Remote and Rural Health Care

– in the Scottish Parliament at 9:15 am on 5th June 2008.

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Photo of Alex Fergusson Alex Fergusson None 9:15 am, 5th June 2008

Good morning. The first item of business is a debate on motion S3M-2056, in the name of Nicola Sturgeon, on remote and rural health care.

I remind members that all speeches should be made through the chair, by which I mean that members should refer to other members by their preferred name or title.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

I am happy to open yet another health debate. I suspect that there are members here this morning who have not been home since last night's member's business debate. That said, this debate is extremely important.

At the outset, I want to re-emphasise this Government's belief that everyone in Scotland should enjoy equal access to the national health service no matter where they live, and that that access should be provided as locally as possible. As we all know, many things need to be done to turn that principle into reality. This debate gives us an opportunity to reflect on what those things are, and on the changing nature and increasing complexity of health care in Scotland; to consider the challenges that are inherent in delivering health care in our more remote areas; and to suggest how best to enhance the accessibility of services in order to deliver further improvements to the health and wellbeing of people who live and work in remote and rural areas.

We all recognise that although the health care needs of rural and urban communities are very similar, there are substantial differences in the way care needs to be delivered. The Government recognises—as, indeed, did the previous Administration—that a one-size-fits-all approach cannot and will not meet the challenges of providing health care in remote and rural areas now or in the future.

That is why I was so pleased to endorse the recommendations of the remote and rural steering group, which was charged with identifying a strategy for sustainable health care in remote and rural Scotland. It delivered its final report to me late last year. I record my thanks to the group for its excellent work and the comprehensive report that it has submitted. The report undoubtedly provides us, perhaps for the first time, with a clear blueprint for the future—a blueprint that will enable more care to be delivered locally to more people and which will, if implemented, secure the future of all our rural general hospitals. After so many years of uncertainty, I know that that will be particularly welcome news for the people who live in our rural communities.

As the group now gets to work on implementing its recommendations over the coming months and years—which, of course, is always the hard, but most important, part of the process—I expect to see developments that will maximise the contribution of each and every member of the health and social care team and encourage further integration through models of care in which the majority of services are provided locally with only a small number of cases requiring onward referral.

I also expect to see e-health solutions—which are already making a big difference to the way in which health care is delivered in rural communities—become an ever more central part of the delivery model. All that means that we will be able to reduce the need for individuals in such communities to travel to access services that their urban neighbours are likely to have on their doorsteps.

As I said, there should be no one-size-fits-all approach. We must all accept that services that are offered locally will vary. That said, those services will include, as a minimum, a range of out-patient clinics, day-case treatment, midwifery services, palliative care and support for people with long-term conditions and mental health problems. Emergencies and minor injuries will also be treated locally, wherever possible.

Our six rural general hospitals will also deliver, as a minimum, a core range of services. Standard protocols for procedures and transfers should be established and formal links with other centres will be established. Rural general hospitals will act as health care hubs and will be staffed by doctors, nurses and other professionals who have the general and specialist skills that are appropriate to the needs of the communities that they serve. They will be equipped to resuscitate, stabilise and prepare patients for emergency surgery where appropriate. They will also provide access to diagnostics and offer a range of in-patient, out-patient and rehabilitation services, which means that more people will be able to access the services that they need much closer to their homes. In addition, by working closely with hospital staff and other specialist centres, the extended community care teams will help to locally manage patients who have more complicated conditions and who cannot be cared for at home.

Of course, all our efforts are aimed at providing better quality care that is patient centred, safe, effective, efficient, equitable and timely. All that must, of course, be underpinned by procedures that ensure patient safety. That is why we have taken the decision to extend, from this month, the innovative emergency medical retrieval service pilot to cover the whole of the west coast of Scotland. The pilot aims to upskill rural practitioners and to provide rapid access to emergency medical advice, including—crucially—the ability to transfer a consultant with critical care skills to the patient, whatever their location. For patients with life-threatening injuries and illnesses in remote and rural hospitals, the service also provides consultant-based, on-site resuscitation and safer transfer.

As well as attending to patients in person, the consultants who work for the service will provide 24-hour online and telephone advice to any health care professional in the rural area. The service not only provides increased support for rural practitioners; it has already been shown to improve survival rates and outcomes for seriously ill or injured patients whom the service has attended. I am delighted that the extended pilot, which covers five health boards, has commenced. I am also delighted to note that the service anticipates attending 160 to 200 patients and providing advice for another 120 to 150 during the 18-month trial.

I am also delighted that NHS Education for Scotland has established the remote and rural health care educational alliance—RRHEAL—to meet the specific educational needs of the staff who provide health care services in remote and rural areas throughout the country. RRHEAL is an integral part of the remote and rural implementation plan. It will develop and co-ordinate new educational solutions to ensure that the staff who work in those areas can access appropriate education and training opportunities.

Since implementation began in January, RRHEAL has started work in co-operation with NHS boards, education providers, communications and technology services, health care staff and other stakeholders to provide a practical remote and rural focus around learner access, content and support. Initial work has focused on mental health, long-term conditions, health improvement, dentistry and front-line leadership. I hope that, in time, the list will expand as needs arise.

Within the implementation plan, RRHEAL has been tasked specifically with taking forward or supporting key actions around the development of pre-hospital psychiatric emergency care courses, locally delivered educational and training packages for paediatric teams, accessible training programmes to fill skills gaps in the nursing workforce within rural general hospitals, and education programmes to support emerging roles in respect of allied health care professionals with special interests. I refer to flexible radiography teams, multi-skilled generalist biomedical scientists and generic support workers.

In all that, RRHEAL will work closely with NHS boards, regional planning groups and education providers. It will do so to ensure that educational responses genuinely meet the speed of change in remote and rural services, to ensure that identified learning needs are used collectively to establish a critical mass of learners to give educational providers a sound basis on which to make viable investment decisions, and to ensure—crucially—that learning is properly accredited, wherever possible.

As specific programmes are developed, RRHEAL will have a fundamental role in remote and rural proofing of education and training provision, and in evaluating its impact on remote and rural health services. No member—certainly not those who represent remote or rural constituencies—will underestimate the size of the task that RRHEAL has been given. However, the task is crucial and vital. I am confident that the team will, in working alongside partner organisations—which is an important element in all this—respond well to the challenges that it has been set.

I would like to say a word about the amendments that have been lodged to today's motion, and also to say a word about the NHS Scotland national resource allocation committee, which many members will refer to in their speeches.

I am happy to accept the Conservative amendment. As I said in my statement yesterday, I recognise the importance of the ambulance service in rural communities, which is why I will by the end of this month receive from the service an action plan detailing how it intends to eliminate rostered single manning of ambulances that should be double crewed.

Although aspects of the Labour amendment have merit, I am afraid that I cannot accept it, although I know that that will come as no huge surprise to Margaret Curran and her colleagues. The amendment attacks the recommendations of NRAC—which is something that Labour MSPs from Grampian, Forth Valley, Fife, Lothian and Lanarkshire might find very difficult to explain to their constituents. The Labour amendment makes criticisms, as it has every right to do, but its key weakness is that it does not offer an alternative. It fails to recognise that NRAC—an independent group that was set up by the previous Administration—is about securing, as far as is possible, fair funding allocations that take into account the real costs of delivering health care. It also fails to recognise that I have made it clear repeatedly that NRAC's recommendations will be implemented on a phased basis, and that no health board in Scotland will lose any funding. It is irresponsible for any member of this Parliament to suggest otherwise.

Photo of Jeremy Purvis Jeremy Purvis Liberal Democrat

I have heard that mantra on many occasions. It is, however, disingenuous. Although the baseline grant has not been affected for this year, boards such as Borders NHS Board—which has benefited from an Arbuthnott uplift in previous years—will not benefit from the new NRAC proposals. Borders NHS Board has received no uplift this year. The baseline has not been cut, but there is no additional resource. That means that there are cuts in the budgets of front-line services.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

Jeremy Purvis came in right on cue when I was talking about irresponsible members. What I said is not a mantra; it happens to be the truth. No health board will lose funding. Increases—I repeat: increases—will be tailored to ensure that we move towards NRAC shares. That is exactly what happened under Arbuthnott, and it is fair to all health boards—in particular, to health boards that currently receive below what is considered to be a fair share. All members have a duty to engage properly in this debate, rather than to scaremonger.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

No—I have to move on and discuss the Liberal Democrat amendment. The amendment is sensible, because a funding formula should not be static. It should be kept under review and should be continually refined. There should be a mechanism for genuine concerns to be addressed—I have had a long discussion with Jeremy Purvis about some of them—which is why the Scottish Government has accepted the NRAC recommendation to establish a standing committee that will be charged with development of the formula.

I am happy to confirm to Jeremy Purvis and others that issues that are raised will be kept under review. That will ensure that the purpose of NRAC and of any funding formula is to deliver fair allocations to health boards. I therefore confirm that I am happy to accept the Liberal Democrat amendment.

I am sure that members look forward, as I do, to the tangible impacts and positive outcomes of the innovative and challenging programme of work that we have set out in "Delivering for Remote and Rural Healthcare". It is a programme that seeks to deliver better health and better care for the one in five of us who lives in a remote and rural community. I hope that we will have a lively discussion this morning, but I hope that all members will ultimately feel able to support that excellent report.

I move,

That the Parliament commends the work of the Remote and Rural Steering Group and recognises that its report, Delivering for Remote and Rural Healthcare, forms the basis of a safe and sustainable service for remote and rural areas that will increase community resilience and guarantee the future of Scotland's rural general hospitals; notes the extension of the Emergency Medical Retrieval Service pilot, providing consultant-led resuscitation and transfer of patients with life-threatening injuries or illness in remote and rural hospitals in the west of Scotland, which commenced on 2 June 2008, and further notes the work of the Remote and Rural Healthcare Education Alliance in providing a co-ordinated approach to the development of remote and rural health education programmes across Scotland to ensure that Scotland's healthcare professionals can provide, and their patients can benefit from, the best possible healthcare, as locally as possible.

Photo of Margaret Curran Margaret Curran Labour 9:29 am, 5th June 2008

On what I hope is a consensual note, I begin by saying that Labour feels that this is certainly a welcome debate on an important issue. Health care in remote and rural areas is, of course, an important part of health care in Scotland and any debate on our health services must take that vital element into account.

We, too, welcome the analysis and findings of the steering group's report. It represents a key step forward in the delivery of services. I associate myself with the cabinet secretary's thanks to the group for its work and for the substance of the report.

I would like to say a little about the broader context, in order to remind members of the issues with which we are grappling and of the world in which we find ourselves. While preparing for the debate and familiarising myself with the fundamental issues that affect health care in remote and rural areas, I have been doing a bit of reading. I was struck by comments that were made by Dr James Douglas, who is a general practitioner from Fort William. He recently wrote:

"The health of rural people remains a global challenge for the developed and developing world. In many poor countries, access to clean water and food by rural populations remains a basic challenge to health. While HIV, TB, Malaria, road trauma and warfare challenge rural health in developing countries, developed countries are challenged by equity of access to sophisticated healthcare."

That equity of access to sophisticated health care is undoubtedly what we will focus on this morning. Our discussions will cover issues of extreme need and, at times, extreme poverty. However, it is worth putting our debate in context and keeping in mind the broader considerations.

As I have said, the final report of the steering group is welcome; it sets the agenda for the Parliament's discussions of health care in remote and rural areas. However, in the article that I just quoted, Dr Douglas says that much of today's work in health care in remote and rural areas is based on the principles that were set out in the Dewar report of 1912. As the article says:

"Dewar's principal recommendations included better training for rural doctors, better use of transport and technology, and guaranteed minimal levels of service provision for rural populations, despite geography."

The aim was to overcome the problems that are caused by remoteness. The issues that we are discussing today are not at all new, and we should be reminded of the issues and challenges that have arisen along the way.

I would, of course, be the first person to acknowledge the progress that was made by the previous Executive. I would want to list the ways in which progress was made, and I am sure that my colleagues in the Liberal Democrats—who did so much work relating to rural Scotland—would agree with me. However, I also support much of the approach that has been outlined by the cabinet secretary. She has given details of some of the issues that we will need to tackle when developing services for our remote and rural communities. Despite some of her comments, I hope that we can use the experience of MSPs of all parties, who are acutely aware of issues in their constituencies and are finely tuned to the needs of their constituents. I hope that we can use that experience consensually to work with national health service staff—professionals and volunteers—to develop services. Obviously, we should also work with staff in the social care sector.

I have to say, however, that I was rather disappointed with the tone that the cabinet secretary struck when talking about what I regard as legitimate criticisms and legitimate points that have been raised. That tone has to be shifted. When we tell the Government that we think that serious issues have emerged from the model of funding that it is using, or when we raise points about any other issues and say that we are concerned and think that the issues need to be interrogated and tested, it is beneath the office of the cabinet secretary simply to dismiss—yet again—our concerns as "scaremongering". You have to pay attention to concerns that are raised in Parliament, be more courteous and deal with the substance of the concerns.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

I am more than happy to engage in debate, but debate usually involves suggesting solutions as well as making criticisms.

Does Margaret Curran agree that she was being irresponsible when she gave a quote to a newspaper saying that if the formula were implemented immediately, X health boards would lose funding? She should also have said that the formula is not going to be implemented immediately in full.

Photo of Margaret Curran Margaret Curran Labour

I think you should pay attention to the exact details of what I said. My argument is not about the amount but about the share, and you know that full well, cabinet secretary. My key point to you is that we have to create an environment in which we interrogate the issues and deal with the substance of the points that are raised. Alternative views should not simply be dismissed out of hand.

We know that the SNP Government's current funding proposals are causing real difficulties the length and breadth of Scotland. You have to recognise that and address it.

Photo of Margaret Curran Margaret Curran Labour

No. I did Nicola Sturgeon the courtesy of taking an intervention, but she did not do me the same courtesy. I would prefer it if you would allow me to pursue my argument.

As The Herald reported on Monday, major concerns have arisen among senior health board figures about the current funding proposals. I presume that you cannot dismiss them so easily. Although the new NRAC formula retains the same structure as Arbuthnott—taking a weighted-population approach—it revises the measurements of population, age, sex, need and remoteness effect. We need to discuss the revision of those measurements and assess the impact of that throughout Scotland. The fact that the revision lessens the impact of those factors needs to be understood throughout Scotland. The overall effect is that shares of funding will be reduced for some rural health boards, because their share of the excess cost weighting will fall.

Concerns about the revision are serious, because it will have an impact on services. Many concerns will emerge in the debate. I remember well that when Nicola Sturgeon was in Opposition, I often told her, "You can't just criticise; you need to suggest solutions." If I were the health minister who received the NRAC recommendations, I would not just say, "Thank you very much. I don't care about the consequences and anyone who dares criticise is not to be listened to." Any minister who receives recommendations in a report has a responsibility to determine and deal with their full impact. [Interruption.] It is inappropriate behaviour for a minister to dismiss concerns and shout from a sedentary position. The considerations are serious.

Photo of Margaret Curran Margaret Curran Labour

No, thank you.

We are talking about the range of resources from funding for ambulance services to funding to ensure equal access to major Government commitments for the health of remote and rural communities, such as the out-of-hours service. To progress telecare effectively, we need to pursue how it will be funded. I hope that the minister will talk about the commitments to the out-of-hours service and how they will be funded in rural and remote areas. Doctors have serious concerns about how surgeries will operate. I presume that when the Government makes a general commitment to the out-of-hours service, it does not add in brackets, "Sorry—that doesn't apply in some areas." A rural experience from which we can all learn is the situation in the Western Isles. I know the Western Isles well from many visits there in my ministerial life and I am familiar with the deep concerns of many people there about leadership and management in Western Isles NHS Board. The parliamentary process has properly considered and interrogated that, but I will focus on a dimension that is significant to the Government's practical work: the appointment process in the NHS. I hope that the minister will address that.

I will ask the minister a direct question. I will be careful in my wording, Presiding Officer, because I know that I am a miscreant. Will she reassure Parliament that all senior appointments in the NHS will be made on the basis of open interview and competitive procedure and will be transparent? [Interruption.] I ask that question genuinely; there is no need for conflict.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

Margaret Curran makes an important point, but will she acknowledge that the appointments in NHS Western Isles that have attracted much criticism were made under her Government?

Photo of Margaret Curran Margaret Curran Labour

I say with the greatest respect that the cabinet secretary has missed the point. The point is not party political. [ Laughter. ]

Photo of Margaret Curran Margaret Curran Labour

The point is not political. It is about the NHS's management. The NHS's appointments procedures are governed not by politicians, but by its administration. When the cabinet secretary looks into that, she will find that the point is administrative and not political. If she seeks to make party-political points, she misunderstands the situation. We are missing a significant opportunity to discuss the issues in the Western Isles properly rather than in a partisan manner. I therefore hope that the Minister for Public Health will reassure Parliament that appointments throughout the NHS will be open and transparent, as I have recommended.

I hope that the Labour amendment's reference to union learning representatives finds wider support in Parliament. I am sure that many of us agree that union learning reps make an extremely valuable contribution in remote and rural settings, as they do throughout Scotland. Employer-union learning agreements have been brokered in Highland NHS Board and Tayside NHS Board. I hope that they will be implemented throughout Scotland.

One in five people in Scotland lives in a remote and rural area. We know that service models that are effective in urban areas might be unsuitable in remote and rural locations and that services need to be accessible and of the highest quality. To achieve that, we need a determined and sustained effort. The debate is important and funding is at its heart. It is deeply disappointing that such issues have been dismissed lightly, but we will pursue them on behalf of people who live in remote and rural areas.

I move amendment S3M-2056.2, to insert at end:

"and recognises the contribution made to remote and rural training by union learning representatives, however, expresses concern regarding the future funding under the NHS Scotland Resource Allocation Committee of rural NHS boards that are facing particular pressures regarding service delivery, including out-of-hours GP services and the provision of ambulance services."

Photo of Mary Scanlon Mary Scanlon Conservative 9:40 am, 5th June 2008

Margaret Curran talked about Western Isles NHS Board. On behalf of all of us and for the sake of NHS staff and patients in the Western Isles, I hope that people there can now look forward to a period of stability.

I commend all those who contributed to the excellent report on remote and rural health care. Urban models, such as that for allocating funding under the NRAC formula, are all too often inappropriate to rural health care, particularly given that, for example, the out-of-hours service in the Highlands costs five times more than that in Glasgow. We are minded to support the Liberal amendment, but we would like to hear more. We will decide whether to support the Labour amendment after hearing more speeches.

The report highlights well the differences of remote and rural areas, such as the higher suicide rates, higher incidence of alcohol-related disease, higher number of accidents on roads and through climbing, farming, diving and fishing, and the palliative care workload, which the cabinet secretary mentioned. I pay tribute to the excellent work of Marie Curie Cancer Care and Macmillan Cancer Support nurses in the Highlands, where many people choose to die in their own homes and localities.

The proposed integrated teams that would be based in GP practices and the potential increase in mobile diagnostic facilities for aneurysm, breast and osteoporosis screening are good news for locally delivered health care. My colleagues throughout Scotland tell me that GPs in remote and rural areas are asking for the flexibility to do what meets the needs of patients in their localities, rather than be forced to follow centrally prescribed agendas. I will leave the matter there—that debate is for another day.

It is worrying to read in the report that the workforce in remote and rural areas

"is ageing and organised"— if "organised" is the right word—

"in a fragmented and reactive way."

We have heard about integration, partnership working and seamless care for many years. The situation has improved, but there is still a long way to go to put the patient at the heart of the service.

The role of allied health professionals is not entirely clear. Given the 18-week target for referral to a consultant, it is possible to see a consultant long before one can see a podiatrist or a physiotherapist. Waits for psychiatry and psychology services, particularly in the Highlands, are very long and just as difficult.

The role of community and rural general hospitals is critical to the model of care: my colleague Murdo Fraser will say more about community hospitals.

I will concentrate on two issues: mental health services and the Scottish Ambulance Service, although I have scored out quite a lot of what I planned to say about the Ambulance Service because of yesterday's statement. I commend NHS 24 for developing cognitive behavioural therapy in the islands. That is an excellent example of the delivery of high-quality professional care and support over the telephone to meet the needs of patients in isolated areas.

It is disappointing that NHS Highland has not provided the small amount that is needed to fund the Depression Alliance Scotland self-help group in Inverness. When people take the initiative and the time to understand and address their mental health problems, surely we should encourage that. The report concluded that consistent difficulties were experienced in managing patients with mental health crises, especially out of hours. Early diagnosis and intervention are as essential in rural areas as they are elsewhere—for example, to prevent mild depression from becoming severe and chronic. However, there is no doubt that community hospitals could be enhanced to deal with mental health and various other issues, as outlined on page 18 of the report.

Although an inquiry is being carried out into the management of the Scottish Ambulance Service, we cannot ignore the substantial part of the report on that service, or the fact that many aspects of patient care are dependent on it. I will move my amendment, although I appreciate that many of the issues were addressed in yesterday's ministerial statement on the Scottish Ambulance Service. To give some examples of the issues, there is a lack of an integrated response, delays occur in accessing health care, little or no planning or co-ordination takes place within agencies, and there is a fragmented approach in which there is duplication and inefficient use of resources.

The report asks for a nationally co-ordinated response and suggests that the service be

"more embedded in the NHS Territorial Boards".

A merger of the Scottish Ambulance Service with NHS boards is not our policy or something that we have discussed but, in the current circumstances and with the serious issues relating to patient care, the suggestion is undoubtedly worthy of further consideration. I hope that the Government inquiry into the Scottish Ambulance Service considers not only what is happening in the service, but how the service works in partnership with other agencies. I cannot say much about the target on responding to 999 calls, given that the data collection is questionable. I simply point out that there is a target to respond to 63 per cent of calls within eight minutes, although people in Bettyhill have a 1 per cent chance of seeing an ambulance in that time.

Page 51 of the report comments on support workers. I am not sure who the new generic support workers are, but the Conservative party welcomes support for young families from all backgrounds. However, my understanding is that a support worker is not a registered nurse and does not have the training and experience of a health visitor. Health visitors are paid at band 6 or 7, but support workers are paid at band 3 or 4, yet they are expected to support individuals with self-care, to carry out health promotion work, to manage chronic conditions, to prevent unnecessary hospital admissions, to support young families and to screen people who are over 75. Although all health professionals have a role, we do not want support workers to be expected to do the work of health visitors but at a significantly lower salary.

I move amendment S3M-2056.1, to insert at end:

"further notes the concerns raised regarding the provision of ambulance services, and asks the Scottish Government to ensure that those living in rural communities are not disadvantaged."

Photo of Ross Finnie Ross Finnie Liberal Democrat 9:48 am, 5th June 2008

I am delighted that we are having a debate on rural health care, as this is the first occasion since the new Government was formed that I have been able to talk about rural matters, with which I am somewhat familiar.

The Liberal Democrats welcome the thrust of the report "Delivering for Remote and Rural Healthcare". To refer back to my time as a minister, I well remember taking a close interest in the remote and rural areas resource initiative that was worked up by a team at Raigmore hospital in Inverness—although the team was based in Inverness, the work that it carried out covered the whole of rural Scotland, not just the Highlands and Islands. Therefore, I am pleased that the report builds on that work and adds substantially to that initial thinking. As the cabinet secretary made clear in her opening remarks, the principle is that everyone in Scotland has the right to expect the same standard of health care wherever they live, and we must recognise that; but, equally, as the initial work of RARARI pointed out and as the report makes explicit, profound differences exist in how we must model the delivery of health care services to meet the needs of rural communities.

I will not recite all those differences, as they are set out well in the report and because I see that almost all the members here represent rural areas, so that would be teaching grandmothers to suck eggs and would be a bit patronising. I will confine myself to measures in the report not only to which the Liberal Democrats want to give our clear support, but about which we feel passionate because they bear a close resemblance to measures in our most recent manifesto.

The general thrust of the report must chime with the approach to individual issues. The report suggests that we need to extend the community care model and acknowledge the differences, which the report brings out, between the primary care model that we need to develop and the current system, which uses an urban model. It is striking how different the suggested model is—it must improve the patient experience of primary care.

The report talks about an enhanced role and improved model for remote community hospitals, particularly in anticipatory care, and shifting the balance of care so that it is more locally based.

That chimes with our view on the need to sustain small rural and community hospitals. Access to sustainable secondary care is a matter of considerable interest, as is the task of eliminating the disturbing variations in treatment in rural general hospitals. As the cabinet secretary pointed out, we need to develop the model so that it provides the hub for a range of services in rural communities. However, I caution those who talk about such developments that my colleagues Tavish Scott, Liam McArthur and Jamie Stone, who is here, believe that some of the services that are claimed as enhancements existed before. That is a minor point.

Some key aspects are particularly important in the rural context. The recruitment, development and retention of the workforce are perennial problems that threaten the quality of delivery in many rural areas. Therefore, the increase in specific remote and rural education through RRHEAL—I am grateful to the cabinet secretary for reducing that mouthful for us in her opening remarks—is an important development. It is difficult to attract people into the service but, when we do, they understand how important and rewarding it is. Getting them there in the first place and providing training is critical, so we must develop the infrastructure to support rural practices.

A further issue that is mentioned in the report is telemedicine. As was the case more than a year ago, we still need to do more work on that. In Scotland, we have failed to grasp the opportunities that telemedicine presents. We should consider the international experience. In Canada, telemedicine is developed in a much more determined way in huge areas. It is unfortunate that, in some parts of rural Scotland, telemedicine is seen as an alternative to a doctor visiting, rather than as an enhancement of the service. The technology is available, it works in other places and we need to develop it.

Photo of Ross Finnie Ross Finnie Liberal Democrat

No—I will press on, because I want to make a point about the purpose of our amendment that I hope will be helpful to Mary Scanlon and other Conservative members.

We want the report to be effective, but it could—I stress that word—be undermined if the funding of health boards is either unfair or seen to be unfair. I want to be clear, as the point may be important. The Liberal Democrats supported the establishment of the Arbuthnott committee and, when in government, we supported its replacement with the NHS Scotland resource allocation committee, or NRAC. We believe that it is right to establish a means of allocation that is based on objective criteria and we continue to support that principle and approach, not just using the current criteria but criteria as they are developed and refined to reflect poverty and health inequalities. However, we have grave reservations about the fact that, having studied the NRAC report in depth, health boards in remote and rural areas have serious questions about the basis on which some of the criteria were developed and may be applied.

My colleague Jeremy Purvis will develop that point in more detail by reference to the findings of NHS Borders. The problem is not simply that concerns have come to light; just as important is the fact that because NRAC is not currently operating—it has not been stood down—and no standing committee has been established, there is no forum for NHS boards in remote and rural areas to raise their concerns, seek satisfactory explanations or have their concerns resolved. In that vacuum, the NRAC-based allocations are perceived to be unfair and the system might be undermined. Hence, our amendment calls for the immediate establishment of a standing committee, as called for in the NRAC report. I am grateful to the cabinet secretary for expressing her willingness to accept that suggestion, and I hope that the explanation that I have given helps to persuade the Conservatives to stick by such principles. We think that genuine issues exist that could affect the delivery of services in rural areas and that addressing them requires the amendment to be agreed to.

I move amendment S3M-2056.3, to insert at end:

"and in line with recommendation 10.12 of the NHS Scotland Resource Allocation Committee's (NRAC) report calls on the Scottish Government to establish without delay a standing committee to lead work on the future development of the NHS board funding formula and to come forward with details on the precise membership, format and remit of the committee, and further calls on the Scottish Government to review the impact of the NRAC report on NHS boards' ability to maintain and develop remote and rural services."

Photo of Alex Fergusson Alex Fergusson None

We move to the open debate. Speeches should be around six minutes, please.

Photo of Christine Grahame Christine Grahame Scottish National Party 9:56 am, 5th June 2008

I welcome the temperate and considered speech that my colleague on the Health and Sport Committee, Ross Finnie, has just made.

The foreword to "Delivering for Remote and Rural Healthcare" mentions the objectives of delivering

"a strategy for sustainable healthcare in remote and rural Scotland" and

"workforce planning arrangements to support the remote and rural agenda."

The report contains a diagram that shows the relationships between district general hospitals, community hospitals and extended community care teams. I want to explore those with reference to an area that I know well—the Scottish Borders—against the area's background of an ageing population and the demands of that, a lack of public transport, long distances and the often historic existing facilities. Areas elsewhere in rural Scotland have a similar background.

We should all welcome a strategy that is not a straitjacket. We know that the cabinet secretary's approach must have built-in flexibility to reflect the topographical differences between, say, the island communities, the Highland mainland, the Scottish Borders and other parts of the south of Scotland. There are remote places and isolated farmhouses in the valleys of the Borders, but the Borders also contain many historic communities, such as Jedburgh, Selkirk and Peebles, which have a culture of proud autonomy. It is to be regretted that, in the face of fierce local opposition, the previous Labour-Liberal Administration supported the closure of the community hospitals in Jedburgh and Coldstream, but effective, efficient and modernised community hospitals, such as Hawick community hospital and Hay Lodge hospital in Peebles, remain.

Hay Lodge hospital is currently at war with the health board over a proposed reduction in the number of long-term beds—I will address that matter shortly. I have met the cabinet secretary, the board and the GP practice at Hay Lodge hospital, and it seems to me that, although on paper there is excess bed provision seasonally across the Borders as a whole and the board may be able to make staff savings—particularly agency savings; all members know that agencies are costly—by not servicing beds, there is no spare capacity at Hay Lodge hospital. I understand the logic behind the board's thinking that there will be economic savings through discharging an elderly Peebles patient to, say, Hawick community hospital, but the patient's family, the community and I do not think that doing so would be in that person's medical, psychological or social interest when they could be placed locally, within reach of their family and friends in Peebles, and not have to use public transport, which is, as I have said, poor in the area. NHS Borders is, of course, responsible for making 2 per cent savings across its budget and balancing its books—indeed, I think that it did so for the first time in the previous financial year—but I ask the cabinet secretary to keep a watching brief on the problem, which may be replicated elsewhere. I know that she will do so.

Page 18 of the report contains commitments. It states:

"CHPs should review their Community Hospitals to determine which, if any, should be enhanced".

The responsibilities at bullet points 5, 6 and 7 would be affected if long-term stay beds at Hay Lodge hospital closed. Palliative care, out-patient treatment and so on would be affected.

On NRAC, it has been said that the previous Administration established the independent committee, but that does not mean that members of that Administration or anyone else must follow it slavishly. That is the key point. Obviously, concern exists that rural boards may be losing out. The cabinet secretary has given an assurance that no board will lose out and that measures will be phased in, and in attending to the Liberal Democrat amendment she agreed to keep things under review and to set up a standing committee. That is the way forward. If we fight such wars in the local press, we may stir up more problems—[Interruption.] I am trying to be straight. If we fight such wars in the local press, we may stir up more problems than may or may not exist. The way forward is through cool heads considering the matter. Indeed, the report says that the report itself should be considered against the background of the NRAC review, which predated it. We have sets of information that need to be assessed together.

Photo of Christine Grahame Christine Grahame Scottish National Party

I want to move on. I have only six minutes in total.

On staff issues, we should consider the delays in implementing the agenda for change. That is not a Scottish Parliament issue, but it has huge ramifications for personnel in NHS boards. I think that Mary Scanlon referred to the matter. Many personnel simply do not yet know what their job description is or what they will be paid. Differentials appear to exist in NHS board areas, and many people who have been reassessed are waiting for their pay in arrears. That is destabilising.

Against that background, a reassessment is having be made of allied health professionals and what they deliver. NHS Borders nominated itself to take part in a pilot on that. The cabinet secretary met me and health professionals to discuss the matter. The health professionals were concerned that things were moving too rapidly. They wanted more consultation, as district nurses, health visitors and school nurses do different jobs. Difficulties are involved, but members must face up to the fact that there is a huge lack of recruits in those areas and there are ageing medical professionals. We cannot simply put our finger in the dyke and say, "We'll try to stop this happening." We must look for consensual solutions.

I look forward to the rest of the debate and commend Ross Finnie for his temperate amendment, which is, of course, out of kilter with what Jeremy Purvis thinks, although Jeremy Purvis is out of kilter most of the time.

Photo of Rhoda Grant Rhoda Grant Labour 10:02 am, 5th June 2008

I am pleased to take part in this debate on remote and rural health care and I welcome the report. The cabinet secretary is pleased to endorse its recommendations and is committed to acting on them, but we have yet to hear a commitment on making extra funds available so that the proposals will be implemented.

The report details what is happening in rural Scotland and outlines future aspirations. Those aspirations would lead to a standard of health care in remote and rural communities that approaches the same standard as that in urban Scotland. However, in describing rural general hospitals, it lists only the minimum services that are required. That greatly concerned a great number of people, because some rural general hospitals already provide a more comprehensive service. Let us consider, for example, the obstetrician-led maternity service at Caithness general hospital. The health board has given a commitment that that service will remain; I would be grateful if the minister did the same.

Photo of Shona Robison Shona Robison Scottish National Party

The member has just said that the report referred to the minimum level of service that we would expect. Where there are more comprehensive services, we would, of course, expect them to be retained, just as we expect the obstetrician-led service at Caithness to be retained.

Photo of Rhoda Grant Rhoda Grant Labour

I am grateful to the minister for that reassurance. I am sure that the people of Caithness will be grateful for it, too.

The report states that there has been a rise in hospital admissions because of the failure of out-of-hours care in remote and rural areas. We all know that it costs five times more to deliver out-of-hours care. The rise in hospital admissions when such care fails adds to the costs that rural health boards bear. When funding is cut in real terms, it does not reflect the real costs of delivering rural health care, and leaves little room for ambition. Delivering services as close to people as possible in remote and rural communities means higher costs. Consultants who travel to patients in rural areas cost more; they are travelling rather than seeing more patients. We should acknowledge that they cost more, but we must also be clear that such an approach is right. It is difficult for people to travel long distances to access health services. They are often worried about receiving bad news, and being a long way from home makes a bad situation a lot worse.

The report's emphasis on telemedicine and the use of other technologies is welcome. Such technologies will also have benefits in delivering health care in more urban settings. Where possible, such services should be delivered at home or as close to home as possible.

The report also talks about team working, which should surely be happening already, but when health care staff are few and far between, that presents a challenge for team working, as people seldom work together. The report mentions multiskilling and the current review of community nursing, but the pilots have just begun and it would be sensible to await their outcome before proceeding. All staff groups, especially those that are most directly affected, should be involved in implementing the measures.

The report makes a passing reference to what I would term one of the really good models of rural health delivery. The Howard Doris centre in Lochcarron provides care for all parts of the community, from nursing home care and sheltered housing to respite care and medical beds. That means that some people do not need to be admitted to hospital and ensures that those who do can move closer to home more quickly. The centre delivers health and local government services seamlessly, so why does it merit only a passing reference in the report? I fear that it is because it is a community-led initiative. In providing cross-service care and the level of service that local people require, it is a model that really delivers. If the Government is keen on matching rhetoric with action, it could do an awful lot worse than use that model in areas where there is little or no in-patient support.

Photo of Jamie Stone Jamie Stone Liberal Democrat

The Howard Doris centre is funded jointly by NHS Highland and Highland Council. Does Rhoda Grant agree that there is a question mark over Highland Council's funding of many social work services that would impinge on something like the Howard Doris centre?

Photo of Rhoda Grant Rhoda Grant Labour

Indeed. However, my point is that if the community had not brought forward that initiative, there would be no joint funding. It was the community that raised the money, pulled forward the initiative and then drew down the money from both the national health service and local government to make it work. Getting the two services to work together to provide similar services in other areas has proved difficult, and I suggest that communities be given that amount of input to services that are delivered locally. Indeed, the services that are delivered in places such as the Howard Doris centre could be added to telemedicine and the like to ensure that local people could attend clinics remotely and would not have to travel to centres.

The report talks about ambulance service technicians undertaking planned home visits to carry out risk assessments. Ambulance staff form part of the emergency service, so I imagine that it is difficult—if not impossible—for them to play a part in planned health care. Patient transport service staff could do the job more easily. Unfortunately, patient transport staff are thin on the ground in rural areas—indeed, the service depends on volunteers who are not properly compensated for their time and expenses. That is a false economy, as the patient transport service has been forced to use taxis, which is hardly a good use of public money.

I welcome what the report says about education, and I pay tribute to union learning reps who identify training needs in remote and rural areas. I also pay tribute to the university of the Highlands and Islands, which offers education up to degree level in rural health care. I suggest that that is a suitable institution to develop remote and rural health care education and training.

I recently became acutely aware of the challenges of providing health care in remote and rural areas when members of my family were unwell. What is a worrying time under normal conditions takes on a whole new dimension when one is struggling with distance. In providing services in remote and rural areas, we must ensure that the needs of the patient are central. In implementing the report, we must force out services on the ground—that must be our priority.

Photo of Rob Gibson Rob Gibson Scottish National Party 10:08 am, 5th June 2008

In order to make this work and to ensure equality of delivery of health care services in our remote and rural communities, we must take some specifically targeted approaches that are different from those taken in urban areas. I will list some of those approaches.

At the point of first response, we must strengthen the community resilience model, which works at the most local level. The first responder scheme is a good example, as it understands that concerned citizens in a remote community can act as the front-line service for health and monitor how people behave. The scheme needs more money and resources, and it needs to have more people trained. It needs a stable population of people who have the time to do such things. Community transport to hospitals is one part of that, but the identification and stabilisation of people in the community—which is what first responders do—must be built in. The scheme is very special and requires that each community be involved in the design of its model.

Secondly, we need more specific information about how the remote community resource hubs will work. Where will the hubs be? How many of them are there? Are they all based around community hospitals? That is just not possible in the north-west of Sutherland, which is 70 or 80 miles from the nearest rural hospital. Because there is no community hospital there, another centre must be identified and developed, which is not an easy job given the geography of the area. We need more specific information about remote community resource hubs.

Photo of Rhoda Grant Rhoda Grant Labour

Surely the problems that Rob Gibson outlines would be solved by initiatives such as the Howard Doris centre. Such a centre would be an excellent facility for north-west Sutherland.

Photo of Rob Gibson Rob Gibson Scottish National Party

As far as I am concerned, the community of Lochcarron has a model that suits its area and geography. North-west Sutherland is very different. However, the need for local control of health services is a matter to which I will return if I have time.

On telemedicine, which Ross Finnie mentioned, a practical consideration is the fact that we do not have a proper map of broadband coverage in Scotland. Although 98 per cent of the population can receive broadband, about 30 per cent of the land area in remote areas is still not served. We need a map of that for telemedicine to work in the remotest areas, such as the islands and the north-west.

We must also consider the networks that the plan envisages. We need explicit mapping of those and a buy-in by the health boards, managers and clinicians who are involved. It is particularly important who the larger health boards explicitly recognise their responsibilities in that respect—it should be added to their list of key performance indicators—because they have such a wide variety of circumstances. We know from the debate that we had on the ambulance service that the situation in Wick is different from the situation in Kinlochbervie. We must make performance indicators that relate to service provision in the remotest areas part of what the health boards are expected to do.

Of course, underpinning the provision of health care in remote and rural areas is the ability of all staff to be able to do their jobs in those circumstances. That is why we must ensure that, at long last, the royal colleges and other training bodies for doctors, nurses and allied health professionals are signed up to the training that is required. That will be a small but, nonetheless, enormously important part of their business. We have talked about the issue over the past 10 years of the Scottish Parliament, and the publication of this more comprehensive report indicates that the Government is now determined to bring those matters to bear. If we are to have a standing committee on how NRAC will work, we must engage fully with the royal colleges to ensure that they deliver for remote and rural areas.

I return to the issue of financial support. Part of the issue in the health service—and in every public service in remote and rural areas—is the need to have a rural poverty index or, as exists in Scandinavia, a form of equivalence that builds into the normal funding a recognition that our geography is as it is and that we must meet the needs of the people who live in it. It is not enough that urban areas are regarded as normal, rural areas are regarded as abnormal and remote areas are regarded as extremely abnormal—we cannot take that approach. RARARI did some good work in the previous session, although it was wound up, and is a good model for how we should deliver services in remote and rural areas. We also need the finance department to buy into the provision of all services in remote and rural areas.

Given the problems with the provision of care at Caladh Sona, Melness and the Assynt centre, both the health board and the social work department require to be funded in a way that allows the work that they do together to be done smoothly. Funding is tight, so it looks as though some projects will be lower priorities than others, and the psycho-geriatric hospital that will be built at Migdale for that part of Sutherland could take from both pots money that is available for the creation of resources in far-flung parts. We must ensure that we consider funding across all public services, including health. We should not think that we have to create an NRAC or an Arbuthnott formula every five or 10 years. Funding should be built in.

Photo of Helen Eadie Helen Eadie Labour 10:15 am, 5th June 2008

I will focus on two aspects of remote and rural health care. The first is policy and resources, and I will give an extremely distressing example of the impact that the failure to deliver quality care has, not just on the patient but on their immediate family. The second aspect is the emergency response service and the Scotland-wide problem with the co-ordination of transport, which is crucial not just for those in remote and rural areas but for everyone in Scotland.

As we prepare for debates, politicians strive week in, week out to inform ourselves of the contents of various reports. We recognise with humility that we can never do justice to the incredible efforts of the authors of those reports, and that is particularly true of "Delivering for Remote and Rural Healthcare". I read with interest the summary report on the Nuffield scholarships to Australia and the comparative analysis that it provides, which describes truly remote living. I readily acknowledge that, although the Dunfermline East constituency undoubtedly has rural characteristics, I have no expert knowledge or experience of the more crucial challenges of remoteness, which are vital to the debate. However, during my service on the Health Committee in session 2, I had the privilege of travelling throughout the Western Isles, from Barra to Uist, over a number of days, and I learned directly from clinicians, patients and health board members of the challenges that confront them daily.

Our opinions as politicians are shaped in many ways. Primarily, we seek to ensure that our constituents' experiences are embraced by the reports that we read and addressed in as realistic and practical a way as possible. Above all, we know that policy documents gather dust on shelves throughout the country. A policy only truly becomes policy when it is matched with adequate financial resources. If policy change is to happen, the allocation of funding is required.

The amount of service change that is required to implement the commitments in "Delivering for Remote and Rural Healthcare" should not be underestimated. I recognise—and I am sure that others recognise—that it is vital that the Scottish Government allocates funding, as called for in the report, for the appointment of a national programme manager. They must have the appropriate administrative assistance to enable them to support NHS boards and other groups in the implementation of the policy changes.

Labour has always recognised that remote and rural communities require a different and tailored approach to health care provision. We showed that with our implementation of the Arbuthnott formula for the funding of health boards, which recognised the additional costs of delivery in those areas. Although there is some recognition of that in the new NRAC formula, it is less transparent, and the cuts in funding to many of the rural health boards are worrying.

The revised NRAC formula will be phased in over a number of years, starting in 2009-10. Although no board will receive less in cash terms, boards' shares will change dramatically. The gap between current spending and the NRAC formula shows big gains for Lothian and Lanarkshire and big losses for Ayrshire and Arran, Highland and Glasgow. The implementation of the NRAC formula will reduce the share that Glasgow and those other boards receive and will increase inequality. NRAC replaces Arbuthnott as the target, not the allocation. If the Arbuthnott index had been retained with the new unmet need weighting, Glasgow's target would have increased.

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

This might be the point that Helen Eadie is making—I am not sure—but for absolute clarity, will she concede that, compared with the Arbuthnott target shares, Glasgow actually does better under NRAC?

Photo of Helen Eadie Helen Eadie Labour

I remain to be convinced about that.

Funding is central to the report in every way. It makes the key point that the Scottish Government should consider providing funding to appoint a national programme manager with appropriate assistance to ensure that capacity is built to support the implementation of the remote and rural framework.

I said at the outset that policy and resources are crucial, but they need to be matched to the needs of constituents. At the heart of my concerns is what we can learn from patients' experiences in Scotland, be they in remote and rural areas or elsewhere. What is their experience of the NHS in Scotland today? My concern is not just for the patient but for his or her family. Take the recent experience of Mr and Mrs X, who are real people. Mrs X arrived home on a Friday night and was informed by answering machine that she has cancer. The message came from clinicians who had left for the weekend but had not said where the family could get more information or support until the Monday morning. Imagine the horror, panic, fear and trepidation of being left to fester for 64 hours until contact could be made once more with the clinicians. Then the specialist nurse went on holiday and no one was put in place to take over. The cabinet secretary was written to, but after seven weeks she still had not responded to the family's concerns. There is no support for the now demented husband, who sits up night after night. I need say no more. The support was simply not there.

I will touch on the crucial issue of transport. From my experience as an elected representative, I am 100 per cent certain that there is a lack of integrated response to transport needs. That has been raised with me consistently in every forum that I have ever attended, from one end of Scotland to the other. The problem results in delays for patients in accessing appropriate health care. Health-related transport is provided by a range of providers and agencies including voluntary drivers, the patient transport service, and neonatal and paediatric retrieval services.

I am pleased to learn that there is to be a pilot to demonstrate the benefits of an emergency medical retrieval service, but there is little or no planning or co-ordination between and within agencies. The result is a fragmented approach that sometimes results in duplication, which is an inefficient use of scarce resources. Transport infrastructure is crucial in the support of health care in remote and rural communities, but it is not the responsibility of any one organisation.

I support the amendment in Margaret Curran's name.

Photo of Murdo Fraser Murdo Fraser Conservative 10:22 am, 5th June 2008

I welcome the debate and hope that it will help to bring positive changes and improved health services to remote and rural communities in Scotland. As my colleague Mary Scanlon said, the Scottish Conservatives support the recommendations in "Delivering for Remote and Rural Healthcare". It is essential that a specific model of health care is put in place that is appropriate for remote and rural communities. We need a health service that works for those communities and does not ignore them. I welcome the remarks that the Cabinet Secretary for Health and Wellbeing made at the beginning of the debate, when she set out her personal commitment to ensuring that those in rural areas are not disadvantaged.

I will take the opportunity to raise a constituency matter, if members will allow me to do so. Highland Perthshire certainly falls within the definition of remote and rural areas, and that applies particularly to the Rannoch area. For all that Rannoch is at the heart of Scotland, it has all the characteristics of a mainland peninsula or even an island community, such is its remoteness from centres of population and the lack of good transport links.

People in the Rannoch area, some of whom have come along to this morning's debate and are in the public gallery, are concerned about what they perceive to be reductions in the health services that they receive in their remote area. I know that the constituency member, who is the Cabinet Secretary for Finance and Sustainable Growth, will have raised those concerns directly with his Cabinet colleague, but I have been asked to raise them in the chamber today. I put on the record my thanks to members of the local community in Kinloch Rannoch who have been campaigning tirelessly to get improved health services for the area.

There is widespread concern in Rannoch about changes to the out-of-hours service following the opting out of the local GP practice. NHS Tayside allowed the Kinloch Rannoch medical practice to opt out of out-of-hours service in May 2006. When the serving GP retired earlier this year, the contract for GP cover was awarded to the nearby Aberfeldy practice, but there was no requirement to reinstate out-of-hours cover. People in the Rannoch area are concerned that lives might be put at risk due to the changed arrangements.

The case is made far more eloquently than I could make it in correspondence that I have received from constituents. I will quote briefly from two letters.

The first is from a constituent in Dall in Rannoch, whose statement relates to recent call-outs for medical help by the wife of an ill husband, both of whom are in their late 80s:

"I think the present system is totally inadequate, I know there are a lot of elderly people in this area. I would want the local medical practice to take back responsibility for out-of-hours cover, as in the past. I believe that the Aberfeldy Practice should cover out-of-hours in the Rannoch Area and put doctors in for that purpose, for medical reasons above all. The present system has been shown to be unsafe."

The second quotation comes from another constituent from the same area and refers to a specific incident that occurred recently:

"My mother, 89 years old, had breathing difficulties on February 16th 2008—a Saturday. I called the Doctor through NHS 24 and he said he'd arrive within four hours. He arrived in about three hours. The doctor was concerned with my mother's rapid heart beat and pulse rate and issued a prescription for these symptoms. My husband drove to Pitlochry and back to access a Pharmacy. This meant a 54 mile round trip and at 4.30pm my mother was able to start medication. This delay could have been saved if the NHS 24 doctor had access to the dispensary service in the Kinloch Rannoch Medical Practice."

The fear locally is that only a tragedy in the area will result in an improved health service for Rannoch.

Photo of Shona Robison Shona Robison Scottish National Party

I understand the member's concerns, but does he accept that NHS Tayside has said clearly that it expects, along with the Aberfeldy practice, to engage the local community to address many of the issues that he has raised?

Photo of Murdo Fraser Murdo Fraser Conservative

I am aware that NHS Tayside has said that, but the local community believes that it is not getting a service that meets its needs. It believes that NHS Tayside is not fully aware either of the strength of feeling in the local community or, perhaps more seriously, of some of the risks attached to the current situation.

The situation has been made worse by recent changes to ambulance cover. Previously, two full-time ambulances were stationed in Pitlochry, but that has been downgraded to one. The cabinet secretary knows my concerns about that, as I have written to her; despite her response my concerns remain. Worse still, the rapid response unit that was based in Aberfeldy has recently been moved to Pitlochry, which is further away from Kinloch Rannoch. I understand that in large rural areas we cannot expect the ambulance response times that we see in cities. However, it is a matter of serious concern, particularly where we no longer have out-of-hours cover, to see a reduction in ambulance cover that is continuing.

In her statement yesterday, the cabinet secretary announced an independent evaluation of the front-loaded model of ambulance delivery. That model has led to the deployment of the rapid response units. I ask her, as part of the review, to look specifically at the question of ambulance cover in Highland Perthshire.

In addition, I invite the cabinet secretary to visit Kinloch Rannoch and meet local residents to discuss their genuine fears about the future of the health care service in the area. I would be happy to facilitate such a meeting. I hope that she or the Minister for Public Health will respond specifically to my comments, either at the close of the debate or, if she prefers, in writing. The community is concerned that lives are at risk. We must ensure that our rural and remote communities are not disadvantaged.

Photo of Ian McKee Ian McKee Scottish National Party 10:28 am, 5th June 2008

Not so long ago, the health needs of rural communities tended to be dismissed on the ground that, if people lived far from centres of population, they could not expect to receive such a high standard of service. That situation continued for far longer than it might, notwithstanding the Dewar report in 1912, simply because country dwellers are hardy folk. They put up with complaints and conditions that those used to the softer life of towns and cities would have found unbearable.

Today, the provision of a high standard of health care in rural communities is a challenge facing countries throughout the world. With the advent of television and improved methods of communication, people living in rural areas rightly demand as far as possible the same standards of health care as are provided elsewhere.

Until recently, that demand was becoming ever more difficult to satisfy for other reasons. Standards of professional practice, often laid down by specialists whose entire training and experience was city based, meant that hospital services were becoming more centralised. The concept that improved outcomes are more likely when more services are performed also tended to centralise services, while the final nail for local services seemed to be driven home when the European working time directive shortened doctors' working hours, so that more doctors are required to provide 24-hour cover.

The results were proposals, especially in the acute services review of 1998, to centralise fairly basic hospital services so much that many people living in the Highlands and other rural areas had to travel for hours over country roads to have a test or attend an out-patient appointment. However, there was a silver lining to that sad state of affairs. Services became, or threatened to become, so outrageously poor that the philosophy of centralisation was revisited and, as it is a worldwide problem, lessons were sought from the experience in other countries, such as Australia, Canada and Norway.

It turns out that not all hospital services need to be centralised to be efficient. Whereas cancer care is better carried out in a centre of excellence, many other hospital procedures can be carried out in a rural or community hospital just as safely as in a larger centre. We welcome the cabinet secretary's decision to secure the future of six rural general hospitals and her general commitment to develop a framework for sustainable health care in remote and rural communities.

Health care is not all about hospitals. Most services are provided in the communities in which people live. Here, too, rural communities face special problems. For example, people living in Kilchoan, at the tip of the Ardnamurchan peninsula, are not only 50 miles and a ferry crossing from the Belford hospital in Fort William but an hour's drive along a single-track road from the nearest doctor, who lives at Salen. There is a weekly surgery in the village, but the doctor is a long way away in an emergency. The same circumstances pertain in many rural communities.

In the first instance, emergency medical care is given by one of the highly skilled nurses in the area, but it is now possible to augment that care using modern technology. I strongly agree with Ross Finnie that we have only begun to scratch the surface of the opportunities offered by such developments as telemedicine and other information technology advances. It is possible, for example, to send faraway hospital specialists heart tracings or recordings of womb contractions for them to advise on. Videoconferencing is an obvious application, but all sorts of images can be sent by wire or radio, enabling specialist opinion to be sought. In time, nurses and paramedics can be trained to perform examinations under the guidance and advice of faraway consultants.

Such developments not only improve the quality of service but eventually save money as costly and inconvenient journeys to hospital are avoided. We are truly limited only by the power of our imagination. However, progress has been far too slow—I was using such facilities in my urban practice 25 years ago.

One impediment to providing satisfactory care in rural areas is still the inadequacy of ambulance services—Mary Scanlon and others are right to highlight that. Steps are being taken to improve the efficiency of the service by prioritising calls, abolishing inappropriate single manning, increasing the number of trained paramedics and using satellite navigation equipment that will ultimately link up with NHS 24 or specialist services. There is also the development of ambulances based on the Volkswagen four-by-four vehicle, which will be more suited to use on Highland roads than the ambulances in service today.

More can be done—I know that, for example, one community is still scratching for money to buy landing lights for the emergency helicopter—but progress is being made.

The lesson—the thread that is constantly present—is to jettison old preconceptions and to look at the health needs of rural communities through fresh eyes, always heeding the opinions of the service users. I am delighted that the cabinet secretary is doing just that, building on the work done by the previous Government, in the Kerr report and, more recently, in the excellent report, "Delivering for Remote and Rural Healthcare". At long last, the rural health service is getting the special attention that it needs and deserves.

Photo of Lord George Foulkes Lord George Foulkes Labour 10:34 am, 5th June 2008

Presiding Officer, you will be pleased to hear that I will make a contribution somewhat different from my usual one. As you know, I am usually only too pleased to put one side of a debate—sometimes strongly—and occasionally even to attack the Scottish National Party Government. There is no shortage of subjects on which to do that—I am reverting to type. Nationally, there is a catalogue of broken promises and locally there is the reality of the council tax freeze coming into play in Edinburgh and causing cuts.

Unusually, however, I can see both sides of the argument around remote and rural health care. Being able to do that is a very dangerous condition, by the way. As members know, in another place I represented South Ayrshire, a large rural area of 800 square miles, so I am conscious of the problems of remoteness and rurality. That is why I opposed the closure of Ayr hospital accident and emergency unit, as previous Labour ministers will have cause to remember. I am aware of the problems of out-of-hours cover, ambulance response times, and of maintaining a full range of services. The Arbuthnott formula was very popular when I was in Ayrshire.

Now that I represent the Lothians in the Scottish Parliament, I am equally aware of the needs of teaching hospitals and of the need to provide centres of excellence. Indeed, I found out how important that is when my wife was taken to the Southern general hospital recently with a brain haemorrhage, so I have reason to be very grateful for that excellent service.

I see the arguments on both sides, but surely the problem is that the cabinet secretary's claim that there will be no cuts is not absolutely correct. Of course, there will be no cuts in cash terms, but that does not take account of inflation, innovations in the health service and demographic change, with the increasing numbers of elderly people. Surely it would be easier to provide the right kind of money, using whatever formula, for all health boards in Scotland through increases such as those that are being given in England.

I have a couple of specific and hopefully non-contentious points to raise. The Audit Committee carried out a thorough investigation of the Western Isles NHS Board, as Murdo Fraser, deputy convener of the committee, will agree. As my colleague Margaret Curran said, there were real concerns about mismanagement, appointments, and the lack of transparency. It all happened under a previous Administration, but it was caused by officials, and I hope that the cabinet secretary will consider that. The report also says that it was not all the fault of the Western Isles NHS Board. Some of its problems occurred because of the lack of supervision from central Government in Edinburgh. When she is considering the accumulated deficit of £3.3 million, I hope that the cabinet secretary will take account of that fact. Western Isles NHS Board is one of our most remote and rural health boards, and to expect it to be able to pay that deficit off on its own while keeping all its services going is to place it under a huge burden.

Photo of Richard Simpson Richard Simpson Labour

Does the member agree that the fact that the Western Isles NHS Board will have a reduction in its budget—

Photo of Richard Simpson Richard Simpson Labour

Under NRAC, the health board will eventually receive £7 million less of adjusted money.

Photo of Richard Simpson Richard Simpson Labour

The point is that, relatively, that will be an additional burden. I apologise to Mr Foulkes.

Photo of Lord George Foulkes Lord George Foulkes Labour

I was getting a bit worried; I thought that someone else had taken over my speech.

Photo of Lord George Foulkes Lord George Foulkes Labour

I thank the cabinet secretary very much, but I hope that she will also take account of what Richard Simpson said.

The Audit Committee also looked at the 999 service, and suggested that the Government should consider a non-emergency service because more than 80 per cent of 999 calls are not emergencies. We got a long explanation from an official, who took hours and hours and hours to explain why a non-emergency call number could not be provided. If he and his colleagues had put that time into considering the possibility, we could have had a non-emergency service.

I agree with Ian McKee and Ross Finnie on telemedicine. I read about it in a report, and saw it operating in Arran. Five years ago, problems in Arran were being diagnosed in Ayr. Surely more can be done about it now.

On democracy in the health service, the cabinet secretary has spoken about having separate elections to health boards. That will cause great difficulty. I do not think that we will get the turnout or the required interest. Many decades ago, when I was a councillor, councils had health committees to deal with public health issues. We ought to involve elected councillors more in the running of the health service.

Although I can see both sides of the argument, it will come as no surprise to the cabinet secretary that I will support the Labour amendment. I hope that, once Mary Scanlon has heard all the arguments, she and her colleagues will too.

Photo of Jeremy Purvis Jeremy Purvis Liberal Democrat 10:40 am, 5th June 2008

Following a member for the Lothians might allow me to demonstrate the reality of the differentials in the cost of rural health provision. Audit Scotland carried out an assessment of the cost of out-of-hours primary care services. In NHS Borders it was £17.73 per person and in NHS Lothian it was £9.66. NHS Borders is no less efficient in providing services than NHS Lothian, but costs are higher because of distances travelled and the other, different pressures on rural areas.

That is why I am pleased that the Government will support the Liberal Democrat amendment. There are significant concerns about the impact of the funding formula that will now be used, from health boards in the Borders and right across rural Scotland, so I welcome the fact that the Government will review it. I hope that it will do that urgently and that the standing committee will conduct its review of the funding formula before the end of the autumn.

Photo of Margaret Curran Margaret Curran Labour

I recognise the substance of the member's arguments about the standing committee, but if it does not resolve the issue, is there not an argument that the Parliament should discuss NRAC and its impact on services? The standing committee might not resolve Mr Purvis's concerns as a representative of the Borders.

Photo of Jeremy Purvis Jeremy Purvis Liberal Democrat

I agree absolutely and will come on to talk about some of those points.

In November, NHS Borders warned the cabinet secretary that, if they were implemented in full, the NRAC proposals would result in a considerable reduction of the funds available. In a letter to the cabinet secretary, the chair of NHS Borders said:

"If implemented, the effect within NHS Borders would be an inevitable, but very controversial, concentration of resources into the Borders General Hospital and away from primary and community care services."

On the Government's policy of equality of provision across Scotland, but in the context of the NRAC recommendations, the chair of NHS Borders went on to say:

"NHS Borders would like to understand how this recommendation will be reconciled with this policy commitment as we believe the impact will be to increase health inequalities in rural areas in terms of access and, over time, in terms of outcomes."

Photo of Nicola Sturgeon Nicola Sturgeon Scottish National Party

I appreciate Jeremy Purvis's interest in the subject; he is one of the few members in the Parliament who understands NRAC. Will he accept, however, that the key phrase in his quote was "If implemented", and that the Government plans to ensure that it will not affect health boards in that way?

Photo of Jeremy Purvis Jeremy Purvis Liberal Democrat

I understand the cabinet secretary's point and will come to it in a moment, but I disagree with her.

The letter from NHS Borders went on to highlight some of the flaws in NRAC.

"Without such an open approach, the members of NRAC will have been presented with a series of technical analyses that may prove one individual aspect of a formula as being reasonable in isolation. It is only when the impact of all analyses are taken together that the broader impactions can be appreciated and assessed."

The impact on the Borders will be the developing differential of an £11.7 million reduction in the budget that was available to NHS Borders under the old scheme, but will not be available to it under the new scheme.

The Government has implemented NRAC's recommendations in full and has not phased them in, because NHS Borders will feel an impact this year. As the cabinet secretary is aware, only boards that both benefited from the previous Arbuthnott formula and would be net beneficiaries under the new formula received an uplift this financial year. That is why, this year, NHS Borders received zero. Over the past four years, its annual average uplift has been £1.7 million; however, over the next four years, the uplift will be zero.

I acknowledge the cabinet secretary's willingness to discuss these issues and was pleased to meet her to do so. However, she is well aware from those discussions that, with regard to health board funding, the differential in the formula's fourth criterion, which replaces the rural weighting, is so perverse that population growth in the Borders will have to be significant to ensure parity. I was alarmed to find that her officials had not studied the registrar general for Scotland's figures for the area's population growth, which is expected to be 15.6 per cent over the next 25 years. That means that, for NHS Borders to reach parity under the NRAC formula, it will in the next 10 years need to find an extra 8,000 patients—for whom, of course, there will be no additional uplift. Such a situation is absolutely unsustainable.

This year, as a result of £3 million in cuts—part of a £10 million programme of cuts that have to be made over the next three years—stroke and palliative care wards in Borders general hospital have been amalgamated until December and 10 community beds have been withdrawn from Peebles hospital. Last week, GPs in the town told me that five patients were waiting for admission to a community rehabilitation bed.

I agree with Rob Gibson that we need long-term solutions to these problems, but this particular situation requires urgent Government intervention. Although there should certainly be a review of NRAC's impact on rural areas, the funding of NHS Borders must be reviewed right away.

Photo of Dave Thompson Dave Thompson Scottish National Party 10:46 am, 5th June 2008

I congratulate the cabinet secretary on her commitment to remote and rural health care. It was certainly demonstrated in her recent visit to Wester Ross, which is about as remote as you can get on the Scottish mainland. I am sure that her little holiday up north revitalised her, especially as we put on excellent weather for the visit and plied her with traditional Highland hospitality and copious cups of tea and scones.

Of course, the visit was far from a holiday. The cabinet secretary started at 8 am in Inverness and travelled over 270 miles on the Highlands' long and winding roads before returning to Inverness at 7 pm for a visit to the Scottish Ambulance Service's emergency medical dispatch centre and NHS 24. I think that the trip gave her a flavour of what the situation is like day in, day out for people in remote and rural areas.

Organised by the Wester Ross medical practice community representatives out-of-hours group, which is led by the redoubtable Liz Pritchard, the trip took in visits to the Howard Doris centre in Lochcarron, the health centre and Strathburn house in Gairloch and Coigach community centre, as well as a chat with the Achiltibuie first responders team. Such a hands-on visit to a very remote area obviously worked wonders on the cabinet secretary. The very next day, in Aviemore, she announced that she had accepted the recommendations of the remote and rural steering group report, which would give a secure future to rural hospitals.

In that welcome announcement, we were told that six Highlands and Islands rural general hospitals—the Gilbert Bain hospital in Lerwick, the Balfour hospital in Kirkwall, the Western Isles hospital in Stornoway, Caithness general hospital in Wick, the Belford hospital in Fort William and the Lorn and Islands district general hospital in Oban—would provide an enhanced range of services that will secure their futures and provide more specialised local health care. As the cabinet secretary has made clear, they will now provide at least minimum core services, including out-patient, day-case, in-patient and rehabilitation services; nurse-led care for urgent cases; initial management of broken bones; routine and emergency surgery; management of acute medical conditions; management of patients who have suffered a stroke; management of long-term conditions; midwife-led maternity care; and the management of patients with more complicated problems before their transfer.

On top of all that, there is more good news. Other local and community hospitals in remote and rural areas will also offer more services, including out-patient clinics, day-case treatment, midwifery services and treatment for minor injuries and emergencies.

The Government will also extend community care teams based in GP practices. Such a move will improve integration and communication by bringing together GPs, community health nurses, midwives, allied health professionals, social care staff and the voluntary sector.

In August, a new pilot project will introduce into our remote and rural communities a new type of doctor who will be able to divide their time between their GP surgery and their local rural general hospital and combine the skills of a general practitioner with specialist training in acute medicine. That is fantastic stuff and exactly what everyone expects of a go-ahead, positive SNP

Government that puts people first and delivers on its promises.

But members should not take my word for it. The British Medical Association has welcomed your Scottish Government's recognition that rural health care needs to be viewed in a completely different way from the provision of urban health care services.

Photo of Jeremy Purvis Jeremy Purvis Liberal Democrat

When my constituents ask me about the cuts in stroke and palliative care provision at the Borders general hospital and other cuts at Hay Lodge hospital, do I tell them that they are being carried out by your health board or your Government?

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

It is my Government, but I do not think that that is quite what Mr Purvis was referring to.

Photo of Dave Thompson Dave Thompson Scottish National Party

Your Scottish Government—the Scottish Government—is introducing all these improvements. Instead of spreading doom and gloom, the member should encourage the Government to continue to improve health services.

As members have already pointed out, another boon for people in remote areas is the announcement that the emergency medical retrieval service, which has been provided by consultants on a voluntary basis, will be extended. The service has been so successful that your Scottish Government has provided £1.5 million for an 18-month pilot, which began on Monday.

As the cabinet secretary has made clear, this move means that patients on the west coast who have life-threatening illnesses or injuries will now have access to the previously limited emergency medical retrieval service, which will now serve everyone from Stranraer to Stornoway and will cover five health boards with three rural general hospitals, 13 community hospitals and numerous isolated practices. This unique and innovative Scottish flying doctor service involves consultants from NHS Greater Glasgow and Clyde working in close co-operation with the Scottish Ambulance Service and rural health boards.

This is all on top of the fact that people in remote and rural areas have benefited not only from the extra £97 million that has been committed to phase out prescription charges and ensure that sick people are not financially disadvantaged but from the extra 19 per cent that will be added to the health and wellbeing budget by 2010-11.

Our Government—mine and yours—is delivering and you should all be proud of it.

Photo of David Whitton David Whitton Labour 10:53 am, 5th June 2008

I thought that it was the other way round, Presiding Officer. Do you want to change the order, or shall I just carry on?

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

You have started so well. Please carry on.

Photo of David Whitton David Whitton Labour

Okay. I've started so I'll finish.

I welcome the opportunity to take part in the debate and will support Margaret Curran's amendment. Like Murdo Fraser, I will use my speech to comment on a constituency matter.

Unlikely as it might seem, remote and rural health care issues are extremely pertinent in parts of my constituency of Strathkelvin and Bearsden, which, like other Scottish constituencies, is a mix of urban and rural areas. This morning, I will focus on its rural areas, particularly the village of Twechar.

A former mining community, Twechar lies almost equidistant between the larger towns of Kirkintilloch in East Dunbartonshire and Kilsyth in North Lanarkshire. Classified as an area of multiple deprivation, it suffers from many of the associated problems such as poor housing, poor transport links and poor health.

In the past, the village's residents were served by a satellite GP service that was provided on a part-time basis from a surgery in Kirkintilloch. However, a few years ago, that service stopped when the GP who provided it moved away, and her patients had to choose whether to register with doctors in either Kirkintilloch or Kilsyth.

As we have heard, rural communities such as Twechar generally face poorer access to health care services. For example, primary care GP services and community health teams are likely to be located at some distance from home. Patients have limited or no choice as to whom they see for treatment, and may be offered a more limited range of services.

Many of Twechar's population of just over 2,000 are elderly or were previously employed in the mining industry and have health problems that are associated with that industry. As we know, older people frequently live on a limited income or pension, often do not have their own car and might well be infirm or in poor health. They do not have the option of walking to an appointment with a health care professional and public transport might be severely limited. Opportunities for women with young children to obtain child care for other youngsters while they attend an appointment might be limited or non-existent and they, too, might have no access to a car. People who have disabilities are similarly affected. That is why the SNP's decision to freeze the bus service operators grant and end the rural transport fund is a mistake, as it leaves villages such as Twechar vulnerable to the possibility of losing vital bus links. However, that is another debate for another day.

In 2005, the Twechar regeneration group successfully secured a capital grant of £100,000 from Greater Glasgow NHS Board for the conversion and refurbishment of the former recreation centre, which was relaunched as the healthy living and enterprise centre. The new centre, which was visited by the Cabinet Secretary for Finance and Sustainable Growth last year, provides the residents of Twechar with access to a range of community health services, such as a pharmacy, smoking cessation classes, parenting programmes and health improvement work with young people. However, there is still no GP service.

Getting the pharmacy to locate in the centre was a major boost because, prior to the centre's launch, there was no pharmacy in the village. Local residents had no alternative but to travel outside the village to collect regular medication. Over the past year, a number of Twechar residents have contacted me about the lack of a GP service and the possibility of reinstating the satellite service in the new centre, close to the pharmacy. I was informed by the local community health partnership that a health survey had been conducted last year, which found that there was no call for a GP practice in the village. However, I have since conducted my own survey of residents and was not surprised to discover that a significant majority of them would like a GP service to return to the village, even if it would be provided only once or twice a week.

On page 16, "Delivering for Remote and Rural Healthcare" states that access to health care should be as local as possible. In her speech, the Cabinet Secretary for Health and Wellbeing repeated that people should have equal access to the NHS and that that access should be as local as possible. Nicola Sturgeon and I really must get out of the habit of agreeing with each other.

The BMA has identified recruitment and retention of doctors in rural areas as a significant challenge but, for now, the residents of Twechar are being denied basic health care provision in their own village. As with so many other villages that are reasonably close to urban areas but which are still defined as remote, the problem is persuading the local GP to get out and about in the community that they serve. Happily, the one GP practice that I have contacted would be happy to hold a weekly surgery in Twechar, if it can get the go-ahead from the health board and the community health partnership. That is the next stage of the campaign, which I hope the cabinet secretary and the Minister for Public Health will support.

As we have heard, around a million people in Scotland—a fifth of our population—live in rural areas. Some of them have very good health care provision, but many do not. In last night's members' business debate, we celebrated the 60th anniversary of the national health service. The fact that the NHS is a patient-centred service means that people in rural areas deserve the same consideration as town and city dwellers. That is why I had hoped that the cabinet secretary would accept the Labour amendment in the spirit in which it was lodged.

Photo of John Lamont John Lamont Conservative 10:58 am, 5th June 2008

I am grateful for the opportunity to speak on such an important topic. It is crucial that we provide health care services to people in every part of Scotland, not just to those who live in the urban central belt, so it is right that we are debating the needs of rural health services in Scotland.

I believe—as I am sure most members do—that quality health care is one of the most basic services that a nation can provide. Governments, especially the most recent Scottish Executive, have failed to provide many people who live in remote and rural communities with the same quality of health care that is delivered to people in urban areas. That must change. My constituency in the Scottish Borders is an area where health services have come under severe pressure, and I will again bring some of the issues to the attention of the Parliament and the Government.

The recent announcement of the closure of ward 14 at Borders general hospital has come as a shock to patients, staff and constituents alike. Although Borders general hospital is not in my constituency, it is an important resource that provides a valuable service to a large number of my constituents.

On top of that news, we have been told that there will be a reduction in bed capacity in the local community hospitals. It was announced only last month that there will be summer cuts of four beds at each community hospital in my constituency, which will be implemented in the coming weeks. Yesterday, I spent time with a senior Hawick doctor who has responsibility for Hawick community hospital, so I know that there is widespread concern among staff about how quickly the decision has been taken and about the lack of consultation.

There is a concern that, without the additional beds, the professionals will not have the flexibility to decide which patients need hospital treatment.

In effect, there will be a waiting list for available beds at the community hospitals. The health board wants more patients to be treated at home but, as any doctor will say, that is not always practical or feasible for patients.

I will tell Parliament of the scenario that the Hawick doctor described to me yesterday. Let us imagine the case of a very elderly patient in Hawick who is in her dying days. Nothing more can be done to help her other than to make her last days as comfortable as possible. She has lived in the town all her life and her final wish is to die in the town where she was born with her family around her. It will simply not be an option for her to go to Borders general hospital, which is 20 miles away. I am told by the doctors and professionals that the proposed bed cuts will mean that such patients might well have to wait two or three weeks to get the bed that they need for their last days. Unfortunately for the lady in question, time is against her and she does not have two or three weeks to wait.

Staff are also concerned that, although the proposed service reductions are described as short-term summer cuts, on numerous occasions in the past short-term cuts have turned into permanent measures. They no longer believe what they are told. Who would blame them, when it transpires that the summer cuts will continue until December? Since when has December been a summer month in Scotland?

Parliament should be aware that those cuts come on the back of a number of hospital closures in the Borders. Thanks to the health policies of the previous Government, we lost Jedburgh and Coldstream hospitals, together with 40 other community hospitals across Scotland. Even though they received overwhelming support from their local communities, the Minister for Health and Community Care, Andy Kerr, and the Liberal-Labour Administration failed to support them and allowed them to be closed, so I find Mr Purvis's crocodile tears, which he has shed both in the debate and in the local press, a little rich, given his Government's record on rural health services in the Borders.

Photo of Jeremy Purvis Jeremy Purvis Liberal Democrat

I understand why the member makes that political point; he is fully entitled to do so. I opposed those closures, as did Mr Lamont's predecessor. Whether we are talking about wrong decisions by Borders NHS Board or by a Government, it is incumbent on all of us who represent the Borders to ensure that, in the long term, the funding formula does not disadvantage any of our constituents.

Photo of John Lamont John Lamont Conservative

It is perhaps a reflection of how little influence the Liberal Democrats had on the previous Administration that, despite the fact that they claimed to object to those closures, they were unable to reverse the decision.

Instead of hospital cuts, I could have focused on the chronic shortage of NHS dentists in my constituency. Only 17 per cent of adults in Roxburgh and Berwickshire are registered with an NHS dentist. What an astonishing figure! Although the opening of new facilities in Coldstream and Hawick in the coming months will result in improvements to the dental care system in the Borders, accessibility remains a significant issue. Patients who do not have a car face a bus journey of several hours to get to the new dentists. I look forward to hearing from the minister how the Government intends to improve accessibility to dental care in the Borders and other rural areas.

The debate has been essential, as people's inability to access health care services in remote and rural parts of Scotland and the lack of health care services in those areas are an issue of growing importance. Access to health care in remote and rural areas is becoming more of a problem. As I have demonstrated, the closure of community hospitals and wards is making it more difficult for the people of Scotland to receive the health care that they need. It is imperative that we keep local health care local and that the people of Scotland have access to health care, regardless of where they live. Improvements must be made to our remote and rural health care services. The mistakes that were made by the previous Liberal-Labour Administration must not be repeated.

Photo of Nigel Don Nigel Don Scottish National Party 11:04 am, 5th June 2008

I will begin by taking the opportunity to correct what I said on 22 May, when we debated the ambulance service in remote areas. I quite incorrectly said that the ambulance service in Braemar had been moved to Aboyne when, in fact, it has been moved to Ballater. I was well aware of that; I simply made a mistake. I apologise. That does not change the thrust of my argument, but it means that what I said was factually wrong.

As is usual at the end of a debate, I will pick up on issues that other members have not picked up on, starting with demographic change. Someone pointed out that our rural communities are getting older, which is partly because more older folk are choosing to stay in rural communities and they are living longer, but also because there is still, to an extent, the historically inevitable movement of younger folk to the cities for employment and training, and the tendency for them not to return. That brings me to a central point that I do not think that anybody has mentioned. Whatever we and the Government are doing now, we need to remember that it will be different in five years, and different again in 10 years. We must therefore have mechanisms that allow us to continue to look ahead rather than rest on where we have got to.

We have talked briefly in the debate about telemedicine, and I would not dream of telling doctors how they can do that. However, as a layman, I am conscious that I have access to a computer and the internet and that we are moving to the point where many folk in rural communities will have access to the internet. If they do not have access, their neighbours may well have it. I wonder, therefore, whether we need to look ahead and consider whether contact with the health service could be made in the first instance through the internet. For example, if someone's bairn was crying at 2 o' clock in the morning and they did not know what to do about it, why on earth could they not switch on to something called, say, and say, "Hey, guys, what do I do with this?" That would be swift, reassuring and cost effective, and it would surely eliminate many problems the following day. I encourage the health service to look further ahead from what we can do now.

In preparation for the debate, I spoke to some rural GPs. I asked them generally what they thought about the situation. As members can imagine, they told me many things that, frankly, I do not have time to pass on. However, I asked them clearly what their top priority was and what the biggest issue affecting them was. The common theme was transport. It is not all about ambulances, although that issue has been well rehearsed; it is also about buses and the long miles between places. In that context, I urge folk to think about how they build their transport models and to recognise that, although we sometimes want the patient to go to the health professional, it is sometimes better for the health professional to go to the patient. I encourage folk to think outside the box of specialties and all that kind of stuff, which the health service naturally thinks about because that is its stock in trade. I want the health service to engage more with the model of thinking that says, "Where do these people need to be? What is the best way of getting good contact time between patient and professional?" I want the health service to acknowledge that travel times are inevitably involved in that, and to consider whether the right person is doing the travelling at the right time.

Photo of Jamie Stone Jamie Stone Liberal Democrat 11:08 am, 5th June 2008

Representing the constituency that I do, I warmly welcome the cabinet secretary's comments about people having equal access no matter where they live. In the past, I have expressed my constituents' worries about the actuality of access, which was rather different.

It was good that the cabinet secretary talked in Aviemore some days ago about securing the future of our community hospitals—we all welcomed that. However, I jumped the height of myself when she talked about midwife-led maternity services, and I wrote to her within minutes. However, I have received an assurance from NHS Highland that it still intends to maintain the consultant-led service in Caithness general hospital, and I take at face value the Minister for Public Health's statement that that is the case. Enormous anguish and anxiety were caused by the previous proposal to downgrade the maternity service in Caithness. Members will remember me and others getting on our feet many times about that issue. We must never revisit that proposal, and we must never contemplate stepping back from the high level of service that is crucial to my constituents and me.

Margaret Curran referred to NHS representation. Before the appointment of Colin Punler to Highland NHS Board, the far north of Scotland lost out on representation on that board. That issue has been addressed, but the previous lack of representation brought us to a dreadful impasse for the maternity service. Now that we have representation for the north, I believe that things are much better. However, we must always be vigilant in ensuring that the membership of not only Highland NHS Board but other large rural boards has sufficient geographic coverage.

I could not let this speech go by without saying something about ambulance services. I welcome the commitment that the cabinet secretary gave yesterday to get right into this issue. I echo two pleas that I made yesterday. First, could the cabinet secretary's officials please talk to the GPs on the ground, who know better than anyone what the situation is? They have told me, for example, about the terrible situation of the GP having to leave the north coast and travel down to Raigmore hospital with a patient because there was no second man in an ambulance. What would have happened if someone in Tongue or Bettyhill had had a heart attack during that time? However, I take at face value what the cabinet secretary said, and I welcome her turning over the stones to see what has been going on. My second plea is for part-time working to be looked at because I believe that it is a considerable disincentive to recruitment.

I intervened earlier to make a point about the interrelatedness of the good intention of what the cabinet secretary has told us today and the difficulties to which working together with, for example, the social work department in Highland Council can lead, as other members have said.

Rhoda Grant mentioned the Howard Doris centre, which is named after the company that built the mighty Ninian Central platform. We in the north are led to believe that Highland Council faces social work budget cuts of approximately £400,000. There is no doubt that that will undermine the good work that is being done in another department.

The future of the Assynt centre was mentioned. It is a respite centre for the elderly whose availability was downgraded some time ago from seven days a week to five. There was talk of upgrading it again to seven, so that old people in Assynt in west Sutherland could stay in the place where they were brought up, which they love so well. There is no talk of taking it back to seven days now, but I have written continually about that. We must always be vigilant in ensuring that difficulties in Highland Council's funding do not undermine best intentions for the health dimension.

Mention was also made of the difficulty in the recruitment and retention of workforces. That was outlined to me on a recent visit to the Lochshell dental clinic in Wick as one of the challenges that the clinic faces. I know that the same challenge is faced in the constituencies of other members.

Photo of Dave Thompson Dave Thompson Scottish National Party

I am sure that the member will accept that Highland Council is doing a great job in replacing five of its residential care homes from within the current budget.

Photo of Jamie Stone Jamie Stone Liberal Democrat

That is a smokescreen that cannot hide the fact that the Assynt centre has not been upgraded and that old people are being forced to move away from the area that they love so well. I sincerely hope that there is no threat to the future of the Caladh Sona facility on the north coast.

What is being delivered in Lochshell is good news for the cabinet secretary because it is cutting edge and it is addressing some of the huge problems that we face in the north of Scotland regarding lack of access to NHS dental services. However, I give credit where it is due. On my visit to Lochshell, I was accompanied by Garry Coutts, the chairman of the health board. It is true that a dent is being made in the huge number of people who need dental services, but that is happening against the backdrop of a big problem. However, I believe that the Lochshell dental clinic is an example that could be replicated in other parts of rural Scotland. With the best of intentions, I cordially invite either the cabinet secretary or the minister to come and visit it as soon as possible. I think that they will be pleased by what they see, which I believe is a step forward.

I have two final points. First, mention has been made of patient delivery. If a private citizen in the Highland area delivers somebody to a hospital for treatment in a car that is up to 1500cc, they get 30.5p a mile; if the car is over 1500cc, they get 36.9p a mile. That may seem a lot, but a gallon of diesel in Durness costs £1.45—sorry, I mean a litre of diesel; I wish it was a gallon. Members can see that the mileage remuneration is being eaten into. The rising price of oil is not the fault of the Scottish Government, but it is having a devastating effect on people who, out of the goodness of their hearts, deliver patients.

My final, brief point is that there must be confidence in the NHS 24 service if all its good intention is to be delivered. Recently I dealt with the case of Mr and Mrs Petrie at my Castletown clinic. Their child took ill and they were advised to put him in bed. Instead, they took him to hospital, where it turned out that he was diabetic. Members can imagine what might have happened had the parents not intervened. Confidence in the service is crucial.

Photo of Jackson Carlaw Jackson Carlaw Conservative 11:15 am, 5th June 2008

This has been another long and worthwhile debate on a significant area of health policy. I say that somewhat wearily because, as others have observed, this is not the first worthwhile debate on a health topic in recent weeks, and I am sure that it will not be the last, because all manner of other initiatives for us to relish are pending. If talking about health were to make us healthier, I am sure that we would all be fit specimens, although when I look around the chamber and in the mirror, I see that that does not follow. I can only hope that a debate on anaesthetics is not planned for the immediate future.

None of what I have said makes today's debate any less important. As Mary Scanlon said earlier on our behalf, we support the conclusions of the remote and rural steering group report "Delivering for Remote and Rural Healthcare" and the Cabinet Secretary for Health and Wellbeing's announcements. We also recognise the work of the previous Administration in preparing to tackle the challenge. Presiding Officer, perhaps you could issue hats to all members, as that would make it much easier for us to doff them to the previous Administration in the ritual act that we are required to perform.

The problems that the report seeks to address are fundamental but particular: higher suicide rates; a higher incidence of alcohol-related disease; a higher number of accidents, whether on the roads or through climbing, farming and fishing; a palliative care load that is higher than the urban equivalent; and the huge seasonal fluctuation of population. Rob Gibson spoke convincingly about the need for a flexible funding model.

As a visitor to the remote north and as something of a townie—although a fan of the countryside—I am struck by the sheer isolation of many communities and individuals there. It is quite a thought that in some places the population can be so low for much of the year. The consequential loneliness can have a particularly strong effect on the incidence of alcoholism and, tragically, suicide. We welcome the actions that are designed to improve mental health in such areas, as the unique lifestyle conditions that I have described can fuel the depression that often leads to tragedies, many of which we ought to be able to avoid.

As Mary Scanlon said, we welcome the cabinet secretary's acceptance that six hospitals should provide core services and her intentions for other local community hospitals.

I was encouraged by the fact that the cabinet secretary sees an opportunity to develop of e-health, where appropriate, especially where it can obviate the need for long and unnecessary journeys. I listened with interest to the sensible comments of Ross Finnie and Rob Gibson on telemedicine. We welcome the emphasis that the cabinet secretary is placing on designing a solution that allows care to be delivered as near to home as possible and as safely as possible. In particular, we look forward to a successful outcome to the extended pilot in the west of Scotland.

It will be interesting to see what role directly elected health boards will play in rural communities, especially given the challenge of geography and the need to ensure that in any one health board—especially a rural one—the elected representatives do not all come from one street or community, as, in theory, they could.

Another emerging challenge is the consequences of the new NHS funding formula. I understand the cabinet secretary's position on the issue. She is essentially correct when she says that a more up-to-date funding method should be applied. However, having seen such arguments lost in politics and business before, I remind her of the old adage that perception is the truth, even if it is not the reality. Whatever she says today, the perception is growing and becoming entrenched that rural health boards face budget cuts—saying that they do not will not be enough. I give her fair warning that NRAC will need careful explanation—and soon—if the Government is to avoid finding itself unable to persuade a public who have reached a conclusion, however inaccurate it may be. It would not be wise for her to rely solely on the argument that people are scaremongering.

However, the cabinet secretary is right to caution the Labour Party against alarming and misleading the public, in its desperation to find a line of political attack, by being lurid rather than factual. The longer Margaret Curran spoke this morning, the more she allowed herself to indulge in the lurid rather than the factual. The Liberal amendment offers a measured way forward and, on balance, we should listen to it.

Photo of Helen Eadie Helen Eadie Labour

Do Jackson Carlaw and the Conservatives accept that NRAC is a target and not an allocation?

Photo of Jackson Carlaw Jackson Carlaw Conservative

Exactly. That is why the Liberal amendment, which proposes a resolution, is preferable to the Labour amendment, which simply identifies the issue. Margaret Curran's genuine concern about appointments in the Western Isles would carry more authority if occasionally the Labour Party accepted that the practice when it was in government could have been improved in some cases, or even one case.

It was good to listen to the speeches of rural members. John Lamont spoke movingly about the practical consequences of proposed service reductions in his constituency and raised the important issue of rural dental care. Christine Grahame spoke with particular reference to the board's proposals for bed cuts at Hay Lodge hospital. I should credit the member, as last week I saw her local paper and can confirm that, as she said, she was all over it fighting this battle.

Rhoda Grant made a fair point about the additional responsibilities of ambulance staff and the need for training and reward. There was a measured contribution from Helen Eadie, on which I congratulate her. George Foulkes, with the breadth of vision that is afforded by his career of so many hats, astonished us all by recognising so late in his political life—after decades of sitting in this chamber, the Commons, the Lords and his local council—that an argument can have two sides. It was a long wait, but it was worth while. Meanwhile, Dave Thompson enchanted us with the news that people in his community get to lie in until 8 o'clock in the morning and that their final activity is at 7 pm—nice work if you can get it. If ever I need a pair of rose-tinted spectacles, I will know where to go. Dave Whitton reminded us again of the 60th anniversary of the national health service. If I had stuck with the Labour Party after my early teens, I would burst with pride at what was undoubtedly its greatest achievement in government so long ago—what a pity that it has been all downhill for the Labour Party ever since.

We appreciate the cabinet secretary's support for the amendment in Mary Scanlon's name, which followed a detailed discussion yesterday. We will support the motion and the Liberal amendment.

Photo of Richard Simpson Richard Simpson Labour 11:21 am, 5th June 2008

This has been a good debate. I start by inviting the cabinet secretary to get through one debate without accusing the Opposition of scaremongering when it tries to make serious points.

Photo of Richard Simpson Richard Simpson Labour

I want to make some progress. I will give way to the cabinet secretary later, but it would be helpful for her to drop the word "scaremongering".

We are having this debate because, as the cabinet secretary rightly said, it is important that people in remote and rural communities and everyone else have equal access to health care. The geography of Scotland is one reason for the Barnett formula, as we need additional funding to support necessary services in remote and rural areas. Members have referred to factors other than geography that are important. There are differences between the health needs of remote and rural areas and those of other areas. Jackson Carlaw mentioned higher suicide rates, a higher incidence of alcohol-related disease, a higher number of accidents and a higher palliative care load.

Five areas need to be addressed, but none of us has time to consider them in the necessary depth. Members have referred to recruitment and retention; education; the fact that organisational structures in remote and rural communities need to be different; ambulance and emergency care services; e-health; and the vexed question of NRAC. I propose to deal with as many of those issues as I can in the time that is available to me.

On recruitment and retention, no one has mentioned the little-understood term "proleptic appointments", to which the report refers. The issue is fundamental, as the situation in remote and rural areas is different from that in towns. We need to appoint people in advance of their taking up posts, to ensure that their induction is not brief and to recognise the peculiar needs of rural communities. In other words, there needs to be extended induction. That requires funding, because it is vital to appoint people three months ahead of time to prepare them. Ian McKee and others referred to the need for multiskill training. The day of generalist surgeons, who operated until recently throughout Scotland, has almost gone, so how do we prepare people for work in more remote and rural communities, where they will have to undertake more traditional roles? That needs to be addressed, and the report goes into the issue in considerable detail.

Multiskilling and multitasking are not just for groups such as general surgeons, but for all workers in remote and rural areas. The report does not emphasise sufficiently the need not only to provide the different skills that an extended community care team requires but to make use of the different skills and aptitudes of individuals, which is especially necessary in remote and rural communities. People also need to be integrated and matched with facilities. A detailed set of management and human resources tools is required.

Another issue that has not been referred to is the role of volunteers. Volunteers are important throughout the health service, but their importance in rural communities is even greater. Jamie Stone and others referred to the problem of volunteer drivers; I am referring to other groups as well.

Some members referred to agenda for change and the European working time directive, which are particular issues in remote and rural communities. The directive makes providing out-of-hours care extremely difficult. On agenda for change, the peculiar skills of individuals need to be recognised, which is particularly difficult for those communities. The extended community care model that has been referred to builds community resilience, which is particularly important.

The need to integrate all services to provide good out-of-hours cover was illustrated extremely well by Murdo Fraser. The situation is difficult, now that GPs are no longer prepared to work 24 hours a day. Jeremy Purvis referred to the cost of the out-of-hours service in the Borders being twice the cost of that in NHS Lothian, but in the Highlands it is actually six or seven times the cost in Glasgow. There are huge differences.

The report refers to replacing fragmented services, different organisations, duplication and a mainly reactive service with one that is integrated and involves partnership, seamless delivery of care and anticipatory care. I will illustrate that briefly with the example of the Ambulance Service. The report states that, for some areas, further embedding that service within the territorial boards would seem to be appropriate. Mary Scanlon referred to that. The cabinet secretary and the Minister for Public Health should consider that carefully. The pilot in which paramedics provide anticipatory care reflects a need for a much stronger degree of embedding within the territorial boards than has happened hitherto.

In the report, we find that there are six different levels of nursing care and eight different levels of allied health professionals, all of which are assisted by support workers. I welcome that—it is appropriate for rural areas—but, as Mary Scanlon said, we need to consider carefully the terms and conditions of those workers.

The bit of the report on e-health is not as strong as I would like. A number of members, including Rob Gibson, Ross Finnie and Ian McKee, referred to the importance of e-health. The report appears to stress the need for service-to-service connection. That is important for delivering diagnostic services in remote communities that are served by primary health care teams, linked to hubs. The report deals with that adequately. However, as Nigel Don referred to eloquently, the report does not deal with the concept of e-health as a tool for monitoring individuals in their homes. West Lothian has one of the leading examples of that in Europe. About 3,000 homes are monitored. We could develop that by monitoring bed pressure and movement, and, as one member suggested, by working with patients to provide online facilities. Northern Ireland has just announced £46 million for such an initiative. Our budget for that is considerably less. Nigel Don's concept was of a vision for the future. I understand the constraints, but the report is weak on e-health and it needs to be strengthened.

We may have difficulties with the detail of NRAC, but we must remember that Arbuthnott was set up by Labour and with the agreement of the Parliament, and was welcomed by everyone. However, it led to problems, for example in Grampian, where the allocation was cut. I remember Mike Rumbles's eloquence in the first session of the Parliament about that "terrible" cut. It is understood that some will be winners and some will be losers, but the concern is that the new system is less transparent and that, by using small areas to define the formula, it loses something that Arbuthnott had.

My final point is one that I made in the Health and Sport Committee. Primary care is fundamental to remote and rural areas, but it has not been considered. That was also a criticism of Arbuthnott. NRAC has admitted that it does not have the data to deal with the issue.

The cabinet secretary may be concerned about how Labour members are expressing themselves, but there is no doubt that there is concern about the cuts. We may argue about the figures, but we estimate that there will be cuts of about £12 million or £13 million for the Borders, over a period of time. Without a cut, costs will rise year on year, but, as George Foulkes said, the rises will not reflect the needs of communities. Labour makes an important suggestion about NRAC in its amendment. We are not scaremongering; we are inviting continued debate with NRAC. The Liberal amendment refers to that, too.

RARARI has done excellent work. I praise Paul Martin, Dr Gibbins and the 30 members of RARARI for their hard work, which comes on top of Lewis Ritchie's community care report. We have vital models, but we need to consider e-health and revisit NRAC from the point of view of its transparency.

Photo of Shona Robison Shona Robison Scottish National Party 11:31 am, 5th June 2008

I thank the Parliament for the helpful and, in the main, constructive way in which it has debated the future of remote and rural health care. The report that stimulated the debate was produced by a working group that the previous Government established, and I am pleased that there continues to be a good deal of consensus among the parties and a shared determination to provide sustainable health care in our rural communities.

I shall deal with some of the issues that have been raised in the debate. Richard Simpson made a good point about the way that we express ourselves. Margaret Curran failed to say whether she would have supported NRAC's recommendations. She talked about interrogating the recommendations. I do not think that any member would believe that the cabinet secretary did anything other than interrogate the recommendations—of course she did. To be fair, Richard Simpson was far more reasonable in his approach to NRAC. The same goes for Ross Finnie, who made a constructive speech on a constructive amendment and demonstrated an understanding of the issues involved. To members such as Jeremy Purvis, John Lamont and Christine Grahame, who raised issues about NHS Borders, I say that NRAC will provide an opportunity for issues and detail to be discussed. I am pleased that members throughout the chamber have welcomed the setting up of that committee.

Photo of Jeremy Purvis Jeremy Purvis Liberal Democrat

The Minister for Public Health will be aware of the urgency of the situation. Can she indicate when NRAC will consider health funding in rural areas?

Photo of Shona Robison Shona Robison Scottish National Party

Work has already begun on setting up the group. The details will be announced shortly.

Margaret Curran talked about out-of-hours care. The expert group that will be established to consider the funding formula will be able to consider and make recommendations on issues such as the cost of providing out-of-hours services in remote and rural areas.

Photo of Margaret Curran Margaret Curran Labour

I refer to the earlier point about the change from Arbuthnott to NRAC. I would have interrogated the importance of house type in determining need and mortality. Perhaps the minister will explain that.

Photo of Shona Robison Shona Robison Scottish National Party

All of those issues were interrogated by the cabinet secretary. Margaret Curran has failed to say what she would have done differently. That is the weakness in her argument. She knows as well as every other member that she, too, would have accepted NRAC's recommendations.

Mary Scanlon raised an issue about generic support workers. That role is being developed and evaluated by NHS Shetland, and is for communities that have no health or social care at present. I can assure the member that generic support workers will not, therefore, replace health visitors in any way, but they will provide essential care and support where no such support is currently available. We will ensure that members are kept informed of progress. Of course, the terms and conditions will be relevant to agenda for change, which I know Mary Scanlon is concerned about.

Rob Gibson made some important points about community involvement in designing models of care. We want communities to be very much involved in the development of their health care services.

Helen Eadie raised a number of points. I confirm that the funding for the national programme manager has been provided by the Scottish Government and that the programme manager is now in place. She also raised a constituency case. It is absolutely right and proper for members to raise constituency cases in the chamber—I have done so myself—but, when they do so, it is important that they get the facts correct. Helen Eadie asserted that she had not received a reply from the cabinet secretary after seven weeks. I say to her that the reply to her letter of 12 March was sent to her on 5 April. Helen Eadie must reflect on her comments in the light of that fact.

Photo of Helen Eadie Helen Eadie Labour

It was not a substantive reply; it was a holding reply, and, given that the case involves someone who is dealing with life-and-death issues, that is not acceptable. I had the constituent in my surgery on Monday night, and they were absolutely devastated, having had weeks of sleepless nights. They were really upset, really angry at the lack of care—

Photo of Shona Robison Shona Robison Scottish National Party

The case involves important issues, and the board is taking them forward. I do not minimise the concerns that the case raises, but I stress that it is essential that members do not misrepresent the facts. The reply from the cabinet secretary, which I have with me, is a substantial letter that deals with some of the concerns that Helen Eadie raised. She should not have implied that there was a seven-week time lag in the reply, because that is not accurate.

Murdo Fraser raised a number of issues regarding highland Perthshire and Kinloch Rannoch, and I am aware of the similar issues that have been raised by the Cabinet Secretary for Finance and Sustainable Growth. As I said to Murdo Fraser, discussions will take place between the Aberfeldy practice and the local community. However, I will respond to him in writing to address some of the detailed concerns that he raised.

Nigel Don raised a point that was, perhaps, not addressed as deeply in the debate as it should have been. The challenge of demographic changes must be met, and we need to look ahead in order to do so. He said that telemedicine and telecare had great potential in that regard, and I absolutely agree. At the moment, we are only touching the margins of the potential of telemedicine and telecare, and the particular relevance that they have for maintaining older people safely in their own homes. I saw some of that potential when I visited the Scottish centre for telehealth, and I think that, over the next few years, we will see the potential of such delivery mechanisms as they roll out.

The programme of action that we have outlined is designed to bring clarity about the services that people have a right to expect and to give people confidence that the services will be sustained. It is realistic about the challenges that the NHS faces in remote and rural areas, such as the challenges of geography, demographic change, rural deprivation and attracting and retaining the best staff, with the skills that they need to meet the needs and expectations of patients, their families and their carers. The programme is also confident—confident about our ability to support the resilience of rural communities, to realise the benefits of new technologies and to work in new and different ways.

The proposals will boost the confidence of patients who live in remote and rural Scotland. We have set out a model of care that can be sustained over the longer term, removed the fear that the axe might drop on our rural general hospitals and turned our backs on the relentless drive towards the centralisation of vital health care services, which was, unfortunately, a hallmark of the previous Administration.