I always welcome the opportunity to debate the national health service in the chamber. It is an institution that we all hold in the highest regard, and we admire what is achieved daily by our hardworking NHS staff. However, there are some difficult issues on which we need an open and honest debate. Everyone is aware of the scale of the demographic challenge that we face. More of us are living to a ripe old age and will potentially be relying on health and social care services.
I do not think that we do not need to rehearse the arguments in the chamber. We all agree that we should fund much earlier intervention to prevent people from having to engage with care services. We agree that keeping people out of hospital when they do not need to be there is the right thing to do, as it is not only better for the public purse but much better for the individual concerned. We also agree that we need to shift the balance of care.
It is fair to say that we have agreed on much of that for some time, but we have failed to deliver the type of transformational change that is required. We will shortly debate the integration of health and social care: the governance arrangements, financial procedures and accountable officers, and myriad structural issues besides.
We must not forget that culture is equally important and is not something for which the Cabinet Secretary for Health and Wellbeing can propose legislation. We have yet to resolve fundamental questions, such as how we bring together two very different approaches. We have an national health service that is free at the point of need and which assesses people’s needs and then treats them, while our social care system assesses people’s needs, rations what can be provided based on how near a crisis the person is and then charges them for providing a service. We will struggle to succeed if we ignore such questions.
I know that the cabinet secretary is grappling with some of those thorny issues, so I was most interested to read his reported comments to the Unison conference in Glasgow on 24 April—just two weeks ago—about demographic change. He said:
“We are still going to need the same number of beds, the same number of hospitals, the same number of doctors and nurses just to stand still”.
If members were in any doubt, that was confirmed by a number of national newspapers and welcomed in many quarters as a firm commitment and a clear direction of travel.
There was nothing equivocal about that statement, and I think that members would all agree that there is nothing equivocal about the Cabinet Secretary for Health and Wellbeing. Indeed, Jackson Carlaw is fond of saying that cabinet secretary is a pragmatic man, and I have to say that I agree. However, it would appear that, since that statement, someone has got to the cabinet secretary.
The cabinet secretary’s amendment is the parliamentary equivalent of shouting, “There’s a squirrel!” to distract attention. Instead of talking about what we need to do to tackle demographic change, and helping us genuinely to understand his comments about no changes to beds, hospitals, and doctors and nurses, he wants instead a discussion on minimum unit pricing.
Both of those subjects are substantial in their own right, but minimum unit pricing should not be used as a cover for avoiding a discussion on the level of health services that we can expect in the future. I confess that I am left to wonder whether the cabinet secretary meant what he said. Has he been silenced by his civil servants, or is it just another case of saying one thing in public to a Unison audience and another thing entirely in private?
Let us suppose for a minute that the cabinet secretary is genuine, because I believe that he is. It is clear that NHS Lothian did not get that message when it was discussing proposals to close three hospitals—the Astley Ainslie, Corstorphine and Liberton hospitals—all in the week that the cabinet secretary said that there would be no hospital closures.
Those closures are likely to lead to a reduction in beds. I applaud the valiant effort of the chief executive of NHS Lothian to convince us otherwise, but there is no disputing the facts. In 2007 there were 2,518 beds in NHS Lothian, and for the last available quarter there are 2,411. That is a reduction by anybody’s standards.
That is not the whole picture, as the argument is made that beds in the care sector will make up for any reduction in hospital beds. However, there will be a need for further capacity just to stand still, never mind to make up for the loss of beds. For example, the City of Edinburgh Council will have to cope with the closure of five private care homes that provide very sheltered accommodation, which was recently announced by Cairn Housing Association, on top of coping with the changing demographics.
Local authorities throughout Scotland are struggling to cope now, never mind as the numbers of older people increase. The capacity is just not there, and there is no promise from NHS Lothian to re-provide each and every one of those beds in the care sector, so consequently we lose beds.
If we delve a bit deeper, we see that, on page 166 of its paper, the health board notes that, in its clinical strategic framework,
“The shape of our workforce is changing. There will be fewer doctors overall and where doctors skills are needed in specialist areas of care, these may need to be provided on fewer sites to ensure that services are safe.”
Let me repeat that:
“There will be fewer doctors overall”.
The number of doctors will decrease. Does that not all fly in the face of the cabinet secretary’s promise to the Unison conference in Glasgow?
The situation is not confined to NHS Lothian. NHS Western Isles proposes to cut the number of its beds from 89 to 53, and other health boards including NHS Greater Glasgow and Clyde are reviewing their acute services. I do not think that the cabinet secretary is saying at the outset that the review will mean no changes to hospital numbers, bed numbers or staff numbers, but perhaps he is.
When we consider the SNP’s record, it makes interesting reading. Bed numbers have been reduced by more than 1,400 since 2007 despite an SNP promise made by Nicola Sturgeon in 2006 to increase the number of beds. Nurse numbers have been reduced by around 2,000. Perhaps more seriously, the intake of student nurses was slashed by 12 per cent in 2011-12 and there was a further cut of 10 per cent in 2012-13. I think that we would all agree that that is a potentially damaging decision that will have serious consequences in the years to come. We are storing up trouble for the future.
If the Government will not listen to me, it should listen to the Royal College of Nursing, which tells us that
“cuts to the workforce are not only bad news for patient care but mean that the remaining staff in the NHS are increasingly over-stretched”.
Furthermore, Unison reports that there are serious concerns about patient safety with the reduction in nurse-to-patient ratios, and the British Medical Association calls for an open and honest debate about what the NHS can and cannot afford. The BMA also points to the need to increase the resourcing of social care and primary care if we are properly to meet the changing demographic profile of our population.
None of this is easy. I recognise that there are real financial constraints both in the NHS and in local government. In that context, the cabinet secretary’s comments were interesting—some would say that they were positively extraordinary. They were a complete departure from his department’s thinking, certainly a departure from the thinking of his predecessor, and a departure from the general direction in which health boards are travelling.
I believe that the comments merit serious debate. Can we have the best of both worlds? Can we maintain bed numbers and hospital numbers even if that flies in the face of what health boards are planning to do? Should we maintain staff numbers to maintain the best possible quality of care and is there a trade-off in there? Those are serious issues that merit serious debate. In addition, how do we ensure that we invest in the social care sector and truly shift the balance of care?
I fear that, having promised one thing in public, the cabinet secretary is saying another thing in private. Perhaps he simply told the Unison audience what it wanted to hear and has since been pulled back into line by his civil servants. If he is serious, however, we urgently need a national strategy and national planning. Announcing that there will be no bed number reductions, the same number of hospitals and the same number of nurses and doctors requires thought if it is to be more than simply a glib soundbite.
Someone said to me that the cabinet secretary was simply playing to the gallery and making it up as he went along. I thought that that remark was uncharitable. However, some evidence of thinking on the part of the Government that underpins the cabinet secretary’s comments would be very helpful; or, if his comments were made in error, he should please tell us, not least because the people of Scotland deserve an honest debate about their NHS.
That the Parliament notes reported comments from the Cabinet Secretary for Health and Wellbeing at the Unison conference in Glasgow on 24 April 2013 that an ageing population means that “we are still going to need the same number of beds, the same number of hospitals, the same number of doctors and nurses just to stand still”; voices concern at reports that the future of three hospitals in NHS Lothian is under threat; further notes that the Scottish Government has already cut over 1,400 beds and almost 2,000 nursing and midwifery staff, and calls on the cabinet secretary to guarantee that his comments mean no further cuts in beds, hospitals, doctors and nurses.
Jackie Baillie rightly said—it was one of the few things that she got right—that society is constantly changing and its needs are evolving. The remarkable achievement is that the health service is, and has been, changing with it. I welcome the opportunity to put on the record my gratitude for the dedication and commitment of all our hard-working NHS and social care staff across Scotland. I recognise that all parties share that gratitude.
Although the shape of the NHS has evolved since its foundation, its core principles of providing the best possible healthcare, free to all regardless of their income or need, must be preserved. For those principles to be protected, we must ensure that the health service develops with the needs of the Scottish people. This Government will maintain and improve—as we have been doing—the levels of quality and provision that the health service requires.
The Government will protect the health budget. We recognise that, if we want a first-class health service, the resources must be there to deliver it. As we look to the future, the twin challenges to be met are the ageing population and the increase in healthcare demands as a consequence of changing lifestyles, including those related to tobacco and cheap alcohol.
Some of the picture that Jackie Baillie painted was rather dark and inaccurate, so let me deal with a number of the issues that she raised. First, she ignored some real improvements in the national health service in recent times. She mentioned the number of beds: the total number of beds in the national health service today is just more than 24,000, which represents a 12 per cent drop over the past five years. However, I have checked the bed numbers for the five years previous to that, while Jackie Baillie’s colleagues were in Government and in charge of the health service. Between 2002 and 2007 the number of beds declined by 13 per cent.
I will make three points. First, we need a proper planning tool to manage bed capacity in a fast-changing health service. Today, I have announced major advances in the development of a bed-management tool.
Secondly, this is not only a numbers game; it is also about the mix of beds. For example, a big challenge in our 30 acute hospitals is the balance between medical and surgical beds.
Thirdly, there have been very good reasons why there have been particular reductions in bed numbers. For example, there has been a drop in the number of long-term psychiatric and geriatric beds because we have been treating people in the community rather than in hospital. If one looks at the shift in many areas to day surgery, by definition the same number of beds are not needed for the throughput in day surgery—which has risen by 10 per cent in recent years—as are needed for longer stays in hospital. If one looks at the turnaround time between coming into hospitals for elective procedures and discharge, for example, that time is reducing all the time. Those issues quite rightly drive bed numbers.
I clarify that the point that I was making at the Unison conference—which I have made many times in the chamber—is that when one looks at the particular challenges relating to over 75-year-olds, one sees that there will be, roughly, a doubling in their numbers over the next 20 years or so. If we were to achieve a 50 per cent reduction in hospital admissions among those 75-year-olds and go no further, the same number of beds would still be needed for that particular group. That is the part that Jackie Baillie missed when she was quoting my speech.
I do not have time, unfortunately.
I believe that we can reduce the hospitalisation rate even more. Recently, I have seen a pilot in East Ayrshire, which through new innovations and new technology has resulted in a 70 per cent reduction in hospitalisation among members of the older age group.
On the other hand, we will continue to expand day care services. I will give Jackie Baillie some workforce numbers. In the past five years, the number of qualified nurses has increased by more than 700, the number of consultants has increased by more than 800, the number of general practitioners has increased by more than 250 and the number of allied health professionals has increased by more than 650.
Investment in the workforce has been paired with the increasing demands on the NHS. The health service is diagnosing, treating and caring for far more people than ever before. In the past year alone, the number of in-patient cases grew by almost 5,000 to 253,000 and the number of out-patients grew by more than 20,000 to 1.1 million. The number of accident and emergency presentations exceeded 1.5 million. Since 2006-07, the number of day cases has grown by 43,000 a year to nearly 450,000. I would have thought that those were all welcome developments.
Over the past five years, the number of GP appointments has gone up by more than 3 per cent, the number of GP practice-nurse appointments has gone up by more than 10 per cent, the number of out-patient attendances has gone up by nearly 5 per cent and the number of in-patient and day-case discharges has gone up by nearly 7 per cent.
I am outlining the improvements that are referred to in the amendment. I thank Mr Carlaw for his point of order.
Over the past six years, the measure of patient satisfaction has risen dramatically, from just under 81 per cent to more than 88 per cent. That indicates to me that patients are increasingly satisfied with the quality and range of provision that they are receiving from the NHS in Scotland.
As we look to the future, we face major challenges. I have already mentioned the ageing population. I have no doubt that Mr Carlaw will point out that over the next 20 years he and I will come into the category of over-75-year-olds. It is not just the ageing population that presents a challenge; our population is at a record level, which means that demands on the health service are at a record level. We know about the budgetary situation and the constraints that it is operating under, even though we are passing on the Barnett consequentials. Inflation in the health service is twice as high as inflation generally. In addition, of course, there is the challenge of addressing the inequalities in access to healthcare, let alone the particular challenges that relate to overuse of tobacco and alcohol abuse.
The reality is that, despite the huge increase in demands, despite the constraints on our budget that have been imposed on our budget by our friends in London, and despite all the challenges to do with an increasing and ageing population—
Despite those things we are providing a far better health service, in which we are investing a record amount. That is why I am proud to move my amendment.
I move amendment S4M-06474.1, to leave out from “an ageing population” to end and insert:
“Scotland’s health service faces many demographic and lifestyle-related challenges in the coming years; recognises that the population of over 75-year-olds in Scotland is set to double over the next 20 years and that Scotland pays too high a price for the consequences of cheap alcohol; welcomes the Scottish Government’s commitment to at least maintaining the level of quality and provision in NHS Scotland in the face of these challenges; further recognises that adult health and social care integration is vital to meeting the future care needs of Scotland’s ageing population, and reiterates its support for the introduction of minimum alcohol unit pricing as one of the measures that will help improve the health of the nation.”
The very serious issues that are highlighted in Labour’s motion and the Scottish Government’s amendment could fill a whole day’s debate and can only be touched on in the time that is available to us. Therefore, I will concentrate on the infrastructure and workforce matters that Labour has raised, while my colleague Jackson Carlaw will deal with the introduction of minimum alcohol unit pricing as a public health measure—to sum up what the cabinet secretary said in support of his amendment.
For many years, we have talked about the increasing challenges that the NHS faces, which are a result principally of an ageing population, but also of the many health problems that result from lifestyle issues. Last October, the Health and Sport Committee received evidence that
“ageing of the population alone, with no alteration in the prevalence of diseases or the age-specific rates of becoming disabled ... will result in a 67 per cent increase in the numbers with disability over the next 20 years. Numbers of the oldest old (those aged 85 years and over) with disability will have doubled”.
In addition, the proportion of the older population with arthritis, coronary heart disease, stroke and dementia will have increased by 40 per cent by 2025—just 12 years from now—and many of those people will have several long-term conditions affecting their health and wellbeing.
Although those figures are from south of the border, there is no reason to suspect that Scotland is greatly different. The increasing numbers of people who require care have been described as a huge train coming towards our health service system and it is not clear whether the system is in a fit state to cope. The BMA itself has said that
“There is an urgent and growing need to improve decision-making on what” healthcare and care
“services are needed locally and how they can best be delivered”,
and that there needs to be
“an open and honest debate ... about what the NHS can and cannot deliver” in the longer term. I do not always agree with the BMA, but I think that it is right to say that services will need to be improved and reorganised to meet changing demands and that that can be done effectively only with the engagement of those who deliver services locally, including doctors and nurses.
I am pleased to note the Government's stated
“commitment to at least maintaining the level of quality and provision in NHS Scotland in the face of” increasing challenges, although the cabinet secretary’s quoted comments to the recent Unison conference were perhaps something of a hostage to fortune in the context of health boards’ attempts to rationalise their services and estate as demand increases.
It is worth looking at the Lothian strategic clinical framework for the next seven years to put the apparently threatened Edinburgh hospitals in context. It states:
“We will look at the physical space and land that we own and make decisions, based on clinical need, on opportunities to safely move off sites, reducing land and property running costs” thus releasing funding to be invested in other services. It continues:
“We will continue a programme of primary care premises development providing accessible community-based healthcare facilities.
Less hospital in-patient care may mean we need fewer hospital beds, with those that we do need provided in appropriate and fit for purpose accommodation.”
Finally, the document states:
“We will review some of our smaller sites” such as the Astley Ainslie, Corstorphine and Liberton hospitals
“which provide a less than optimal setting for patient care in terms of privacy, dignity and safety ... as we modernise the facilities and locations in which the care of older people is provided.”
I do not profess to be familiar with the Lothian hospitals, but we have similar on-going issues with the Grampian hospital estate, where provision is gradually being realigned to cope with a changing population and changing demands. I think that that approach is sometimes necessary.
Change is never popular, but to cope in the future we will need proper integration of healthcare and social care. People will also have to be a little bit more self-reliant and will be assisted by steadily improving technology such as telecare, which can now be successfully used by elderly people who have, for example, no knowledge of computing.
However, although the balance of care is continuing to shift towards more community-based health and social care and more service provision by the third sector, there will still be high demand for acute services, partly because of ever-advancing medical and surgical technology but also because of the greater numbers of older people.
That brings me, finally, to the nursing workforce, which according to the RCN is facing unprecedented pressures. I have seen that at first hand at night in a busy orthopaedic ward, when I was looked after by only one charge nurse and one auxiliary who were dealing with six intravenous infusions and a number of very frail elderly patients. It would take just one emergency in such a ward for the system to fall apart—and the management are well aware of it.
The planning tools for nursing, which ensure that the right number of nurses and healthcare assistants are in the right place at the right time in all hospital settings—use of which are, indeed, now mandatory for all health boards—can help if they are used regularly and in every ward and health team. Unfortunately, however, some health boards are continuing to cut the nursing workforce, which is causing yet another postcode lottery of patient care, and putting immense strain on overworked nurses and healthcare assistants.
I conclude by quoting the RCN once again:
“We ... urge all health boards ... to work with us stop the cuts to staffing levels right across Scotland and ... the Scottish Government to plan for the long term and face up to the ... pressures on our NHS, for the people who work in it and the patients who rely on it.”
I welcome the opportunity to speak in support of Alex Neil’s amendment, and want to focus my four minutes on the specific longer-term healthcare and social care challenges that face Scotland as a society and which the Scottish people will look to MSPs to address and resolve together.
Let us be clear: it is a mark of our success as a society that our citizens are living longer and healthier lives. Also, the Scottish Government is determined, by reducing the health inequalities that continue to blight our communities, to improve the life expectancy of people who live in Scotland’s most deprived areas.
However, as we all know, a rapidly increasing ageing population presents challenges, too—especially with more people living with multiple long-term conditions and complex support needs. The Government recognises that, which is why it is changing how the NHS delivers care, why it is focusing on outcomes, why it is redesigning services around the patient, and why it is placing the patient’s journey at the centre of everything that the NHS does. The very welcome announcement today of a new bed-management tool underlines the Government’s commitment to ensuring that there is the necessary hospital capacity with the right type and number of beds and staff in the right places to support such changes and to help our boards to plan their services.
We need, in order to reduce demands on the NHS, to continue to develop preventative measures, such as the detect cancer early programme, and to develop measures that decrease the incidence of avoidable lifestyle-related diseases, such as the decisive action that the Government is taking to introduce alcohol minimum unit pricing, which will help to save lives and address the pressures that are put on the NHS through the thousands of hospital admissions and attendances at accident and emergency departments that result from alcohol misuse.
We need to develop measures that improve co-ordination between different elements of our healthcare and social care systems, measures that make it easier for our elderly people to continue to live fulfilling lives in their own homes and communities rather than in acute and institutional care, and measures that build capacity at very local level to provide proper care and attention to our most vulnerable people.
The SNP Government has not only begun the reforms that are needed to implement those measures; it has already made significant progress in delivering tangible outcomes.
However, no one is under any delusion about the scale of the challenges that we still face. The direct cuts that have been imposed on the Scottish budget by Westminster, and the potentially devastating impact of the welfare reforms that are being rolled out by the London Government are bound to increase the scale of the challenges that face sustainable delivery of high-quality healthcare and social care.
By protecting the NHS budget, as we are committed to doing for the remainder of the current spending review period, by maintaining our commitment to there being no compulsory redundancies in the NHS, by investing in our NHS workforce, and by protecting the founding principles of the NHS, the Government is taking the appropriate steps to meet those unprecedented challenges.
In conclusion, the SNP Government is committed to ensuring that
“the level of quality and provision” of health and social care in our NHS, which the people of Scotland quite rightly expect and deserve, are maintained into the future. At a time of unprecedented challenges to our health and care system, I believe—I think the overwhelming majority of the Scottish public believes it, too—that our hard-working NHS staff and social care staff are due an immense vote of thanks for their dedication and professionalism. I also believe that the Government has the support of those health professionals in tackling the challenges ahead in a determined and robust manner.
I support the cabinet secretary’s amendment.
This debate goes to the heart of the challenge of long-term demographic change and to the heart of the short-term challenges that already face health boards, those who commission care services and, crucially, older people and their families, who are looking for quality services to support them in living good-quality lives.
A bit of a reality check is needed. We could all see what the amendment was about; in fact, the cabinet secretary’s opening speech demonstrated that in spades. I quite like the cabinet secretary’s new improved interpretation of his quotation from two weeks ago, as it perfectly sets up what I was going to say. He says that he is against any hospital closures and that, in terms of the needs of older people in Scotland, we do not need to close any beds in the long term, but NHS Lothian’s strategic clinical framework says otherwise. There is no getting away from that, with respect to older people. The framework states:
“Less hospital inpatient care may mean we need fewer hospital beds, with those that we do need provided in appropriate and fit for purpose accommodation.”
I want to highlight the massive pressures that already exist in NHS Lothian. I welcome the extra beds that are being put in place in the Royal Infirmary of Edinburgh, but the Royal Victoria hospital, which was specifically for older people, was closed. It had to be reopened within months because of the short-term capacity problems in the ERI.
There is also a question mark over three more hospitals. I do not need to go into the cabinet secretary’s quotation in depth, because that has already been done. However, it is vital that, before any decisions are taken on those smaller hospitals, a replacement strategy is in place that is funded and is clear about the numbers of people who need to be looked after, about the range of types of care, and that facilities are in place for that. The closure of the Royal Victoria teaches that lesson, as does the situation in respect of the new sick kids hospital and the replacement hospital for the department of clinical neuroscience in Lothian, because the money was not in place in time to build the facilities.
I do not need to lecture members about the cash-strapped nature of NHS Lothian, because it has been well documented. However, we need the health secretary to engage with the reality of his funding decisions. The BMA has made it clear that real-terms spending on the health service is reducing. We therefore need guarantees on replacement plans. As my colleague Ian Murray MP put it, the needs of
“some of the most frail and vulnerable people in the city ... are not necessarily best met in a community setting.”
We need a proper and honest debate about that.
As Jackie Baillie said, the closure of the five Cairn homes is a timely reminder that we must be concerned about more than just the health element of integration of healthcare and social care, because the social care element is in crisis and faces real problems now. There is a particular problem for the City of Edinburgh Council in that the five Cairn homes are very sheltered accommodation that is not financially sustainable, according to Cairn. However, its model of very sheltered housing is precisely the sort of provision that we will need more of, rather than less.
The Cairn closure proposals have, understandably, created stress and worry for the families involved. As one relative put it, having searched in vain for alternative accommodation:
“There is nothing that will give elderly frail people a dignified and independent (with support) way of life.”
That refers to the people about whom Alex Neil talked in his opening remarks: the increasing numbers of over-75s, many of whom will want to live in their own homes with support, or who will need to live in very sheltered accommodation or care homes. However, there is simply not enough funding to go around.
I am told by my colleagues in the City of Edinburgh Council that they will need to rebuild or refurbish eight care homes. They provided a new one in Drumbrae, but they simply do not have the capital to build, never mind to staff, more new care homes. The problem is therefore a current one rather than a long-term one. We need from the health secretary an honest commitment, not just glib statements at conferences, and we need an understanding of the reality on the ground and action on it.
It was interesting to hear Sarah Boyack say that this is a current problem, because I suggest that it is an historical one. One of the problems in the health service’s infrastructure is that for too many years issues were put on the back burner, and we did not in the good times use money to redevelop facilities and services as well as possible. We have a resultant backlog, and difficulties are emerging. It is therefore a problem from the past that is affecting us in the here and now.
I have only four minutes. Were it a longer debate, we might have had more time for interventions. I have a lot to get through.
It is always good to be in the chamber discussing the health service and its importance. It is disappointing how we sometimes find ourselves discussing it, though. I want to look at some strong local examples, then perhaps to focus more on the national picture.
There are two good examples of facilities being developed in Aberdeen that I think will make a real impact on how health services are delivered there. Nanette Milne and I have both visited the new state-of-the-art emergency care centre in Aberdeen, which is a £110 million project that will improve and enhance the patient experience and will, I hope, lead to a reduction in the length of time that people are required to be in the care of the health service, which will obviously be beneficial.
In addition, in terms of the gateway services that we rely on, a project to build a new Woodside Fountain health centre serving the communities of Woodside and Tillydrone is being delivered through hub funding of £4 million. There are in that area some deprived communities that the new centre will benefit. The point is that facilities require to change and move with the times—and they do—in order to adapt themselves to changed circumstances.
On the wider picture of Scotland’s health, I note the cabinet secretary’s announcement about a bed-management tool, which will help health boards to plan appropriately for their future requirements. For too long, the short-termism that has dominated how we do things—not just in politics, but in general—has meant that we have not looked at and dealt with long-term challenges that are on the horizon. The tool will assist in that.
Demographic change will not just put pressure on beds in the health service. There will also be a requirement for more people to act as unpaid carers. I have experience of that; my mother cared for her mother, who had dementia. More people will choose that option, rather than rely on social care or health services to take on the caring role. We need to ensure that appropriate support is in place, which is why the carers strategy and the dementia strategy are so important.
We need to ensure that there is early diagnosis and intervention and that individuals get the most appropriate care and support, in the setting that is most appropriate for them. If that setting is in the health service, we must ensure that capacity exists, but the preference will always be for care to be delivered in the person’s own home, to give them a degree of personal independence and to allow them to live as fulfilling a life as possible.
I am sorry, but I have only 45 seconds left.
The integration argument is key. The integration of healthcare and social care is absolutely about closing gaps, breaking down silos and ensuring that unnecessary hospitalisation does not occur. Let us be honest: in the past, people have found themselves in an acute-care setting when they did not need to be there, because social care and healthcare services were not taking a joined-up approach.
The health service will always evolve to address needs, so we must ensure that it is properly resourced and flexible enough to change. The Government’s commitment to protecting the health service budget will help in that regard, as will measures that are being taken to ensure that there is flexibility in the future.
I declare an interest, in that my wife is a nurse in a high dependency unit in Glasgow. I am in no doubt about the challenges that NHS staff face daily, nor about the exceptional job that they do as they meet those challenges.
It is simply not an option for Scotland’s NHS to stand still. That is not just because of the ageing population, but because we should always look for continuous improvement in the health service. Much of what the NHS has done in the past has been demand led; it has been about downstream intervention. In other words, the system waited until someone was ill and then took steps to make them better—or, at least, as comfortable as possible.
Scotland’s NHS is—and needs to be—increasingly involved in early intervention and public health initiatives. That has been a key strategy of the Scottish Government. It is far better to detect illness early, be it through national initiatives, such as the Scottish Government’s detect cancer early initiative, or local initiatives, such as NHS Lanarkshire’s efforts to detect and treat irregular heart rhythm, which can lead to health problems including atrial fibrillation and stroke, which put great demands on Scotland’s NHS.
The Scottish Government is also involved in key public health initiatives, such as minimum unit pricing of alcohol, which can dramatically improve Scots’ health and ease the burden on our NHS. Recent evidence from Canada shows that over a number of years a 10 per cent increase in alcohol prices has led to an 8.9 per cent decrease in admissions to acute services. There has been a direct public health benefit and a direct saving. We should be mindful of that when we talk about pressure on Scotland’s NHS.
I would like to, but I honestly do not have time.
Nothing is standing still in Scotland’s NHS, which means that we need to ensure effective planning in relation to staff and bed management. That is where the focus of much of this debate should be. Unison and the Royal College of Nursing have been helping to develop workforce and workload management tools, which will be mandatory in the coming year.
The cabinet secretary announced a bed-management tool. As healthcare and social care are integrated, we must consider how the tool can be developed in the context of the knock-on effects of reconfiguring the bed estate in the traditional hospital setting. In other words, when we move older people out of a traditional hospital setting and put them in a care home environment or support them at home, we need to ensure that we monitor whether local authorities put in place adequate provision for support services.
In the future, those issues need to be combined within an overall bed-management tool that deals with where our most needy citizens stay, whether that be in hospital, at home or within a home setting within the community. I would like more information on that.
All politicians can become obsessed by numbers, but I have deliberately not given the numbers that relate to the increase in the health budget or to staffing numbers, on which we have done very well—
We can all be obsessed with numbers, but surely to goodness any individual politician giving the number of beds within Scotland’s NHS would be sticking to an arbitrary number—
We need to get the bed-management tool correct in order to make a proper assessment. I point out to Ms Baillie that this is my speech and not hers, if she does not mind.
Presiding Officer, I was just finishing off, but I was quite rudely interrupted.
The point that I am trying to make is that any number that is arrived at must be based on evidence and it must be based on getting the bed-management tool right. If Labour had come to the chamber in a positive and constructive vein, we could have had an excellent debate, but yet again—unfortunately—Labour has let itself down on health.
A lot has been said about the change in demographics, which it is noticeable was referred to by all my colleagues on the Health and Sport Committee as well as by others. One of our greatest challenges—whether that be under the current budget or under an increased budget to meet increased demand—will be how we manage that change.
What is surprising, though, is that we did not discover that just today, given the reports that we have had from Beveridge, Christie and Lord Sutherland. We have also had six years of an SNP Government. I recognise that the cabinet secretary has been in the job for only seven months—as he keeps telling us—so I do not hold him personally responsible, but that challenge needs to be recognised.
We all know and should accept that change is difficult for all politicians, but it seems to be even more difficult for Governments that want to win a referendum. As I have said to the Cabinet Secretary for Finance and Sustainable Growth, I am concerned that we are dodging hard decisions and building up pressure for the future. We need to deal with the issues that we face. I think that we should judge Governments on their actions rather than on their good intentions, but I know that the Cabinet Secretary for Health and Wellbeing would like to get to that point and I hope that he wins his fight in the Cabinet and is able to address these issues.
As has been rightly said, we should look at what those who deliver services, who are seeking such a change, have said about the Government’s strategic approach. In its comments on the change funds that have been designed to drive change in the care system, the Scottish Council for Voluntary Organisation stated:
“We need to see a significantly accelerated shift of spend away from institutions”— the reference to institutional care includes residential care. The SCVO submission continued:
“There is nothing in the current budget structure - on the face of it - that would serve as the necessary catalyst for this change.”
Another concern was mentioned by the BMA, which stated:
“The reduction in eHealth funding is concerning given that the Government is expecting IT integration between health and social care”.
We need to be clear that, as part of that process, investment in information technology is carried through. The BMA submission goes on to say that it is very worried that the planned integration of health and social care will not be achievable.
There is concern about the strategic approach, but there is also concern about the limited funds that are available and how they are being used. The Coalition of Care and Support Providers in Scotland said that the change fund spend on services and activities is
“questionable in terms of the contribution they make to the agenda for reshaping care.”
Age Scotland pointed out that research that it has carried out found that
“despite the guidance prescribing 20 per cent of funding”— that is, the change fund—
“be allocated for carers services in 2012/13, the reality is much less.”
In Aberdeenshire, only £153,000 has been spent on carers services from a budget of £1.9 million. In Angus—
I could go on.
There is a difference between the good intentions of Government and what we must do. Let us not allow things to continue to drift. We need to address the issue now—it cannot wait for an independence referendum.
Much of the debate is predicated on the future demographics in Scotland. We have heard the facts and figures on that, but it is important that, in looking at the demographics, we also look at the changes that have happened in healthcare in the past 20 years and those that will certainly come in future. For example, medical and technological advances allow much more day surgery and more ambulatory care and diagnostic centres. There are also advances in the preventative health agenda, through measures such as minimum unit pricing, tobacco control and falls prevention work. Legislating on such matters now will ensure that we have a healthier population in future.
We must also consider the public’s changing expectations of healthcare. From many surveys and much research work in the past 10 years or so, we know that people, particularly those in the elderly population, increasingly expect that their healthcare will be delivered to them at home or in a homely setting, apart from in acute episodes.
I ask Ms Baillie please not to try to intervene, as she has done with everybody. It was her party that chose to have a very short debate on the issue. I am 90 seconds into a four-minute speech.
It would have been better to have had a longer debate to produce more facts and figures but, to have a rational debate, we cannot focus entirely on bed counting or on the numbers of nurses on wards. The debate is about what the Scottish Government is doing on the redesign of the health service. It is about forward planning for the health service and the 21st century delivery of healthcare.
The Scottish Government is already doing that. We have protected funding for the NHS and we are increasingly looking at moving from capital to revenue spending, because that is where we need the services. We are looking at the integration of health and social care, so that we ensure that the elderly population in particular have all their care needs met in one package. I have talked about the preventative health agenda.
I want to introduce some evidence into the debate, so I will talk briefly about North Lanarkshire’s hospital at home project, through which 80 per cent of elderly people stayed at home rather than being admitted to hospital. The NHS Forth Valley reablement service resulted in a 20 per cent reduction in care needs and a 35 per cent reduction in falls. Crucially, 58 fewer long-term care beds were needed. Ms Baillie’s talk about the numbers of beds must be viewed against that background. We need to consider numbers in the round, not numbers in the raw.
In 2002, research by Foote and Stanners found that, in 20 to 30 per cent of cases in which over-75s were admitted on an acute occasion, the admission was inappropriate. I think that Mark McDonald referred to that. Not only were the admissions inappropriate, they resulted in longer stays in hospital.
What I do not understand is this. Jackie Baillie obviously gets what we are talking about—the change in the kind of beds we need. She made that point herself in her intervention on the closure of Lennox Castle hospital, although she forgot to mention that her party shut Stobhill hospital. Sarah Boyack also got it when she talked about the need to build care homes. We need beds in care homes—that is the future.
I will finish by saying that the cabinet secretary has got it right. We need the health professionals and the delivery, but it will be in different places and with a different emphasis.
A great deal has been made in this debate—it was the centrepiece of Ms Baillie’s motion—of the quotation from the cabinet secretary in his speech to Unison. We know that NHS Lothian decided not to take what the cabinet secretary said seriously. When I read the rest of his speech, I was not sure that we were meant to take it seriously either. He went on to say that he was offering to franchise himself and Alex Salmond out to run England and Wales. I thought that perhaps Ms Baillie and I might contact our respective parties’ members of Parliament who represent England and Wales to see what they made of that offer. I know that Scotland would only rejoice if the cabinet secretary could persuade the First Minister to concentrate on the day job he has, namely to run Scotland.
The cabinet secretary also said—this is very Alex Neil:
“We will not be privatising by the back door, front door, side door or any other door. We will not be privatising the health service in Scotland”.
Alex Neil’s amendment this afternoon was a trap door to escape from the substance of the debate in hand. I stood to sum up on the cabinet secretary’s contribution on his amendment, yet the only person to mention minimum alcohol pricing—other than a cursory reference from one lone SNP back bencher, Bob Doris—was Jackie Baillie. There was nothing on alcohol minimum unit pricing. I think that there should be something; it is now a year since the Alcohol (Minimum Pricing) (Scotland) Act 2012 was passed, and we do not have minimum unit pricing. The Government owes it to the Parliament to tell us what the status is of alcohol minimum unit pricing.
Mr McDonald did not wish to speak to the amendment in his own speech, so it is a bit late in the day for him to try to speak to it in mine. After all, the amendment was lodged by his side.
The Conservatives supported alcohol minimum unit pricing; we believed that it should be given an opportunity to succeed. We asked that it be notified to the European Union, to find out what the legal status was. The Government responded at the end of December to the EU queries. We know that the cabinet secretary has been in discussions with the EU, but we also know that there is a dissolution of the European Parliament less time away now than when we passed the legislation. Is the act simply going to go nowhere?
The UK Government supported the SNP against the challenge made by the Scotch Whisky Association in the Court of Session. We had a resolution of that last week and the UK Government is working on that before finalising its own plans. I want to say to the Scotch Whisky Association what I hoped the cabinet secretary might have said this afternoon: that I wish it would respect that judgment and present no further obstacle to the implementation of alcohol minimum unit pricing.
Mr Paterson is interjecting from the back benches, but that was the substance of the Government’s amendment and nobody from the Government had anything to say about it.
I come to the subject of the debate. I thought that Ms Baillie was being a bit disingenuous, because in all the years that I have sat in this Parliament, her colleague Dr Simpson has repeatedly said that bed numbers do not matter and that they are not a yardstick by which anything should be judged. The important point is surely one that we spent a whole afternoon debating. This is not an argument between both sides as to which one has cut more beds or when. The honest debate for which Ms Baillie was calling, which I believe—and have said before—we all need to have, is one that recognises the cabinet secretary’s point: that we have a hugely ageing demographic.
I think that the cabinet secretary was trying to suggest that, unless we are successful on the preventative agenda and in finding out which of the processes and treatments that we are currently undertaking in the NHS are no longer sustainable or can be done in other ways, we simply will not have the money to meet the ageing demographic population challenge. We need to get smart and efficient in the NHS, not to cut the funding of it but to ensure that we are able to meet the challenge that the ageing demographic represents. We will work with the cabinet secretary on every occasion if that can be the case. I look forward to the minister offering me the reassurance on alcohol minimum unit pricing that I thought his amendment would afford him the opportunity to give.
Although it has been a short debate, it is fair to say that no health debates in the Parliament lack proper recognition of the challenge that the demographic shift that is taking place in Scotland creates.
We are at one in recognising the challenges that that shift creates not only for our health service but for a range of our public services that have to respond to the demands and needs of an ageing population. In itself, it is something to be celebrated that people are living longer, healthier lives, but I will pick up on the twin challenges that our NHS and social care system face because of the ageing population and lifestyle choices that can impact on our health system.
Jackie Baillie and Nanette Milne recognised in their speeches the challenges that our ageing population creates. Other speakers also did that—Jackson Carlaw just made the same reference. The biggest challenge that it creates for us is how to configure our NHS and social care system in the future so that it can meet the demand.
I do not think that any member is arguing that not changing is an option. Change is required even with an increasing budget. Even if we lived in the land in which Labour believes—the one with the money tree in the corner that can provide everything—we would still have to change our system to allow us to meet the ever-increasing demand that is being placed on it. If we are to do that, it must address what Nanette Milne referred to as the huge train that is speeding its way towards our health service.
The problem that I often have with Labour debates is that a nice, orderly queue of Labour back benchers lines up asking for money for X, Y and Z but at no point do they give any suggestion as to how we should configure services to address the challenge or where the resource will come from.
To address the challenge, some key measures need to be taken. They concern getting the balance between our acute and primary care services right; getting the balance between our health service and social care support right; and ensuring that we have the right skills mix among our NHS and social care staff at the acute end and the primary care end. We must ensure that we implement all those measures in a way that is anticipatory and addresses the prevention agenda.
I will pick up on a couple of examples of that. Some of the challenges that we have had with unscheduled admissions to our NHS services come about because of inadequate planning and services to prevent the need arising for someone to be admitted to hospital.
The issue is also how we deploy our NHS staff to meet that challenge. For example, we know that, if we put allied health professionals in our accident and emergency departments, we can reduce the potential for older people to be admitted to hospital at any given time for certain conditions. Where that has happened in one part of our NHS, we must ensure that it happens across the rest of the NHS.
The biggest change that is coming to our NHS and social care system—I believe that it is the biggest one in a generation—is the integration of health and social care. Jackie Baillie mentioned culture and referred to finance, but she did not address the real cultural challenge that will come about from the integration of health and social care. That will come from the different professional viewpoints about how services are provided, not whether they are financially assessed for one thing or another. That will be the real challenge that we face in ensuring that integration works effectively. One of the opportunities with which integration provides us is that it will allow us to ensure through joint commissioning that we bring those services together in a much more targeted and focused way with a clear focus on the long-term outcome.
When we consider how we configure our NHS, it is important to look downstream, to some of the things that cause challenges in the health service. No one would dispute that both alcohol and tobacco continue to cause major public health challenges, which contribute to the pressures on our NHS.
Minimum unit pricing is an important measure, which I believe can help to address the issue. I was delighted that, only yesterday, the European Union Commissioner for Health and Consumer Policy, Commissioner Borg, said to the European Parliament’s Committee on the Environment, Public Health and Food Safety:
“All the studies of which I am informed regarding measures to control either tobacco or alcohol have shown that the measures which are most effective are the fiscal ones.”
That is why minimum unit pricing has an important part to play in dealing with some of the challenges that we face from alcohol. The Alcohol (Minimum Pricing) (Scotland) Act 2012 indeed continues to be challenged by the Scotch Whisky Association, and we have to wait for that legal process to be completed—just as was the case with the tobacco display ban.
There are around 13,000 deaths a year and more than 56,000 people are admitted because of tobacco use each year. Those are challenges that we must address if we are to get the balance right in taking forward the NHS and social care system and if we are to ensure that it is fit to meet the challenges that it faces in the years to come.
This has been an interesting debate. Despite the pressures that face the NHS in Scotland, we have managed to come together and make it clear that we remain proud of our service, particularly of all our hard-working NHS staff, who are at the front line of delivering a service that is responsive to the needs of patients and which prioritises quality as well as efficiency.
When the Unison national health conference met in Glasgow two weeks ago, I was delighted to attend and to welcome delegates to my city and to Scotland. The discussions that I had with visitors and local Unison activists reflected that in Scotland, under successive Scottish Governments, we have chosen a different path for our NHS.
Alongside consensus, there is a need for honesty. Delegates who work in Scotland’s hospitals were not quiet about the challenges that they face in the service for which we are all responsible. At a national level, the Auditor General for Scotland has described the service as being “on amber warning”; at a local level, front-line NHS staff have described the reality of working on a ward with too few nurses. When the standard of care suffers, no one is more frustrated by it than the hospital staff. Health board managers also know that the financial and staffing pressures are having an impact on the ground. Each of us will no doubt be contacted regularly by constituents regarding the service that they are getting.
Labour has therefore sought to confront the politics of this place with the real-life picture of what is happening in our hospital wards. We should be honest about the funding and staffing pressures that the service is facing, as well as the demographic challenge. The cabinet secretary has spoken about the latter before, and so have we. Health and social care integration is partly a response to our shared view that the current set-up will not work into the future.
A number of members have pointed out that bed numbers should not be our only guide. The NHS exists to help people get better if they are sick and to help those with longer-term conditions—and all of us—as we get older to live our lives as fully as we can. None of us would want to see anyone in a hospital if their admission could be prevented, or to see people lying in a hospital bed for any longer than they need to. That point has been made consistently by this party, both in opposition and when we were in government.
There is a contrast there with the words of Nicola Sturgeon, which have already been quoted this afternoon. When she was in opposition, she said that cutting bed numbers had been going on for “far too long”. In The Scotsman on 8 July 2006, she said:
“We should ... increase the number of acute staffed beds to the benefit of the patients of Scotland.”
The reality, six and a half years later is this: in 2007, the average number of available staffed beds was 17,505—members should remember that that was after bed cuts had, according to the SNP, been going on for “far too long”—and, in December 2012, the average number of available staffed beds was 16,085. Although Nicola Sturgeon said that
“We should ... increase the number of acute staffed beds to the benefit of the patients of Scotland”,
what she did was reduce the number of available beds by 1,420.
At the Unison health conference, Alex Neil decided to revisit the issue of bed numbers. Perhaps he wanted to clarify the Scottish Government’s position. Perhaps he thought that it was time for an update. For the benefit of Fiona McLeod, Bob Doris and others, it was not Jackie Baillie who said this; it was the cabinet secretary who said:
“we are still going to need the same number of beds, the same number of hospitals, the same number of doctors and nurses just to stand still”.
That is the direct quote that the Scottish Government has argued should be deleted from today’s motion and replaced with a reference to minimum pricing. Minimum honesty might have been a better bet from the Scottish Government this afternoon.
Standing still is also a term that might require further definition. Since 2009, the Scottish Government has cut almost 2,000 nursing and midwifery staff, and student nurse numbers have also been slashed. The number of nursing and midwifery staff is now lower than when the SNP came to power. Far from standing still, an awful lot of nurses seem to have managed to find their way out the door. On bed numbers and staffing, therefore, we seem to have a problem with what is said in public about our hospitals, and what is actually happening in our hospitals.
On hospitals, Sarah Boyack was absolutely right to point out that, at the same time as the cabinet secretary was making his comments to Unison about bed numbers and staffing, he also asserted that changing demographics—more older people—means maintaining
“the same number of hospitals”.
Again, that is a clear commitment from the Scottish Government. I am sure that, given the cabinet secretary’s interest in hospital campaigns, it was a guarantee that he was pleased to give. It therefore remains rather unfortunate that, as the same time as Mr Neil was talking to Unison in Glasgow, here in Edinburgh NHS Lothian was confirming that it was looking at closing not one or two but three hospitals. Asked about that apparent inconsistency, a spokesperson for the Scottish Government said
“We are committed to at least maintaining the level of quality and provision in Scotland’s NHS – and that means having the right numbers of staff and beds”.
In 2006, the SNP claimed that NHS Scotland needed to increase bed numbers; by 2012, it had actually cut them. Two weeks ago, Alex Neil was promising Unison activists that the numbers would be kept the same; by the day after that, the SNP wanted to talk about finding the “right numbers”. Today, the SNP is asking Parliament to delete all references to numbers and it is also saying that we should have talked about minimum pricing—except that we did not, so we will have to come back to that one another day.
Since the cabinet secretary came to his role, we have had a scandal over the SNP’s hidden waiting lists and attempts to change the four-hour accident and emergency waiting time target, which is the same target that has not been met across Scotland for the past three years. As Jackie Baillie said, Scottish Labour is happy to debate all those issues, and minimum pricing, with the Scottish Government any day of the week. It would however make for a more honest debate if comments that are made outside of the chamber in one week were a bit closer to the comments that are made in chamber a few weeks later.
When the cabinet secretary was speaking to Unison, he was addressing workers who cope on the front line day and daily. When our constituents come to our surgeries or telephone our offices, they tell us of a service that is under pressure. When the Auditor General says that the NHS is on an “amber warning” and when ministers’ comments fail to reflect the situation on the ground, it is the Parliament’s duty to pause and think about whether we want to have a debate in which the rhetoric reflects reality rather than obscuring it.
The cabinet secretary simply asserts that beds, staff and hospitals all need to stay the same, at the same time as NHS Lothian confirms that it wants to close three hospitals. NHS Lothian’s most recent board paper says that the overall number of doctors will decrease. NHS Western Isles is currently proposing a cut from 89 beds to just 53, and my own health board, NHS Greater Glasgow and Clyde, is conducting an acute services review. None of that squares with the cabinet secretary’s comments to Unison but it does square with the Government’s amendment today.
If the civil servants got to Alex Neil after his comments today, they also got to all his backbenchers, not one of whom was prepared to defend his comments of last week.
On the number of hospitals, the number of beds in those hospitals, and the number of staff around those beds, the Scottish Government would do well to remember the purpose of those beds: to provide a warm and safe place for the treatment of someone who is in need. Let us give those people the respect that they deserve by taking their experiences seriously and being honest about how we respond to the challenges that we all know caring for them presents.
I urge the Parliament to support the motion in Jackie Baillie’s name and to reject Mr Neil’s amendment, even though it served the purpose of clarifying that, when he told Unison that all nurses, doctors, beds and hospitals would stay the same, he did not really mean it.