Certainly, just throwing money at the problem is not the answer.

Photo of Johann Lamont Johann Lamont Labour 11:33 am, 25th April 2002

I welcome the opportunity to contribute to this debate. I acknowledge the important role of primary care staff, GPs, health visitors, community psychiatric nurses and others, in my constituency and elsewhere. In a past life as a schoolteacher, I was struck by the role of health visitors, who had the capacity to pick up problems in families and who, as trusted people, were able to support those families in times of difficulty. When someone can no longer be offered any help by the acute services, there is no doubt that the care and support of district nurses and GPs can be beyond price.

We all know that we live in a sick country, and that Glasgow is the sickest of our cities. There are high levels of prosperity in some parts of Glasgow, but we have to confront the reality that ill health is concentrated most in our poorest communities. The challenge to us all is to address that health inequality. I have no doubt that primary health care can be central to addressing that problem. Despite there often being a focus on acute services in debates and discussions on the health service, the reality is that in too many of our communities, poor diet and living conditions lead to such chronic ill health that people do not reach the stage at which they can benefit from the improvement in acute services. I trust that with the new money that is coming to the national health service, which is welcome, the Minister for Health and Community Care will ensure that primary care is given a share that acknowledges its significant role.

We have to see primary care as a vehicle to promote health initiatives and to develop health education initiatives. Primary care should not only have the capacity to identify problems, but where possible it should be able to treat those problems in the community.

Photo of Mary Scanlon Mary Scanlon Conservative

Given what Johann Lamont said about the shift from the acute sector to the primary sector, is she concerned that in the past five years the number of consultant posts has increased by 19 per cent, while the number of GP posts has increased by 3 per cent?

Photo of Johann Lamont Johann Lamont Labour

My concern is that we did not focus on where people's needs are. In my community, the issue is often one of getting people to the stage of asking for help, or of addressing the broader problems that people face.

Difficulty in accessing health care is an issue. For example, the problem of travelling for help in rural areas has been mentioned. Difficulties in travelling to be treated can also be a deterrent to poor families. Access can be a problem for families that are already under pressure and, in some circumstances, people do not take up appointments when they desperately need them. There is a key role to be filled in working with other agencies in local communities, such as social inclusion partnerships, to understand the depth of the problem.

I welcome the minister's comments about the importance of the treatment of mental health problems, and I acknowledge Adam Ingram's comments in that regard. There is a clear connection between poverty and mental health problems. It is important to recognise the role of community psychiatric nurses and others who work in the field, and services such as those provided by Rossdale resource centre in my constituency, which seeks to make care accessible and non-stigmatised, and acknowledges the often episodic nature of mental health problems, which means that hospitalised care is not always appropriate.

I ask the minister to consider the environment in local health clinics. The problem of families being deterred from going to their local health clinic because methadone treatment is provided there has been raised with me. We have to examine how centres are laid out, in order that all care needs are addressed. We also have to support GPs in signing up for the primary-care-team model and moving away from the only-the-doctor-knows-best model. With regard to access to care, we have to address the problem for GP practices of patients failing to keep appointments. We need to educate local communities about the impact of that on services.

I acknowledge the importance of joint working at a local level. The Minister for Health and Community Care talked about joined-up health and social care. It is essential to develop practice in that field. Arbuthnott produced a distribution formula for health care that tracks need. I contend that the social care side of the partnership deserves to be financed in the same way. I urge the minister to use his influence to press for funding for local government on a needs basis. Such a formula would benefit many in my constituency.

I welcome the report "Making the Connections", and support the commitment to local communities that it reflects. I support the motion in the name of Malcolm Chisholm.

Photo of Dorothy-Grace Elder Dorothy-Grace Elder Independent 11:38 am, 25th April 2002

We heard in the minister's speech, and have heard elsewhere, familiar phrases such as "integrated joined-up ... system", "patient centred" and "best practice". Those platitudes have tripped hand-in-hand through this chamber for three years, but what have the results been? If the person on the number 62 omnibus to the east end of Glasgow is asked whether there has been any discernible change in the past three years that has benefited their health and life, they will reply in decidedly unparliamentary language. I will not use it in this chamber, but members can see me about it outside.

People in Glasgow are still dying six years earlier than people in other parts of Scotland, never mind those in the much more prosperous south-east of England. We continue to have the worst health record in Britain. The minister has announced some overall changes, but, unfortunately, the NHS continues to operate on the same basic commercial lines that were established by the Conservatives, who first conceived the notion that a public health service could be run like a chain of baked-beans factories. That did not work, and the public showed that when they kicked out the Conservative Government.

The minister's promise that the maximum wait to see a member of a primary care team should be 48 hours would be regarded as a tad unambitious in other parts of western Europe. I cannot imagine a German minister telling the Bundestag that with any great pride, because people in other parts of western Europe expect access to good services right away. We must be a bit more ambitious. The sum of £30 million is not too huge for a country whose health services have been run down in the past 15 to 20 years. However, I welcome many parts of the minister's announcement, such as the experimental 24-hour helpline service, which is a good idea, and the greater involvement of nurse practitioners, which is long overdue.

GPs are increasingly overworked, as are practice nurses and medical secretaries, who are still not numerous enough. Yesterday, doctors and representatives of Epilepsy Action Scotland told the Health and Community Care Committee that although all 15 health boards have signed up to the Scottish intercollegiate guidelines network's guidelines on epilepsy, only two implement the guidelines and provide an annual check for patients who suffer from epilepsy. Annual checks are necessary, because some sufferers of epilepsy die in their sleep. Many GPs can manage a check only once every three years, because of the pressure that they suffer from other work.

Some 30,000 people in Scotland suffer from epilepsy. I would be pleased to hear whether the minister regards epilepsy patients as a priority for primary care. Are multiple sclerosis patients a primary care priority? Only yesterday, we heard from Forth Valley NHS Board that only a small number of people will receive beta interferon. Forth Valley estimates that it does not have the funds to test in a year more than 56 of its 500 identified MS patients. That will be a long, slow and degenerative process.

I make no apology for returning to the subject of chronic pain. If we can alleviate the pressure on primary care—on GP practices—of dealing with people who have chronic ailments that cause pain, we can start to make radical changes, because the number 1 reason for bothering to see a GP is pain. If we isolated people who could benefit from more specialist pain clinics, surgeries would not be so overcrowded. It is estimated that a person who is in pain may visit a GP six, seven or eight times a year. Once they are referred to a specialist pain clinic and can obtain relief through all sorts of methods that are offered, they may visit that clinic only once or twice a year and see a GP just once every two years.

I ask the minister, please, to think radically, because 550,000 Scots suffer pain. I am sure that the minister can reach a more sensible conclusion that will benefit patients and front-line practice, which is bogged down in the trenches and needs all the help that the Parliament can give it.

Photo of Murray Tosh Murray Tosh Conservative

Time is tightening a little. I ask the last two speakers before the closing speeches to restrict their comments to four minutes.

Photo of John McAllion John McAllion Labour 11:44 am, 25th April 2002

The motion, which is in the name of the Minister for Health and Community Care, links further investment in primary care to further reform. When I see the words "investment" and "reform" linked in these new Labour times, my internal alarm bells ring. That is mainly because those words have become code in England and Wales for greater private sector involvement in delivering health care. Nicola Sturgeon said that she agreed with Alan Milburn some of the time—that puts her politically closer to him than I am.

I was delighted to hear the Minister for Health and Community Care reject any suggestion that the reforms to which he refers will involve any return to GP fundholding. The Tories should listen to the following part of my speech. GP fundholding was a disaster in Scotland. It created inequalities in access to health care, wasted resources and stopped the targeting of clinical priorities and clinical need. It was a great day for the national health service when GP fundholding was abolished.

Nobody has said this, but I suppose that every political party in the chamber would argue that the Scottish NHS is safe in its hands. The test of that is ensuring that the NHS remains a wholly public service that is funded from general taxes and guarantees access to health care on the basis of medical need and not ability to pay. The service should be wholly planned and provided in the public sector. If that is too Soviet for David Davidson, so be it. The Soviets did not get everything wrong in the many years that they existed during the 20th century.

That is why I find Mary Scanlon's amendment offensive. It talks about purchasing care from the "appropriate provider", the definition of which includes the private sector. Profiting from illness and diverting public investment in the health service into the pockets of profiteers are offensive and unacceptable.

Photo of Ben Wallace Ben Wallace Conservative

Does John McAllion agree that those words are Alan Milburn's words? Does the member agree with Mr Milburn and me?

Photo of John McAllion John McAllion Labour

Ben Wallace did not listen to what I said about Alan Milburn. I disagree with Alan Milburn—full stop. If they are his words, I am glad that I said what I did.

The amendment by Nicola Sturgeon looks inoffensive, but after I heard her speech, it took on a sinister hue. She talked about giving local health care co-operatives commissioning power, which she defined as the power to decide the hospital to which they will send patients. She even backed that up by saying that the SNP would give LHCCs financial muscle—control of 75 per cent of the budget. That is as good a definition of GP fundholding as I have heard anyone give. Nicola Sturgeon has proposed GP fundholding in the form of LHCCs having control of budgets.

Bill Butler is right—GPs are private sector people. If they are given the freedom to choose, how will they be stopped from sending patients to private hospitals such as HCI, Ross Hall and the other private providers of health care? That is why the Tories want to return to GP fundholding. If the SNP takes the road that it proposes, that will happen, too.

I thought that the centre left in Scotland had reached a consensus that it rejected the provider and purchaser split with which the NHS internal market operated. If the LHCCs are free to shop around hospitals, does not that put hospitals in competition with one another and return us to the internal market, which we said not so long ago that we had abolished?

What about strategic planning? Most health boards in Scotland have undertaken a painful process of taking difficult decisions about which services should be located in which hospitals and what funding should be invested in which hospitals. Is that all to be undermined by allowing LHCCs to shop around and play off one hospital against another? I think not. That would be a disaster.

It was strange that Margaret Smith championed the global pharmaceutical industry. She painted a picture of those businesses as benevolent capitalists that invest millions in research not because they want to make a profit, but because they want to help ill people around the world. That is fantasy pharmaceuticals, and Margaret Smith should know better.

Photo of Stewart Stevenson Stewart Stevenson Scottish National Party 11:49 am, 25th April 2002

My father graduated as a doctor at the age of 42—he came to the primary care sector late in his life. He was the centre of the health service for his patients. He started in medicine just before the health service was established. He was a strong supporter of the health service and welcomed its coming to pass. My father came from another age. He shared a GP cottage hospital with colleagues in Cupar in Fife. The hospital had X-ray equipment and an operating theatre. Occasionally, he even carried out an appendectomy. He did all his maternity work in patients' homes, which people welcomed.

We should not imagine that 50 years ago was the golden age of medicine, although it was the golden age in respect of customer care and the relationship between the primary care provider—the GP—and the patient. In many other respects, that period was the dark ages. When my father graduated, there were no antiobiotics. What could be done for people with severe infections was strictly limited. Diabetes was diagnosed by the doctor's tasting the patient's urine—there was no other effective means of diagnosis. Often, the smell of acetone on the patient's breath was an indicator, but the test was inaccurate and incomplete.

There was blood and guts. Once, on a Saturday night at 11.30 pm, a rugby player appeared at the front door at home. He had survived the rugby match, but the post-match dance had had a severe impact on him. He stood at the door with his ear in his hand—a fellow celebrant had bitten it off. My father sewed it on. The patient had already taken sufficient anaesthetic and there was no requirement for more.

We know that there are still health care problems in Scotland. Indeed, yesterday at the Justice 2 Committee meeting, an interesting and alarming statistic from the Procurator Fiscal Service was mentioned. Do members know that, in Strathclyde and Glasgow in a single year, 1,570 accused people died before their cases came to court? That says something about the state of health care.

People in Banff and Buchan do their best. We produce the best food in the world—oily fish—and we will certainly play our part in improving Scotland's diet.

I welcome a return to primary health care as an important part of the NHS. Practical measures can be taken in the primary sector. Type 2 diabetes—late onset diabetes—for example, is largely a matter of diet and lifestyle. The primary health care sector has a huge role to play in advising people. Nurses can weigh patients and give them advice on lifestyle.

I have come across curious little facts. My sister-in-law is a nurse in a nursing home. She is fully qualified but is not allowed to give injections, as the nursing home is not insured for the consequences of any errors that might occur. Therefore, she must call out GPs to supervise her when she gives injections.

My father had some interesting patients who were Tories. He refused to give them private service. Consider the leader of the Tories in the House of Lords and the Chairman of Ways and Means in the House of Commons. Even Tories can support the health service if we give them the quality. With the exception of the Tories, all parties in the chamber strongly support the health service and the public provision of that service.

Photo of Murray Tosh Murray Tosh Conservative

We move to winding-up speeches. Donald Gorrie has six minutes.

Photo of Donald Gorrie Donald Gorrie Liberal Democrat 11:54 am, 25th April 2002

Before I get stuck in to the subject, I should say that those who run our affairs still do not have their timetabling right. Today is a relaxed debate in which members are encouraged to speak for around five minutes. Yesterday, the Parliament passed important amendments to an important bill with no debate whatever. We must sort that out.

Many good speeches have been made by members who know much more about health than I do, but I want to speak about a particular part of the motion—the development of primary care. My argument is that if people are ill, we must help them, but we put minimal resources into keeping people healthy—that is what we should be talking about. A lot of illness is unnecessary and far fewer people should fall ill. I appeal to the minister. A considerable amount of new money is available for health and a sizeable chunk of it should go into developing community activities of all sorts to keep people healthy. If people are lonely, unhappy, unemployed, under stress and fed up in a community, they will fall ill. If a community is vibrant, there are community activities for all ages—for example, sports, arts, discussion and social activities—and there is support for people such as lone tenants, people will not fall ill. The idea is simple—it is not rocket science—but we ignore it. We must get stuck into that issue.

I will give two examples. In the past, I tried to help a community group and had some success. The group dealt with people who suffered from stress and nervous problems. It did not cost much, but limped along from year to year with minimal grants. One person who usually spent several weeks each year in hospital did not go to hospital at all for several years because of the group. Another person who consumed legitimate pills by the shovelful came off those pills. Those two examples must have saved the NHS a bomb, yet funding for such organisations is minimal. We need many more organisations like it.

Many people are trying to do positive things in the community. Not only do they not receive funding increases, but the grant that helped voluntary organisations to train people has been removed. The grant has been demolished. The Executive places great new demands on voluntary bodies under part V of the Police Act 1997, but there is no funding. There was a success in the Executive's agreeing to fund the £10 charge for people to be scrutinised by the police to find out whether they were suitable for helping with youth work. However, there are now demands on organisations, as opposed to individuals, which the Guides, for example, say will cost them an additional £25,000 a year. There is no money and those organisations must be helped.

I plead for money to keep people healthy through vibrant and worthwhile communities. That idea is simple and straightforward, but something must be done, for God's sake.

Photo of Tommy Sheridan Tommy Sheridan SSP 11:58 am, 25th April 2002

When the minister sums up, I ask him to elaborate on some points that have been made in the debate.

The minister mentioned the 48-hour time limit in respect of GP appointments. He will be aware of the BMA survey that members have mentioned. In that survey, the point is made that 94 per cent of family doctors wish to spend more time with their patients. We must ensure that we do not simply improve waiting times to see GPs; we must also increase patients' time with their GPs. That will be done only if more GPs and essential medical and administrative support staff are employed. Far too little has been said about that. I hope that the minister emphasises the importance of administrative back-up and medical support staff. If GPs deal with too much administration, they will not have enough time to dedicate to their patients. That is an acute problem in the most deprived areas of the country in particular and we must direct more health resources to such areas.

The Executive previously said that resources would allow the Arbuthnott report to be implemented over a five-year period. We have now been told about an increase in resources. Will the minister tell us today that the timetable for the implementation of the Arbuthnott report will be speeded up so that the city of Glasgow will get the extra resources that it deserves and requires?

On the point that Margaret Smith raised about the pharmaceutical industry, I have to correct a figure that I gave. I talked about the profits of GlaxoSmithKline and I think that I mentioned £5 million a day. I meant to say £5 billion last year, which works out at about £13 million a day. One of the company's biggest sellers is one of its anti-depressants. I am sure that they would be able to use those anti-depressants for politicians who lack the vision to realise that we have the resources and knowledge to make medical advances in our country. I defy anyone to talk about medical advances that have been based on profit. The biggest medical advances that have been developed in this country have been made through expanding medical knowledge to try to help people. That is why I believe in a publicly owned pharmaceutical industry. As a nation, we should have the vision to recognise the wealth of knowledge and research that we have at our fingertips. Is it not about time that, instead of paying the private sector through the nose to service the public health service, we developed our own public pharmaceutical industry to service the public health service?

Photo of Murray Tosh Murray Tosh Conservative

No. Mr Sheridan understands that he was allocated a very brief time period and it is time for him to close.

Photo of Tommy Sheridan Tommy Sheridan SSP

Finally, I hope that the minister will reiterate that the direction of reform is away from accommodating the private sector and towards using public money for public health.

Photo of Ben Wallace Ben Wallace Conservative 12:01 pm, 25th April 2002

Primary care has always had to take the brunt of changes in patient expectations of treatment. There are always more services, more need and more demand. That is truer today than it ever has been.

The Executive's motion stems from the report "Making the Connections", which was published at the end of March. That report set out to reinforce the Minister for Health and Community Care's ideas for LHCCs and set out the aims and functions that they have. However, when one reads the report carefully, one discovers that it re-enforces a centralist approach. Sadly, it does almost nothing to empower the GPs and primary care teams and does not put money where the report's mouth is.

Many of the recommendations get bogged down in micro-management and patronising claptrap. Suggestions include making

"better use of support staff" and

"getting rid of unnecessary paperwork".

However, no attempt is made to explain how or who is empowered to make that decision. The new NHS boards will become responsible for telling LHCCs—no, sorry that should be "clarifying" to them—what their responsibilities are. Members can bet they will. The boards will not be slow to ensure that they say who does what, where, with their money.

Before we move to the alternatives, it is right to examine where we currently are in primary care and what outcomes it produces. Over recent years—irrespective of the new money that has been announced—record sums have been invested. Let us consider manpower. One of the manifesto commitments of Labour and the Lib Dems was that they would reduce bureaucracy in the NHS. According to statistics from the information and statistics division, since 1997 the NHS has employed 500 more administrative and clerical staff. Tragically, the billions of pounds of record investment has given us only 18 more health visitors and two fewer midwives in Scotland than when the Conservatives left office. I will give credit where it is due: there have been increases in the numbers of community psychiatric nurses and district nurses, although that increase has been slower during the past four years than it was during the Conservative's last four years in office. The fact remains that the Executive has recruited fewer people more slowly than was the case under the Conservatives.

It would be wrong to overlook outcomes, but that picture is equally bleak. Health visitors are seeing 50,000 fewer clients a year and district nurses are seeing 10,000 fewer clients a year than they were in 1997. GPs only recently withdrew from a mass resignation and, according to Audit Scotland's report last May, LHCCs are not leading to the vital multi-decision making that is needed. Those patients waiting over 18 weeks for referral have doubled under this Administration. That is not an outcome to be proud of, despite the record investment.

There is a need to address some of the current problems that are wasting time and resources. The issue of missed appointments, which was raised earlier, is a major source of waste. A recent study by the Doctor Patient Partnership concluded that in Scotland alone, 35,000 GP appointments and 8,700 practice nurse appointments are missed weekly, yet the Executive seems content to bury its head. The primary care modernisation group does not even mention that in its report.

Bedblocking is another big waste of resources. Mary Scanlon and many members have reiterated the problems time and again, so I will not repeat them. Waste is also associated with lost or wrongly prescribed medicines. The Executive has at least dealt with that. Its recent document "The Right Medicine" is just that. The minister and his department ought to be congratulated on the measures in that document.

The next two policy measures are about the future. First, the Scottish Conservatives urge the Scottish Executive to lobby Her Majesty's Government to ensure that any new changes to the GP contract, which is out for consultation, include financial incentives for the provision of certain services—such as epilepsy—and take into account that the new contract has an impact on pay. Given that GP's surgeries are smaller in Scotland than they are in England, GPs may well experience a reduction in their salary. I hope that the minister will address that.

We think that there is a best way to develop primary services, which is to empower primary care teams and practices with funds. We believe in allowing commissioning to return to LHCCs in order that the money flows from the patient. Real choice means empowered choice.

Photo of Brian Fitzpatrick Brian Fitzpatrick Labour

On assisting primary care teams in relation to funding, David Mundell earlier pointed to a Scottish Tory policy on the NHS. Will Ben Wallace help us on the detail of that policy? We are now in year three of devolution, without even a shadow budget from the Scottish Tories or the SNP. Will Ben Wallace help to secure consensus in Scotland by telling us that the Scottish Tories now commit themselves to matching the funding allocations for health that the Scottish Cabinet approved last week?

Photo of Ben Wallace Ben Wallace Conservative

As Brian Fitzpatrick knows, the Conservatives in the United Kingdom voted against the increase in the budget. We do not believe that spending such large sums of money without those sums being attached to reform is the best way to go. In five years' time, Scotland will be the highest spender, as a proportion of its gross domestic product, on health care in Europe.

In five years' time, we expect that there will be no waiting lists, no staff shortages and no bed shortages. That is the target that the Government has set. It has not set a target of shorter waiting times. It has set out to achieve the very best. I am happy to say that in Scotland we deserve the very best. Dorothy-Grace Elder alluded to patient service in Germany. Look at the German system. That is not the system that has been fixed by Gordon Brown in an attempt to keep hold of his power and put his unions and paymasters before patients.

We believe that fundholding is the right way to go. We believe that LHCCs should be allowed to commission care from the private, voluntary and public sectors and we are not the only ones. Our amendment today is taken word for word—apart from the fact that we inserted LHCC where he said primary care trusts—from Alan Milburn's statement in the House of Commons last Thursday. The statement has not been fiddled, fixed or skewed. John McAllion obviously now finds Alan Milburn as offensive as the Tories. I will quote Alan Milburn's exact words, so that the Deputy Minister for Health and Community Care cannot wriggle out of the situation by saying that we fixed them:

"Primary care trusts will be free to purchase care from the most appropriate provider - be they public, private or voluntary."

Those are the words of Alan Milburn; the other words in our amendment are from Alan Milburn, too. Today, Labour in Scotland will reject new Labour or it will carry on trying to make amends, but without having the guts to say that it has got it wrong. To dance on the head of a pin about contracting is not to address the issue of the internal market. Whether there is electronic contracting, whether the funds are held for secondary care within the primary care trust or whether they are held in acute care is not the issue. The internal market was characterised by the Griffiths report in the 1980s, which stated that if purchaser and provider were split and commissioning was allowed, that was the internal market. The Executive is returning to that. It cannot dance on the head of a pin and say that a computer will do it instead of a contract manager; it is still commissioning care.

The Deputy Minister for Health and Community Care could perhaps alleviate John McAllion's fear by saying that primary care teams are not allowed to buy care from anybody except the public sector. That may go some way towards alleviating John McAllion's fear, but does that mean that primary care teams will be allowed to buy care from the voluntary sector, the not-for-profit sector and the private sector? We will see from the minister's answer. Nicola Sturgeon said that primary care must be the engine for change. The Conservatives said that in the 1980s, so I welcome that.

I do not think that there is anything that Stewart Stevenson or his family has not done. A relation of his probably carried the cross at the crucifixion. If we had a debate on that, I am sure that he would tell us. He is fast becoming the Walter Mitty of the Scottish Parliament, and the less said about that, the better.

The choice will be whether to back the amendment that we have lodged, which is very much in the vein of new Labour and Alan Milburn, or to reject it. Will members go back to old Labour or come on board and recognise that the internal market delivered better outcomes, was a better use of money and put the patients first? I support Mary Scanlon's amendment.

Photo of Shona Robison Shona Robison Scottish National Party 12:11 pm, 25th April 2002

I do not know about Walter Mitty, but Ben Wallace is doing a very good "Just William" impression. I will not tell Mike Rumbles what impression he is doing—perhaps I will tell him afterwards.

There has been a large degree of consensus on primary care in the health service. All members agree that that is where the focus must be, although differences of opinion have appeared concerning how we get there.

The quote of the day is:

"If it can be done in primary care, it should be done in primary care."

All members can sign up to that.

We have heard that 90 per cent of the public's contact with the NHS begins and ends with primary care, so it is imperative that the primary care sector is able to develop to meet the demands of 21st century Scotland, as Bill Butler mentioned. As many members have said, a number of issues require resolution if that is to happen.

To maximise what we can achieve, we must address capacity, which means addressing work force issues. Recruitment and retention remain a huge problem. Although the incentives for dental practitioners are to be welcomed, we must do much more if we are to compensate for the potential loss of 25 per cent of nurses, as was highlighted by Margaret Smith. The primary care sector has the highest vacancy rates among nurses, so we must do more.

Roles and responsibilities are also key. The minister is right to say that people need to receive services at the right place at the right time and from the right professional. There are huge opportunities to enhance the delivery of services to those with chronic disease, as Janis Hughes said. There is agreement among members that GPs should not be the gatekeepers for services. We all agree that primary care is bigger than GPs. Nurse prescribing is important, as is the enhanced role for community pharmacists, direct access to physiotherapy, and so on.

The expansion of the role of LHCCs has been a key issue in the debate. I agree with Mr Fitzpatrick—which might cause him some concern. We want to devolve powers that are held by the health boards to the LHCCs. We want to give the LHCCs the clout to which Mr Fitzpatrick referred by giving them commissioning powers. That should also please Margaret Jamieson, who gave the example of the one-stop-shop community ownership model. We would want to enhance that further by devolving powers to LHCCs so that they can deliver services in partnership with local people, as Margaret Jamieson outlined.

The debate is not about GPs—it is about the whole primary care team. It is about empowering them to the maximum in partnership with local people. We need to get a dynamic system of LHCCs if we are to deliver the change that we have talked about. For LHCCs to be dynamic, they need to be empowered. John McAllion and other members have made the mistake of confusing LHCCs with GPs. They are not the same. LHCCs are the primary care teams. Either LHCCs are the right people to deliver local services or they are not. If they are, they must be given powers to allow them to do so effectively; if they are not, we have to stop pretending that they are. Saying that they are is mere rhetoric, which is not good enough. The ministers cannot have their cake and eat it. If LHCCs are the way to do things in future, we must give them the necessary powers backed up by the necessary resources. Such a system should have accountability structures to ensure that standards and guidelines exist for the delivery of effective local services. Socialists should not be afraid of devolving power to local people; I had thought that that was what socialists believed in.

In the Health and Community Care Committee and in this chamber we have discussed public health many a time. The primary care sector has a crucial role in delivering public health. In my view, public health is not the domain of any single medical professional but should be the responsibility of every single member of the health service. For example—and to consider a subject that Margaret Jamieson has spoken about on occasion—when a GP sees a pregnant woman, the GP should be considering the early years of the child and ensuring that the mother-to-be has all the information that she will require to ensure that her baby is as healthy as possible. The public health agenda starts early and has to be the responsibility of all.

Primary care must be the most important element in tackling health inequalities in our society. That is a big aim, and one that can be achieved only if all sections of the health service work together. We are not talking about a service that deals only with people in ill health, but a service that deals with the whole population to prevent people becoming ill in the first place.

Adam Ingram reminded us of the scale of the problems that we face in mental health. A total of 30 per cent of all GP consultations arise from stress and depression; and the frightening number of 100,000 out of 700,000 women aged between 25 and 45 seek treatment for depression each year. Those figures should make us pause and reflect. Adam is right is to highlight the need for other members of the primary care team to take responsibility for the delivery of mental health services in their broadest sense. His proposal for a mental health task force deserves consideration.

The shift from the acute sector to the primary care sector has happened only in rhetoric. We have spoken about it in this chamber time and time again, but the problem is that resources have not always followed the rhetoric. If we are serious about radically changing the way that our health service is delivered, those resources must follow. The Executive will certainly have the support of the SNP in making that happen.

Photo of Hugh Henry Hugh Henry Labour 12:18 pm, 25th April 2002

It is clear from the contributions this morning that there is much support in the Parliament for many of our proposals. Most of us would acknowledge the fundamental role that primary care plays in the delivery of good quality health in all the communities that we represent across Scotland.

People want to be supported to help them stay well; or, if they are ill, they want to be cared for in or near their homes, as many members have said. Primary care is about providing continuous, comprehensive and co-ordinated care to individuals and communities. That is why we are modernising primary care. We want to ensure equitable access to a wider range of primary care services, working towards a target of access to a member of the primary care team—not, as Tommy Sheridan suggested, to a GP—in 48 hours. We want to increase the number and type of staff in primary care in order to make full and effective use of their professional skills. That will allow us to provide appropriate, high-quality care.

Photo of David Davidson David Davidson Conservative

Will the minister clarify something that he said earlier about patients being able to see a member of the primary care team within 48 hours. I understand that that does not necessarily mean seeing a GP. In the model that the minister outlined, who will conduct the triage?

Photo of Hugh Henry Hugh Henry Labour

There will be no difference to the situation at present. The role of nurses will continue to be critical. Many members have spoken about the contribution that nurses can and will play in the delivery of primary care. Equally, we want to be clear about wanting to free up GPs to do the work that they are qualified to do and to have nurses do the work that they are capable of doing. I am not talking about asking nurses to do work that is most appropriately done by GPs, but about freeing up qualified staff to do the work that they are best able to do.

Photo of Hugh Henry Hugh Henry Labour

No thanks, Tommy.

We also want to pursue measures to recruit and retain staff, particularly in remote, rural and deprived areas. Malcolm Chisholm made a number of comments on that subject. I am sure that the announcement that Mary Mulligan is to make today on dentistry will be welcomed widely.

We want also to improve the infrastructure of primary care by modernising existing premises and building new ones. Janis Hughes made reference to the contribution that is made by the centre in Rutherglen. Other centres in Ayrshire were mentioned as examples of primary care that is transforming the quality of service to people in communities.

I want to make clear our intentions in respect of the amendments to the motion. We do not intend to accept Tommy Sheridan's amendment. Tommy Sheridan has failed to answer the questions that were put to him about what he would do about doctors and the privately funded and run facilities that are used by doctors.

Photo of Tommy Sheridan Tommy Sheridan SSP

Does the minister consider that, although GPs are self-employed, they are part of the private health sector? Does the minister include referrals to physiotherapists as a front-line of primary care?

Photo of Hugh Henry Hugh Henry Labour

If I have time, I will return to the issue of physiotherapists.

It is not for me to try to define what Tommy Sheridan has included in his amendment. It is clear that the terms of his amendment would have a severe and devastating effect on much of the privately provided care service that constitutes 60 per cent of GP services.

We cannot accept the Conservative amendment. It is clear that the Conservatives are attempting to drive Scotland back to GP fundholding. John McAllion and others made it clear that fundholding was a disaster, but the Conservatives were clear about wanting to do that.

Photo of Mary Scanlon Mary Scanlon Conservative

The minister announced that budgets will be devolved to LHCCs and yet, in many parts of the Highlands and Islands, there are no LHCCs. Does the Executive plan to devolve budgets to local GPs?

Photo of Hugh Henry Hugh Henry Labour

If Mary Scanlon had listened carefully, she would have heard us talk about primary care teams. In that respect, Shona Robison and Nicola Sturgeon have raised an issue that requires clarification. Shona Robison said that LHCCs are primary care teams. That is not the case. A distinction must be made between primary care teams and LHCCs. It is usual to refer to the team of primary care professionals who work in close association with GPs and individual practices as the primary care team. LHCCs are voluntary groupings of GP practices. To answer John McAllion's point, we are clear that we are not talking about transferring commissioning powers to LHCCs. We want to empower primary care teams.

That is why, despite our reservations about some of what was said by Nicola Sturgeon and Shona Robison, we are inclined to accept the SNP amendment. It chimes with what we are trying to do, which is to devolve power to LHCCs to support and empower primary care teams. We will accept the SNP amendment.

Photo of Hugh Henry Hugh Henry Labour

No, I must press on. A number of points have been made, but unfortunately, because of lack of time, I will not be able to address them all. I mentioned our view on the SNP's attitude to commissioning powers. SNP members said that we must address undercapacity, recruitment and retention and the work load in the health service. We have introduced a number of measures that are bringing staff into the service. There are not enough new staff and staff numbers are not increasing fast enough, but we are doing more than ever before. We have addressed many issues about the conditions in which staff work and we will continue to do so.

Mary Scanlon and her Tory colleagues are trying to take us back to the days of GP fundholding. I want to make it clear that our proposals do not include GPs holding funds for secondary care. Mary Scanlon endorsed our claim that we must listen to GPs and other staff. The issue of joint futures is critical to the delivery of care in communities and to people working in partnership at a local level. I hope that I made clear my point about nurses taking on appropriate responsibilities.

Tommy Sheridan wants an assurance that no public money in the NHS will go to private care. I pointed out the inconsistencies in Tommy's amendment. It is clear from Gordon Brown's talk of a tax-based NHS system and from many of Malcolm Chisholm's comments today and in recent months, that in Scotland we are committed to a publicly funded and publicly delivered health care system. Nothing in our proposals for primary care will take us away from that fundamental principle.

Physiotherapists have a role, which has been addressed in a number of reports and will continue to be addressed. If Tommy Sheridan is concerned about specific issues, he should contact me and I will be more than happy to consider them. David Davidson and Margaret Smith mentioned the role of pharmacists in communities, which is critical to delivering good care. One welcome change in attitude in recent years has been the recognition that pharmacists can make a significant contribution. The Executive has made significant steps towards empowering and involving pharmacists, but we can do more.

Janis Hughes is right that the majority of care should be carried out at the primary care level. She mentioned the role that primary care can have in chronic disease management. I would welcome the opportunity to visit the Rutherglen primary care centre to see how that can be done locally.

Margaret Jamieson is right that—as I said earlier—primary care is about more than GPs and that LHCCs are not the only issue related to primary care. There are good examples of effective partnership in east Ayrshire. I have seen at first hand the work that is done by rapid response teams, which not only makes a difference to primary care service delivery, but can benefit the hospital sector significantly. Margaret Jamieson was right to talk about local delivery and empowerment. She can rightly take pride in the innovation in east Ayrshire.

We must give credit to the Conservatives—at least they were consistent. They talked about private health and their determination to involve the private sector.

Photo of Hugh Henry Hugh Henry Labour

No thanks. It is good that the Conservatives are so consistent, but there is a problem—Ben Wallace's speech did not chime with David Mundell's. David Mundell did not answer the question about the money that would come to Scotland.

Ben Wallace said that the Conservatives voted against the tax increases and the extra money for the health service that was proposed in the budget. If that money does not come to Scotland, how could David Mundell fulfil the commitments in Scotland that he mentioned? The development of the health service is dependent on that consistent flow of money. The Conservatives are inconsistent and contradictory, but the public will see clearly that they plan to dismantle the health service.

Elaine Thomson mentioned the benefits advice that citizens advice bureaux provide. Malcolm Chisholm recently met Citizens Advice Scotland, which will have further meetings with officials to discuss how best its work with patients can be supported. Many local authorities also make a valuable contribution by funding welfare rights services, which provide that type of service.

Mike Rumbles and others welcomed the money for dentists that will make an impact in many communities across Scotland. I cannot deal with Brian Fitzpatrick's comments on men's health in detail, but it is true that we need to facilitate the clout of primary care with the secondary and tertiary sectors. We will work carefully to see how the developing role of primary care plays in that.

Because of time constraints, I cannot deal with the rest of the contributions that were made today, but I will say to Johann Lamont that we are aware that Glasgow has particular problems. The Executive has attempted to address many of the problems that are specific to Glasgow and that will form a considerable part of our thinking in the coming months and years. We know that there are acute problems in Glasgow.

As there is broad support for the role of primary care, I am sure that we will start to see a real difference in many of our communities. For us, primary care is fundamentally about unleashing the full potential of our staff in local communities to deliver more and better care sooner, and nearer to where people live.