National Health Service Reform (Scotland) Bill: Stage 1

– in the Scottish Parliament at 2:34 pm on 3 March 2004.

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Photo of George Reid George Reid None 2:34, 3 March 2004

The next item of business is a debate on motion S2M-215, in the name of Malcolm Chisholm, on the general principles of the National Health Service Reform (Scotland) Bill, and on one amendment to that motion.

Photo of Malcolm Chisholm Malcolm Chisholm Labour 2:37, 3 March 2004

The National Health Service Reform (Scotland) Bill contains the legislative changes that are necessary to realise the vision that is set out in the white paper "Partnership for Care" and in the partnership agreement. It is a vision of a health service with a culture of caring that is to be developed and fostered by a new partnership between patients, staff and Government. It is a vision of a health service fit for the 21 st century, in which patients are the key drivers of change and front-line staff are the leaders of the change process.

The Scottish Executive is spending £7.2 billion on health this year and the figure is planned to rise to £8.7 billion by 2005-06. That investment must be matched by patient-centred reforms that deliver improved health and more integrated health services.

The Health Committee took evidence from a wide range of interests and I thank it for its report. I very much welcome its endorsement of the bill's general principles, subject to the reservations that it has expressed.

I will now deal with the bill's provisions. The first of the reforms that I have included in the bill is the final step in the dissolution of national health service trusts. Trusts were set up as a key feature of the internal market and, although they have lost much of their original purpose, they are still a hindrance to the single-system integrated working that we believe is best for Scotland.

Patient-centred services of the highest quality cannot be delivered by a market-style NHS in which trusts compete with one another, but they can be delivered by NHS staff working together as part of the same organisation. That is why we are moving towards single-system working.

Photo of Brian Monteith Brian Monteith Conservative

The minister suggests that patient-centred care can be provided only by a centralised system. Does he acknowledge that opticians, which are not centralised and are generally free from direction, provide patient-centred care?

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I agree with the second point, but the leap from a single system to centralisation is enormous. I have been trying to tell the Conservative party for months that we support a single system that is decentralised—that is exactly what I will go on to describe.

In removing the powers to establish trusts, we wish to establish single-system working in a decentralised context with the delegation of decision making and responsibility to the point of patient care. That is where community health partnerships are so crucial. Community health partnerships will build on the achievements of the most innovative local health care co-operatives. They will help to make the planning and delivery of health care more responsive to the needs of local populations and to develop more services in community settings. They will also be a key vehicle for integration.

On the one hand, CHPs will act as a focus for the integration of primary and specialist services. That will bring about a shift in the balance of care to enhance local community-based services with improved access for local people. On the other hand, CHPs will be able to progress the joint future agenda locally through substantive partnerships with local authorities. If CHP boundaries are coterminous with local authority administrative boundaries, the potential for further integration becomes greater.

CHP committees will comprise representatives from front-line staff and key partners such as local authorities, the voluntary sector and the public. They will have greater responsibility and influence in the deployment of all resources by health boards and they will play a more influential role in service redesign locally. We will ensure that schemes of establishment are focused on health service and health improvement outcomes. We will also ensure that the health boards prepare robust development plans to support the evaluation of CHPs.

Photo of Bruce Crawford Bruce Crawford Scottish National Party

On coterminous boundaries, we must ensure that we get the best fit and the best efficiencies. Will there be a shift in health board boundaries to meet council boundaries or, vice versa, will councils be restructured to meet health board boundaries?

Photo of Malcolm Chisholm Malcolm Chisholm Labour

We do not have any such proposals at the moment. We want to ensure that, as CHPs are set up, they are coterminous as far as possible with local authority boundaries. It may be that one CHP will have representatives from two NHS boards but not from two local authorities. That is the best approach at present.

It is vital that the CHPs involve their communities when planning and delivering services, as they cannot provide effective services unless they know what their communities need. Each CHP will be required to support effective community involvement through public partnership forums that will ensure that the CHP engages effectively with its local community. That should build on good existing local approaches and on the work of local user and carer groups. The forums will be involved directly in the decisions that are taken by each CHP on the planning and delivery of services.

Photo of John Swinney John Swinney Scottish National Party

I agree entirely with what the minister said about the importance of community involvement and locality. However, some of what he said does not sit comfortably with the feelings of many communities in Scotland about the way in which decisions are taken to reconfigure services, especially when the outcome fundamentally reduces access to those services at the local level. How will he ensure that the rhetoric that he uses in Parliament is much more closely reflected in the reality that some of us see on the ground in the communities that we represent?

Photo of Malcolm Chisholm Malcolm Chisholm Labour

We have seen several excellent examples of good public involvement in the part of Scotland that John Swinney represents. I will visit NHS Tayside on Friday. The public partnership forums that have been set up in that area are a good example of better engagement with local communities.

I will now deal with public involvement more generally. Underpinning the obligations of the CHPs to involve the public will be a statutory duty that requires all health boards and special health boards to involve and consult the public on the planning, development and delivery of health services. It is essential to our vision of a modern health service that patient focus and public involvement are fully integrated with day-to-day management and delivery.

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I will give way to Bill Butler and then I think that I will have to get on.

Photo of Bill Butler Bill Butler Labour

The minister will be aware of my proposed member's bill, which would provide for direct elections for a majority of places on health boards. Does he recall the words of his colleague the Deputy Minister for Health and Community Care in a debate on the national health service last year? The deputy minister said:

"The Executive will seriously consider the proposal alongside its own radical agenda".—[Official Report, 18 June 2003; c 853.]

Have ministers reflected on the proposal? What will the Executive do formally to assist?

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I will report back to Bill Butler on the issue. Obviously, there would have to be a wide public consultation on his important bill. I will look into the matter in respect of any help that we can give.

The new Scottish health council, which featured quite a bit in the Health Committee's report, will be a major step forward in supporting patient focus and public involvement in the NHS. We wish to see the Scottish health council created as part of NHS Quality Improvement Scotland, which reviews and reports on standards in the NHS independently of the Government. That is because we see achieving a real patient focus as inseparable from improving the quality of our health services, the starting point for improving quality being the experience of every patient who passes through the health care system.

I know that there are concerns about the future structure of public involvement and the independence of the Scottish health council, but I say again that we are committed to creating a Scottish health council that acts independently, brings professionalism and expertise to the patient focus and public involvement agenda and builds on the strong local roots and commitment of the health council movement. Detailed arrangements to secure those objectives are being developed in partnership with the Scottish Association of Health Councils. I shall write to the Health Committee about that before stage 2.

The duty that I have just mentioned requires boards to involve and consult the people to whom they provide services. A key role of the Scottish health council and its local advisory councils will be to ensure that the boards do that job properly. They will therefore be a key driver for the improved public involvement that we all want.

If the public are not receiving services, or are receiving poor-quality services, it is important that Scottish ministers have appropriate powers to intervene to ensure that those services are brought back up to the required standards. That is why I have included a power in the bill that is flexible enough to cope with a wide range of issues, yet can be used only as a last resort by virtue of the necessity test. That legal test will ensure that the new power will be available only where intervention is more than just desirable, useful or expedient.

The Scottish ministers can use many indicators to decide whether an intervention is necessary, including lengthening waiting times, information from the performance assessment framework, clinical standards not being met and persistent complaints from patients. I do not expect that ministers will use the new powers often, but in the event of a serious failure, or where a serious failure is likely, patients would expect ministers to be able to step in quickly to ensure that the problems are addressed.

The bill also includes a new duty on boards to co-operate to advance the health of the people of Scotland. If we are to maximise the level of service that we can provide to all communities throughout Scotland, we need NHS boards to work collaboratively with other boards to share skills and resources to provide a better service. To do otherwise is simply not sustainable.

As some health services become more specialised and complex, we need more regional planning to ensure that the services are delivered successfully and to the highest possible level of care. Health board chief executives are working up a proposed regional planning framework that will allow for a co-ordinated approach to regional planning. I shall scrutinise that and ensure that we have much more effective arrangements than we had in the past.

Health improvement also features in the bill, as the NHS should be a service about health, not just about illness. The duty in the bill makes it clear that it is a responsibility of Scottish ministers and health boards to promote health improvement; the bill provides them with powers to enable them to do just that. I recognise that boards alone cannot improve health, so the powers will enable them and Scottish ministers to work with, and give financial assistance to, other organisations, including local authorities, in promoting health improvement.

In "Partnership for Care", we said that none of the reforms will happen without staff. A key role for the Government, as I said in the debate last week on the NHS work force, is to support, value and empower staff to lead the change process in partnership with patients. I have already set out how we propose to empower front-line staff by devolving decision making to them. We also wish to value and support them. That is why we have a staff governance standard, which reflects our fundamental belief that staff should be well informed, appropriately trained, involved in decisions that affect them, treated fairly and consistently, and provided with an improved and safe working environment.

At stage 2, I will lodge an amendment to ensure that systems are in place to make a reality of staff governance. That will be achieved through compliance with the staff governance framework, which has been agreed by a partnership of the Executive, the NHS, trade unions and professional bodies.

Section 1 of the National Health Service (Scotland) Act 1978 requires Scottish ministers to promote a comprehensive and integrated health service designed to secure improvement in the health of the people of Scotland. It is important that the health service improves the health of all the people of Scotland, irrespective of gender, race, disability, age, sexuality, beliefs and opinions. That is why we will lodge an amendment at stage 2 to require boards to promote equal opportunities when undertaking their functions.

I know that some members have questioned the statement in the financial memorandum that no additional expenditure will be associated with the bill. I remind members that there has been an uplift of 7.8 per cent in the resources provided to boards in 2003-04 to manage and provide services. Moreover, an additional £173 million will be spent on health improvement over the next three years under the "Building a Better Scotland" programme and money has been invested in supporting the delivery of the patient focus and public involvement programme.

Boards have a great deal of capacity to manage change. Some boards have already dissolved trusts and demonstrated savings, for example. The change from LHCCs to CHPs is evolutionary. The move to regional planning will require a redistribution rather than an augmentation of resources. The reforms should result in more efficient use of resources and can be managed in the record sums that are being provided to boards to manage and provide services. I am determined, therefore, that no additional management costs will be associated with the bill.

The bill has been broadly supported by a variety of organisations. It represents an important step towards the vision set out in "Partnership for Care" and the partnership agreement. I hope that members will give their support to the principles of the bill and reject the unnecessary amendment in the name of Shona Robison.

I move,

That the Parliament agrees to the general principles of the National Health Service Reform (Scotland) Bill.

Photo of Shona Robison Shona Robison Scottish National Party 2:51, 3 March 2004

I begin by thanking those who gave evidence to the Health Committee and the clerks who, as ever, did a great deal of hard work to enable us to get to this stage 1 debate. I welcome the bill's principles, which have been the thrust of SNP policy for some time—it has taken the Executive approximately five years to catch up, but better late than never.

The SNP has been keen for a long time to abolish trusts because we want to remove the artificial barriers that exist between primary and secondary care and that have hindered the delivery of an integrated system across Scotland. It is important to simplify the system for the public, patients and staff. There is too much bureaucracy in the NHS, but we are slowly getting rid of it, which is to be welcomed.

Structural changes alone will not cure the ills of the health service. We need to address more fundamental issues and to build capacity in the NHS to respond to the needs of the Scottish public. That does not mean that the bill is not necessary, however.

Photo of Phil Gallie Phil Gallie Conservative

When Shona Robison spoke of a reduction in staff, I presume that she was referring to administrative staff. However, how will the centralisation of the health boards and the division of primary care and acute trusts help to retain staff? Will she estimate how many jobs will be saved?

Photo of Shona Robison Shona Robison Scottish National Party

I hope that there will be cost savings as a result of the reduction in bureaucracy—I would be concerned if that were not the case. The bill seeks to simplify bureaucracy and to deliver a better service. As the trusts have no role in that regard, their abolition is long overdue.

The bill deals with other important matters, such as regional working. The severe lack of co-operation across Scottish health board boundaries and the lack of regional planning have been highlighted by the debacle in maternity services in Glasgow and the west of Scotland. I know that Stewart Maxwell will have more to say on that in his speech. We have to ensure that such a debacle does not happen again.

Community health partnerships are another important development. Such partnerships have great potential, but we need to know more about the Executive's thinking on how they will operate and what they will do. I do not think that all is clear on that front.

It is fair to say that LHCCs have been something of a mixed bag. Some of them work well; some not so well. The difference is that community health partnerships are to be statutory bodies, unlike the LHCCs, which are voluntary. CHPs must be dynamic organisations that can respond to local needs. I do not believe that that will be a cheap option. The NHS Confederation in Scotland, the body that represents the managers to whom the minister referred, is raising concerns about that. It has stated:

"The creation of new bodies almost inevitably has additional costs attached ... and Ministers should be aware of this."

Where is the money to meet those additional costs to come from if not from the Minister for Health and Community Care? Is it to come from other budgets? If so, from which budgets? We need to know that.

Public involvement is an important element of the bill. As John Swinney highlighted, there has been widespread dissatisfaction about the quality of public involvement in many areas. Many members of the public feel that public consultation is a sham and a game played by those in power to get the result that they wanted in the first place. If we are to change that perception, we need to ensure that the bill's provisions, as well as other measures, bring about change and that health boards consult the public properly on the planning and development of services. Crucially, there must be changes in the way in which health boards take decisions once they have listened to the public. The jury is currently out on that.

The Executive's assertion that public involvement can be entirely achieved without any additional resources is a matter of concern. The financial memorandum states that the public involvement duty will involve "no additional expenditure" by health boards. The NHS Confederation, which represents managers—those who know the financial constraints in the health service—stated:

"continuous public involvement is not cheap, as NHS organisations have found through experience".

If the experience of managers is that public consultation is not cheap, either we will end up having public consultation on the cheap, which will not work and will not deliver the change required, or, yet again, other budgets will have to be used to fund adequate public consultation. Either way, the situation is not acceptable.

Photo of Shona Robison Shona Robison Scottish National Party

I am a bit tight on time, otherwise, I would do—I am sorry about that.

I have no problems with the new Scottish health council monitoring how well health boards engage with the public—that is all well and good. However, I have concerns about the independence of the health council, as it is located within NHS Quality Improvement Scotland, which is an NHS body. There is a strong argument that that does not send out a message to the public that the Scottish health council will be truly independent and able to protect their interests. There are arguments for a different structure to be established so as to guarantee the new council's independence. I would urge the minister, even at this late stage, to reconsider the matter.

There are further concerns about the abolition of the local health councils, which have carried out an important advocacy role in their communities. The local advisory committees, we are told, will not take on that role, although they may have to if no one else can fulfil it. That is extremely confusing—the role should be taken on by one body or the other. Local health councils have fulfilled an important role in directly assisting the public to take up issues with the local health boards. The loss of that important advocacy role is a retrograde step and I urge the minister to reconsider the proposal.

The bill also covers health improvement, which is important, and powers of intervention, which are welcome, although concerns have been raised about them. I agree that the bill must be clear about what "intervention" means and under what circumstances the powers will be used. If the bill is not clear on that point, situations could arise in which there is a lack of clarity about when the powers should be used. The financing of intervention is also a crucial issue. If a financial problem is being investigated and the health board has to pay for the costs of the intervention, is that not a double whammy for our already financially stretched health boards? The minister must consider that issue.

The focus of my amendment is the independence of the Scottish health council and the lack of detail in the financial memorandum. We cannot have a situation where additional responsibilities are put on health boards, which are already strapped for cash—they are trying to meet junior doctors' working hours and are facing additional drugs costs—without funding those new duties fully. The money has to come from somewhere; if it is not coming directly from the minister, it will have to come from other budgets, as NHS managers and other organisations are telling the Executive. The Executive must have another look at the financial memorandum and come back with something a bit more realistic.

I move amendment S2M-215.1, to insert at end:

"but, in so doing, believes that there must be safeguards in place to ensure the independence of the proposed new Scottish Health Council and is concerned about the lack of detail in the Financial Memorandum regarding potential additional costs arising from the Bill."

Photo of David Davidson David Davidson Conservative 3:01, 3 March 2004

As a matter of principle, we are opposed fundamentally to the National Health Service Reform (Scotland) Bill, which is designed to centralise even more power in the hands of the minister. Once again, devolution starts and ends with the Executive. At this stage we have no desire to amend the bill, because we oppose it and we do not want an amended version of it to proceed.

Unlike the Labour party's Airborne brigade sitting on my left, we will stick to our manifesto pledges of 1999 and 2003 to abolish health boards.

Photo of David Davidson David Davidson Conservative

I will take an intervention from Mr Rumbles later. He should remind me, in case I forget him.

Health boards are well past their sell-by date, as we have been saying for the past few years. Even health board officials agree that the development of managed clinical networks covering several current health board areas will provide a strategic overview and the networking requirements of the future.

We want localised health care delivery to respond to what the patient needs, not what the Minister for Health and Community Care calls for. We want to see a system that will provide patient choice, in which people will be free to make financial and clinical decisions to suit the community and in which patients will be served through independent, not-for-profit organisations that are better able to respond to local needs. One size does not fit all in Scotland.

Photo of Bruce Crawford Bruce Crawford Scottish National Party

Will the member give us a bit more explanation of the not-for-profit trusts? Is he talking about companies limited by guarantee?

Photo of David Davidson David Davidson Conservative

We are talking about a new form of public service that is simple and has been understood in Westminster—in fact, John Reid has adopted some of our proposals. It is not a case of buying shares and floating a trust on the stock market.

Photo of Bruce Crawford Bruce Crawford Scottish National Party

Is the member confirming that he would support the principle of not-for-profit trusts being companies limited by guarantee?

Photo of David Davidson David Davidson Conservative

Absolutely. I have no problem with that. We do not need any more comfort zones and boards hiding behind the targets set by the minister. We need there to be real incentives for the people who deliver health care to deliver the best possible care to the maximum number of patients on the basis of the best value for money.

Foundation hospitals are accepted in England, and Scottish Labour MPs believe that they are the correct way forward. That view is apparently shared by the Co-operative Party, of which I believe there are members in the chamber. Brian Wilson has been quoted as saying that

"The NHS should always be responsive to local need", and Nigel Griffiths, an Edinburgh MP, has stated that he would not object to the Edinburgh royal infirmary becoming a foundation hospital. The risk of not adopting foundation trusts in Scotland is that we will lose key staff, not just because of the money but because of the opportunity that such trusts provide of allowing people to concentrate on professional practice rather than ticking boxes for the minister.

I have stated regularly in the chamber that we do not wish to privatise the NHS but to add capacity through better partnerships with the independent sector. John Reid, that wonderful Scottish MP, has gone some way towards that—he has not gone far—by setting up 60 or so diagnostic treatment centres throughout England, all delivered by independent companies that are run by foreign doctors and designed to reduce waiting times by increasing throughput with no dilution of standards. Why cannot Scotland receive the same treatment?

We will not support the financial resolution, not only for the same reasons but because of our disbelief in the minister's claims about cost neutrality. The bill is undeliverable without cuts in service, and the minister has just said that the boards have had the money; they will have to pay for the reforms out of what they have got. The only solution to that problem is to cut the costs, the staffing or the throughput. There is no arguing with what the minister said today. However, Audit Scotland is concerned about a lack of transparency if trusts go, and committees of the Parliament are not convinced that the move is correct.

Local health councils are to be merged into a national organisation. Existing health councils agree with that move—they want a national body—but they and I believe fundamentally that the new Scottish health council must not only be independent, but must be seen to be independent. I therefore cannot support its being placed within NHS Quality Improvement Scotland, where management will be confused. Having "NHS" in the title will create the wrong impression, and I do not believe that the minister has addressed the costs of setting up the new organisation.

Community health partnerships are supposed to be coterminous with local councils. Sticking to the principle of a patient-centred system, if that is the case, why can we not merge the social care budget with the primary care budget, combine the staff and do away with dual assessments? That would simplify the system and focus on patient need. I saw such a system in the Falkland Islands just over a week ago.

Photo of Bristow Muldoon Bristow Muldoon Labour

If Mr Davidson had taken the shorter journey to West Lothian, he would be aware that West Lothian Council and a local trust are already deep in negotiations about the pooling of social care and health budgets.

Photo of David Davidson David Davidson Conservative

I take it from Mr Muldoon's intervention that that is now official Labour policy, which I welcome.

The management boards of the new CHPs must include representatives of the main primary care professions, but there must also be clear input from communities in the boards and in local management. The communities that the CHPs serve must have a clear voice and must be able to get it across.

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I assure David Davidson that primary care professionals, including those from his profession of pharmacy, will be represented. I have already spoken about the public partnership forums. The CHPs are an example of power being given to front-line staff and of the involvement of local communities. Of course, CHPs completely disprove the nonsense that Mr Davidson and Brian Monteith have spoken about centralisation under the bill.

Photo of David Davidson David Davidson Conservative

The minister has not yet provided much detail about how the CHPs will be set up and managed. The evidence that the Health Committee took certainly gave the impression that many professionals are concerned about their opportunity to have an input. Perhaps the minister will come back with more details.

To date, the minister has failed to convince anyone that sufficient funding is in place for the CHPs. He has failed to say how they will be structured and manned and to whom they will be accountable. Will the CHPs be accountable to the minister, to the health boards—if he keeps them—or to the communities that they will seek to serve?

Government has a major role in health care: it should fund it and seek ways in which to introduce new funding schemes and capacity. Government also has a role in supporting the educational needs of staff at all levels and it should set standards and ensure that audits are carried out. Given the vast sums that are spent in Scotland, the Government should also begin to seek value for money. Most important, it should ensure patient choice. Our patient passport would give patients the right to access care wherever it can be delivered appropriately and timeously within the NHS. If care is not available, the passport would allow patients to seek it in other sectors while taking some of the NHS tariff with them. Surprisingly, in England under new Labour, if patients go to one of the new independent sector diagnostic treatment centres, they can take the whole fee with them. Why can we not have that system here?

We believe that the issue is not about narrow political ideology, but about real reform that frees up our excellent professionals to respond to patients' needs, wherever they live. This flawed bill will not do that; the detail is thin and its basis is wrong. The bill will merely entrench the inequalities in our health service, which we are determined to eradicate.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat 3:09, 3 March 2004

The bill sets out to abolish NHS trusts and to ensure that patients' interests are put first and that services are planned efficiently through collaboration with and among NHS bodies. In addition, the bill will establish community health partnerships, develop managed clinical networks and place a duty on ministers and health boards to promote health improvement. Most important, the bill will impose a duty on health boards to encourage public involvement.

As the Health Committee's stage 1 report on the bill makes clear, we are

"satisfied that this Bill should improve health service delivery."

The last sentence of the committee's report is in paragraph 75, which states:

"the Committee recommends that the Parliament approves the general principles of the Bill."

David Davidson, who is the Scottish Conservative party's health spokesperson and a member of the committee, supported that position. The report is a unanimous report by the Health Committee. David Davidson argued in favour of the bill in the committee, but he has just talked about the bill being flawed. He took one position in the committee and has taken an entirely different position in the chamber.

Photo of David Davidson David Davidson Conservative

The committee took evidence and produced a report that is based on that evidence. We tried to reach a conclusion that was based on the evidence that we took, so that the bill could move forward. I remain opposed in principle to the removal of trusts, although I said clearly that I am happy to see them change into foundation trusts. It is for Mr Rumbles to decide whether what I have said has been reported in a different way and misunderstood. However, in simple terms, there are many things in the bill that I worked as a committee member to try to clarify, but we have not received clarity.

Photo of George Reid George Reid None

Mr Rumbles will have another couple of minutes.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

Thank you, Presiding Officer—that was a long intervention.

It is interesting that David Davidson has said twice in two weeks that he has been misreported. We cannot get away from the fact that, as the Scottish Conservative party's representative on the Health Committee, he has supported the bill.

As I said, he supported the committee's unanimous recommendation that

"the Committee recommends that the Parliament approves the general principles of the Bill."

The motion that is before members simply states:

"That the Parliament agrees to the general principles of the National Health Service Reform (Scotland) Bill".

That is not exactly greatly different from what we put in the committee's report. For David Davidson come to the chamber and realise that—oops—he has made a mistake is just not on.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

I want to return to the committee's report.

Two areas of concern were highlighted in the evidence to the committee. The first focused on the public perception of the independence of the new Scottish health council and the second focused on the lack of detail in the financial memorandum that accompanies the bill. Indeed, those two issues are highlighted in the SNP's amendment.

I will deal first with the Scottish health council. It is absolutely true that, although the committee was not convinced that the Scottish health council should necessarily be part of NHS Quality Improvement Scotland, the committee did not come to a view as to where the council should lie in the great scheme of things.

I found the Scottish Consumer Council's evidence convincing. It said:

"In objective terms, we have no worry about its independence as part of NHS QIS, but we have significant concerns about how that would be perceived."—[Official Report, Health Committee, 16 December 2003; c 468.]

Therefore, the issue, in effect, relates to perception. I am glad to see that, in the minister's response to the committee's report, he has assured us that the convener, the vice-convener and the director of the Scottish Association of Health Councils are members of the steering group that will set up the new arrangements. I am confident that the issue of the perceived lack of independence in the new arrangements will be successfully tackled.

I turn to the second issue—the lack of detail that was produced by the Executive in the financial memorandum that accompanies the bill. The committee report states:

"The Committee has concerns that it has not been given a breakdown of costs for the creation of the new bodies and therefore cannot make a fully informed comment."

That is absolutely true and self-evident. However, that does not mean that we believe that the initiatives in the bill are underfunded. From the evidence that we received, I believe that the opposite may be the case.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

The member should listen to the point that I am going to make first.

Dumfries and Galloway NHS Board, one of the smallest of the 15 health boards, has already gone down the road of integration. In its evidence, it said:

"We have made local and recurring savings in excess of £500,000 ... We also took the view that we did not need three chief executives or three directors of finance and so on. We started with a blank sheet of paper and redesigned everything."—[Official Report, Health Committee, 9 December 2003; c 426.]

I commend Dumfries and Galloway NHS Board for its clear evidence to the committee. That evidence was reinforced by written evidence from NHS Borders, which stated that management cost savings have been reinvested in patient care, although it did not give a figure.

Photo of Shona Robison Shona Robison Scottish National Party

I bring to Mike Rumbles's attention the other section in the committee report that deals with that issue. It says—

Photo of Shona Robison Shona Robison Scottish National Party

It is section 62. It says:

"The Committee would not wish to see the initial phase of change compromised in any way due to a lack of funding."

That raises the committee's question about the potential lack of funding for the bill. Given the comments of the NHS Confederation—the managers who know—and its concern about the lack of funding, does not Mike Rumbles recognise that there is a potential shortfall?

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

I recognise clearly what was stated in section 62 of the committee's report. I have it in front of me and was about to quote from it. On the strength of the evidence that we have received, I am convinced that there are real and substantial savings to be made in this whole process. Although those savings may not be available everywhere, I support the committee's view that additional funding should be made available

"where it has been clearly demonstrated by Health Boards that the obligations imposed by this legislation have resulted in additional expenditure which could only be met by cuts in front line services."

However, I will believe that when I see it, as the evidence does not indicate that that would be the case.

There are significant savings to be made by ending the duplication of the unnecessary management systems with which the NHS was saddled by previous Conservative Administrations. Unfortunately, I have to return to the Conservative position, which ducks and dives all over the place. Conservative members say that they are supportive of the Health Committee's unanimous position in favour of the bill. However, David Davidson has referred to patient passports, and every time that we hear about patient passports, they are presented as some sort of gift that the Scottish Executive or the Government would be able to give to create freedom of choice for individuals throughout the country. For many of my constituents who live in rural Scotland, there is no choice of hospital; therefore, the idea of patient passports is a non-starter.

In addition, what the Conservatives fail to emphasise about their so-called patient passports is the fact that a patient would have to dip into their savings book for several thousand pounds before their choice would be subsidised by the Scottish Conservatives' plan. That money would have to be available in the first place, as there is no way that the Conservatives could afford it otherwise.

Photo of Brian Monteith Brian Monteith Conservative

I thank the member for giving way, despite the fact that I was constantly heckling him about Airborne. Can he tell me whether all the operations that patients in his constituency require are delivered in his constituency or whether people have to travel outside his constituency to a variety of other hospitals that are chosen by clinicians?

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

Brian Monteith makes a ridiculous point. In the north-east, there is only the Aberdeen royal infirmary and very few people can go to other hospitals. I do not suppose that the Conservatives are advocating that people should travel hundreds of miles away from their relatives, friends and loved ones to have their operations.

This is a very good bill indeed. It was supported by all members of the Health Committee, including David Davidson. It is a shame that he has suddenly realised that he should backtrack on the issue and is leading the Conservatives to vote against something that he supported as recently as last week.

Photo of Dr Jean Turner Dr Jean Turner Independent 3:19, 3 March 2004

I draw members' attention back to what we are trying to do through the bill. Patients are the most important people in this debate. We are trying to make the patient's journey better through the bill. I have no difficulty with that objective, but I have some difficulty with some of the things that have been mentioned with regard to funding, and I think that the bill will have hidden costs.

Not every patient's journey is a comfortable one. Too many people are still on waiting lists or are turned away. I got a letter the other day from a lady who was told that because she was a bit long in the tooth and had a chronic illness, perhaps she did not need to go to the outpatients department, as it was overwhelmed. There are not enough nurses and doctors. Anything that we do to change the health service will have to lead to more patients being treated, and that will require more doctors and nurses.

It is a jolly good idea to get rid of the trusts—not before time, as everyone in medicine would agree. My colleague Bill Butler talked about electing the members of health boards. That would be a good idea because people would have more trust in their board members and would feel that their problems were being taken on board. Board members who were elected would understand people's problems better.

The NHS should also be more user-friendly in the area of patients' complaints. Too many people find that, although their complaints are dealt with, it is as if the point has been missed. We have to make sure that when patients complain, they have an independent voice.

Health boards have to co-operate; that is also long overdue. Many boards probably do not realise how much cross-boundary flow there is. Every board should be paying for work on their patients that is done in other board areas. Some areas are short of cash because they do not get paid for such work.

Powers of intervention in cases of service failure have been mentioned—Glasgow is probably getting pretty close to needing them. For the sake of argument, if we think about the problem of trolley waits, which has been going on for approximately two years, we are not really thinking about the patients but about the management structure that cannot cope because it does not have the capacity. How on earth are we going to improve such situations?

If the bill can improve the patient's journey, I am for it—we should all work towards improving that. There have been far too many changes in the NHS, which makes it hard to keep morale up. There has been change after change, and this new change is the greatest that there has been since the inception of the health service. I would like all of us in the chamber to work together for the good of the patient.

A gentleman in my constituency has been incontinent for more than a year. It is appalling for the trust to tell me—it did not tell him—that it does not undertake the highly specialised surgery required; it is expecting his consultant to report back to say whether the procedure is clinically effective. I am for anything that will improve communication between consultants, patients and—if they would get their act together—health boards. If the bill helps us to do something better for the patient, I am 100 per cent behind it and will vote for it.

I would love the minister and his deputy to reassure me that patients will be listened to. Public involvement is extremely important. I am an MSP because people truly do not feel as if they have been involved. They have attended expensive meetings for so-called consultation, but at the end of the day, all they want is their bread-and-butter services, such as medicine, general surgery and help when they have their heart attacks, to be near to where they live. They do not want to know that the working time directive means that there are not enough doctors to provide a service near to where they live.

There is nothing wrong with specialisation and centralisation for specialised services, such as neurosurgery or maternity and paediatrics in cases such as the Queen Mother's hospital and Yorkhill children's hospital. Those are specialist units in the same way as a cardiothoracic unit is a specialist unit.

People should be able to get their heart attacks, hernias or hip replacements dealt with. There are people in my constituency who are paying to have their hip replacements done in the private sector, but they should not have to use their hard-earned savings to pay for that. The private sector does not train nurses or doctors; it steals them from the NHS.

I would like the NHS to be improved. If the bill helps to do that and if the minister and his deputy can assure me that they will find the money to provide the doctors, nurses and all the other paramedical services to make the NHS work, I am 100 per cent behind them.

We must remember that we are here not just to talk about the NHS but to ensure that patients are seen when they are sick and when they are at their most vulnerable. Quite often, patients are afraid to complain about inefficient services because they fear that they will receive an unfavourable response.

At the moment, I am for the bill.

Photo of Trish Godman Trish Godman Labour

I call Kate Maclean. [ Interruption. ]

I call Kate Maclean.

Photo of Kate Maclean Kate Maclean Labour 3:26, 3 March 2004

In our debates on the NHS, it is always reassuring when the Tories oppose what we are doing. It is hardly surprising that the Tories do not like the bill because it puts patients first, it respects the role of staff in the planning and delivery of services and it abolishes the last bastions of the internal market that was set up when the Tories were in power. Therefore, I am delighted that the Tories are opposing the bill.

As a member of both the Health Committee and the Finance Committee, I have been fortunate to have read and heard a significant amount of written and oral evidence that will, I hope, shape the way that the bill ends up. The Health Committee's stage 1 report details the several concerns that were raised, which I thank the minister for attempting to clarify during stage 1 and in a recent letter to the convener of the Health Committee. I certainly found it useful to have some of the outstanding issues clarified.

I particularly welcome the minister's commitment to allow the Health Committee to comment on the draft regulations and statutory guidance on the operation of community health partnerships. In principle, CHPs are a good thing, as they should ensure that services are delivered in a way that puts patients at the heart of the service. An important feature is that CHPs will enable all the agencies to work together, which has often not happened very well in the past. CHPs will also ensure that services are planned by the people who deliver them.

Some of those who gave evidence raised concerns, which have been raised again this afternoon, about the membership, governance and geographic boundaries of CHPs. However, most of those concerns have been addressed by the minister during stage 1 or will be covered in the regulations and guidance, into which the Health Committee will now have some input.

I had some concerns about the powers of intervention, although I whole-heartedly agree with the need for the Scottish ministers to have such powers for exceptional circumstances. The intervention that took place in the health board in my area was welcome as it has resulted in services being delivered in a very different way. However, I still think that the bill, the explanatory notes and the minister's evidence to the Health Committee are unclear about what "intervention" means and about the circumstances in which the powers of intervention would be used. I realise that it would be impossible to provide an exhaustive list of circumstances, but I would feel more comfortable about agreeing to the Scottish ministers having such wide-ranging powers if I was clearer about what the powers were and when they would be used.

I am also concerned about the estimated cost of intervention that Shona Robison mentioned. I have some sympathy with the SNP amendment, although Shona Robison will hardly be surprised to learn that I will not support it. I will not support the SNP amendment because it says that

"there must be safeguards in place to ensure the independence of the proposed new Scottish Health Council".

I am reassured by the commitment that the minister gave in his letter to Christine Grahame, in which he said that the steering group that is setting up the new Scottish health council and the local advisory councils will consider management issues and how to safeguard the health council's independence. I think that the Health Committee will want to monitor the issue, but I am reassured by the minister's commitment.

I agree with the concerns raised in the SNP amendment about the additional costs that might arise from the bill. Indeed, I completely disagree with Mike Rumbles on that matter. He is being very unrealistic if, on the evidence of a small health board that has coterminous boundaries with a local authority, he believes that having unified health boards will lead to savings and that that situation will necessarily be replicated elsewhere in Scotland. Notwithstanding that, I will not support the SNP amendment.

In the Finance Committee—and, I think, in the Health Committee—I raised concerns that the costs of intervention had been significantly underestimated. Indeed, it is not that the costs have been underestimated; it is that we just do not know what the costs will be. The Scottish Executive's estimate, which was in the region of £85,000, was based on its intervention in Tayside Health Board some time ago. In his summing-up, will the minister tell us why that figure was plucked out of the air and used as an estimate, rather than the figure of £300,000, which was the cost of the more recent intervention in NHS Argyll and Clyde?

Unusually, I find myself agreeing again with Shona Robison on the issue of intervention. In most cases, the Scottish ministers will intervene because financial problems in health boards have led to the discovery of operational problems. As a result, I find it very strange that a health board will have to pick up the tab for intervention, especially as that figure has not been worked out sensibly.

Despite those comments, the legislation is very welcome and could potentially bring the NHS in Scotland up to date as a dynamic and efficient service for the people whom we represent. The minister has already shown great willingness to take on board the issues that were raised during stage 1. I hope that he will address issues that members in the chamber and in various committees have raised and ensure that what the Executive delivers through this legislation makes a positive difference to health services in Scotland.

Photo of Rob Gibson Rob Gibson Scottish National Party 3:32, 3 March 2004

I hope that the reform will bring welcome stability to the structure of the NHS. After all, the many changes over the years have led people to lose heart in the NHS's claim that it puts patients at the core of its activities. From the Conservatives' comments about foundation hospitals, I do not really believe that they are interested one bit in patients. Because of our general communitarian spirit in Scotland, we believe that we can create a public structure that will put patients at its heart and that will in due course give them the confidence to feel that they can receive treatment where they need it.

The creation of CHPs will mean some centralisation, because in some of the remote places in the area that I represent local health care co-operatives were bedding in and working quite well. The islands have a separate set-up, because they are small enough to be coterminous with local authority boundaries; however, in the Highland Council area, that slight centralisation will require some staff regrading. Indeed, that might well be the case in some other health board areas and CHPs elsewhere. Some retraining will be required, so extra costs will be incurred. That is a small example of how aspects of the changes that cannot yet be quantified will test the system. I will return later to finance.

I agree with Unison that front-line staff and people who deliver the services will have much more of a say within the proposed structure. However, like Unison, I would prefer trade unions to be more formally involved at health board and CHP levels; I would be interested to hear the minister's comments on that.

On health promotion, I should point out that we already have a structure for a sickness service. However, I wonder whether the minister hopes to have an overarching brief as far as the Government's approach to the matter is concerned. Health boards are being given responsibilities in health promotion, but NHS Scotland must provide benchmarks and targets for other departments, whether in food production or in the various means by which we ensure that the population has a healthy life. Health promotion is an exciting area and I welcome its potential. However, it must cut across other departments and the health service must take a strong lead. When the minister winds up, I hope to hear a bit about that.

On regional working, the managed clinical networks about which we hear so much tend to think about patients being moved to where the specialisms are. I will be interested in how the new structures in the health service will create contracts that take the specialists to where the patients are. A members' business debate on maternity services is coming up next week, which I hope to lead.

Photo of Rob Gibson Rob Gibson Scottish National Party

Excuse me; I will finish my point.

The patients rather than the professionals are expected to travel to many central points.

Photo of Keith Raffan Keith Raffan Liberal Democrat

I thank Rob Gibson for giving way. I have seen how managed clinical networks work in Tayside and Fife and Mr Gibson's point about specialists is not accurate—certainly not in my experience of the health boards in my region—because they do travel. Does he agree that with the developing information technology within the NHS, distance and travel are becoming irrelevant anyway?

Photo of Rob Gibson Rob Gibson Scottish National Party

I recommend that Keith Raffan attend the debate about maternity services in Caithness.

I was surprised to hear Mike Rumbles dismissing the Conservatives by saying that we should not expect people to travel hundreds of miles. That is precisely what is happening to people in the north of Scotland who need treatment. That is why we hope that the managed clinical networks will take a different approach from that of merely moving patients.

On public involvement, the proposed Scottish health council that will replace the existing structure seems to me to be a form of centralisation, but one which could be powerful. I am surprised that it has not so far been suggested that local involvement could happen through elections and that the national committee could also be elected. We want more active citizens, so let us see whether the minister has ideas about having a directly elected Scottish health council.

As far as finances are concerned, the geography of Scotland will not change. We have accumulated debts in various parts of the health service, so we are not starting with a blank sheet. The proposed reforms can create stability in organisation, but there will have to be generosity from the Government and, indeed, extra cash if we are ever to provide the practitioners who will help patients through the managed clinical networks.

I very much welcome the bill, but I have concerns about the finance arrangements—those arrangements have not been clearly stated—and I have questions about the accountability and democracy of the proposed Scottish health council. I reserve my judgment on those issues and will wait to see what happens. I support Shona Robison's remarks.

I crave members' indulgence; I must now leave the chamber to attend to a constituency matter.

Photo of Eleanor Scott Eleanor Scott Green 3:38, 3 March 2004

First, I say for the record that until last May's elections I was a doctor in the NHS and that I am still a member of the British Medical Association.

I generally welcome the bill's provisions, which will make NHS structures more logical and more functional. I hope that the new structures will ultimately make staff happier because low staff morale in the NHS is one of the biggest problems in recruitment and retention. I, too, support Shona Robison's amendment and will say why as I go through my speech.

I welcome the opportunity that the bill gives to streamline NHS management, but I agree with one of the evidence givers to the committee—I cannot remember who—who said that people who work in the NHS have no appetite for major upheaval. Dr Jean Turner and other members referred to a history of changes, which has had a definite effect on staff morale; there is concern at ground level about the impact of another change in management structure. There is sometimes a perception that a change in the management structure means that it is one step removed from the patients. However, I know from experience that being in the front line of patient contact while being managed by somebody who is demoralised and insecure and who does not know whether their job will be there after the next reorganisation is not good for anybody. It is important that the change is effected relatively seamlessly.

I understand that the bill is intended to be cost neutral, but I doubt that that will be the case in the short term. There is always a transitional cost whenever there is change.

Photo of Duncan McNeil Duncan McNeil Labour

Eleanor Scott has mentioned uncertainty about finance a couple of times. Does she agree that the evidence shows that the people who have moved to a single board—in the Borders and in Ayrshire and Arran—have said that, in their experience, the process was not costly and could actually create savings?

Photo of Eleanor Scott Eleanor Scott Green

As I was saying, there will be savings in the medium term, because bureaucracy will be cut down, and I think that there will ultimately be savings. However, change always brings a transitional cost, because there are always people whose jobs have to be protected and there are always redundancy payments to be made. That has to be factored in. I do not think that change ever comes cheap.

Photo of Eleanor Scott Eleanor Scott Green

I have no expertise on Ayrshire and Arran, so I do not particularly want to take another intervention, if Mr Gallie does not mind. I come from the Highlands, so if members want to make interventions about Highland NHS Board, that is fine.

I hope that the Scottish Executive is ready for any investment that might be needed in the initial phase of change. It was noted in evidence to the committee that there has sometimes in the past been underinvestment in change, so that the change has not delivered as much as had been hoped. I note that local health care co-operatives, which we can now refer to as a kind of ancestor of community health partnerships, have lasted for only four or five years. However, they did make achievements—in inter-practice and community working, for example—during the years when they existed; care should be taken that that expertise is not lost. I agree that the community health partnerships should be better and that they should lead to better working with local authorities—with social work departments, for example.

I note in passing the democratic deficit that Bill Butler identified in his proposal that there be directly elected health boards. One wonders whether the logical end point would not therefore be to have health care delivery as a local authority function. I am not suggesting that as an amendment to the bill, but it is something that could perhaps be considered in the future.

I agree that the NHS must ensure public involvement, but I am not absolutely convinced that the new structures will in themselves deliver that at local, regional or national level. I wait with interest to see whether that happens. In that regard, I have some concerns about the numerous functions of NHS Quality Improvement Scotland that were identified by some witnesses who gave evidence and I am also concerned by the fact that the public are unlikely to view it—or the new pan-Scotland health council—as an independent body. There is a bit of selling to be done on that matter.

The provision for health boards' working together is welcome. The acute services review envisaged for Scotland an NHS without boundaries; I hope that the collaboration between health boards will be a move towards that and that it will be done on a planned and strategic basis, with one board undertaking to provide a specific specialist centralised service so that that service is provided in one centre and not everywhere. That would allow economies of scale and the development of expertise. I would hate to see the item-of-service and payments-per-patient approaches across health board working. I do not think that that is what the bill envisages—I hope that it is not. That transition will require a smooth transfer of resources between boards.

I note that the bill gives powers to ministers to intervene on health boards in the event of service failure. I do not disagree with that, but I would like to turn that on its head and ask how sympathetically the minister would view and treat a health board that came to him to warn of an incipient failure due to funding shortages.

Finally, I would like to cite a point that the BMA made in its written evidence. It said that

"The BMA would like to see the health improvement strategy taken a step further where all policy decisions made by the Scottish Executive should be required to take account of potential health implications e.g. agricultural policy, housing policy", and—dare I add it?—transport policy, just as equal opportunities and human rights must now be factored in. That would be a helpful step in mainstreaming health improvement, which is a major thrust towards the delivery of the health care that we want in Scotland.

Photo of Mary Scanlon Mary Scanlon Conservative 3:44, 3 March 2004

I was pleased to be asked to speak in this debate on national health service reform, until I read the bill, that is—all six pages of it. A unified health board has already happened in the Borders without the bill, so I have to ask the minister what kind of an NHS we have that the Parliament has to legislate to place a duty on health boards to co-operate with other health boards. If the patient's needs came first, the health boards would have to talk to each other.

Consider the section of the bill on powers of intervention when there is service failure: what is acceptable and unacceptable? Are financial deficits as boards struggle to make ends meet acceptable? Will the long wait from GP referral to seeing a consultant or for a magnetic resonance imaging—MRI—scan be included in performance assessment?

I looked to the section that is entitled,

"Duty to promote health improvement" in part 2 of the bill. The Western Isles NHS Board is certainly promoting health improvement, but that is exactly what boards are meant to have been doing for years.

Part 3 of the bill is even more exciting. It states:

"The Scottish Ministers may by order made by statutory instrument make such incidental, supplemental, consequential, transitional, transitory or saving provision as they consider necessary or expedient for the purposes, or in consequence, of this Act."

I think that the people of Scotland will all rest well in their beds tonight, given that they have received those assurances from the Minister for Health and Community Care.

Of course, the three island authorities already have unified boards. I will show how impressed Orkney NHS Board was by the bill by quoting from its submission to the Health Committee. When it was asked whether it supported the general principles of the Bill, the board's response was that one member of the board did. The board's submission also states:

"We don't have a LHCC in Orkney and I do not know what kind of animal a CHP will be. I do not know where it sits in relation to the Joint Future Agenda."

It seems that the LHCCs have passed NHS Orkney by and that just as it was getting to grips with the joint future agenda, LHCCS have now been passed by for CHPs.

When Orkney NHS Board was asked about the quality of the consultation, it stated that five weeks was not enough—particularly given the active and highly regarded work that is done by the local health councils. The submission states that NHS Orkney

"would prefer that we have power to choose the way we spend the funds, as Scottish Executive directives don't always fit Orkney's situation".

At least we can depend on Orcadians to tell us how it is.

Again, on what constitutes an acceptable service, would NHS Orkney's cash-saving measure to cut the number of patients who go to Aberdeen for treatment because it does not have enough money be regarded as acceptable, or would that be a service failure? Perhaps the minister could tell us which cuts will be regarded as acceptable when the level of activity exceeds the financial allocation.

I quote from a statement issued by NHS Orkney:

"Clinically urgent cases should continue to be dealt with where the Consultant feels that postponement of treatment would significantly impact on his/her patient's health."

We have had telemedicine for some years; now telepathic medicine is being applied from Aberdeen to Orkney. Those actions have been taken with no consultation of patients or GPs.

When the money comes through for the next financial year, there will already be a waiting list in Orkney left over from this year. I hope that the minister will now review the financial allocations to the three island authorities—Orkney NHS Board, Shetland NHS Board and the Western Isles NHS Board.

The policy memorandum states that the Executive's policy is that care should be delivered as close to home as possible; in Caithness, people would like their babies to be delivered as close to home as possible and in Applecross and Lochinver, on the west coast of Scotland, people would like an out-of-hours service that is closer to their homes than the east coast.

Western Isles NHS Board, which faces a £600,000 overspend, now has the pleasure of intervention by the man from the ministry. I understand that he has proposed that the Western Isles should have four medical directors—three more than Lothian NHS Board has, although the Western Isles has a fraction of the Lothians' population. Much more could be said about the Western Isles, but given the current problems with staff suspensions and so on it would be unwise to discuss the matter further.

Will the minister include registered practitioners of complementary medicine in the CHPs so that they are fully included in the delivery of health care and will he also ensure that the professions that are allied to medicine are included? As I said last week, the health service is not just about doctors and nurses.

I want to come back to a point on local authority accountability that Unison made in its submission to the Health Committee. I am pleased that Unison highlighted this point: if partnership is to work, the performance of social work must be monitored and evaluated. If the performance of social work is included, the proposals that are being discussed today will, I hope, help to meet the expectations that are being raised.

Photo of Keith Raffan Keith Raffan Liberal Democrat 3:50, 3 March 2004

I welcome the principles on which the bill is based. The bill puts the treatment of patients first; or, to use the words of Dr Jean Turner, it will "improve the patient's journey", which is NHS jargon, but I like it. As the minister said, that means increasing the integration of primary and specialist services and removing the artificial barrier between the services that trusts represent.

I hope that the minister will agree that another artificial barrier is put up by the boundaries of the NHS boards. I welcome the emphasis that he placed on regional planning and on the boards collaborating with one another. As we move towards greater specialisation and, indeed, sub-specialisation, such collaboration will be inevitable. In my region, that is very important; the region is covered by three health boards—Tayside NHS Board, Fife NHS Board and Forth Valley NHS Board. Only one—Tayside—has a teaching hospital. As the minister rightly said a couple of weeks ago in response to a question of mine at question time, extra strains are put on boards that do not have a teaching hospital. It makes it much harder to run them. Consultant vacancies invariably take longer to fill in boards in which there is no teaching hospital, which has a knock-on effect on waiting lists and waiting times.

Earlier, I intervened on Rob Gibson. Where managed clinical networks exist—I would like them to develop further—they can ignore health service boundaries. Tayside's managed clinical network on diabetes is very effective. Specialists go from Ninewells hospital into Fife to hold clinics; patients do not necessarily have to go up to Ninewells. That is integrating primary and specialist care effectively. We want those networks to develop.

I agree with Dr Turner about financial disputes; I have seen at first hand at health board meetings with MSPs disputes between different health boards over who should pay for what. An example of that concerns patients from north Fife who tend to go to Dundee to use services at Ninewells hospital, who should pay for health services that are used by Fife patients in Tayside. We have to sort out such problems, which can consume too much of management's energy and time.

As the minister said, CHPs, growing naturally as they do out of LHCCs, focus on local delivery. We all want the NHS to be much less of a national illness service, so there should be greater emphasis on primary care and on reducing hospital admissions.

A year or so ago, I spent a day at the Bellyeoman surgery in Dunfermline. I sat with one of the specialist nurses there—Nicky Credland—as she saw patients. She saw a young boy who had asthma and was able to spend 30 to 45 minutes with him going through the different inhalers that he could use to see which would be most effective. Then—again with the patient's agreement—I sat in as the nurse talked at length to a middle-aged man who had recently been diagnosed as having diabetes. She gave him advice on diet, showed him different types of food and advised which he should eat and which he should not eat. She has time do that, whereas a GP does not.

I have seen the statistics, and the specialist nurse service at the Bellyeoman surgery has greatly reduced the need for hospital admissions. With the likely doubling of the incidence of diabetes over the next seven years, and with an ageing population suffering from chronic diseases, I want an increase in specialist services especially for people with chronic diseases; for example, advice on arthritis or on stopping smoking or whatever. I want to see anything that will take pressure off GPs and acute services.

Public involvement is, of course, very important. I hope that we can learn lessons from the health boards' consultations during the acute services review—not all of which were very happy. It is important that public involvement is balanced, representative and genuine and I welcome the moves towards that in the bill.

I also agree that the minister must have a clear power of intervention; I do not believe that that is contrary to devolved health service management. The minister's predecessor sent a task force into Tayside, which proved to be highly effective in combination—I like to think—with the work of the Parliament's Audit Committee, which also undertook an inquiry into the NHS in Tayside. That helped to set Tayside back on the right track. It is important that the minister has that power of intervention from the centre; the crucial thing is the timing of its use, which is a matter of judgment rather than something that can be set down in legislation.

It is important that the structure of the NHS keep pace with the development and integration of services. I have no doubt that the structures will continue to change and evolve as the integration of primary and specialist services continues and—I hope—accelerates. As all parties have occasionally pronounced, ultimately we will have to examine the number of health boards, but that is an issue for another day. The important thing is that structures are changed and are allowed to evolve as and when they should; they should be flexible, because their purpose is to serve the health service.

Photo of Des McNulty Des McNulty Labour 3:56, 3 March 2004

The fact that the bill will give ministers and health boards a duty to promote improvement to the physical and mental health of the Scottish public is potentially its most important element. As a former member of the then Greater Glasgow Health Board, I am well aware of the fact that spending on health improvement can be pressured or squeezed when the acute sector has clinical priorities. It is important not only that there is a duty to promote health improvement but that, to some extent, protected budgets are associated with promotion of health improvement. If we are to move from having a sickness service to having a health service—in principle, we all agree that we should do that—there must be some protection of the ability to deliver health improvement.

When the minister considers how to spend his £73 million over the next three years, he should have particular regard to distributing that money on the basis of health improvement need rather than general clinical need. There is a clear need for targeted health improvement, particularly in west-central Scotland, which has the worst health in the country. To reflect that pattern of need, the mechanism through which the minister should distribute money should be Arbuthnott plus, rather than Arbuthnott.

Some health improvement measures can be highly effective. In the past, I chaired Glasgow healthy city partnership, which was responsible for a number of distinct health improvement initiatives that were targeted at particularly vulnerable groups in greater Glasgow. Many of those interventions were effective, but they survived on a hand-to-mouth basis; funding—which was the result of partnership between the health board and the local authority—was renewable every two or three years. There needs to be a solid strand of continuing funding and a commitment that health improvement measures will be implemented and will last for a considerable time.

Another important element in the bill is health boards' duty to co-operate. I accept what members have said about the importance of managed clinical networks, which are obviously valuable, but it is crucial that health boards co-operate with one another, not just in service delivery, but in planning. Health board boundaries are of necessity artificial—they are constructed on the map and they do not necessarily make sense when one looks at the map in the context of patterns of travel and use, for example.

We can continue with the existing health board boundaries, provided that they do not become barriers to sensible planning—there are instances in which that has happened. In pursuing the duty of health boards to co-operate, I hope that the minister will ensure that strategic planning is properly co-ordinated, that resources and ideas are transferred effectively and that there is a working out across health board boundaries of the best ways in which to deliver services, rather than each health board deciding for itself in a vacuum.

It is important that that regional planning is also linked to national planning. As can be seen from the minister's welcome intervention in taking over the Health Care International (Scotland) Ltd hospital and making it the national waiting times centre, national planning can be particularly effective in dealing with issues such as those that, for example, Jean Turner mentioned, including hip replacements, and with the issue of the cardio-thoracic unit that we are consulting on with a view to taking it into HCI. Real and effective change can be delivered through co-ordinated regional and national planning—through people working out the best ways in which to work. Although HCI is making an excellent contribution already, it could do more. The one thing that I would hate to happen is for the vested interests of existing health boards and the ways in which money is transferred to be allowed to restrict the growth of the service that it is clear HCI can deliver.

I have some sympathy for some of the issues that Shona Robison raises in her amendment to the motion. For example, there is an issue about the advocacy role of health councils and how that is to be protected. There is also the issue of independence. As an ex-member of Greater Glasgow Health Board, I am well aware of the excellent work that was done by the greater Glasgow health council in contributing patient ideas and patient perceptions to the work of the board. I would hate to see that conduit of information and expertise lost. We need to watch that issue carefully.

I am a bit less convinced by Shona Robison's approach to the financial issues. That is largely because her party has to start from a position of the £2.1 billion that would be sacrificed if Scotland were to go down the constitutional route that the SNP favours. Of course, the deficit would be added to if the SNP got its way in relation to business taxes. Some SNP members advocate changes that are in line with the Conservatives' proposals, whereas others want to take different approaches. We have to be honest about the issue—we have to say that there is only so much money and we have to decide how best to deal with it.

There is a real issue of honesty in relation to consultation. Although I want to see better consultation, I do not want spent on consultation huge amounts of money that should be spent on patients. The real issue is to get the plans right first time and to consult efficiently and effectively. That is the way to improve the service to patients. As other members said, that is the most vital thing for us to do.

The final issue that I want to raise is the cost of intervention. I accept that ministers cannot necessarily cost intervention accurately before they have identified the problem that they want to resolve. However, the Finance Committee is clear that the evidence that we heard suggests that the cost of interventions will be more than were estimated in the financial memorandum for the bill. If the minister is going to use the power to intervene, he needs to draw up a pattern that shows how much an intervention will cost and how much can be delivered on that basis.

Photo of Sandra White Sandra White Scottish National Party 4:03, 3 March 2004

Des McNulty was doing so well, but as always, he spoiled what was a good contribution at the end. I point out to him that if Scotland was independent, the health service would not be in the situation that it is in today.

I give a sincere welcome to the bill. Like Shona Robison and other members said, the bill is long overdue. I will not rehearse all of the problems that we have had with the health boards, consultations and so on. Instead, I want to concentrate on two specific areas. The first is the duty on health boards to co-operate in the planning and provision of services. My colleague Stewart Maxwell will elaborate on that issue in his contribution. The other area that I want to cover is the duty to encourage public involvement, which has caused such a lot of consternation not only in Glasgow but in other areas of the country. The reason why I cite those two areas for attention is that it was the lack of proper co-operation and public involvement that caused such a furore and such concern in the review of maternity services in Glasgow and in the health board's recommendation to close the Queen Mother's hospital.

This morning, a petition was submitted to the Public Petitions Committee on behalf of six eminent medical practitioners. They called for some of the things that I think are included in the bill, but I ask the minister to clarify that when he sums up. The petitioners called for a legal framework for consultation, for guidelines and for an independent process for the selection of expert witnesses when a national review of services is to take place, whether or not that is a maternity services review. If those are included in the bill, that is most welcome. If they are not, perhaps the minister will lodge amendments at stage 2.

The minister said in his opening speech that the bill is very much needed. One of the key aims of the bill is to enhance the powers of ministers, in particular to intervene in areas where there are service failures. That point was raised by Kate Maclean. The powers that ministers will have are of concern.

I will elaborate on that a little bit. I have considered the issue from a different angle, through consultation, legal advice and the Scottish Parliament information centre. If it is found that health boards have not complied with the legislation, for example with section 5, on public involvement, will they be guilty under section 44(2) of the Criminal Law (Consolidation) (Scotland) Act 1995 of not following through an act of Parliament? I would like the minister to think about that. If he cannot give me an answer in summing up, he can give me an answer later.

I seek clarification because we all know that health boards have a duty to consult, but the bill will make the duty to encourage public involvement legally binding. If they do not do that, they will be guilty of committing a criminal act under the Criminal Law (Consolidation) (Scotland) Act 1995, because the duty is in the legislation. I would like verification of that important point.

I sought advice on that point when the health board's maternity review was on-going in Glasgow and was given lots of good legal advice by officials and SPICe. Because the duty to consult is only a duty, boards are not guilty of committing a criminal act for not carrying it out. However, if the duty is in legislation of the Scottish Parliament, they could be guilty of committing a criminal act. Would they be guilty of committing such a criminal act? Is the point that ministers have enhanced powers and can intervene?

Like other members, I am worried about the lack of detail in the financial memorandum. Perhaps we will see savings in the long term, but in the beginning, during the transition period, there will be costs. I ask the minister to look favourably on Shona Robison's amendment, and particularly the part about the financial memorandum, because it is not only me and my party who have raised concerns, but members from all parties.

Photo of Murray Tosh Murray Tosh Conservative

I call Carolyn Leckie, to be followed by Bristow Muldoon. I give notice that Bristow Muldoon and the others who speak in the open debate will have their time reduced to five minutes, with my apologies.

Photo of Carolyn Leckie Carolyn Leckie SSP 4:08, 3 March 2004

I welcome the abolition of trusts. It is no surprise that the Tories oppose it, although it is unusual for them to oppose NHS legislation from this Executive. However, I regret the phased approach that is being taken to the abolition of trusts, having been through the reorganisations as a result of trust mergers. The abolition of trusts and the direct control of health boards should have happened sooner, and the pain of reorganisation should have been avoided.

I will concentrate on the context in which any NHS legislation should be set, which is that of reversing our abominable health record. That should be the goal of any legislation. The duty in the bill to promote health improvement must be placed in perspective. People in the worst health areas are also poor. They earn only 65 per cent of what people in the best health areas earn. More than half of the million people in the United Kingdom who are worst off in health terms live in Scotland. If someone is poor, their risk of contracting coronary heart disease is more than doubled, their risk of contracting lung cancer is more than tripled, their life expectancy is reduced by up to 12 years and they have increased rates of suicide. Legislation without resources and radical economic and redistributive measures will mean that the achievement of health equality is a pipe dream. We must bear that in mind. Promotion, persuasion and propaganda will not improve the drastic health statistics of Scotland. Let us not pretend otherwise.

I want to discuss some specific aspects of the bill. I share the concerns that have been expressed about the absence of allocated resources to fund the bill. The costs relate not only to unifying health boards; some of the other measures will have cost implications. We need to bear in mind the fact that no savings were achieved through the reduction of trusts and trust mergers. When one considers the multitude of pressures caused by other legislation, the working time directive, consultant and GP contracts and so on, it is clear that the idea that this bill can be implemented without additional funding is preposterous.

The 1997 document, "Designed to Care: Renewing the National Health Service in Scotland", promised

"a National Health Service for the people of Scotland that offers them the treatment they need, where they want it, and when".

Has that promise translated to reality? It is unlikely that it has, particularly when one considers the loss of confidence in consultations by health boards, for example in maternity services, or the gap in the provision of out-of-hours GP cover. The bill gives us an opportunity to pursue meaningful consultation—that is the difference. We should be concerned not with hundreds of glossy leaflets or numerous roadshows, but with people's ability to affect consultation and to change outcomes if they feel disengaged from health boards.

At this morning's meeting of the Public Petitions Committee, Sandra White spoke to a petition relating to maternity services. I do not wish to get into the details of the petition, but I am glad that Sandra White did so. I urge the minister to consider the content of the petition when it arrives on his desk. I ask him to take evidence from the petitioners, as their suggestions could improve the bill at stage 2.

Photo of Phil Gallie Phil Gallie Conservative

Carolyn Leckie referred to a 1997 document. The minister spoke of the great consultation processes under the new system. Is Carolyn Leckie aware that consultation about paediatric ward services in two hospitals in Ayrshire has been on-going for the past eight or nine months?

Photo of Murray Tosh Murray Tosh Conservative

I ask Mr Gallie to come to the point.

Photo of Phil Gallie Phil Gallie Conservative

Does she agree that a decision will be taken to close one of the units, regardless of the outcome of the consultation?

Photo of Murray Tosh Murray Tosh Conservative

It was a self-inflicted wound.

Photo of Carolyn Leckie Carolyn Leckie SSP

Phil Gallie's intervention was opportune and the problem he mentioned is not untypical of those faced across Scotland.

The SSP supports direct democracy and accountability of health boards. It believes that that is the only way to empower the public's opinion and to prevent health boards from making bad decisions.

The proposed community health partnerships have been opposed. I share Unison's concern that there is no guarantee that geographical inequality will not spring up. I would appreciate a comment from the minister in that regard. I am unhappy about the composition of such partnerships, particularly the fact that trade unions are to be excluded from them. Why is business being included when trade unions and the public are being excluded?

While health councils are imperfect, at least they are statutory. The new proposals are neither statutory nor independent. I hope that that can be amended at stage 2.

The minister said that regional planning arrangements will be much more effective than has been the case in the past. If he acknowledges that regional planning has been ineffective until now, does he not consider that maternity services and hospitals should be given a stay of execution from centralisation and closure until effective regional planning, including full public consultation, is implemented across regions and across the country?

I am glad that staff governance is being implemented, but serious consideration should be given to Unison's demand that the terms and conditions of staff be harmonised. There should be direct employment by health boards and accrued terms and conditions should be protected so that staff can transfer without losing them.

The bill does not provide for a sufficiently democratic or accountable structure. I have a number of other criticisms of it, but it can be improved and I hope that it will be.

Photo of Bristow Muldoon Bristow Muldoon Labour 4:14, 3 March 2004

I welcome the general principles of the bill and I hope that members from all parties—with the possible exception of the Tories—will back it at stage 1 today. The bill marks the completion of reforms to remove marketisation from the health service, which started off with "Designed to Care" back in 1997, and which have been rolling back the agenda of marketisation that the last Tory Government introduced.

Like my colleague, Kate Maclean, I am very much encouraged by the Tories' attitude in opposing the bill. If they oppose it, there must be quite a bit of merit in it. Their continuing hostility to the national health service and its founding principles show what a threat to the NHS the re-election of a Tory Government would be.

One area of the bill that I strongly welcome, and which lies at its heart, is the establishment of the new community health partnerships, which will build on existing strong local partnerships. In my intervention on Mr Davidson, I referred to a strong and growing partnership in West Lothian where, as the minister knows, detailed discussions are taking place between the health board and the local council on ways to bring budgets together and to enhance the delivery of services, particularly for elderly people.

That builds on a strong existing relationship, which has already had some successes over recent years, including the establishment of the Strathbrock partnership centre in Broxburn, which brings together enhanced GP services—with more primary care facilities being provided—and has social care staff working in partnership with the primary care staff. A partnership between the health service in West Lothian and West Lothian Council gave rise to the opening of a new GP practice in south Livingston, which will address problems of population growth in that area. Therefore, strong partnerships between local authorities and the health service already exist, and I believe that the creation of new community health partnerships, and the emphasis on their being, where practical, coterminous with the local authority area, will prove to be a strength of the eventual act.

On unified health boards, Rob Gibson, and later Carolyn Leckie, spoke about the role of the trade unions and staff. I think that the current Government has done more than any previous Government to try to involve staff in decisions in the national health service. The well-known Unison representative in my area—and a national representative—Eddie Egan, is employee director of Lothian NHS Board. He is right at the heart of many of the key decisions that affect health in the Lothians.

Photo of Carolyn Leckie Carolyn Leckie SSP

Does the member agree that, if trade union involvement in democracy is to be genuine, employee directors should be accountable to their members and not to the Scottish Executive, as is currently the case?

Photo of Bristow Muldoon Bristow Muldoon Labour

Anyone who has ever known or met Eddie Egan will know that he is 100 per cent committed to the national health service and to delivering the service to the people. I do not think that he would ever take a decision on the health board that would compromise that commitment.

Carolyn Leckie in particular addressed some of the pressures that face the unified health boards, which include the European working time directive and changes in how medical staff are trained. I would like a clear message to be sent out to the health boards that such pressures are not to be used as a reason to centralise acute services. Of course, where there is a strong clinical case to do so, highly specialised acute services will be provided at only a small number of sites, but we must ensure that the public receive their health service as locally as possible. That is good clinical practice and ensures access.

Health improvement is one of the most critical areas for Scotland. We must recognise that many countries that are poorer than Scotland have better health than Scotland. Largely, the situation comes down to personal behaviour and choice about alcohol consumption, the use of tobacco, diet and exercise. The role of health boards and local authorities, working together, can be vital in helping to develop the health improvement agenda and creating a healthier Scotland.

I believe that the National Health Service Reform (Scotland) Bill completes the process of ending the marketisation of the NHS that the Tories started. It will enable the NHS to enhance the local delivery of health services, particularly through primary health care facilities. We must ensure that there is no centralisation of acute health services.

It is clear that, with the exception of the Tories, every member and every party fully supports the NHS. I call on every member to express that support by expressing their support for the bill today.

Photo of Brian Monteith Brian Monteith Conservative 4:20, 3 March 2004

I am pleased to rise as a Tory. Before devolution, one of the concerns that many people expressed about Labour's proposals was the potential that they offered not for real devolution of power to the people but for the centralisation of power, not in the Parliament but among Government ministers and their departments. I believe that the National Health Service Reform (Scotland) Bill is yet more proof—as if it were needed—that those fears were well founded.

One of the first acts of the Parliament was to abolish self-governing status for Scotland's schools, which was a symbol—albeit a small one—of what was to come. Since then we have seen moves towards a national transport authority, an all-encompassing cultural quango and ever more ring fencing of local authority spending. We have seen the merger of trusts—an action that led directly to the rationalisation of hospitals—and now we see their abolition. Those moves, together with the bill, are all about centralisation. There is no other word for it.

What we know—as would anyone who cared to turn over the stone—is that, within the Scottish Executive Health Department over the past few years, an almighty private debate has gone on among civil servants, advisers and ministers about whether to devolve decision making in the NHS further down to the trusts or to centralise it in the boards. As we know, the centralisers won. Sam Galbraith ultimately triumphed and got his wish—he wanted to centralise power in the boards for no other reason than that the Tories brought in the trusts. That was evidenced by a number of unguarded comments today.

Let us agree on some facts. The trusts are being replaced by divisions run by the health boards.

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I repeat to Brian Monteith that the decentralisers won, which is why we are setting up community health partnerships. That must be done within a framework of national standards and with a power to intervene as a last resort.

Photo of Brian Monteith Brian Monteith Conservative

The minister might not like the words of Tony Blair, but he clearly likes the words of Eric Blair, because that intervention was nothing less than double speak. The bill abolishes NHS trusts but replaces them with operating divisions under health boards. It extends ministerial powers to intervene and establishes 50 community health partnerships, developed from the 80 local health care co-operatives. To me, that is nothing less than centralisation.

What is being discarded is not great swathes of bureaucrats, but the independence of thought and action that the trusts enjoyed. That independence allowed trusts to respond to local or sectoral needs and demands. What the bill proposes can only be called centralisation.

No savings are promised, just greater direction from the centre disguised by euphemisms such as guidance, co-ordination and—Labour's favourite word—strategy.

Photo of Brian Monteith Brian Monteith Conservative

I will possibly give way later.

No savings are promised, for none are expected. Indeed, we can expect costs to rise. That is why the minister has taken the precaution of presenting a financial memorandum to authorise additional costs, which he fears will arise.

I have no doubt that everyone in the chamber wants to see top class, world-beating public services in Scotland. Unlike the Prime Minister, Bristow Muldoon and Rob Gibson, I do not challenge the motives of members of other parties or question their good intentions. Where I differ is in questioning the belief that market systems cannot be utilised to provide better public services. They can, even in health care.

The NHS has prospered for more years under the Tories than under Labour. When I look at the spectacles that members in the chamber are wearing, do I see NHS spectacles or frames? No, I do not; I see designer frames. Devolving power down to the lowest level can liberate our NHS and make it more responsive to patients' needs. That is the direction in which we should be going.

Photo of Stewart Maxwell Stewart Maxwell Scottish National Party 4:24, 3 March 2004

I assure Brian Monteith that this is not an unguarded comment: I completely and whole-heartedly welcome the abolition of the NHS trusts. We are long past the time when they should have gone.

I am sorry that Des McNulty has left the chamber because I want to mention the rather silly point that he made about debt in Scotland. The UK debt is many billions of times more than the supposed and inaccurate figures that were given out about Scottish debt. If debt is to be the criterion for independence and for good public services, the UK fails the test in spades. Perhaps Des McNulty should think twice before he goes down such silly roads.

The real problem with the NHS structure is the discrepancies and lack of co-operation that exist between health boards. That is why I welcome the formalisation of the duty of co-operation in section 3, which could prove to be an important step in improving and equalising service delivery throughout the country. Perhaps when the deputy minister sums up, he will explain what will happen if health boards fail to abide by section 3, given that many boards are failing to co-operate at present, although a duty to do so does not exist in legislation. If the bill becomes an act and section 3 is approved, what will happen if health boards fail to abide by it?

I will give three examples that shine a light on the lunacy of the current situation, in which different decisions are taken in different but often neighbouring health board areas. The examples are maternity services, postcode prescribing and drug rehabilitation services and prescribing.

Other members have mentioned the first example. The situation with maternity services in Glasgow and the west of Scotland is, frankly, woeful. Neighbouring health boards appear to have taken no cognisance of each other in taking decisions about maternity services provision. The west of Scotland has lost consultant-led services at the Vale of Leven hospital in Dunbartonshire and the Rankin maternity unit in Greenock. When those moves were first mooted, it was stated that mothers-to-be could travel to Paisley to have their babies, if they so wished. However, when it was pointed out that the natural transport corridors for people who live north of the River Clyde and from the Vale of Leven hospital area are up the north side of the river to Glasgow rather than across it— there are no decent public transport links between Dunbartonshire and Renfrewshire—it was suggested that patients could choose Glasgow as the place to have their babies.

Within weeks of the comments by Argyll and Clyde NHS Board, Greater Glasgow NHS Board announced its plans to close the Queen Mother's hospital, which is north of the river, and, in effect, to remove that choice from women in the Dunbartonshire and Argyll areas. If the Queen Mother's hospital is closed, the services will be transferred to the Southern general hospital, which is south of the River Clyde. The lack of joined-up thinking between the two boards is not only a problem of administration; it has a detrimental impact on ordinary patients' lives and on their day-to-day experience of the health service in one of the most crucial areas—giving birth to their children.

The second example is the issue that is commonly called postcode prescribing. I will cite the example of a couple who came to see me at a surgery, which highlights the different policies in the health board areas of Argyll and Clyde and Glasgow. The minister will be aware of the issue because I have written to him about it—it is about differences in fertility treatment between Glasgow and Argyll and Clyde. The man in question had cancer, which I am glad to say was treated and cleared up, but, unfortunately, the treatment made him infertile. The man then sought the infertility treatment that would allow his family to grow, but Argyll and Clyde NHS Board said that it would not pay for the treatment and, worse than that, that it would not pay for the drugs. The family then found out that if they had lived a couple of miles up the road in the Glasgow area, Greater Glasgow NHS Board would have paid for the drugs, although it would not have paid for the infertility treatment. That is a cost of £1,000 to patients in Argyll and Clyde that does not exist for those in Glasgow.

My third example is about methadone prescribing. Unfortunately, a boy died in the Barrhead area of East Renfrewshire because no tests were taken before he was prescribed methadone. The fatal accident inquiry has just been completed. If the boy had lived in Glasgow, tests would have been carried out; it would have been discovered that he did not have heroin in his system; he probably would not have been prescribed methadone, which was inappropriate; and the outcome would have been different. In fact, the boy had Valium in his system, which is potentially lethal when combined with methadone, as many members will be aware. That lack of testing means that, in certain areas, people can be prescribed methadone at the same time as they are taking drugs that should not be mixed with methadone.

In conclusion, the three examples that I have cited show the importance of co-operation among health boards and why we must end the inconsistent service delivery throughout Scotland. I hope that section 3 of the bill will end such problems, inconsistencies and discrepancies and that the bill is strong enough. If it is not, I hope that stage 2 amendments will be lodged to ensure that postcode prescribing and differences are ended and problems are sorted out.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat 4:30, 3 March 2004

This has been a good debate and members have made interesting speeches. I would like to focus on half a dozen of those contributions.

Jean Turner said that the bill is about improving the patient's journey. I could not agree more—that is what the bill is about. The patient must be the focus of everything that the national health service and the Parliament do. Jean Turner made it clear that she supported the general principles of the bill in the committee and that she will support its general principles at decision time.

Unfortunately, Rob Gibson is not in the chamber—I understand that he has been called away. He called for extra cash and talked about uncertainty, which my Labour colleagues have highlighted. The point was made that that ignores the evidence that has been given to us by NHS boards that have gone through the process—Dumfries and Galloway NHS Board and Borders NHS Board.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

No—I must press on.

Eleanor Scott made an interesting speech. I was a bit agog when she ventured to suggest that health provision in Scotland could become a function of local authorities. I met a group of local authority leaders last night over dinner and I am sure that they would really welcome such an initiative. I assume that Eleanor Scott was not being serious.

Photo of Helen Eadie Helen Eadie Labour

Is the member aware that, in Denmark, a function of local authorities is to manage health budgets and to provide the service?

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

I thank the member for intervening. I was not aware of that, but I am now.

Mary Scanlon made fun of NHS Orkney's supposed opposition to the bill. My colleague Duncan McNeil said to Steve Conway of NHS Orkney by videolink:

"you say in your evidence that you generally support the bill."

Steve Conway replied:

"The bill is about making better use of the resources that are available."—[Official Report, Health Committee, 6 January 2004; c 499.]

Des McNulty took the opportunity to raise, among quite a few issues, the Arbuthnott formula and he talked about Arbuthnott plus. I have real difficulties with what he said and will respond on three points. First, it is absolutely and fundamentally right that we have a progressive and clearly redistributive taxation system and it is right that those who can afford to pay more should do so. Many such people are constituents of mine in north-east Scotland, in West Aberdeenshire and Kincardine. I recognise that people in the north-east are better off than people elsewhere in Scotland. The taxation system is the process through which we can redistribute.

Secondly, the Arbuthnott formula makes the big mistake of considering only deprivation indices between health boards. There are areas of deprivation throughout Scotland and we should focus on how we should tackle that problem rather than on the relationship between health boards as if deprivation appears in one health board area but does not appear in another health board area. That issue needs to be tackled throughout Scotland.

Thirdly, I will take NHS Grampian as an example. NHS Grampian is responsible for 10 per cent of Scotland's national health service activity, but receives only 9 per cent of the record resources that are being allocated by the Scottish Executive. For such reasons, we must have a review of the Arbuthnott formula. I suppose that at least I agree with Des McNulty on that matter, although we obviously have opposite reasons for thinking that there should be a review.

The pièce de résistance of the debate was David Davidson's speech, to which I must return. I would like to know how the Tories can support the abolition of NHS trusts in committee and sign up to a unanimously agreed report in favour of the general principles of the bill, yet, in this afternoon's debate on that report and the motion, the same Tory spokesperson can state clearly that they are against the bill in principle.

That is no way in which to conduct business in the committees of the Parliament. We all compromise in an attempt to reach agreement if we can. The most honest approach would have been to make it clear to all colleagues on the committee that the bill would be opposed in principle by the Conservatives—an honourable position—instead of giving the pretence of support to try to mould the committee's report, as may have occurred. That practice would be unacceptable and would undermine the work of the committee. A more likely explanation—there is only one other explanation that I can think of—is that, when the rest of the Tory group found out what their health spokesman was up to, they forced him to change his mind. I do not believe that David Davidson is dishonourable. I think that it is likely that that happened at the Tory group meeting yesterday or the day before.

The bill sets out to abolish NHS trusts and seeks to ensure that the patient's interests are put first and that services are planned efficiently and effectively throughout the national health service. It is a good bill and I urge members to support it at decision time.

Photo of Nanette Milne Nanette Milne Conservative 4:36, 3 March 2004

Members have heard from David Davidson why we will not support the motion. I emphasise that I did not work in the health service for more than 20 years without believing in it.

Although the general principles of the bill are aimed at achieving a more streamlined and unified NHS, the resulting organisation will still be centrally driven, as Brian Monteith said, with the Executive empowering the new health boards to run the service via operations divisions derived from the abolished trusts and with community health partnerships representing the primary care sector and associated health professionals. The intention is to focus more on the patient and to increase input from the patient; however, the structure will still be top down and driven from the centre. As David Davidson said, that concept is fundamentally at odds with our thinking, which unequivocally puts the patient at the heart of the service—a patient who is empowered to get appropriate treatment whenever and wherever it is needed.

Budgets that were progressively devolved to local levels through GPs would allow GPs to take responsibility for all their patients' care, including health-related social services, and would bring the budget for health and social care within the health service. That would allow social and nursing care to be commissioned from the most appropriate source in either the public or the private sector and would significantly reduce the problem of delayed discharge from secondary to primary care.

The gradual introduction of foundation status for hospitals in the public sector, together with the introduction of a patient passport, would eventually enable GPs to commission all care and would allow hospitals to plan on their own behalf in response to local demand. Alongside that, the role of health boards would be progressively reduced, bringing the service ever closer to the patient.

The Labour Party at Westminster has come close to adopting our approach by setting up foundation hospitals. Indeed, it has gone further by planning independent diagnostic treatment centres for south of the border, which will allow many more patients to receive appropriate and timely secondary care in new centres that are staffed from outwith the NHS. That care will follow referral by the NHS and will be paid for by the NHS. The centres will help to overcome the lack of capacity in the health service and will work in the best interests of patients. The new system was approved by Labour MPs at Westminster, many of whom represent Scottish constituencies. If such a system is reckoned by Scottish Labour MPs to be good for English patients, should not the Executive consider following their example for the benefit of patients up in Scotland?

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

Will the member take an intervention on that point?

Photo of Nanette Milne Nanette Milne Conservative

I am not going to take interventions.

That is all that I will say about our views. Members know where we are coming from and why we oppose the bill in principle.

There is a lot of concern in all quarters about the detail of the bill, even among those who think that it will go a long way towards improving the NHS in Scotland. I am not a member of the Health Committee, but I have read the committee's report from cover to cover, including all the evidence that is appended to it. Almost every piece of evidence in that document contains caveats. Many witnesses said that the proposed structural changes, in order to be effective, would have to be accompanied by a culture change, with hearts and minds showing willingness to co-operate across boundaries, whether those are geographical, between health boards and local authorities, or between different professions in the NHS.

There are particularly widespread concerns about the composition and role of the proposed community health partnerships; about the independence of the new Scottish health council if it is placed, as planned, within NHS QIS; about the meaningful involvement of patients in planning and developing the service; and about the powers of ministerial intervention when the system shows signs of failure and who would bear the cost of such intervention. There is also widespread concern about how the proposed changes will be financed; few seem to agree with the Executive that the bill will be financially neutral.

I have heard those concerns voiced by members throughout the chamber this afternoon—by Shona Robison, Jean Turner, Rob Gibson, Eleanor Scott, Mary Scanlon, Des McNulty, Sandra White, Carolyn Leckie and even Kate Maclean. In fact, such concerns have been voiced by almost every member who has spoken in today's debate.

I am particularly concerned about the composition and size of the proposed community health partnerships. Despite the minister's reassuring words, associated health professionals seem to fear that GPs and nurses will dominate the CHPs; almost every associated professional organisation is clamouring for representation on the CHP boards. I worry that that could result in large, unwieldy organisations, along with dilution of the essential primary care input and loss of the goodwill that will be required for the proper functioning of the partnerships. It is crucial that the CHPs are dynamic and that they work effectively, as Shona Robison said.

Co-operation with local authority services will be vital. Although coterminous boundaries will help with that, unified health and social budgets will be necessary for long-term success in the area. That is being planned in some authorities, as we have heard.

In the event that the motion is agreed to today, the statutory guidance and regulations in relation to the operation of CHPs will be all-important. I am glad that the Health Committee will have the opportunity to scrutinise the guidance and regulations and to comment on them before they are introduced. It is clear that there is a long way to go and that there are many issues to be resolved before the bill finally becomes law. Assuming that the bill continues through the parliamentary process, we will take our full part in scrutinising the detail at stages 2 and 3. However, for the reasons that I have given, we will not support it at stage 1.

Photo of Stewart Stevenson Stewart Stevenson Scottish National Party 4:42, 3 March 2004

We welcome the ending of the NHS trusts and the burden that they have placed on the organisation of the NHS over a period of time. We welcome the move towards integrated working and the assurance that goes with it that a single system does not imply a centralised system. Of course, those assurances will go for nought if the implementation drops short of that and we will remain alert and watch carefully as the implementation of the proposals evolves.

The minister, in his response to the various committees' investigations of the bill to date, has made encouraging signs of flexibility. For example, he has shown that he is prepared to amend the bill at stage 2 on local staff governance. I will return shortly to the apparent lack of flexibility on finance.

The Executive has turned its mind with great energy to consultation across many of its policy areas. There are clear signs—in the consultation on this bill, as in many others—that although the process allows the public and special interest groups to make their points, the Executive's specific responses are not always so clear. Not all points that are made in response to a consultation can be accepted, because consultations bring out points that conflict with each other; that is a fact of life. However, there is considerable scope for improving the feedback to consultees.

Bill Butler made a point about direct elections to health boards. I have enormous sympathy with that idea and I know that my colleagues feel the same.

I give the minister early warning that if he is not able to indicate, in his summing-up, a preparedness to take away and re-present the financial memorandum in the light of the comments that have been made today, it is likely that we will be unable to support the motion on the financial resolution come decision time. Nonetheless, we will support the substantive motion on the bill and I look forward to doing that.

Like Kate Maclean, I was extremely reassured to hear the Tories' concerns about the bill and similarly felt that we must be on the right track. Of course, the Tories have mentioned the money that will be required for the bill. However, I recall John Scott telling me in a previous debate that he did not care how much it would cost to decommission nuclear power stations, so the Tories' interest in money is somewhat selective. I will return to that issue. Kate Maclean also broke with tradition by putting Mike Rumbles in his place over some of his remarks.

Eleanor Scott made an excellent contribution to the debate by making the point about health improvement that the British Medical Association raised in its evidence to the Health Committee. The BMA wants the health improvement strategy to be taken further, so that all policy decisions take account of health. Rural areas in particular cannot be developed if they do not have health provision. Without health provision, the development policies simply will not work.

My colleague John Swinney made an important point about consultation. Tayside's three public partnership groups count for nought if local services are cut in the face of considered and considerable input from local communities. The minister might care to ponder whether there is any value in consultation that leads to no change.

Carolyn Leckie, quite rightly, echoed Unison's point about the need to ensure that the trade unions and staff are fully involved in the process. Indeed, Unison's written submission incorporated the Munich declaration, which highlighted the need for authorities across Europe to strengthen nursing and midwifery by

"Ensuring a nursing and midwifery contribution to decision-making at all levels of policy development and implementation".

Let us hope that there is considerable scope for that in the way forward that the Executive has chosen.

If we do not get the staff on board, we will not be able to deliver for patients or for the public purse. Staff must end up in a position in which they are given individual freedom to make decisions that are in the interests of the service and in the interests of patients. Health service staff want to help patients. That is the fuel in their tank. That is the engine that drives them.

Let me turn to finance—I see that the Tories nearly woke up at the mention of that word. Paragraph 33 of the stage 1 report states:

"The Health Committee shares the concerns of the Finance Committee insofar as we believe the cost of intervention has been considerably underestimated".

We should hear more about that. Paragraph 62 states:

"The Committee would not wish to see the initial phase of change compromised in any way due to a lack of funding ... The Committee seeks further reassurance from the Minister".

I hope that the minister will be able to give us that reassurance.

I also highlight paragraph 65. Mr Rumbles signed up to that paragraph in its entirety, so I note his comments about the Tory member of the committee. Paragraph 65 states:

"The Health Committee endorses the view of the Finance Committee. We are not convinced that no additional funding will be required to increase public involvement."

The financial memorandum, which was considered by the Finance Committee, sums up the many changes that the bill will make to the NHS. The Finance Committee's report on the financial memorandum stated that

"it was regrettable that further information could not be provided" about the costs of the bill, so there is clearly an issue about costs. On the costs of using the powers of intervention, Argyll and Clyde NHS Board thought that the cost per intervention would be £200,000, whereas the Executive says that it would be £85,000. Quite a lot of work is obviously needed on the costs associated with the bill. That is why the Finance Committee said that the work that the Executive had done did not provide adequate information about costs.

Even the Subordinate Legislation Committee, from which we seldom hear very much, had quite a lot to say about the powers that the Scottish ministers will retain for themselves. That committee expressed some concern and unease about the four significant powers that ministers will retain.

I must respond to Brian Monteith, who referred to Eric Blair. Brian Monteith is certainly not a Winston Smith, but far less is he a Winston Churchill. He has neither the gravitas, the dedication or the insight.

It is 40 years since I worked in the health service. I do not want a health service that is driven by an economic model in which the purchase of health care by money, however obtained, delivers dividends to people who provide it. All of us, apart from the Tories, want a health service that is driven by people's health needs and which delivers a dividend of good health and protection from illness to all people in our society, whatever their condition.

Photo of Tom McCabe Tom McCabe Labour 4:50, 3 March 2004

I have listened with interest to this afternoon's debate and, in my closing remarks, I will do my best to address at least some of the issues that have been raised. As Malcolm Chisholm said earlier, the bill contains some important provisions that are necessary for building a strong NHS, whose strength lies in close co-operation and collaboration among staff, patients and Government. For that reason, the bill has generally received wide support from many organisations that represent NHS, staff and patient interests.

I will begin by addressing the issue of public involvement. Shona Robison set out her concerns about the need for safeguards to the independence of the Scottish health council. We are already in discussion with the Scottish Association of Health Councils and other bodies on how best to achieve that. The council needs to be able to act independently if it is to command respect and credibility in its quality assurance and monitoring role. After all, its whole approach will be based on evidence and the ability to report openly what it finds. Those are key criteria of independence.

The Scottish health council does not need to be isolated in order to act independently. Although I know that some would like the Scottish Health Council to be a completely separate organisation, we think that there are alternatives. For example, establishing the Scottish health council as a unique and distinct part of NHS QIS has a number of advantages. First, it will help to contribute to the wider quality agenda. It will also offer the council the clout and profile that NHS QIS has to address deficiencies when standards fall short of what is expected. Boards will know what is expected of them and what the standards are. We are developing guidance on how boards can involve the public and will make that available to the Health Committee shortly. We seek to create a Scottish health council that will strengthen quality and public involvement and that will clearly express its own views and findings. Although it will fit within NHS Quality Improvement Scotland, it will have its own distinctive identity and ways of doing things.

Members also raised concerns that local advisory councils will not represent patients' views, although I know that some have been reassured by what they have heard. I hope that, as we have made clear today, the new structure will encourage patients to speak for themselves and, where they cannot do so, will provide independent advocacy services to support them. Local advisory councils will do everything they can to ensure that patients can represent themselves, which will include ensuring that advocacy services are available for all those who require them.

I want boards to involve the public directly, either individually through patient groups and interest groups or through the public partnership forums that will be set up to inform the provision of health services in the community. Health boards must think laterally; they must consider how to work with others and how to establish constant engagement with the people whom they serve. Where health boards fail to involve the public appropriately, local advisory councils will take action to ensure that the patient's voice is heard, understood and acted on. It is important that health boards hear the views of patients at first hand and that the local advisory councils' functions support that.

In response to Sandra White's point about section 44 of the Criminal Law (Consolidation) Act 1995, I must point out that that particular section applies to a person who "knowingly or willingly" gives false information in a statutory declaration. It does not stipulate that there should be criminal sanctions for a breach of a statutory duty. As a result, I can tell the chamber that we have no intention of criminalising health boards.

Several members, including Shona Robison and Kate Maclean, referred to the powers of intervention in the bill and said that the bill should include examples of when the power would be used. It would be extremely difficult to try to set out in legislation all the instances when ministers could intervene. Indeed, there would be a serious risk that we would miss a particular instance, which might have serious consequences. I stress that intervention is a last resort. It would be preceded by an escalating intervention protocol, which would seek resolution long before intervention became an option. Of course, at the same time, I stress that we see the power of intervention as a necessary part of our good governance strategy.

Several members mentioned community health partnerships. Much of the detail on community health partnerships will be contained in the guidance and regulations, on which we will be consulting shortly. That will ensure that responsibility is devolved and that front-line staff are able to take decisions on the best way to deliver care to patients and carers in their local communities.

Local authorities will have a strong role in community health partnerships; where services are provided in partnership as part of the joint future agenda, local authorities will have an equal say on how those services are to be provided. Local authorities and health boards need to have the courage to delegate management and financial responsibility for functions to CHPs. Producing better results through CHPs will require all partners to take the initiative and to share some risks in the search for solutions to problems. After all, all of us—politicians and professionals alike—came into public life to make things better, not to defend internal structures. The challenge is to be courageous enough to share power in the greater interest of those whom we serve.

Several members, including Shona Robison, David Davidson, Kate Maclean and Carolyn Leckie, mentioned the costs of the bill.

Photo of Carolyn Leckie Carolyn Leckie SSP

Thank you very much—there's a wee surprise. On costs, three of the commitments in the staff governance standard are that all staff will be

"appropriately trained ... treated fairly and consistently" and

"provided with an improved and safe working environment".

If that will not require additional resources, is the minister prepared to say that all that is being delivered within the current resource?

Photo of Tom McCabe Tom McCabe Labour

I will give my comments on the cost of the bill during the next few minutes.

Members have suggested that the bill is not cost neutral and that many things, including those mentioned by Carolyn Leckie, cannot be done. Let me give some examples. We have seen the dissolution of two trusts already. The evidence that we have from the two health boards that dissolved their trusts at the beginning of last year—NHS Borders and NHS Dumfries and Galloway—is that savings have been made. However, moving to single-system working is not about cutting costs. It is about improving health care for patients through greater co-operation and collaboration.

Photo of Tom McCabe Tom McCabe Labour

If savings can be made, I expect them to be reinvested in front-line services. [ Interruption. ] Presiding Officer, I have some difficulty in hearing requests for information.

Photo of Murray Tosh Murray Tosh Conservative

I think that the minister is giving way to Shona Robison. I ask members to calm down the level of conversation, so that we can all hear what is going on.

Photo of Shona Robison Shona Robison Scottish National Party

We all hope that savings will be made and that the money will be reinvested in services, but is it not the case that it will take some time for that money to come through? The up-front costs of establishing community health partnerships and the Scottish health council, and of ensuring public involvement, will be immediate. Where will those funds come from?

Photo of Tom McCabe Tom McCabe Labour

Of course, health boards have considerable funds available to them. The funds that have been made available to them have increased greatly year on year. It is not the case that there will be immediate poverty in boards and we think that the changes will generate savings. I cited some examples where trusts have already been dissolved and we think that savings have been generated. There is no reason to suggest that the same savings cannot be generated throughout Scotland.

Photo of Tom McCabe Tom McCabe Labour

No, I will not. I need to get on.

Creating CHPs is about redesigning existing resources to ensure more effective use of them. NHS boards are able to manage that change and many of them have already done a lot of work in anticipation of the change. Reorganisation will not—I repeat, not—be done at the expense of funding for front-line services.

The Executive has always recognised that the exact costs of intervention will depend on the size and the nature of the intervention; the figure in the financial memorandum is, of course, indicative. However, it is important to remember that, as well as improving services, any intervention is likely to save money in the long run, as it will prevent money from being wasted on ineffective services and poor planning.

Again, some members have commented that additional funding will be required to increase public involvement. We accept that if boards are to put much more effort into information, communication and involvement, that will have a cost. However, that is integral to providing a patient-focused service and will lead to more effective expenditure on health services generally. Of course, it is an evolving situation. As we embrace meaningful engagement with our communities, we will always be open to discussions about what the costs and benefits are. We also expect boards to work with other partners locally, through the CHPs and the community planning structures, so that we have a joined-up approach to delivering local services and to sharing the costs of community involvement.

Members have also asked how the new duty of health improvement is to be funded. The important point to make in that regard is that it is not about creating new costs but about making it easier for boards and ministers to spend existing money more effectively on promoting health improvement. We already expend large sums of money in the promotion of health improvement. Examples of that include the extra resources of £173 million announced in "Building a Better Scotland", and that is on top of the £134 million already being spent between 2003 and 2006. Malcolm Chisholm recently announced pilot areas to study unmet need. We are clearly looking forward to seeing the outcomes of that study and to being guided in our future expenditure decisions by those pilots.

It is simply not possible in the time available to address all the points that have been raised. At stage 2, there will obviously be a further opportunity for more detailed scrutiny of the bill and we look forward to working with the committee, and indeed the entire Parliament, on refining the bill. However, I believe that there is broad agreement, both inside and outside the chamber, that the general principles of the bill are sound, and I hope that members will support the bill. Our view of Shona Robison's amendment is that it is unnecessary, so I urge members to reject it.