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Rural Out-of-hours Health Care Provision

– in the Scottish Parliament at 2:56 pm on 11th November 2010.

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Photo of Alasdair Morgan Alasdair Morgan Scottish National Party 2:56 pm, 11th November 2010

The next item of business is a debate on motion S3M-7190, in the name of Christine Grahame, on out-of-hours health care provision in rural areas.

Photo of Christine Grahame Christine Grahame Scottish National Party 3:26 pm, 11th November 2010

This has been a busy week for the Health and Sport Committee, with our regular meeting on a Wednesday morning, the stage 3 debate on the Alcohol etc (Scotland) Bill yesterday and now a committee debate this morning.

Photo of Christine Grahame Christine Grahame Scottish National Party

I mean this afternoon. I am just checking that members are awake.

I feel in particular for my colleague Helen Eadie, who rounds the week off with her members' business debate tonight. Next week for the team, it is stage 1 of the Patient Rights (Scotland) Bill. Perhaps we should look at the legislative agenda closely and read the runes—the Patient Rights (Scotland) Bill, the Palliative Care (Scotland) Bill, the End of Life Assistance (Scotland) Bill and the grand finale in more ways than one, the Certification of Death (Scotland) Bill. It could drive us to drink.

That said, it is time to turn to the topic. It would be useful to remind members why the committee undertook an inquiry into out-of-hours health care provision in rural areas. It reflects not only the radical changes to general practitioner contractual duties, but the facts that so many members, including me, represent wholly rural constituencies and that even some urban members—if I may call them that, because of Scotland's rural nature—have rural corners of their constituencies.

In the days of Dr Finlay and his casebook and his very worthy Janet the housekeeper—this is a generation test—and right up until 2004, GPs had 24-hour responsibility for care of their patients. They could not delegate that responsibility and were required to make arrangements for any cover that was needed. However, as demand for out-of-hours care increased steadily, and perhaps because of raised expectations of medical care—which is no bad thing—together with the demographic shift in population, it was recognised by the mid-1990s that GPs who were providing out-of-hours care were under significant pressure. As a result, new ways of working developed and GP co-operatives became the main vehicle for delivering out-of-hours services. Those new ways involved GPs giving one another shift cover, as it were.

Step forward into the picture NHS 24, which was launched in 2001 and which has three core functions. It provides nurse-led consultations, aided by clinical-decision support software, or triage by phone; it provides referral, where appropriate, to a range of other services; and it provides health information through health information advisers. It is fair to say that, in the early days, the news for NHS 24 was not all good. Some high-profile cases rightly set alarm bells ringing as to the efficacy and even safety of the service, but I believe that today it is realised that NHS 24 is a different kettle of fish. It is not perfect, but it is improved and improving. However, damage was done and our report emphasises that there remains

"a substantial degree of work to be done to re-build confidence in NHS 24, in order to ensure that it operates as a fully effective element of the out-of-hours range of services."

On the plus side, NHS 24 now takes responsibility for the Scottish centre for telehealth. Established by the previous Scottish Executive in 2006 to promote the use of telehealth by health boards in Scotland, it could have a much enhanced role to play in delivering health care in remote and rural areas, with the prospect of saving some patients what can amount to a round-the-globe trip to see a consultant, with costs to the health service in personnel and cash, to patients' wellbeing and even to their pockets. To date, the centre for telehealth has been a bit of a Cinderella operation, but the move to NHS 24 will give it impetus, changing its modus operandi from advice to advice and action. We hope that it will go from having no teeth to having a full and biting set, which all committee members want—I mean its efficacy, not its teeth. I refer Parliament to our earlier report, which was debated on 22 September this year, busy little committee bees that we are. I digress.

Into the mix with all those pressures was added the UK-wide GMS contract, or, to give it its Sunday name, the new general medical services contract 2004. The days of team Dr Finlay, Dr Cameron, Janet and the unforgettable Dr Snoddie, were not just numbered; more than just being television history, it was curtains for the likes of that couthy doctorial team. What did that GMS contract change? It brought in two key changes, with ramifications that were perhaps not fully appreciated at the time. It freed GPs to opt out of providing any services out of hours—not in itself a bad thing, because a tired doctor is not always the best doctor—and it transferred the responsibility for securing that out-of-hours provision to NHS boards.

How was the 24-hour service to be delivered and has it been delivered? NHS boards are free to enter into contracts with GPs who wish to provide out-of-hours cover and/or to employ salaried GPs to deliver services. That has had financial consequences for some boards, which might find themselves buying GP time at an expensive ad hoc hourly rate. That consequence was noted by Audit Scotland in its 2007 report, but more on that later. New service models have developed and some now have multidisciplinary teams comprising doctors, specially trained nurse practitioners and paramedics. Members are no doubt familiar with that arrangement from their constituencies. Done well, and ensuring that patients are part and parcel of that kind of delivery, the arrangement can be a plus.

How are the arrangements doing in general? In August 2007, Audit Scotland published its report into primary care out-of-hours services. That investigation found that 80 per cent of patients were happy with the care that they had received, but the report also warned that with fewer GPs choosing to provide out-of-hours services, there was a risk that the service was not sustainable in its current form. It also said that NHS boards, particularly in rural areas, had borne the additional costs of the new service because, as Audit Scotland found, of GPs who opted out of providing out-of-hours services, 1,440 re-provided those services for NHS boards on a fee-for-service basis. I alluded to that earlier and I might come back to it later.

Audit Scotland also raised the concern that, in some areas, GPs dictated the rate of pay for working out of hours because there was no nationally agreed rate. Boards often had to enter lengthy discussions about pay rates, particularly in remote and rural areas where the cost of providing out-of-hours services is greater for self-evident reasons. I referred already to the cost to NHS boards of that solution, to which I also refer in the penultimate conclusion of our report. I might not have time to talk about it further today, so members can read it for themselves.

In September 2009, Randolph Murray lodged public petition PE1272, calling on the Scottish Parliament to urge the Scottish Government to ensure that there is adequate provision for out-of-hours GP cover in all remote and rural areas in Scotland. That petition presented the out-of-hours situation in the community of Kinloch Rannoch, subsequent to the introduction of the new GMS contract. Out-of-hours care in that part of NHS Tayside is now provided by first responders. We had already decided to undertake an inquiry into the impact of the new GP contract on remote and rural areas and so subsumed that petition into our inquiry and travelled to Kinloch Rannoch to take evidence from the petitioners in situ.

Our committee report was published in April 2010. In it, we express concern that trust and confidence in the out-of-hours service had been lost and that a substantial amount of work remained to be done to rebuild confidence. That can be achieved only when the system can be depended on to work properly, which will require out-of-hours services to be fully joined up, which they are not currently. An example of that is the confusion and lack of clarity over when to access ambulance services and, indeed, the reliability of accessing those services. That is not the only example, but it is probably one of the more dramatic ones.

The committee recognised the Scottish Ambulance Service's stated commitment to service enhancement, but community groups reported grave problems with the availability of ambulances to deal with emergency situations. There was also a worrying 41 per cent increase in emergency calls made out of hours since the GMS contract was introduced in 2004. That seems to suggest—and reasonably so—that the Scottish Ambulance Service is filling a gap in service that, properly, NHS boards should have filled and that, as a consequence, ambulances are not always available for real emergencies.

The committee concluded that NHS boards should be given the responsibility for devising—and should be enabled to deliver—specific, sustainable and often innovative arrangements for out-of-hours services that meet the needs of individual communities. Those should, and must, be delivered in consultation with those communities. That is how we build trust.

There are shining examples that we urge other boards to examine, such as in the Borders—I refer to paragraph 87 in our report. The Borders success was achieved in part by making extensive use of salaried out-of-hours doctors with appropriate training and, therefore, by having a handle on costs. Lochaber and Wester Ross also come out with a pat on the back; I refer to paragraph 88 in our report. I hope that colleagues will expand on those and others matters that I have mentioned.

The committee received a response from the Scottish Government in June 2010. The response sets out the actions that the Scottish Government and NHS Scotland are taking. I am sure that the minister will expand on those during the debate.

I commend the report by the Health and Sport Committee. I look forward to the informed speeches of colleagues and, indeed, to the informed update from the minister.

We all wish our constituents, who are supportive of the NHS and the personnel within it, to trust that when they need medical attention—or simply advice or reassurance—the NHS will be there for them at the appropriate level. We also all wish that the people who live in our remote and rural areas feel secure that there will not be a rural health care postcode lottery.

I move,

That the Parliament notes the conclusions and recommendations contained in the Health and Sport Committee's 4th Report, 2010 (Session 3): Report on out-of-hours healthcare provision in rural areas (SP Paper 421).

Photo of Alasdair Morgan Alasdair Morgan Scottish National Party

I should have said at the beginning of the debate that we are short of time. The debate is oversubscribed, so everyone will need to stick to the time limits that I give them.

Photo of Shona Robison Shona Robison Scottish National Party 3:37 pm, 11th November 2010

I welcome the opportunity to report on what the Scottish Government and NHS boards are doing to improve out-of-hours health care provision, including for people who live in rural areas. I also pay tribute to the work of the Health and Sport Committee in producing the report. It has been a busy time for the committee's members.

I will repeat what the Cabinet Secretary for Health and Wellbeing said to the committee. First, the Scottish Government is committed to providing the highest-quality health care to the people of Scotland at whatever time of day and in whatever part of the country it is required. Secondly, we believe that the current arrangements for out-of-hours services are fit for the purpose of providing such care.

Out-of-hours primary care should not be considered in isolation from all the NHS and other services with which it interacts. Therefore, I will touch on the wider issues, including integrating out-of-hours services with other unscheduled and scheduled care services; providing better information to the public about the range of services that are available and when they are available; and assuring the quality of the services that are provided in different NHS board areas.

For clarity, I will set out what we are doing under the three headings in the Health and Sport Committee's report. The first is accessibility and availability. I certainly attach importance to NHS boards conducting regular reviews of out-of-hours services with the appropriate engagement of the local community. Earlier in the year, the Scottish Government issued new guidance that is designed to assist NHS boards with their engagement with patients, the public and other stakeholders when progressing potential service changes. I am happy to say that boards are making good progress with their efforts and are developing strong partnerships with communities, many of which are influencing how local services, including those that are provided out of hours, are delivered. That is a positive thing and I encourage boards to continue that dialogue.

Out-of-hours services contribute enormously to managing people in the community by avoiding unnecessary admissions and, thereby, improving the patient experience. That lies at the heart of the increasing number of anticipatory care initiatives throughout Scotland. The services are also about ensuring continuity of care for patients with chronic conditions, whether or not the patient's GP continues to provide 24-hour primary care services. We also know that good access to general practice is a key factor in out-of-hours demand. I am therefore pleased that the cabinet secretary will next week launch a toolkit that has been developed by the Royal College of General Practitioners to help GPs to take the practical steps that are necessary to ensure that there is consistent high-quality access for patients during in-hours periods.

The Scottish Ambulance Service is making a significant contribution to managing people in the community with the continuing development of its see-and-treat initiatives. That is resulting in increasing numbers of people being treated by paramedics in their homes, which avoids unnecessary journeys to hospital. The potential benefits include optimising the use of telehealth. That is just one of the areas that are covered in the good practice guide that was issued to the NHS in August.

We are aware that many people are uncertain about how and where to access the service that is best placed to support them. That is why we supported the pilot of the know who to turn to campaign in NHS Grampian, and it is why, earlier in the year, we made the marketing toolkit that supported that pilot available to all NHS boards, along with funding to help them to run similar campaigns in their areas. All NHS boards are adopting the toolkit or a variant of it. Supporting patients to get to the right treatment at first contact is a key objective of the work that the Scottish Ambulance Service and NHS 24 are undertaking on a new common triage tool.

In recent years, NHS boards have been working with NHS Quality Improvement Scotland to assess the quality and effectiveness of their local out-of-hours primary care services against the set of NHS QIS standards that were published back in August 2004. That has assured us that NHS boards have developed safe and effective services, that they all have in place robust clinical governance arrangements, and that they all monitor and report on service performance. The NHS QIS standards have been invaluable in supporting the development of out-of-hours primary care services in the past six years, but as we told the committee in evidence, we also believe that the time is right for NHS QIS to refresh the standards so that NHS boards may better examine their services and make improvements where appropriate. Since we gave that evidence, NHS QIS has started work with key stakeholders to develop and pilot new standards, and it aims to complete that work by this time next year.

In the meantime, I stress that all NHS boards provide for real-time monitoring of how they are handling calls and delivering services against a timeframe that has been set by NHS 24; that they ensure on-going sound clinical governance around the clinical workforce that supports out-of-hours services; that they have robust processes in place for investigating and learning from adverse incidents; and that they have regular reporting arrangements, whereby their out-of-hours performance feeds into the clinical and corporate governance structures of the board.

The third heading in the committee's report is sustainability and cost. Ensuring sustainability means different things in different places. What it certainly does not mean is turning the clock back. We believe that there is added value in, where geography allows it, co-location and, where possible, in integrated primary and secondary care services. That fosters closer working between professions and will help to sustain services and standards throughout the challenging times that lie ahead. In nine of the 11 mainland NHS boards, GPs work in support of hospital doctors in accident and emergency departments out of hours.

There are a range of models that reflect local circumstances. In most, GPs work as an integral part of the hospital team, in which they undertake a generalist role. Their experience of working across the system with knowledge of the services that are available in the community is of benefit to the whole system. Those increasingly integrated models are in the best interests of improving and sustaining patient care and service delivery alongside delivering effective and efficient services.

We should recognise just how far out-of-hours services have come since responsibility passed to NHS boards in 2004. It took time for boards and NHS 24 to put in place robust, responsive and effective services. I was very struck by what Christine Grahame said about NHS 24 in particular having had its challenges in the past. One of the strong things that came through the committee report is how far NHS 24 has travelled in making its systems and processes more robust. There is an element of truth in what the committee says in its report—Christine Grahame also raised it in her speech—that we now need a rebuilding of reassurance among the public on the progress that has been made. We all in the chamber know that to be the case, but we need to ensure that everyone out there is also assured of it. We are looking at how to do that and how to communicate to the public the ways in which they can access the right bit of the service at the time when they require it.

A lot is in place across Scotland. There is still more to do, but NHS 24 now has a range of initiatives that are designed to support patients in the community, to help to manage demand on an out-of-hours basis and to provide other unscheduled care services. We are not complacent. I look forward to the opportunity that the debate provides to explore how best to continue to drive up standards.

Photo of Richard Simpson Richard Simpson Labour 3:47 pm, 11th November 2010

I will try not to repeat the excellent speech that our convener made, in which she covered much of the ground. Instead, I will try to amplify a little on some of what she said.

Christine Grahame covered well the development of the service. One model that emerged in the 1990s was GP co-operatives with telephone triage and walk-in nurse-led clinics. General practitioners in rural areas were given the opportunity to have the support of an associate practitioner, which strengthened their role. Models of best practice developed in centres such as Glasgow and Stirling, but in the main the co-operatives covered urban areas. That said, at the time, Grampian came closest to having a more inclusive model.

The challenge for us going forward is to understand that the development of out-of-hours services over the past 20 years has, in essence, been provider oriented. The challenges that face out-of-hours care are evident in the increase of 41 per cent in emergency calls to out-of-hours services since the introduction of the new GMS contract. While non-emergency demand on the Scottish Ambulance Service has remained static, emergency out-of-hours demand has risen. That seems to suggest that a proportion of out-of-hours services, which are properly the responsibility of NHS boards, is now being picked up by the Scottish Ambulance Service and may be partly incorporated into its see-and-treat mechanism, which is growing quite rapidly. We know, too, that the level of contact with NHS 24 has grown hugely over the past few years. We should note also that, within that, the Scottish Pharmaceutical General Council contract, which again is a unique Scottish innovation, and which supplies emergency medicines, has also grown. Indeed, 35 per cent of the calls to NHS 24 are pharmacy related. We should not forget that.

Accident and emergency provision, too, is developing and changing. It has evolved from a service that was basically a district general hospital service with one or two full trauma units to one that has a mix of services from minor injury units, through the mixed DGH units, to full trauma units and specialist units such as children's units. General practitioners in out-of-hours services still continue to provide a slightly different type of service with health boards running the primary care out-of-hours services that, in the main, they inherited from the GP co-operatives of the 1990s.

In rural areas, there is an absolute need to integrate into the entire service the British Association for Immediate Care-trained doctors who work with the Scottish Ambulance Service. It will be necessary to use all available practitioners to provide a seamless service.

The Commission for Rural Communities in England reported:

"Those with responsibility for providing or commissioning GP services" in rural areas

"did not appear to be using objective evidence about rurality to shape or improve out of hours provision."

It came to conclusions similar to those of the committee—that there must be an integrated approach that involves listening to and working with communities to incorporate all the services.

The committee felt clearly that there was a lack of clarity—indeed, a great deal of confusion—among the public about accessing out-of-hours services. The first thing that a patient must do is decide what their condition is and which of the raft of possible opportunities—contacting 999, contacting NHS 24, going directly to accident and emergency or, in rural areas, calling their GP—is appropriate. I understand that the Grampian pilot is endeavouring, with some success, to address the failure to integrate services and to give clarity, but the issue is difficult.

Christine Grahame indicated that NHS 24 had made considerable progress. Its handling of last year's flu pandemic was evidence of the organisation's growing maturity and credibility, but the evidence that we received indicated that there is further to go.

With NHS 24, GPs' surgeries on extended hours so that we do not know when out-of-hours services are and are not available—the arrangements are different in every area—999 calls and testing of 888 calls, the situation is not getting easier and confusion is multiplying. If that were not bad enough, I hear that there is a proposal for NHS call handlers to handle minor cases. How do we decide what is a minor case? We know about cardinal symptoms, but if someone presents with a headache, it can be anything from a brain haemorrhage that is about to occur, to meningitis, to simply a bit of stress. Will call handlers with no training really be able to handle such cases using a protocol? One bad case will set NHS 24 back on its heels.

Christine Grahame referred to the financial situation. I will not go into detail on that but, according to Audit Scotland, it has cost the health service an additional £31 million to switch from the GP-based service in which I practised—for 25 years, I was on duty for 85 hours a week—to a situation in which the work-life balance of the modern GP, along with their pay, has improved considerably. Only 51 practices are providing integrated out-of-hours care. The number of practices using the alternative model, to which Christine Grahame referred, of developing associates or salaried GPs has increased, but only from 61 in 2004-05 to 89 in 2006-07; I do not know the current figure. The model has been developed in the Borders and is worthy of further development.

Our other big problem is that GP numbers are dropping. We have gone from 3,500-odd GPs having to provide the service to about 1,800 providing it. The previous audit indicated that the figure is now down to 1,400; I suspect that it will continue to drop. As we have seen in England, when locums are brought in they can cause considerable problems, because they come in without proper review. I know that Audit Scotland looked at that issue.

Quality standards are important and must be addressed. However, the message that I have taken from this interesting review is that, unless we have a totally integrated unscheduled care service, we will continue to have considerable difficulties. The report must take us forward.

Photo of Murdo Fraser Murdo Fraser Conservative 3:53 pm, 11th November 2010

I thank members of the Health and Sport Committee for their extensive report and the clerks to the committee for all of their hard work and assistance. Although I am not a member of the committee, I joined it on its visit to Kinloch Rannoch to take evidence, on a day that I am sure will live long in the convener's memory. I take this opportunity to thank all of the individuals, health boards and organisations that gave evidence and contributed to the report. In particular, I thank members of the Kinloch Rannoch community, some of whom have made the long trip from highland Perthshire to be here to watch today's debate.

As we have heard, the inquiry was generated by a petition that a resident of Kinloch Rannoch submitted to the Public Petitions Committee in summer 2009. The petition outlined concerns about the provision of out-of-hours GP cover to rural communities.

In its final conclusion, the report refers to the fact

"that trust and confidence in the out-of-hours service have ... been lost."

It states:

"a substantial degree of work" is required

"to re-build confidence. This can only be achieved when the system can be depended on to work properly, which will require out-of-hours services to be fully joined up—which they are not currently. NHS boards should be given the responsibility for devising ... specific, sustainable, and often innovative arrangements whereby out-of-hours services meet the needs of individual communities. This should be delivered in consultation with those communities."

I entirely agree with that. It is clear from the report's conclusion that there are significant problems with the out-of-hours health service in rural and remote communities. I hope that health boards throughout Scotland will take note of the report's findings and will work with those communities to ensure that they have a health service that they are satisfied with and in which they can put their trust.

The Scottish Conservatives believe that rural and remote communities require an out-of-hours GP service that is fit for the 21st century. The local GP service should be the focus for out-of-hours services in rural areas. There are still great concerns in rural communities regarding NHS 24's lack of knowledge of local services and geography. We have already heard various examples of that in the debate, and I am sure that we will hear more of them later. Such problems would not occur if a local GP provided the out-of-hours service—a GP in the community who knew their patients and who knew the area.

The British Medical Association Scotland has made it clear that there will be no return to a universal Dr Finlay style of service, and I understand why that cannot happen. I do not think that anyone is calling for a whole new system across the country. We believe that a one-size-fits-all approach is not appropriate. The complexities of rural communities must be considered when designing out-of-hours health services.

The Conservative and Liberal Democrat Government at Westminster has pledged to amend out-of-hours provision south of the border and to put GPs back in charge of commissioning the service, even if they do not provide it directly themselves. I urge the Scottish Government to work closely with Andrew Lansley and his team to see what lessons Scotland can learn from what is happening south of the border.

The committee convener has mentioned, and the report covers, important issues concerning ambulances in rural areas. The report notes the 41 per cent increase in the number of emergency calls that were made out of hours following the introduction of the new GMS contract in 2004. That suggests that a proportion of the out-of-hours service, which is properly the responsibility of NHS boards, is now being picked up by the Scottish Ambulance Service, which, in some cases, diverts its fleet from emergency situations. As Christine Grahame said, it seems that the Scottish Ambulance Service is being used to fill gaps in provision.

In places such as Perthshire, where there is already a threadbare ambulance service, that is a worrying trend. Only one ambulance is stationed in highland Perthshire, and it covers an area of 600 square miles. Many rural communities feel that ambulance cover is simply not sufficient.

I return to Kinloch Rannoch as an example of a remote and rural community whose out-of-hours health service has been removed. In May 2006, the local general practice opted out of providing an out-of-hours service, against the wishes of the local community and, to be fair, against the wishes of NHS Tayside. At that point, NHS Tayside made a commitment to the community that it would insist that the new general practice that was due to begin following the retirement of the then doctor would provide an out-of-hours service. That promise was broken, and out-of-hours cover is now provided via NHS 24, with the result, local residents claim, that there are lengthy waits for ambulances and residents call one another out during the night for help rather than rely on the service. As the minister will know, there is a great deal of concern in the community that NHS Tayside is not addressing its responsibility to provide an appropriate out-of-hours service in that remote and rural area.

Given those concerns, I ask the minister whether the Scottish Government is prepared to intervene on the issue with NHS Tayside. The Scottish Government has intervened on a range of important health issues, such as reversing the closure of accident and emergency departments at Monklands and Ayr, so is it prepared, on this occasion, to get involved in this important health issue and to take up cudgels on behalf of the community? I would be grateful if the minister responded on that point when winding up the debate.

What is happening in Kinloch Rannoch is an illustration of what might well happen—and what probably is already happening—elsewhere. We cannot allow health services to be diluted in this case, as it could set a precedent for other communities in Scotland. Kinloch Rannoch residents are standing up for their community, but also for all other rural and remote communities in Scotland. I thank them for the work that they are doing, which highlights a hugely important issue.

Photo of Jamie Stone Jamie Stone Liberal Democrat 3:59 pm, 11th November 2010

I thank the convener of the Health and Sport Committee for taking us down memory lane, with her references to Dr Snoddie, Dr Cameron and Dr Finlay. Of course, I am far too young to remember those television characters and their doings in the small community of Tannochbrae.

The talk of Dr Finlay reminded me of my great-uncle, Dr Edward Fraser, who was very much in that mould. I can see him yet, as I did when I was a small boy, going round the straths and glens of Ross-shire in his old grey Humber, with his bag and his stethoscope. I am proud to say that he was a much-loved figure, and when he died every pub sent a wreath to his funeral—there might be another story there, which we do not know about. The manner of his death stays with me. He was changing his tyre at a croft near Edderton—Mary Scanlon will know Edderton—when he died of a seizure. He must have had high blood pressure or some other condition that had not been spotted because of the way in which he worked. We should remember that when we think about NHS 24 and why we are trying to shape services in the way that we are doing. It is about health professionals as well as patients.

I will speak on behalf of my party as I draw out some of the points that strike me. People deserve to be treated as individuals when they receive health care, and whether they live in a remote and rural area or in a built-up area should be no barrier to their receiving high-quality, personalised care. Members have heard me talk about the matter many times in the Parliament, specifically with reference to the Scottish Ambulance Service. A national health service must surely provide consistent standards to patients throughout the country.

When GP contracts are renegotiated, the opportunity arises to address deficiencies in out-of-hours care. Last time, negotiations took place on a United Kingdom-wide basis. We question whether it would not be better for communities and patients if negotiations took place on a Scotland-only basis. I am sure that many members would work with the BMA and others to develop proposals that would involve GPs far more in the planning and delivery of out-of-hours care and would ensure greater co-ordination between out-of-hours services.

As members said, services that are provided by GPs, NHS out-of-hours centres, NHS 24, the Scottish Ambulance Service and A and E departments need to be fully joined up. Everyone must play their part in a joined-up approach. There is a clear need to rebuild public confidence in NHS 24 and to improve public awareness about which service to contact. Patient confidence is critical if we are to avoid unnecessary emergency attendance at hospitals.

My party is highly supportive of telehealth technology, which can be particularly beneficial to patients in remote and rural areas—I am sure that in saying that I speak for every member who represents a constituency such as mine. Telehealth technology can empower patients and play a key role in enhancing services, but the availability of high-speed, reliable broadband is crucial if we are to achieve that goal. That remains an issue for the Parliament and the Government—and not just with reference to my constituency.

The Government and the NHS must provide training and relief for GPs in remote and rural areas who retain responsibility for out-of-hours care. The key challenge for the service is to provide care for people who have long-term conditions, so that they can avoid unnecessary hospital admissions out of hours. It is important that patients understand that self-management is an essential strand to the strategy.

I thank the convener and members of the Health and Sport Committee for their report, which I read with great interest. I noted that the chief executive of NHS 24 described a new model, which is being rolled out, whereby Scottish Ambulance Service dispatch centres are co-located with the NHS 24 service, to improve service when calls are passed between services.

The committee reported that the Scottish Ambulance Service said in its submission that there was

"a 'lack of awareness about which service to access', that patients were 'confused about the most appropriate route to care' and that, particularly in remote and rural communities, there remained a 'traditional role and expectation on GPs as the first point of contact'."

The committee noted that such confusion remained, although there has been improvement. In its conclusion, it said:

"The Committee is concerned that trust and confidence in the out-of-hours service have, as a consequence, clearly been lost. There remains, therefore, a substantial degree of work to be done to re-build confidence in NHS 24".

There it is, in black and white.

The Scottish Ambulance Service sometimes does work that it perhaps should not be doing, which should fall to be done by other NHS services. That takes me back to a question—I wish that I had intervened on the minister earlier—about patient transport, which I have raised before. I would be obliged if the minister touched on that subject in her summing up.

In fairness to the Scottish Government and to the minister, not all is bad news. Paragraph 88 on page 19 of the report says:

"The Committee recognises that solutions to the provision of out-of-hours care need to be informed by the historical and geographical contexts of each individual area. The Committee notes that in areas where effective solutions have been found, such as Lochaber and Wester Ross, it has been as a result of community buy-in, integration of services, and practitioners sharing the responsibility".

In other words, there are success stories. In north-west Sutherland in my own constituency, out-of-hours care works because of the willingness of the professionals and the community to realise what is possible practically. I pay tribute to those people.

Photo of Ian McKee Ian McKee Scottish National Party 4:05 pm, 11th November 2010

One theme that came out of just about every evidence session at our committee, and again in the cabinet secretary's response to our report, is that one size does not fit all, and out-of-hours cover needs to be tailored to the needs of each individual rural community, yet in reality some NHS boards seem to attempt to do precisely the opposite. Like the ugly sisters in the fairy tale, who try to squeeze their feet into shoes that manifestly do not fit, NHS boards try to force out-of-hours medical services that are designed to work in urban areas on to the countryside, where they patently do not meet the health needs of the different community.

I will take as an example what happened in Kinloch Rannoch. I do that not because that rural area represents all other rural areas—to claim so would be to fall into the one-size-fits-all trap—but because much of the evidence that the committee heard focused on that community and the petition that we received. I do not intend to go into every detail of the concerns of those who live there; I will draw out some relevant themes.

Because of a collapse in the existing out-of-hours arrangements, which we have heard about, NHS Tayside set about providing an alternative. Local people, not unnaturally, wanted the re-establishment of local GP cover, but they did not get it. NHS Tayside argues that suitable GPs did not come forward to offer a more local service and, in any case, the health board decided that it was impractical, because it would cost a staggering £556,468.77 per year, according to health board officials. That is more than half a million pounds, even if we forget the 77p.

One can understand how board members could come to a decision not to go ahead with such a service, given that figure, but let us look a bit more closely at how that figure was reached. The officials estimated that Kinloch Rannoch would require the services of four full-time equivalent drivers, as it is the board's policy not to allow unaccompanied visits. Perhaps that is good policy when the GP who is on call has to make regular visits to tough housing estates, but it is a little bit over the top when we are talking about 800 hardy rural souls who usually generate no more than one out-of-hours call every three weeks or so. The truth is that no drivers are needed in any other rural areas, so why should they be needed in Kinloch Rannoch?

The board then said that the service would need 3.8 full-time equivalent doctors to cover an out-of-hours service because of the European working time directive and NHS employment policy. Again, that might be appropriate for an urban area, but is it required for a handful of requests per year? The board must be joking.

It seems as if someone at NHS Tayside was determined that a local GP out-of-hours service would never see the light of day. It is not as if many health boards, including NHS Tayside, show the same concern about the working hours of the doctors who staff the out-of-hours services that they run in busy urban areas. I found out from NHS Tayside that it employs GPs for that purpose without any knowledge or apparent concern about how many hours they have worked that week in their own practices. As the GPs are self-employed, they fall outwith the scope of the European working time directive, and there seems to be no desire to ascertain that information before allowing them to put in a shift or shifts for the health board. If the health boards can use those GPs—who might be working 50 hours a work in their own practices—to staff extremely demanding on-call rotas, why can they not devise a scheme to do something similar in places such as Kinloch Rannoch, where the workload is miniscule in comparison?

How might that be done? Our committee heard evidence on GPs in the Highlands who are contracted satisfactorily for an agreed lump sum, many times lower than that mentioned by NHS Tayside, to provide out-of-hours cover. They run a rota among themselves. Boards could devise innovative rotations of young doctors or pre-retirement doctors to cover needs in suitable areas. Telemedicine and the use of highly trained, locally based community nurses—whom we have talked about already—both have enormous potential if used wisely and with the on-going support of all concerned.

Advertisements for such posts could be made 10 times more attractive to potential applicants. Many of our rural areas are most beautiful and provide opportunities for country pursuits and an escape from the urban rat race, but those benefits need to be sold positively, not just by a tiny anonymous advertisement in the British Medical Journal.

Indeed, one size does not fit all, and a solution for one area will not always work elsewhere. The important thing is that the health board looks for a solution and takes on the local community as a partner in the search.

Having a locally based out-of-hours service also saves money and misery as a doctor who knows the patients can often avoid expensive ambulance journeys and hospital admissions. He or she knows what treatment a patient needs, what treatment they have had in the past, and what works and what does not work.

In summary, let me quote the two last sentences of the report:

"NHS boards should be given the responsibility for devising—and should be enabled to deliver—specific, sustainable, and often innovative arrangements whereby out-of-hours services meet the needs of individual communities. This should be delivered in consultation with those communities."

Give them the responsibility and tell them to get on with it.

Photo of Helen Eadie Helen Eadie Labour 4:11 pm, 11th November 2010

At the outset, I compliment Ian McKee on what was a very good speech.

I found the inquiry into out-of-hours services in the NHS to be very interesting and, I hope, useful, particularly for those who live in the more remote and rural areas of Scotland. One of the more enjoyable aspects of that work was a rare treat—an outing for the committee, with a visit to meet the people of Kinloch Rannoch despite the snow. At the start of the visit, we heard the bad news that the convener Christine Grahame could not be with us because of an unfortunate car accident. We are pleased that she was not seriously hurt, and although she was badly shaken I am reliably reassured by her that she was not stirred. The people were hugely helpful in telling us about the reality of living in one of Scotland's more remote and rural areas and accessing the services of the NHS. The hotel in which our meeting was held and in which we stayed overnight was both warm and welcoming, and we thank the staff for their good service and hospitality.

I had another rare committee outing with Mary Scanlon when we had a fascinating visit to London to see different examples of city-based out-of-hours health service facilities—something that has left a lasting impression on me.

One of the more striking points that I learned from the committee's work was that people are often not referred to the most local services and on occasion have had to experience journeys of 100 miles and more when, if the co-ordination and collaboration had worked better, they would have been able to access assistance much more swiftly locally. We were told that that happens often because the calls are handled in regional offices where the call handlers have no idea of the geography of the area or of any particular logistical problems. I hope that the work of our inquiry will provoke the action that is necessary to organise better that aspect of care for patients.

The reality is that every area of Scotland is different in many ways, and the solutions have grown up locally when sometimes a different, more collaborative approach might have been better. That is why Murdo Fraser is right when he says that there should not be a one-size-fits-all approach.

Another hobby horse of mine—although not just mine, because everyone in the chamber has referred to it—is the way in which e-health could improve services and minimise costs for all patients, with potential added benefits for patients who live in remote and rural areas. If my memory serves me right—I have heard members refer to this—we heard that e-health is to be located with NHS 24, so there seems to be a recognition that both services will benefit by closer working. I believe that the majority of committee members see the possibilities that can emerge if there is a real driver with determination to see improvements in e-health. To date, that has been missing. As politicians, we have to champion that cause. Some of us are already doing that, but NHS employee champions need to be appointed, too.

Speaking of costs reminds me of one of the most staggering things that I learned in the course of the inquiry—the huge differences between health boards in GP charges for holiday cover. The report of our inquiry sets out the detail of those staggering differences, which were absolutely huge. The Ambulance Service complained that people were simply not clear about whom they should phone for assistance, and that demands a major educational campaign. I very much hope that the cabinet secretary will tackle what I think is an unacceptable situation.

One of the most reassuring things about our inquiry was learning that there is continuing work to improve out-of-hours services. It seems that, because of the high-profile cases, NHS 24 has been constantly under the microscope, with reviews being undertaken by NHS Quality Improvement Scotland and Audit Scotland, which have been constantly measuring its performance.

I hope that the petitioners will feel that the Parliament has listened carefully and with understanding to their issues. It is the job of the Government to listen to the petitioners and the Parliament, and I hope that it will respond by ensuring an improvement in the delivery of out-of-hours services and building on the trust that—as Christine Grahame and others have rightly said—is so important.

Photo of Alex Fergusson Alex Fergusson None

Thank you, Ms Eadie. As a result of the extra minute that you have kindly given us, I can offer Nanette Milne and Mike Rumbles four minutes each.



Photo of Alex Fergusson Alex Fergusson None

Mind you, much more of that and they will not have any time left. [ Laughter .]

Photo of Nanette Milne Nanette Milne Conservative 4:16 pm, 11th November 2010

I will be brief, Presiding Officer. The early problems with NHS 24 and its undoubted failures, which were exposed in the 2005 review, inevitably led to patients receiving poor levels of out-of-hours service. Patients were—and, indeed, still are in many instances—unsure of the difference between out-of-hours primary medical care and emergency services. They are unsure whether they should call NHS 24 or an ambulance. I feel that the failure to prepare the public properly in 2004 for the changing pattern of out-of-hours care, together with a lack of information about the standards of care that they should expect, has had much to do with the public's lack of confidence in the service, particularly in rural areas.

Enormous improvements have been made, with NHS 24 now much more local and working more closely with health boards. Indeed, in some places, such as Aberdeen, it is co-located with the on-call GPs and alongside accident and emergency and telemedicine facilities. However, more needs to be done to integrate out-of-hours services with each other and with the systems that operate in normal working hours, as the Health and Sport Committee's inquiry found out.

In a country with Scotland's geography, a one-size-fits-all approach to out-of-hours provision is of no use. The needs of specific communities require services that are developed locally and in consultation with local people. In parts of Grampian, for example, advanced nurse practitioners and paramedics work with GPs in rural areas. They are in telephone contact with their GP colleagues, who have telemedicine links to their out-of-hours hub, and with accident and emergency services in Aberdeen if advice is required. They are able to diagnose, prescribe for and treat many acute conditions, and they can refer patients for admission to hospital when necessary.

In Braemar and upper Deeside in Aberdeenshire, where the GP did not opt out of 24-hour responsibility for his patients and where there are also trained first responders, patient calls can be answered very quickly. Problems arise, however, if urgent hospital admission is required, as it can take far too long to get an ambulance there to transport the patient safely to Aberdeen with a paramedic free to care for the patient en route.

I have been working with MSP colleagues from all parties, with the GP, with the local community and with the Ambulance Service to solve the problem. It is hoped that, following a productive meeting here a few weeks ago that the cabinet secretary presided over, it might be possible to set up a retained ambulance service for out-of-hours cover in the area similar to one that already operates in Shetland. I am hopeful of a satisfactory result in the not-too-distant future, and I put on record my thanks to the cabinet secretary on behalf of the local community for her help in the matter. They greatly appreciate that.

I am confident that with co-operation between communities, health boards and the emergency services, satisfactory out-of-hours care can be provided for patients throughout Scotland using appropriate models of provision. There is still a long way to go before everyone receives the seamless service that they look for and deserve, but I am encouraged by the Government's response to the committee's report—notably, its commitment to continuous improvement and its commitment to work with NHS boards to develop national out-of-hours quality standards. It has taken far too long, but I am certain that, if the will exists, we can have out-of-hours services that restore the confidence of rural communities.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat 4:20 pm, 11th November 2010

I welcome the Health and Sport Committee's report on out-of-hours health care in our rural areas. I will take this opportunity to focus on one specific issue that involves the out-of-hours service in my rural constituency.

At the moment, there are two doctors with vehicles who are available for people in my constituency who require the out-of-hours service. One is based in the community hospital in Aboyne, on Deeside, and the other is based in the other part of my constituency, in the community hospital in Stonehaven, on the coast.

NHS Grampian has launched a public consultation on drawing down that service, and there is a suggestion that my constituents could cope with having just one doctor with a vehicle, based in the community hospital in Banchory, to serve the entire area, which covers hundreds of square miles. That suggestion is a result of the reduction in the budget that is available to the out-of-hours services across Grampian. It is interesting to note that that budget is being reduced by NHS Grampian, even though we are being told in this chamber that the Scottish National Party Government is protecting NHS budgets.

Anyone who has a grasp of the geography of my constituency will realise that a proposal to put an out-of-hours doctor and vehicle in Banchory and expect them to cover the whole of my constituency is simply not feasible. I can see why, looking at the map, such a single location is attractive to the cost cutters in Aberdeen, but anyone with any experience of trying to drive over the Cairn o' Mount or the Slug road between Deeside and the Mearns in winter will immediately appreciate the impossibility of such a location for such an essential service.

I defy anyone to tell me that a doctor based in Banchory—or, indeed, Aberdeen, which is the other suggestion—could reach my constituents within an hour, which is what we were told to expect, yet that is what is being suggested. I am concerned that if the proposal to base a doctor and vehicle in Banchory is not changed, my constituents in the Mearns will be left without adequate cover. Further, my constituents on Deeside could be left without cover if that doctor and vehicle are dispatched to the Mearns in the middle of winter.

If we are to rebuild confidence in NHS 24 and the out-of-hours service, as the committee report says that we must, we must bear it in mind that that will be made much more difficult, if not impossible, if NHS Grampian replaces the two doctors in my constituency as planned. I hope that NHS Grampian sees sense and, after the consultation, accepts the limitations of geography and maintains two out-of-hours doctors, based in Aboyne and Stonehaven.

Originally, regional MSPs and I were promised, in a meeting with NHS Grampian, that the service would be maintained. Now, several years later, with the reduction in budgets, someone is looking at a map and saying, "Couldn't we just move the service there?" That is the result of people not understanding the local circumstances or appreciating the level of service that my constituents should be able to expect from their out-of-hours service.

Photo of Liam McArthur Liam McArthur Liberal Democrat 4:23 pm, 11th November 2010

We started this short but perfectly formed debate with a tour d'horizon by the committee's convener, Christine Grahame. She complained about the workload of the Health and Sport Committee. I do not want to alarm her unduly but, given the tenor of the exchange between the Transport, Infrastructure and Climate Change Committee convener and Stewart Stevenson earlier, it is not impossible that she may yet have the forthcoming water bill to deal with, should it ever see the light of day.

I congratulate the Health and Sport Committee on its excellent and timely report. It goes into detail on the significant changes that have taken place in out-of-hours care prior to and subsequent to the introduction of NHS 24 in 2001. Richard Simpson spoke insightfully about the history of the service and, at one stage, almost seemed to regret his decision to change careers. However, that was as nothing to young Jamie Stone, who appeared to regret or have forgotten his decision to retire.

I commend the report for stating, in the first paragraph:

"Out-of-hours services in our remotest areas constitute a critical lifeline in the most testing and diverse geographical situations. Each location presents a unique set of challenges, for which there is no one-size-fits-all solution."

That is a theme that a number of members quite rightly picked up on. It is as much the case in general practice as in out-of-hours care, and—as the minister rightly said—we need an integrated service.

The debate has been interesting and largely consensual, and members have drawn on their experiences of how these vital services are being delivered and how various agencies are performing in different parts of the country. Jamie Stone, Murdo Fraser and Mike Rumbles have all contributed well in that regard, and Ian McKee drew on his personal experience.

We all need to recognise the improvements that have been made. Members will recall the all-too-frequent and graphic illustrations of how NHS 24 struggled in its early days to meet the expectations not only of patients, but of health professionals. There were sometimes calamitous repercussions and Richard Simpson, in drawing on the flu pandemic experience last year, provided an illustrative contrast.

Concerns remain, and further improvements must be made, but we are in a better position to respond to those challenges if we acknowledge the progress that has been made and learn the lessons to date. The improvements so far have been achieved in large part due to the work of NHS 24, which has worked closely with health boards, GP practices, the ambulance service and patients.

I commend the creation of the regional call centres, and closer working between NHS 24 and local health boards. That journey is not yet complete—I will come to that in due course—but I recognise that significant strides have been taken.

It is essential that we now build on the recent improvements. Members have pointed to the continued evidence of a residual lack of public trust in NHS 24, but they have also noted the rise in demand for those services. Despite that rise, as the committee report makes clear, one of the principal problems that NHS 24 faces is the on-going confusion among the public about accessing out-of-hours services.

That theme is taken up by the BMA, which points to the role of Government and NHS Scotland in raising awareness and increasing public understanding. Through that work, we may help to address the issue—which many members picked up—of the marked increase in the emergency workload of the ambulance service. The report identified a 41 per cent increase in emergency call-outs since 2004, and noted that that indicates

"that a proportion of out-of-hours service, properly the responsibility of NHS boards, is now being picked up by the Scottish Ambulance Service".

The risk, as other members have pointed out, is that in some cases that diverts the ambulance fleet away from emergency situations. I agree with the comments of many members about the need for a more joined-up and collaborative approach. Richard Simpson and Ian McKee were right to point out not only that integration is needed, but that it must be based on a listening exercise and the involvement of communities.

The investment in building up capacity and training first responders in communities around the country may help to take some of the pressure off, but I am aware from my own constituency that that can often be viewed as an attempt to scale back the role of the NHS and emergency services. It should be about complementing and enhancing what is currently provided, rather than achieving it on the cheap.

Murdo Fraser rightly drew on the experience of those in Kinloch Rannoch. Given the comments from Helen Eadie and other members, I almost wish that I had been on that Health and Sport Committee visit; it seems it was the stuff of legend.

Photo of Liam McArthur Liam McArthur Liberal Democrat

Not in the convener's car.

I accept entirely the need for issues of sustainability and cost to be addressed, as the committee notes in its report. The question is whether that is best achieved on a UK-wide basis or by adopting a Scottish approach; more work is needed in that regard.

I conclude with some observations on how the service works in Orkney, which is in some ways one of the most challenging of rural environments, given its island nature. It includes the island of Flotta, with which I know the convener has a particular empathy.

There continues to be scepticism about triage over the phone, but that has been helped by the fact that the two GPs who provide the out-of-hours service are familiar with the idiosyncrasies of Orkney, a familiarity that is crucial in delivering health care across the islands. There have been developments in telehealth, which I mentioned in a recent debate, but the out-of-hours hub is not in Orkney, and the nurses and those who answer the phones out of hours need that familiarity. It would be remiss of me not to point to the need for a locally based air ambulance to improve response times, which are still too long.

We owe a huge debt to all those who work in the health service, in whatever capacity, and we can play a part in repaying that by helping to support the efforts to innovate and improve services. The committee report and the debate have been useful in that regard. I congratulate the committee on its work, and—like Jamie Stone—I hope that the minister will take on board the committee's recommendations and members' comments, so that the public in rural areas can have confidence in a high-quality, integrated service that deals with and treats them as individuals.

Photo of Mary Scanlon Mary Scanlon Conservative 4:30 pm, 11th November 2010

In debates on anything remote and rural, I am generally able to give examples from the Highlands where the situation is worse than it is in the rest of Scotland, so I was delighted that the example of best practice for rural out-of-hours care was brought to our committee by a representative from Lochaber and Wester Ross, where they had

"community buy-in, integration of services, and practitioners sharing the responsibility for out-of-hours care at a local level."

That compared very favourably to what was found in Kinloch Rannoch.

Not only has this been an interesting debate but, as Helen Eadie said, the inquiry—very unusually—allowed the Health and Sport Committee to hold a meeting outside Edinburgh. It was right and proper to hold the meeting in Kinloch Rannoch, given the problems faced by that community in recent years. We found that issues raised in remote and rural communities were generally very similar to the concerns about NHS out-of-hours provision across Scotland. I thank the Kinloch Rannoch group that submitted a petition to the Parliament. It helped to lead to this inquiry, which I believe will, in time, benefit patients throughout Scotland.

The BMA and the previous Government may have negotiated every last detail of the new GMS contract but, unfortunately, they left people throughout Scotland with no idea of what they should expect in terms of emergency response and clinical care, as no standards were set. As Liam McArthur said, neither did patients throughout Scotland know the circumstances in which it was appropriate to call an ambulance, call NHS 24, visit accident and emergency or wait until the next day to see their GP. That is acknowledged in paragraph 39 of the committee's report, which states that there is

"a great deal of confusion amongst the public over accessing out-of-hours services."

The Health and Sport Committee recommended what countless committees and MSPs in the Parliament have recommended since May 1999: for our publicly funded services to talk to each other, work together and put the patient first. That does not even cost money—only good will and a commitment to a patient-focused health service.

Like other members, I am pleased to note that the medical director of NHS 24 is also a board member of the Scottish Ambulance Service. I was a harsh critic of NHS 24 in the early days, and I think that my criticism was justified, but I feel that Dr George Crooks has turned the organisation round by improving response times and bringing a more professional and integrated approach.

The inquiry highlighted the need for standards based on clinical outcomes rather than on processes and tick boxes, which is something that should have happened in 2004 when the contract was implemented. As recommended in paragraph 66 of our report, patients need to know the minimum service that they can expect. That is what the people of Kinloch Rannoch were asking: what is the minimum that we can expect? Process-driven health standards will, I hope, be consigned to the dustbin, with a new focus on clinical outcomes becoming the norm.

I do not think that it is helpful when local BMA representatives compare the out-of-hours service in Kinloch Rannoch to the NHS needs of people in Dundee. Our NHS has evolved to ensure that the health needs of all the people in Scotland are catered for, whether that relates to out-of-hours provision in a remote area or to narrowing the health inequalities gap.

I met Pauline Howie of the Scottish Ambulance Service last week and I have been assured that much has happened since the Health and Sport Committee inquiry started, with improved integration of the Scottish Ambulance Service, NHS 24 and others.

In the Scottish Ambulance Service's annual report, which was published today, Chris Bennett from Orkney tells how the

"ambulance got to" him

"in minutes", and how the paramedics "diagnosed a stroke" and got him

"to Aberdeen Royal Infirmary for a CT scan, after which" he

"was given clot-busting treatment".

He has

"now made a full recovery".

Given that NHS Orkney is the only board without a computed tomography scanner, we should give all credit to the ambulance service.

Like others, I feel very passionate about the need to embrace telehealth, which is simply not being used to its full potential. After complimenting George Crooks of NHS 24, who is now in charge of the matter, I send him the message to please move this issue forward.

I suggest that the care home could provide the most appropriate environment for rehabilitation for many elderly people who might otherwise be placed in hospitals for weeks, sometimes months. Given that ambulance crews are now able to take X-rays in a person's home, such a move might result in more accurate assessment of and placement for elderly people.

The final four points in the health secretary's response to the Health and Sport Committee's report sum up precisely what is needed for rural and, indeed, urban out-of-hours care in Scotland: "Improved collaboration", "Clear communication", "Clinical excellence" and "Continuity of care". I hope that the inquiry takes us in that direction.

Photo of Richard Simpson Richard Simpson Labour 4:36 pm, 11th November 2010

The debate has been useful, not least in drawing together the individual experiences of so many MSPs. Indeed, that is a measure of the fundamental importance of this report's main thrust: the need for local solutions to local problems. Liam McArthur mentioned the need for call handling services to have local knowledge of the idiosyncrasies of the area that he represents and Mike Rumbles highlighted the serious challenge faced by more rural areas where mountain ranges and difficult roads mean that one cannot simply look at a map and assume that the area is flat.

Murdo Fraser and Ian McKee dealt in considerable depth with the situation in Kinloch Rannoch, which was one of the factors that stimulated this particular inquiry. Indeed, when one hears that the out-of-hours service in that area is supposed to cost around £500,000, one has to begin to question certain reality factors with regard to the health board involved. People in the boards need to learn that they must talk to their local communities and look at everything: fire, ambulance, police and health services; first responders; and what the local GPs are prepared to provide in the extended round. In fact, Linda Harper from the Royal College of Nursing and lead nurse for G-MED—the Grampian out-of-hours medical service—told the committee:

"to deal with Grampian's remote and rural areas, we have developed a team of advanced nurse practitioners, who have a lot of good skills and work well together. As far as the six dimensions of quality are concerned, we certainly provide safe, effective, efficient and person-centred care, which for patients is the most important thing. If the appropriate training is available for advanced nurse practitioners, paramedic practitioners and so on, they can be very supportive."—[Official Report, Health and Sport Committee, 20 January 2010; c 2582.]

We—and indeed our boards—need to think imaginatively if we are to develop the effective co-ordinated and integrated services that lead not to the kind of postcode lottery in which people do not get the care or service that they want, but to a new form of postcode service that is not a lottery but provides care on an individual basis.

We are not alone in this—other places face similar problems. The Commission for Rural Communities, which I cited earlier, has said:

"Allowing staff to undertake a wide variety of tasks (for example, where nurses from Minor Injuries Unit cover out of hours centres) ... offers opportunities to gain the critical clinical mass necessary to keep a service viable (especially in rural areas), and it allows staff to experience a varied workload."

In Fife, which is part of the region that I represent, the health board is endeavouring to co-locate minor injuries units and general practice units. Such an approach can lead to considerable efficiency gains. Most co-locations with emergency units began with closed doors; indeed, I experienced that very situation in the 1990s. There were two entrances, one for accident and emergency and the other for general practice, and before NHS 24 came along the patient had to choose which door to go through. We find in the research that 40 per cent of the accident and emergency attendances in the reported literature were actually for general practice and primary care matters. People went in the wrong door. Many people who went through the primary care door ended up being admitted to hospital. We need single entrances and an integrated service.

No matter what the benefits and gains will be from the coalition budget that we will see next week, members should make no mistake: we are faced with major budgetary challenges for the NHS. Unless we are imaginative and integrate services in a novel way at every level, not just in rural and remote areas, we will be faced with considerable difficulties.

I want to speak a little more about NHS 24. I have already expressed concern about call handlers managing minor issues. The cabinet secretary has spoken about the other side of the issue. She said:

"A big misconception is that NHS 24 provides out-of-hours services. It does not. Its job is to provide the call-handling service, the triage and the referral to the appropriate services consistently throughout Scotland."

I have no argument with that. She then said:

"NHS 24 therefore has a key role in ensuring that patients are referred to the appropriate service, which is the Ambulance Service if the incident is immediate ... If the matter is less serious, the appropriate service might be a minor injuries unit, a GP out of hours, a community paramedic or a patient's GP in hours, when their GP's surgery next opens."—[Official Report, Health and Sport Committee, 3 February 2010; c 2669.]

However, NHS 24 provides much more than that. We know that it provides links to social workers and that there are social work experts in the unit at Cardonald. It has much stronger links with the Ambulance Service. There are ambulance workers in the call centre. It has mental health nurses, and it provides cognitive behavioural therapy telephone triage. It also deals with suicide and other mental health issues. It is developing into a much more comprehensive service than one that simply signposts and directs—and so it should. However, we must be careful that it provides appropriate services and that we do not inadvertently again add to the confusion of members of the public about precisely where they should go. That is the fundamental issue in the report.

I am heartened by the report and by the many speeches that have been made, as they illustrate members working in a highly consensual way. All members have a common objective that can be met with good will. However, NHS boards must listen to their communities. If they do not, we are in trouble. The Government has tried to democratise at the board level through the health board elections, but there must be democratisation much further down the line at the community partnership level. With that, we can drive forward the sort of care that everybody in every community in Scotland deserves from their out-of-hours services.

Photo of Shona Robison Shona Robison Scottish National Party 4:43 pm, 11th November 2010

I, too, thank members for their varied and useful contributions to what has been an interesting and consensual debate on an important topic that touches the lives of everybody in Scotland, including those who live in rural areas.

Members have acknowledged the good work that is in progress, and the need for the pace of change to speed up and for the service to have greater cohesion. That was very much the flavour of the cabinet secretary's response to the committee's report. She laid out clearly who was going to do what to take forward particular elements of the report and its recommendations.

Perhaps we need to get a little better at recognising best practice throughout Scotland and at encouraging its take-up when benefits have been demonstrated. We have heard about a few of those benefits, and I will refer to one or two of them in picking up on members' remarks. If I do not get round to dealing with all members' comments, I will attempt to do so by writing to them.

Christine Grahame talked about several issues, including the increase in pressures on the Ambulance Service and the accident and emergency service, in particular since 2004. We are beginning to get a better understanding of that situation. I am not sure that it is all related to the changes in the GP contract. Some of it might be, but there are other pressures, such as the ageing population. The profile of people who use the Ambulance Service or A and E shows that there is still very much a balance towards older people, which we must address in a number of ways. So there are complexities.

Richard Simpson made several good points. He talked about the use and contribution of BASICS-trained GPs. That was an important point, and one on which we absolutely agree. The other point that he made, which to a degree answers Mike Rumbles's concerns, is that, even with the level of protection that the health budget is receiving, the increases in the health budget are nowhere near the increases in previous years' budgets. At the same time, we still have the pressure of rising costs in the health service, whether in drugs budgets or other areas. Therefore, we need innovation and we need to consider efficiency and redesign.

Photo of Shona Robison Shona Robison Scottish National Party

I will come back to the member's point in a moment. In fact, go on—sorry.

Photo of Mike Rumbles Mike Rumbles Liberal Democrat

My point was not about the reducing budget—that is incidental, although it is the reason why NHS Grampian has said that the changes I mentioned are happening now. My concern is about geography. People have to understand the geography of the area that they serve, and that does not mean just looking at maps.

Photo of Shona Robison Shona Robison Scottish National Party

I understand that. As I understand it, NHS Grampian is at an early stage of consultation and there are no proposals on the table. Therefore, there is an opportunity for communities to influence the decision making. We expect communities to be part of any service changes, and not only major ones. That is good practice, so we would expect it.

Murdo Fraser talked about health boards taking note of the committee's report. I am sure that they will do so. The cabinet secretary laid out in her response to the report how that will happen—how it will be picked up and responded to directly, which is important.

I am not sure about this, but Murdo Fraser seemed to indicate that there is a case for GPs to take back overall responsibility for 24-hour health care. Our opinion is that that is not the way forward and it certainly would not be welcomed by general practitioners; indeed, they are likely to reject it. Things have moved on since the days when GPs had that responsibility. Although the current system might not be perfect and there is still work to be done, Richard Simpson laid out some things that show the potential if we can just complete the integration of services. There is potential for something far better.

Murdo Fraser also mentioned the future of the GMS contract and the fact that the UK Government has produced a white paper proposing changes to the way in which the NHS is run, including out-of-hours proposals. The Scottish Government has said on a number of occasions that we do not support GP commissioning, and we would not support it in the current case. One reason for that is that we believe that NHS boards are best placed to commission and pay for services, because they can take a wider perspective. Handing over even more resources to GPs to commission services might not be in the interests of patients or the public purse. The UK Government should think carefully before embarking down that road, because the law of unintended consequences might come out at the other end. We should be cautious.

Murdo Fraser raised several issues about Kinloch Rannoch, as I expected him to. I recognise his interest in the issue over a long period. The point that I make to him, which has been made already and which I know that the cabinet secretary said a fair amount about in her evidence to the committee, is that we expect boards to ensure that they meet the NHS QIS standards when they provide out-of-hours care and that they listen to local communities.

However, that does not mean that they will always agree and accede to the demands of local communities. There is a balance to be struck. I encourage the continuation of the discussions of the reference group that involves NHS Tayside and local residents, which have been going on for quite some time. As I understand it, that process has resulted in some positive developments. The community might not have got everything that it wanted, but improvements to the service have emanated from the work of the reference group.

Jamie Stone mentioned transport issues. I am sure that he will be aware that the Scottish Ambulance Service is undertaking a considerable programme of work on the patient transport system, which is important.

One other thing that I want to mention—

Photo of Shona Robison Shona Robison Scottish National Party

Okay. I will write to the members whose points I have not responded to. Some other important points were made but, rather than take up any more time, I will deal with them in writing.

Photo of Alex Fergusson Alex Fergusson None

Thank you. I am sorry to have drawn you to a close.

I call Ross Finnie to wind up on behalf of the committee.

Photo of Ross Finnie Ross Finnie Liberal Democrat 4:51 pm, 11th November 2010

It has been a useful debate and, as many have observed, there has been a great deal of consensus. Of course people have different views on how out-of-hours care might be better provided, but there is a common view across the chamber that its provision is an essential part of the work of the health service.

As our convener pointed out at the opening of the debate, our inquiry had a number of purposes. We embraced the petition on provision in Kinloch Rannoch, but we did so only as part of the process of looking at out-of-hours care in the round.

Confusion is one of the issues that arose. People who have been listening to the debate all afternoon might be wondering what it is about. The committee's report was on out-of-hours health care, but most members have mentioned NHS 24. People who have been listening to the debate must think that we have been discussing the provision of care from early in the morning until last thing at night: NHS 24 has been mentioned, so, according to the ordinary use of the English language, MSPs must have been talking about all-day care. However, some MSPs have chosen to talk only about out-of-hours care. In the ordinary use of the English language, even the title "NHS 24" is likely to cause confusion to any ordinary citizen who might be confused about what they want.

Some members who are present started the morning by attending a BMA event—the association was launching its manifesto at what can accurately be described as an out-of-hours event, in that it started at 8 am. A number of interesting points were made on out-of-hours care. One thing that the BMA appeared to be clear about—but which not every health board is clear about—is that every citizen, regardless of where they are, should be able to access a GP within an hour. I found that interesting. I am sure that the minister is aware of that aim and that she wishes that all health boards were able to meet it.

The difficulty is that the general provision is uneven across Scotland. The committee found it difficult to frame its report when good examples emerged—such as in the Borders or in Wester Ross—alongside specific difficulties, some of which have been picked up graphically during the debate. Murdo Fraser and Ian McKee dealt with the Kinloch Rannoch episode. As part of his analysis of the figures, Ian McKee noted that NHS Tayside will provide a driver even if there is not a whole person available, which is an interesting concept and one that we ought to pursue. However, there were serious issues about whether the board's objections were based on sustainable numbers. Murdo Fraser and Richard Simpson referred to that.

We had other specific examples. Liam McArthur talked about the real difficulties in island communities and how air ambulance and telehealth services function in remote and rural areas. Then we had the geographical example from my colleague Mike Rumbles. The redesign of a health service is always possible, but I suspect that redesigning Cairn o' Mount will be beyond even NHS Grampian. That might be a fundamental barrier to its making any progress on its redesign proposal.

A number of members picked up on key aspects of the report. The minister and the cabinet secretary have made reasonably positive approaches on those key aspects, by which I mean that they understand that there is still work to be done, particularly on the standards that have to be set. That remains a matter of some concern. We are now quite well into the process and we need to see the standards that QIS is to develop because, as the committee pointed out, we need to have a greater handle on whether we are able to measure our out-of-hours care service in a way that makes sense.

The integration of the various services is another possible cause for confusion, but people must have clarity. We have been told that patients should not be confused, because NHS 24 is actually a call-handling service. However, Richard Simpson and the committee have pointed to areas where there is still confusion and overlap. Some of the overlap is being addressed. Experiments such as co-locating the Ambulance Service with NHS 24 should eliminate a lot of the confusion.

Photo of Alex Fergusson Alex Fergusson None

Order. There is far too much noise in the chamber.

Photo of Ross Finnie Ross Finnie Liberal Democrat

I will speak more quietly.

The matters that I mentioned need to be addressed. We have to be clear about the purpose of services and eliminate the overlap.

The report is addressed to the public. It is not addressed to the Parliament and not really addressed to practitioners. It is intended to meet the needs of the public and address their expressions of concern, because it was firmly rooted in a call from a petition to the Parliament. That petition was about a specific community, but it was clear from the evidence given to us that many of the issues that the petitioners raised were shared with communities throughout Scotland.

Members from throughout Scotland spoke in the debate, and all were able to articulate individual concerns that remain, despite the fact that, as the committee's report recognises, substantial improvements have been made in the delivery of the NHS 24 service.

However, the difficulty is that the availability of the service remains uneven. We must recognise that there are differences between communities throughout Scotland. That is where the QIS standards might help, because, if there were standards against which we were able to measure the service—notwithstanding the different ways in which it is delivered to meet particular geographical or economic and socio-economic needs—that would provide clarity.

In response to the committee's report, the minister has made clear her position on sustainability and cost. The committee is more concerned about sustainability. Of course we understand that there is an inextricable link, but that takes me back to the need for a clear understanding of how we deliver it and by whom it is to be delivered.

There is also, in our report, a clear question about people's need to understand what they ought to expect from their local doctor during hours so that there is no further confusion about leaving something to out-of-hours services. That is brought out clearly in the report, and I am not entirely clear that we have received much of a response from the Government on that. If that delineation was to be much clearer and we were to make it understood to the patient, their understanding in that regard would be greatly helped.

The committee is pleased that the report appears to have gained general support. It exposes for the benefit of the Parliament and the public the issues that remain to be addressed within NHS 24. We have made it clear to those who work in NHS 24 that we acknowledge the huge improvements that have been made. However, as the minister said, work is still in progress and much still needs to be done. There certainly needs to be greater clarity about NHS 24's purpose, its effect, and what it is intended to deliver. Only when we have that clarity will we be able to ensure that communities throughout Scotland get equality of treatment, but not on a one-size-fits-all basis.