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General Practices at the Deep End (Healthy Life Expectancy)

– in the Scottish Parliament on 28th October 2015.

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Photo of John Scott John Scott Conservative

The final item of business is a members’ business debate on motion S4M-14164, in the name of Patricia Ferguson, on general practitioner practices at the deep end, healthy life expectancy. The debate will be concluded without any question being put.

Motion debated,

That the Parliament records its appreciation of the general practitioners and staff in the “Deep End” practices, who it considers work in the most challenging of circumstances; understands that these practices serve the 100 most deprived populations in Scotland; is concerned that patients in the areas served by the practices will have up to 20 fewer healthy years in their lifetime; considers this to be a matter of serious concern both for the people affected and for the GP practices that they attend; considers that the funding distribution arrangements take no account of the additional burden that this places on staff and resources; regrets that the Balmore Practice in Possilpark has been forced to appeal to the local NHS trust for assistance in respect of its financial situation, and notes calls for the Scottish Government to review the present funding formula and do all in its power to eradicate health inequalities.

Photo of Patricia Ferguson Patricia Ferguson Labour

I thank colleagues from across the Parliament who have signed my motion and made this debate possible.

General practitioners at the deep end are those who work in the 100 most deprived populations in Scotland, based on the proportion of their patients with postcodes in the most deprived 15 per cent of Scottish data zones. I apologise now for the fact that my speech will contain an awful lot of statistics, but I think that they will help to emphasise the case that I wish to make. The statistics show that people who live in such areas are likely to attend their general practice more often and will need longer appointment times, because they are likely to present with more than one health issue at a time. That, in turn, means that GPs with even a small or average-sized patient list in those areas are likely to have a greater workload than their colleagues in more affluent areas, simply by dint of their geographical locations and the health issues that their patients have.

To understand the situation, it is helpful to compare the statistics. Across Scotland, the average prevalence per 100 patients of chronic obstructive pulmonary disease—COPD—is 2.21. I repeat: that is 2.21 patients out of every 100. In the Balmore practice in Possilpark in my constituency, that jumps to 4.18 in every 100. At the other end of the scale, in a relatively affluent area of Glasgow, Hyndland, the figure is only 0.63. The figure is 0.63 in Hyndland, it is 2.21 on average in Scotland and it is 4.18 at a particular practice in my constituency.

The equivalent statistics for smoking-related ill health show that 24.87 people per 100 is the average figure for Scotland. The Balmore practice has a figure of 29.17, and Hyndland has just 13.6. It is no wonder that GPs in practices such as Balmore are frustrated and angry about their predicament and that of their patients.

It is widely recognised, and has been for a very long time, that men and women in the most deprived fifth of the population will die 10.4 and 6.9 years earlier, respectively, than those in the least deprived fifth.

The fact that disturbed me most—it was new to me when I read it first, I have to confess—and which has been the catalyst for this motion and debate, is the difference in healthy life expectancy, which is the estimate of how many years people are expected to live in a healthy state. Looking again at the most deprived fifth and the least deprived fifth of the population—the two extremes—we find that the figures could not be more stark. The healthy life expectancy of men and women in the most deprived fifth ends 20.8 and 20.4 years earlier, respectively, than for those in the least deprived fifth. That potentially means 20 years of productivity lost for individuals and their families—20 years, possibly, of pain or discomfort, and potentially 20 more years of stress and anxiety. That is not right, and it cannot be acceptable.

Practices such as Balmore provide their patients with an excellent service. The team of doctors and nurses and the pharmacist work together to continue to do so. However, they are struggling to do everything that they want to do and everything that they are expected to do within their existing resources.

In summary, GPs at the deep end are dealing with patients who have higher levels of multimorbidity at a younger age. Those patients need longer appointments and more follow-up and support. The average spend per annum in those practices is £118 per patient per year, compared with the Scottish average of £123, and £127 per patient per annum in the most affluent fifth.

If those general practices have no additional funding for recognising the difficulties and problems that they and their patients face, it stands to reason that the staff in those practices are working longer hours in more challenging circumstances, and that that will eventually affect recruitment and retention. There is even a name for that phenomenon: the inverse care law. It states that the availability of good medical care tends to vary inversely with the need for it in the populations that are served.

In their submission to the consultation on a fairer Scotland, the GPs at the deep end stated that that is

“not a law of nature ... but a longstanding man-made policy which restricts access to care based on need.”

It is surely time to end that situation and to recognise that we have a particular set of circumstances that puts huge demand on the deep-end practices and everyone who works in them. We surely have to find a way of funding GPs that does not take a one-size-fits-all approach. Across the country, we have already witnessed GP practices without those problems and issues experiencing problems with recruitment and retention of staff. It is sheer dedication and commitment that is keeping many of our GPs in post at the moment.

The First Minister’s announcement yesterday of additional funding for GP training is good news, but how long will it take to filter through the system and make a difference? We need more action now to avert escalation of this crisis.

In July, the Balmore practice sent an 11-page open letter to the health board; I am sure that the Minister for Sport, Health Improvement and Mental Health has had an opportunity to see that for himself. The letter detailed the problems that are faced and made some suggestions about solutions. Fortunately, NHS Greater Glasgow and Clyde has decided to give the practice some additional support and help. That is welcome, but it is not a long-term solution and it seems to me that such practices need long-term solutions.

In closing, I can do no better than to quote again from the submission that the deep-end practices made to the Scottish Government’s consultation on a fairer Scotland—a document that actually did not talk about their particular predicament, in any case. The submission said:

“Equitable access to emergency care has been a shining example of the NHS commitment to comprehensive health care, based on need and free at the point of use. A similar commitment is needed to reduce inequitable access to non-emergency care, especially general practice, and to reduce social variations in access to specialised and centralised services.”

That is surely a sentiment that we can applaud, and one that our policy and funding should support.

Photo of Bob Doris Bob Doris Scottish National Party

I welcome the debate this afternoon as an opportunity to draw attention to the significant pressures that are being experienced by Balmore practice in Possilpark. I have not signed the motion itself because I do not accept the proposition that is made in the motion that, in relation to deprivation levels,

“funding distribution arrangements take no account of the additional burden that this places on staff and resources”.

However, I welcome the debate around whether sufficient account is taken of deprivation levels, and I commend Patricia Ferguson for putting many of the statistics on the record this afternoon. They need further interrogation.

I want to focus on Balmore practice in Possilpark. It has made a powerful case to NHS Greater Glasgow and Clyde for additional resources for the pressures that it faces. Following a meeting with the GPs there, I have also corresponded with the health board to make the case for additional resources. I have also drawn the matter to the attention of the Scottish Government and I welcome the fact that the Cabinet Secretary for Health and Wellbeing has agreed to meet me to discuss some of the concerns.

I welcome the additional locum cover that is being provided to Balmore practice by the national health service. That cover amounts to three half-day sessions by a locum GP for 12 weeks. Correspondence that I have received from NHS Greater Glasgow and Clyde says that the additional support will

“fully explore the issues raised by the Practice and together take steps to ensure the continued viability of the practice”.

In fully exploring those issues, I urge the NHS to consider properly the high level of patients with complex health needs and significant multimorbidities, as well as the profound health inequalities that exist. It is also worth highlighting the many asylum seekers who have enriched Possilpark but who often also have complex health needs.

I will highlight two additional matters before looking at a positive and constructive way forward. First, locum GP support is welcome, but for understandable reasons of continuity of care, locum GPs often do not see the most clinically challenging and complex patients when they are providing cover. Those patients would see their regular GP. We must ensure that any exploration of the demands that are placed on Balmore practice takes account of the day-to-day reality for the resident GP partners.

Photo of Patricia Ferguson Patricia Ferguson Labour

I would surely echo the point that Mr Doris is making about continuity of care. I am sure that he will agree with me that the fact that another GP has now resigned from that practice makes the situation all the more critical.

Photo of Bob Doris Bob Doris Scottish National Party

I thank Patricia Ferguson for making that point. If I had had time, I would have developed that point further, but it is a point well made.

Secondly, the additional locum GP support will end just before Christmas. In other words, it will be withdrawn just as the peak winter pressures are about to be placed on Balmore surgery. I hope that NHS Greater Glasgow and Clyde will continue the additional locum support into the new year while it analyses the findings of its review of Balmore practice. I am making those points to NHS Greater Glasgow and Clyde, and I would like the Scottish Government to consider making similar representations to that health board.

The Scottish Government has recently announced an additional £60 million for the primary care development fund to help to ensure the quality of care in general practice. It is being delivered following discussions with the British Medical Association and the Royal College of General Practitioners. Given that some of that cash will seek to support, develop and test new ways of working in order to improve services, I ask that consideration be given to working with Balmore practice to fund any new ways of working. A pilot could take place in Possilpark. The practice is already developing new models of working—for example, giving a greater role to pharmacists. The citizens advice bureau is also involved, as are addiction workers and a range of community nurses.

I believe that working with Balmore practice, including by ensuring that there is sufficient locum cover to allow the resident GP partners to develop those new services and pilots, is essential. It is a good way to use Government and health board money on the new ways of working that we all want to see.

I finish by thanking practice manager Susan Findlay for taking the time to speak to me this morning. Susan, along with doctors Allison Reid and Lynsay Crawford, as GPs at Balmore practice, have to deal with the day-to-day reality of working at the coalface of a wonderful community, but one with huge challenges. I am delighted to be part of this debate, because I think that together, and constructively, we can build a better way of delivering the health service for the constituents whom we all want to represent to the best of our abilities. Thank you, Presiding Officer.

Photo of Richard Simpson Richard Simpson Labour

I congratulate Patricia Ferguson on obtaining this important debate.

As I always do, I want to begin by giving credit to the Government for providing funding to the deep-end group so that it can meet. That type of getting together by doctors from practices in the 15 per cent most deprived areas of Scotland has in itself been beneficial in reducing the isolation that is often felt by general practitioners. Recognition that there are problems that they share is a good starting point. It is clear from the extensive papers published by group members that their views have a wide resonance not only in Scotland but across the United Kingdom.

The unpalatable fact is that the inverse care law to which Patricia Ferguson referred, and which was propounded almost half a century ago in Wales by Dr Tudor Hart, is alive and well in Scottish general practice. In essence, the inverse care law is that the provision of resources is in inverse proportion to the level of need.

As Patricia Ferguson has illustrated, the level of need is beyond question. The people we are discussing have significantly higher levels of both physical and mental ill health and a shorter life expectancy. Almost as important, the period during which they have to put up with ill health is much longer.

In the first session of the Scottish Parliament, the Health and Community Care Committee interrogated what was then known as the Arbuthnott committee about the basis for NHS resource allocation. I would like to ask the minister to indicate in his response whether the successor committee, known as the NHS Scotland resource allocation committee, now takes into account not just population, the elderly and deprivation but actual need, which can now be largely determined by the far better recording of epidemiological data—something that the Arbuthnott committee could not achieve.

In my view an instruction to health boards to ensure that resource allocation to primary care is based on need is long overdue. It is clear that the poorest decile have double the amount of mental illness and much greater amounts of physical illness. The greater prevalence of mental illness is a feature of the poorer areas. They account for twice the number of face-to-face consultations for mental illness and three times the prescribing of antidepressants. The fact that more resources are allocated to practices with much lower levels of deprivation is utterly appalling.

The challenges of multiple morbidities, social complexity, shortage of time for the GPs and their staff, reduced expectations, lower enablement, poor health literacy, increased practitioner stress and weak interfaces with the rest of the services appear collectively in the deep-end publications.

The only move that the Government has taken so far, as far as I know—the minister can correct me—is to fund the recruitment of a small number of liaison workers. That is no doubt helpful. It has been demonstrated by deep-end sponsored research that there is a significant need for benefits advice, for example, to ensure maximum uptake. That is vital. The study in question was actually done in Possilpark, although not in the Balmore practice. Every practice in the deep-end group should be supported by someone helping with benefits advice to ensure the maximisation of benefits uptake, because this is about social medicine as well as physical and mental health.

GPs need to have an understanding of the current conflicted and fragmented benefits system, and they will need to understand the new systems that will come in with the proposed transfer of powers under the Scotland Bill.

Hitherto, Scotland was blessed with equality of GP provision, in that every area had a GP available, but that is no longer the case. We are now facing a crisis, which the Government is beginning to appreciate. If GPs resign from more practices, such as the Balmore practice, and if more practices close, such as the Methil practice in my area, we will have real problems.

The announcement of 100 more GP training places is welcome but 20 per cent of current trainee places are vacant, mainly in the west of Scotland, so that is not really going to help.

In a recent freedom of information request we asked health boards whether they had undertaken a risk assessment and had a risk register for the risks being faced by their general practices. Only three boards said yes—only three. If health boards do not assess the risks for their GPs, we are in as much trouble as we were when the Government previously denied the problems in general practice.

The Deputy Presiding Officer:

Due to the number of members who still wish to speak in the debate, I am minded to accept from Patricia Ferguson a motion without notice, under rule 8.14.3, to extend the debate by up to 30 minutes.

Motion moved,

That, under Rule 8.14.3, the debate be extended by up to 30 minutes.—[Patricia Ferguson.]

Motion agreed to.

Photo of Nanette Milne Nanette Milne Conservative

I realise that this is a serious issue in Patricia Ferguson’s constituency, but the debate also gives us an opportunity to look at the wider problems associated with GP practices and patients in deprived areas. I therefore congratulate Patricia Ferguson on securing the debate.

I think that we would all agree that general practice in Scotland faces challenges ahead, with factors such as the growing shortfall in the number of GPs to look after an increasingly elderly population with complex comorbidities and the number of GPs who are set to retire in the next five years but who are unable to attract replacements. There are also many qualified GPs who are moving abroad to practise.

We start with a situation in which there is if not a crisis then a serious problem with overworked GPs and understaffed practices. It is clear that that problem is magnified in areas where there is manifest deprivation, including, as Patricia Ferguson said, places such as Possilpark and other parts of Glasgow.

The University of Glasgow’s research into general practitioners at the deep end throws up some very concerning facts and figures regarding life expectancy and the broad health and wellbeing of people in the most deprived areas of our society.

The fact that men live over 10 years less and women nearly seven years less than the Scottish average in the most deprived fifth of the population is something that needs to be addressed. We also need to address the fact that, as has already been said, in the most deprived fifth of the population, men and women spend twice as long in poor health before they die, with men facing 23 years of poor health compared with an average of nearly 13 years and women facing nearly 26 years of poor health compared with an average of 12 years.

Clearly, those statistics have a huge knock-on effect on GP services, with poor health leading to greater demands on local surgeries. However, the real problem lies in the difference between demand and unmet need. In giving evidence to the Health and Sport Committee on health inequalities, Professor Graham Watt from GPs at the deep end told us that the challenge lies in defining the extent of unmet need in the primary care system. In deprived areas, there are people with conditions—often of a specialist nature—that are not dealt with, either through individuals not seeking help or through specialist services being seen as remote.

Photo of Bob Doris Bob Doris Scottish National Party

I forget—I forgive—no, I thank the member for giving way. Perhaps she will forgive me for that.

Does the member recognise that a significant issue for the Balmore practice in Possilpark is the additional pressure that results from the consequences of UK welfare reform and the additional burdens that that places on GPs?

Photo of Nanette Milne Nanette Milne Conservative

I am sure that welfare changes have an impact on behaviours in certain areas, but I will not go into the UK welfare reforms in detail.

In deprived areas, specialist services need to be local and readily accessible. There are distinctive problems with the physical and mental health of vulnerable children and families in very deprived areas, and the contribution of health visitors is vital. Unfortunately, however, the uniform health visiting service—which was designed to provide support to all families, regardless of circumstance—is under serious pressure in such areas because of the very high volume of vulnerable people who require support. There are also recruitment difficulties, and the situation will be compounded next year when the named person role is introduced throughout Scotland—not just in deprived areas—as a result of the Children and Young People (Scotland) Act 2015.

It is realised that, in areas with a high incidence of socio-economic deprivation, new approaches and different skills may be required to help people address social issues and gain more control over their own health and wellbeing. To that end, the Government-supported national links worker programme is being delivered in seven deep-end practices, including in Possilpark, which it is hoped will lead the way in best meeting the challenges that are presented by the current health inequalities in Scotland.

Patricia Ferguson’s motion emphasises that the present

“funding distribution arrangements take no account of the additional burden” that is placed on staff and resources in the deep-end practices. I accept that resource distribution is a significant factor. However, any potential redistribution across Scotland would have to take account of the fact that deprivation is not confined to west-central Scotland but exists even in parts of relatively prosperous cities such as Aberdeen, and is significant in a number of our rural communities. Of course, demands on health services are increased in communities with a growing elderly population, among whom dementia and comorbidities are an increasing problem.

Although I understand completely the issues that concern Patricia Ferguson, the funding and provision of primary care services is a concern to all of us.

The Deputy Presiding Officer:

The member must close, please.

Photo of Nanette Milne Nanette Milne Conservative

I hope that the minister will address those points in his closing speech.

Photo of Jim Hume Jim Hume Liberal Democrat

I thank Patricia Ferguson for bringing the debate to the chamber. It is a good opportunity for us to remind ourselves that focusing solely on people in the most deprived areas is only a starting point; we also need to look at the resources that are available to people in their communities.

We all know that GPs are in most cases the first point of contact. They deliver 90 per cent of patient care in the NHS, although they receive less than 8 per cent of the NHS budget. The group of GPs that we are talking about tonight is a special group: general practitioners who are literally at the deep end in their deep-end work in the hundred most deprived communities in Scotland, and who had until 2009 never been convened or consulted by anyone. We should, of course, not forget the other hard-working staff in those practices, including our nurses. I welcome the creation of the deep-end group by Professor Graham Watt.

There are harrowing facts out there about the environment in which that group of GPs have to work. They provide care for a population that experiences 20 per cent more mental health problems and comorbidities than those in the least deprived areas—a gap that has widened since 2008. Alcohol-related illness and the ramifications of unemployment combine to create an “unfolding epidemic”, as the Royal College of General Practitioners has put it. Attempts to tackle that epidemic have so far failed—there has not been enough progress in that regard.

Yesterday, the 2015 “Long-term Monitoring of Health Inequalities” report revealed that there is a healthy life expectancy gap of 22 and a half years between women in the most and least deprived areas, and that the gap is 24.3 years for men.

The principle on which the NHS was founded—that good healthcare should be available to all, regardless of wealth—has clearly failed to translate into an effective policy. The plea for care to be delivered proportionately on the basis of need, as expressed by Professor Graham Watt, is what we should strive to provide.

However, I regret to note that that is the opposite of what is actually happening. Since 2007, there has been a constant reduction in GP funding as a percentage of the total NHS budget. This year, another £21.7 million left the primary and community care services budget. Next year, the keep well programme will have its funding phased out completely. That programme targets middle-aged men in the most deprived communities in Scotland and gives them a health check, with the aim of preventing heart disease and diabetes, which are the two biggest killers in Scotland.

Last night, the First Minister made a commitment to increase the number of training places for GPs by 100. Of course I welcome that, but the First Minister made no reference to the current understaffing of GP practices in the deep-end areas. The fact is that the practices that serve the most affluent 20 per cent of the population have twice the number of GP trainees than those that serve the least affluent 20 per cent. Unless the Government commits to changing that fact, it will be maintaining the imbalance and inequality between communities.

Members have pointed out what the GPs at the deep end are calling for, which is for the Scottish Government to allocate the right type and amount of support and resources to practitioners, which should be based not on financial ability but on the needs of the population. The solutions for the GPs at the deep end are of course not easy—nobody says that they are—but they are there, and we need to enable GPs to achieve them.

Photo of Mark McDonald Mark McDonald Scottish National Party

I thank Patricia Ferguson for bringing the debate to the chamber. I have two practices in my constituency that serve areas of deprivation in the city of Aberdeen, although I am not sure whether they fall within the deep-end 100—they are the Woodside and the Northfield and Mastrick practices. For both of them, more than 30 per cent of their patient cohort comes from the most deprived areas of the city.

Much has been said about pressures on the deep-end practices and on GP practices more widely. I have experienced that in my constituency as a result of the Brimmond medical group’s announcement that it was going to withdraw from the provision of general medical services. It had to give six months’ notice, but that was a very tight timescale to put in place a solution and resolve matters.

The new Dyce medical practice, which has opened up in response to the situation, is now in place and is seeing patients. I have written to the cabinet secretary to suggest that the six-month period needs to be reconsidered, with the aim of allowing health boards and others a longer period to put in place the required solutions to service communities with a general practice should the need arise.

One thing that drives some decisions by GPs on retirement is pension changes. I have heard from a number of GPs in my constituency that, as a result of changes that have been made, it has become more beneficial to GPs to take their retirement earlier in order to get a better pension. That perhaps needs to be looked at but, obviously, the powers on that do not sit with this Parliament.

Another issue that has been raised is how we attract more young medical students and graduates to view general practice as a career option. One GP in Aberdeen, Chris Provan, who leads on general practice for NHS Grampian, is a good and enthusiastic advocate of the benefits of general practice and of being a family doctor. We need to get that message out there more. We often hear about the pressures in general practice, and nobody denies that those pressures exist, but we must ensure that we get out the message that a number of rewards come from entering general practice. If we do not balance the message, we will not sell general practice as an opportunity for young graduates and we will not do enough to promote it.

We need to consider how best to structure health services and we should welcome the work that the Scottish Government is doing on that. There are examples out there. The minister has been to my constituency and has visited the Middlefield healthy hoose, which is a nurse practitioner-led service in one of the most deprived communities in the city of Aberdeen. The service supports the work of the general practice in the area, which is the Northfield and Mastrick practice, by seeing patients and offering them advice and support. The service therefore reduces some of the pressures and improves health and wellbeing in the local community.

We must also ensure engagement by organisations from the third sector, such as Home Start, which I readily accept have an important role to play. Home Start in Aberdeen does play an important role and is currently working with families to encourage, for example, home cooking and healthy eating, demonstrating how that can be done within the limited financial abilities that many in deprived communities have.

All those things working together can not only support the work of general practice but reduce some of the burden on general practice. One of the things that we want to ensure is that, when an individual sits in front of a GP, they are there because it is the GP who is the most appropriate person to see them and not because that is who they feel they need to go to.

The answer to the problems that GP practices have is working with other organisations and health professionals. There are good examples out there that we need to look at and ask whether they can be transplanted into other areas; if the answer is yes, we must ask why that has not happened before now.

Photo of Margaret McCulloch Margaret McCulloch Labour

I, too, congratulate Patricia Ferguson on securing this debate on deep-end general practices and health life expectancy. In bringing this debate to the chamber she has allowed us not only to delve into issues concerning the health service and health inequalities but to put on record our appreciation for the hard work and dedication of all those who work in the deep-end practices, serving some of the most deprived and excluded communities in Scotland.

As the motion makes clear, patients in the areas served by the deep-end practices will have a lower-than-average healthy life expectancy. We need to think carefully about how our public services deal with that kind of inequality. How do practices and front-line services cope, and how do we as a society ultimately overcome inequalities in health?

I draw members’ attention to the work of the Socialist Health Association Scotland and the report into health inequalities commissioned by my party colleagues. The uncomfortable truth documented in that report is that, today, a boy born to a family in Lenzie can expect to live until he is 82, but a boy born just 8 miles away in Calton has a life expectancy of 64. The progress that we have made as a nation simply is not enough when poverty and inequality take so many people from us so soon. The life expectancy gap between the richest and the poorest in our society is the stubborn and stark reality of health inequality in Scotland. It should shame us and offend us, but it should also motivate us to close the gap.

The inequalities in health and wellbeing that the people who are served by the deep-end practices experience are created and influenced by a number of economic and social factors: insecure employment; family income; housing conditions; and a sense of social coherence, or lack of it. We cannot tackle health inequalities if we do not reduce the social risk factors that lie behind them, and that is as much about education, welfare and housing policy as about how our health services are organised and configured.

The Health and Social Care Alliance Scotland is quite right to call for a cross-portfolio response to health inequality, and I associate myself with that call today. Patricia Ferguson is right, too, because we will struggle to deliver the level of service that people in communities like Possilpark need and deserve if the burden on general practice keeps on mounting.

I welcome the recent efforts to understand and quantify the additional pressures that deep-end practices face. I accept the consensus view that inequalities rooted in multiple deprivation require a multilayered response. I am personally interested in the national links worker programme, which some of us have received briefings about, and its work on new models of primary care for communities in the greatest need.

I echo the sentiment of the motion before us and suggest that we should do more to understand the financial consequences of health inequalities for our public services. Deep-end practices are on the front line in the struggle against vicious health inequalities, and we must give them our support.

Photo of Joan McAlpine Joan McAlpine Scottish National Party

I, too, congratulate Patricia Ferguson on securing the debate. I think that we can all sign up to supporting GPs in deep-end practices. I praise the work of the University of Glasgow in drawing attention to many of the challenges that the practices face.

As a representative of a rural constituencySouth Scotland—I do not wish to take anything away from the concentrated levels of poverty and associated ill health and mortality that deep-end practices deal with in particular postcodes in urban areas. However, I would be remiss in my duty to my constituents if I failed to point out that rural poverty is also a serious problem that is encountered by GPs in my region—often few GPs.

In Dumfries and Galloway, we need to replace 19 per cent of the 132-strong GP workforce. That is in addition to the 12 existing vacancies. I very much welcome the measures that the Government is taking to address GP shortages, such as its plans to increase training places by one third and, of course, the £8 million increase in funding for primary care.

Photo of Richard Simpson Richard Simpson Labour

The problem is that vacancies are running at 20 per cent. While the announcement is welcome, another 100 training places will not be helpful if vacancies are at 20 per cent already.

Photo of Joan McAlpine Joan McAlpine Scottish National Party

I said that we will be looking to replace 19 per cent of the workforce; those are not vacancies at the moment. That refers to Dumfries and Galloway as a whole. The Government is working closely with GPs and I am sure that the minister will say more about that. As I know Richard Simpson is aware, the challenges of GP recruitment are complex.

I will speak specifically about the motion’s reference to the distribution of funds. As I said, I do not want to take anything away from the particular challenges that practices in urban areas face, but it is important to talk about poverty affecting all parts of Scotland. In Dumfries and Galloway, for example, average wages are lower than the Scottish average and the population is older, which has associated health problems. Fuel poverty is experienced by 45 per cent of homes in Dumfries and Galloway, compared with rates of 36 per cent in Glasgow and 26 per cent in Renfrewshire, which is another urban area.

This morning, the Economy, Energy and Tourism Committee had a session on fuel poverty and heard from witnesses that the index of multiple deprivation, to which many members have referred, does not accurately reflect or identify some of the poverty that exists in rural areas. For example, the committee heard that a household’s having access to a car often means that it scores lower on the deprivation index. In the countryside, a car is often a lifeline and the only way to get to work. That can result in families experiencing more severe poverty, because to run the car they have to make even more cuts to essentials such as food and heating.

The committee heard about the role of GPs and the NHS in providing indicators of deprivation in a rural context. In relation to fuel poverty, which has serious health implications, we heard that quality advice from trusted people on the ground is one of the most effective ways to deliver home insulation programmes and other improvements that the Scottish Government offers, which can lift families out of fuel poverty. GP practices have an important role in that, particularly in rural areas that suffer extreme levels of fuel poverty. It is not just urban areas that face those significant challenges.

It should be said that the committee’s witnesses praised the Scottish Government’s efforts, such as the home energy efficiency programme Scotland, which address the fabric of buildings, but they commented that key drivers of fuel poverty and all kinds of inequality are outwith the Scottish Government’s control. Several witnesses said that the £350 million in cuts to tax credits that families in Scotland are experiencing are plunging more people into fuel poverty.

We need to support everyone who is in need, whether they live in an urban or a rural area. We must recognise that GPs in every part of Scotland are dealing with the consequences of inequality, which are being exacerbated by welfare reforms over which we have little control.

Photo of Malcolm Chisholm Malcolm Chisholm Labour

I congratulate Patricia Ferguson on securing the debate on this important motion, which focuses on healthcare in the most deprived general practice populations. The general problems of general practice, which we debated on 1 September, are highly relevant to the subject. For example, we know about the recruitment and retention problems, and Richard Simpson has reminded us that the level of training-place vacancies is at 20 per cent in the west of Scotland.

We know that much of the problem relates to the increased workload and, in the debate on 1 September, we heard how that relates partly to the shift towards primary care—although there has, unfortunately, been no shift in the percentage of resources that are allocated to primary care. Many of us spoke about demographic change as a key factor, as is the fact that more people are living with complex medical conditions.

In that debate, we focused on complex medical conditions in older people, which are important, but today we are reminded that those conditions often affect younger people, particularly in the most deprived communities. That is why healthy life expectancy is mentioned in the title of the motion—that refers to years of good health. As Patricia Ferguson reminded us at the beginning of the debate, among men and women in the most deprived fifth of the population, healthy life expectancy ends 20.8 years earlier for men and 20.4 years earlier for women than it does among those in the least deprived fifth of the population. That is perhaps the most shocking and important fact to remember from the debate.

The consequences of that have been highlighted by Professor Graham Watt and his colleagues in the deep-end practices. They have more patients with complex comorbidities, and there is also the issue of unmet need in those communities. One of the key issues that Professor Watt highlights is simply a lack of time. He has stated:

“Since 1948, the NHS has supplied GPs in the same way that bread, butter, and eggs were rationed in World War 2—everybody gets the same. In severely deprived areas this results in a major mismatch of need and resource, with insufficient time to get to the bottom of patients’ problems—hence the swimming pool analogy in which GPs at the Deep End are treading water.”

That is the strong message that comes out of the deep-end work. There must be funding changes in the health service that shift a higher proportion of resources to primary care in general and, within that, health boards must ensure that the way in which they distribute money takes account of deprivation. That fundamental shift must take place if we are serious about dealing with the profound problems of health inequalities.

Doing more in primary care will not, on its own, solve the problems of health inequalities. We all know about the upstream influences related to life circumstances that are the primary cause of health inequalities. We also accept that there must be lifestyle initiatives to address the problems. However, the role of health services is crucial, and getting more resources into practices in areas where the most deprived people live is essential in dealing with health inequalities. That is not just about GPs; we have to remember the role of other health professionals—I am thinking about nurses in particular. We had a debate about nursing at the edge, in which we talked about the role of nurses in dealing with individuals in the most deprived circumstances. We need more resources for primary care in those areas, and they must go to the whole primary healthcare team.

As a strong supporter for a long time of community health projects—I always mention the Pilton community health project in my constituency—I believe that their contribution should also be recognised and valued. However, the general message is that deprived communities must receive more resources to deal with the profound health inequalities that are manifest in them.

Photo of Jamie Hepburn Jamie Hepburn Scottish National Party

I join others in thanking Patricia Ferguson for securing the debate, and I make it clear that the Government attaches the highest value to Scotland’s GPs and the work that they do.

It is appropriate that—as Margaret McCulloch invited us to do—we place on record our particular thanks to those GPs who are working in the deep-end practices. I have met representatives of the deep-end practices on more than one occasion, and I have been hugely impressed by their commitment to their patients. We would do well to reflect on the fact that many actively choose or have chosen to work in the communities that they serve. That is what they want to do, because they recognise that there are communities that require support.

This Government wants to ensure that local community-based services are delivered by the appropriate range of health and social care professionals working together more effectively. That comes with a commitment to invest in Scotland. This year, we are spending £12 billion on our health service, of which £770 million is being invested in general practice.

Patricia Ferguson and Richard Simpson raised issues around funding for general practice in deprived communities. It is important to place on record that there is recognition of the additional needs of patients in areas of deprivation in the calculation of funding to GPs for the provision of core services, as is shown in the weighting given to reflect deprivation. In that way, the allocation formula takes account of deprivation. Government will shortly publish statistics showing all funding to GP practices for 2014-15. I would urge members who take an interest in those matters to take a look at the figures.

We will be investing our recently announced £60 million primary care fund, which Bob Doris mentioned, to transform primary care, building on the great examples that exist across the country of providing care for patients at or near home rather than in hospital. The fund will help to address the immediate workload and recruitment issues through long-term sustainable change.

Dr Milne suggested that all of us here would accept that there are challenges in general practice. I agree: there are challenges in general practice. This Government knows that GP workload is increasing, as is the complexity of healthcare. While more healthcare is being delivered outside hospital settings, resources have not always followed. We understand that GP services in some places are stretched. At the same time, communities rightly expect more from their health services.

Our plan is to transform our approach to primary care to ensure that, in future, people see the right professionals more quickly. We will continue to work with Scotland’s GPs to design that new future. That is why a review of primary care out-of-hours services was commissioned; that is also why we need to redesign primary care collaboratively and inclusively, transforming and invigorating the workforce, creating new roles and supporting communities to innovate, so that services are available where people need them.

Our challenge is to evolve our health service to best meet the needs of an older population who will often have multiple complex conditions, while ensuring that we drive down health inequalities found in our most deprived communities.

There was some focus, understandably, on the situation at the Balmore practice in the north of Glasgow—Patricia Ferguson and Bob Doris in particular raised the issue. It should be acknowledged that Greater Glasgow and Clyde NHS Board has begun work to address the issues that have been raised in order to ensure that the practice is sustainable over the medium and long term. I expect it to engage closely with GPs and local communities as it begins to develop sustainable, future-proofed primary care services.

Mr Doris mentioned that he had written to the Cabinet Secretary for Health, Wellbeing and Sport. In her reply, she was clear that she will use every avenue to encourage the board to work closely with the GPs in the Balmore practice to address the issues that have been highlighted. I am sure that when he meets the cabinet secretary, Mr Doris will be able to raise the issues that he has raised in the debate.

Overall, health in Scotland is improving. People are living longer, healthier lives. Reducing the health gap between people in the most deprived and affluent communities is one of our greatest challenges. At its root, as members said, is income inequality. We recognise that that problem cannot be solved with health solutions alone. As Joan McAlpine and Mark McDonald mentioned, the UK Government’s welfare reform programme presents the most immediate threat to health inequalities. We have taken action to tackle health inequalities. The Government has responded and will continue to respond to mitigate the worst effects of welfare reform wherever we can.

As I have said, we also need to look at the further support that we can provide to practices at the deep end. As Dr Simpson mentioned, the Scottish Government has provided consistent financial support for the deep-end project, including via locum-funded meetings and conferences.

Dr Simpson, Dr Milne and Margaret McCulloch mentioned the series of deep-end projects that led to the establishment of the five-year link worker programme. I understand the desire for that programme to be rolled out further, but it is right that we fully assess its efficacy and seek to learn from it. Members can be assured that we will do that and that we will continue to support other innovative projects in the deep-end practices.

We know that we need to continue to innovate and look at the future of primary care. We know, too, that one size does not fit all—that is why we want to test and seek views on new models of care, including those that might be delivered by multidisciplinary teams in a community hub-type arrangement. There are good models out there. I was delighted to join my friend Mark McDonald on the visit to Middlefield healthy hoose, which is an extremely impressive arrangement. Professionals need to collaborate across the boundaries of primary and secondary care.

Patricia Ferguson rose—

Do I have time to take an intervention, Presiding Officer?

Photo of Patricia Ferguson Patricia Ferguson Labour

I think that we would all recognise that this is not a problem just for GPs and that the multifaceted approach that Mark McDonald described needs to be adopted, but the problem that I have is that although Balmore practice already has a pharmacist, has employed additional nursing staff, has links with the financial inclusion service, has signed up to a new alcohol initiative and now has a drop-in clinic on a Monday to sweep up those people who have not seen a GP over the weekend, it is still at breaking point. One and a half sessions per week for eight weeks and a review team will not get the practice over the hurdle. It needs a bit more help than that.

Photo of Jamie Hepburn Jamie Hepburn Scottish National Party

I have put on record the fact that reforming general practice generally and making sure that it is fit for the future is a priority area for the Government. In relation to the Balmore practice specifically, the cabinet secretary is aware of the situation. Ultimately, it is a matter for the health board but, as an Administration, we are clear that we expect the health board to engage positively with the GPs in the practice and the wider community to ensure that it has a sustainable future.

It is important that we do what we can to talk up Scotland’s general practice and to encourage more doctors to stay in the profession. We had the First Minister’s announcement just the other day, and we need to ensure that medical students choose a career in general practice, because it is one that deserves to be admired and respected. That is particularly true in Scotland’s most deprived communities.

We face challenges in primary care, but members and the wider public across Scotland can be assured that this Government is determined to meet those challenges going forward.

The Deputy Presiding Officer:

I thank everyone for taking part in this important debate.

Meeting closed at 17:57.