I am delighted to have the opportunity to share with members the many successful initiatives that are being rolled out to continue to improve patient safety in Scotland. I thank all staff who are involved in that very important work.
When we launched the Scottish patient safety programme, it was ambitious. It was also unique to the world, because no country had ever decided to tackle patient safety head-on in that way. That is still true eight years on—we remain the only country with the level of ambition that I will describe today to strive for zero harm across our national health service and social care settings.
“What I love about what Scotland has done, is it has done it scientifically. It has done it through developing the capabilities of the country to be a learning nation, to actually improve things. That’s how you’ve done brilliant work in patient safety.”
Our initial focus—understandably—was on acute hospitals, with the aim to reduce mortality by the end of 2012. The work has expanded to include safety improvement programmes across six strands: adult hospitals; healthcare associated infections; maternity and children; medicines; mental health; and primary care.
This morning, I visited the public dental service centre in Glenrothes, which is one of the practices participating in the Scottish patient safety in dentistry pilot. The aim of the dentistry programme is to improve quality and safety in general dental practice through a collaborative approach. Dental teams now see many more patients who are on high-risk medications, such as antiplatelet drugs or anticoagulants, and the work has focused on reducing the potential impact of dental treatment on that group of patients. I am delighted that Healthcare Improvement Scotland is further investing in dentistry, extending the testing phase and developing a plan to spread the learning.
The expansion of the work to dentistry, community pharmacy and nursing homes means that we have SPSP work in all healthcare settings, from our largest hospital in Glasgow displaying real-time safety data in each ward to small general practices in Fife discussing patient safety at staff meetings.
The Scottish Government’s position on patient safety is clear. It is—and will continue to be—of paramount importance in the daily work in healthcare settings throughout Scotland. Today, the Care Quality Commission down south announced a clear need for change in the NHS in England, including the need for safety to remain of central importance, with many trusts failing to learn when things go wrong.
The position that is taken in Scotland is why its unique national patient safety programme is internationally renowned and has made patient safety in Scotland the global benchmark for safe care. Since its launch in 2008, the SPSP has contributed to a significant reduction in harm and mortality through a national collaboration to improve the quality and safety of care.
A number of factors have been key to that improvement. We have built capacity and capability in clinical and non-clinical roles to develop and to apply quality improvement methodology through testing of focused safety interventions to understand and to deliver reliable, evidence-based processes. We have used data to support improvement, shared through national and local forums and networks—those data are on the walls in our healthcare facilities for all to see. We have tested and implemented leadership activities, providing strong organisational support for safety, such as executive safety walkabouts.
Taking all those measures has helped to create a culture in care that is more transparent, learns from success—and failure—and continuously improves. Crucially, in that culture, individuals and teams have risen to the challenge and continually work to improve safety.
The programme has sought to engage front-line staff in improvement work by promoting the application of a common set of tested, evidence-based interventions. That comes from a common improvement model based on the Institute for Healthcare Improvement model.
However, we recognise that, in order to meet the increasing demands that are being placed on our health service, we must reform as well as invest and work to accelerate the shifting balance of care. Consequently, we have committed to introducing a national and regional workforce planning system across the NHS in Scotland. The national plan will look to strengthen and harmonise workforce planning practice, take full account of the future demand for safe and high-quality services for Scotland’s people, accurately identify gaps in supply and help to deliver the vision that is set out in the national clinical strategy.
The plan, which is currently being consulted upon and will be published in the spring of this year, will take full account of the many demographic and other influences on our NHS workforce and enable us to continue to deliver a safe and sustainable NHS.
We have also committed to enshrine safe staffing in law by placing the nursing and midwifery workforce planning tools on a statutory footing. The work on legislation for safe and effective staffing is progressing, and the consultation will begin in early spring of this year.
A crucial element of the programme is that the changes are led by the staff who are directly involved in caring for patients. They can monitor and see the improvements through the collection of real-time data at the individual unit or ward level.
Many countries around the world—including Norway, Denmark, Sweden, Australia, Mexico, Chile and Tanzania—have looked at the Scottish model with envy. They are keen to emulate what we have been able to achieve for the people of Scotland through the Scottish patient safety programme, and many have begun to do so. This month, people from Singapore are visiting to learn from our approach.
The Scottish surgical checklist, which has been introduced under the safety programme, has been praised internationally, including by renowned experts such as Atul Gawande. That simple but powerful technique has been adopted across Scotland. It uses techniques that were developed in the airline industry to ensure that the safety of every surgical procedure is checked and assured every time.
We continue to strive to improve. This week, the chief medical officer’s annual report, “Realising Realistic Medicine: Chief Medical Officer’s Annual Report 2015-16”, was published. It sets out an ambition to put the person who receives health and social care at the centre of decision making and it encourages a personalised approach to their care. Its aims of reducing harm and waste, tackling unwarranted variation in care, managing clinical risk and innovating to improve are essential to a well-functioning and sustainable NHS.
In response, Sir Muir Gray, who is the director of the national knowledge service and chief knowledge officer to the NHS in England, tweeted:
“NHS Scotland is the future of healthcare”.
That is good praise indeed. We will take that.
Patient safety goes beyond the programme. Our diabetes improvement plan includes actions to improve the quality of care for people living with diabetes who are admitted to non-diabetes wards in hospital by improving their glucose management and reducing the risk of complications, such as foot ulcers. Only this week, we have written to the chief executives of NHS boards to begin the national adoption of two important diabetes initiatives. To support that, the Scottish Government will fund 1,000 hypo boxes, which are to be made available to acute wards across Scotland. That will ensure a standardised and improved approach to the management of low blood glucose and will improve patient care.
It is important to share with members some of the specific improvements that have been achieved throughout Scotland. The primary care programme, which was launched in March 2013, has been successful in improving the care that is delivered by health and social care partnerships. That includes general and dental practices, community pharmacies and care homes. One programme aim was for 95 per cent of primary care clinical teams to be developing their safety culture and achieving reliability in three high-risk areas by 2016.
An increasing number of mental health wards and units are showing improvements. Those include a 78 per cent reduction in violence, a 57 per cent reduction in the use of restraint and a 70 per cent reduction in self-harming. Speaking about the identification of physical conditions for people in Scotland with mental illness, Frances Simpson, the chief executive officer of Support in Mind Scotland said recently:
“Among the most supportive has been the Scottish Patient Safety Programme … team, whose staff have opened up access to hundreds of health professionals across the country for the Equally Fit message.”
On maternity and children, it was revealed recently that stillbirths at Forth Valley royal hospital in Larbert were disproportionately higher than the national average but those deaths do not seem to be counted in the mortality rates according to the National Records of Scotland. Will the cabinet secretary comment on that?
There has been an 18 per cent reduction in stillbirths. A lot of that reduction is due to the patient safety programme working with front-line professionals to change some of the practices. However, there is more work to be done. That is why we have just had the review of maternity and neonatal services, which makes a number of recommendations that we will implement to make further improvements.
We should recognise that that has been a significant improvement, but there is more work to be done.
I turn briefly to the medicines programme, which aims to bring together improvement activity related to medicines from acute care, primary care, the maternity and children’s service, and mental health. That provides a unique opportunity to consider the safer use of medicines from a whole-system approach, focusing on the patient as they move between care settings and home. The first key area of focus for the programme is medicine reconciliation, which focuses on reducing harm from medicines across transitions of care by ensuring that medication is accurately checked and prescribed.
Finally, I am delighted to report that the hospital standardised mortality ratio, which provides details of unexpected hospital deaths, continues to decrease. As that was the primary aim of the programme, the continued reduction in those figures is a success that I am proud to celebrate. The latest available hospital standardised mortality ratio figure, published last month, indicates that it has reduced nationally by 8.6 per cent since 2014, and it is well on track to reduce further to 10 per cent by December 2018.
Similarly, national data published at the end of 2016 indicates that there has been a 24 per cent reduction in surgical mortality, a 21 per cent reduction in sepsis mortality, an 18 per cent reduction in stillbirths, as I mentioned earlier, a 93 per cent reduction in healthcare associated infections and a 78 per cent reduction in ventilator associated pneumonia rates.
I recognise the very significant challenges that face our health and social care system, in terms of our ageing population and the increasing numbers of people living with multiple and complex conditions. For that reason, we need to maintain momentum and continue to improve quality of care. We must apply our successful improvement approaches to allow us to continue to deliver today, and into the future, better outcomes for the Scottish people.
That the Parliament recognises that the work of the Scottish Patient Safety Programme, which is the first programme of its kind to be implemented on a national basis, is world leading and represents the international benchmark for safe care; notes the efforts of the many staff throughout the NHS in a variety of care settings all over the country to ensure that the people of Scotland can undergo safe and effective treatment; acknowledges the huge challenges that face the NHS in meeting the demands of an ageing population and those of integrating health and social care services, and recognises the role that innovative improvement approaches can play in helping to meet those challenges.
I am delighted to open for the Scottish Conservatives in this very important debate. I am pleased that we are finally having it, since it originally appeared in the
Business Bulletin several weeks ago.
I have said many times in this chamber that, on issues across health and beyond, our party will act as a strong Opposition, scrutinising the actions of the Scottish Government at all times. We will critique the Government when we feel that it is not performing to standards expected by the people of Scotland and, similarly, we will welcome positive achievements that make a real and tangible difference to people’s lives.
In that spirit, we on this side of the chamber fully support the Scottish patient safety programme and its aims and objectives, and we will continue to support it as its remit grows. That means ensuring that every Scottish citizen who enters a hospital, whether that be for an out-patient appointment, for minor treatment or for a longer stay, should have a right to outstanding treatment, professional care and, above all else, know that they are safe from further illness or complication where that can be prevented.
The need for every patient in our health service to be safe is obvious and paramount. However, context is important in understanding why the Scottish patient safety programme came into being in the first place. Before the programme was introduced, it was recognised that the number of hospital deaths was too high, and that the number of people succumbing to infections or other complications was excessive.
In fact, the Scottish patient safety programme acknowledged that there are many severe risks in Scotland’s hospitals. In 2008, it was estimated that around 2,000 falls occurred in Scottish acute hospitals every month, accounting for a third of all reported patient safety events. In 2011, NHS statistics showed that around 22 per cent of all healthcare acquired infections were urinary tract infections, with 4 per cent of patients developing life-threatening bacteraemia or sepsis as a result. Those statistics range over different timelines and different conditions, but all highlight that there are always risks in hospitals, proving the need for a monitoring body to ensure that those risks can be reduced as much as possible.
Given the original aims of the Scottish patient safety programme when it was established—to oversee reductions in infections, life-threatening developments and, sadly, deaths in acute hospitals—there have been many successes that must be welcomed and that I am happy to welcome. Since 2007, there has been a 16.5 per cent reduction in the hospital standardised mortality ratio and it is good that the up-to-date information that the cabinet secretary just provided confirms that that is on-going. In plain English, there are now fewer avoidable deaths in Scotland’s hospitals, which is testament to the hard work and commitment of our NHS staff, and we should all welcome that.
The remit of the patient safety programme has expanded in the past 10 years to include the monitoring of healthcare associated infections, maternity and neonatal services, the safer use of medicines, mental health services and primary care services. There have been many notable achievements in primary care, including the fact that 93 per cent of all general practices regularly participate in the Scottish patient safety programme’s safety climate survey. That allows practices to monitor their performance against that of other practices, enabling patient safety to develop within a practice. Practices can also check not just safety within the practice but the perception of safety within the practice.
I will talk only briefly about maternity services because I have colleagues who want to elaborate on the issue later. It is notable that since 2007 stillbirth rates have fallen. There are many achievements to praise, and I cannot stress enough that we on the Conservative benches and, I am sure, all members across the chamber support our NHS front-line staff and the phenomenal work that they carry out in keeping patients safe in ever-changing and difficult circumstances.
However, it is also right that we talk about what we need to do better to ensure that the aims of the programme are and continue to be fully met. While many of the overall statistics are delivering better outcomes for patients, there remain inconsistencies in the performances of individual hospitals. My local hospital, the Belford in Fort William, had a significantly higher mortality ratio than the national average in the first quarter of 2016. Dr Gray’s hospital, the Inverclyde royal, the Royal Alexandra and the Vale of Leven were all recorded as being above the upper warning limit for the mortality ratio in the most recently available information.
The cabinet secretary mentioned the chief medical officer’s report that came out this week. In that report, the CMO noted that between 2011 and 2015, the incidence of E coli rose by 5.2 per cent, and that half of the near 4,600 cases of E coli in 2015 were associated with healthcare. Public confidence is important and it remains an issue. As last year’s in-patient experience survey notes, one in five people say that they experienced problems during a hospital stay, and nearly a quarter of people felt that their condition worsened while they were in hospital.
It is clear that, while much progress has been made on patient safety, there is still a lot to do. Any debate on patient safety must consider current levels of NHS staffing, and it is here that I have to adopt a more critical tone.
It is no coincidence that every Opposition amendment to the motion mentions staffing. The amendments were lodged without any collaboration, so there are clearly huge concerns about the issue across the chamber. We need to ensure that the great work that is being carried out by NHS staff is supported and aided by ensuring that the NHS has the right number of front-line staff to deliver those changes.
NHS staff cannot be expected to deliver a Scottish patient safety programme and reach its targets when there are so many unfilled vacancies across the board. We have been consistent in our calls for a solution to that crisis and have highlighted it time and again. That is why we lodged our amendment. The terms of the Government’s motion are entirely laudable but, given the crisis in staffing, we cannot leave matters as they stand. It is only realistic to expect progress.
Will the member accept that NHS staffing rates are at the highest that they have ever been and that this Government has increased staffing rates across all the staffing groups in the NHS?
I have said many times—and professional bodies say it too—that it is not enough simply to say that we have record numbers of staff. There are record numbers of people in Scotland who are getting old, and we need sufficient numbers of staff.
This is not just the cry of the Opposition parties. Some of the major professional bodies have voiced real concerns. The British Medical Association Scotland said that staff shortages can lead to a system breakdown and that the NHS is being stretched pretty much to breaking point. The Royal College of Midwives says that, due to higher birth rates and a lack of recruitment, Scotland’s maternity services are beginning to buckle. The Royal College of Radiologists says that Scottish radiology is on the brink of collapse and, crucially, that patient safety is at risk.
We welcome and acknowledge the work that is being carried out by the Scottish patient safety programme to uplift standards and share best practice. We recognise and support our NHS staff as they work to implement the changes required to ensure that all Scotland’s patients receive quality care, but we also believe that in order for the programme’s results to continue to improve and come to fruition, the Government must commit to ensuring that staff vacancies are filled so that expectations can become reality.
I move amendment S5M-04324.1, to insert at end:
“; notes that staffing levels are essential to patient safety; believes that, across a range of clinical specialities and across the country, the NHS is facing severe workforce and staffing issues, and therefore believes that to sustain further progress on patient safety, further action on staffing must be a priority.”
I start by thanking the cabinet secretary for bringing the debate to Parliament. Labour members will support the Government motion today. There is a lot to welcome in the Scottish patient safety programme and what it has delivered for Scotland, and we should pay tribute to all the staff and management who have helped to deliver the programme and thank them for the work that they are doing on the front line to support people in our national health service.
Like Donald Cameron, I welcome the improvement in mortality rates, the reduction in hospital deaths and the very welcome reduction in hospital-acquired infections—I am sure that everyone across the chamber will want to welcome all those things.
In a moment, I will talk about some other challenges that are associated with patient safety, but I want to take the opportunity to thank not just all the staff members who are involved in the patient safety programme but staff right across the national health service, who go above and beyond in delivering care for people right round the clock and all year round, whether in primary care, acute care or social care or in specific services such as maternity and mental health services. I genuinely thank each and every one of them.
However, we have had a lot of challenges in the national health service since this session of Parliament began. There are still some severe issues around the decisions that the cabinet secretary has made, and the mismanagement of the NHS has left staff overworked, undervalued and underresourced. Although I welcome the motion and will support it, I do not think that the cabinet secretary should be patting herself on the back. She, too, should look at the genuine challenges that we face.
I welcome the fact that we are finally having a meaningful debate on the NHS in Government time. However, I hope that we can also have meaningful debates on the new health and social care delivery plan, which is a strategic approach for the NHS for years to come, on access to new medicines, on the maternity and neonatal services review or on what is happening in our social care sector, where we see continued cuts to local government budgets, meaning that there will be cuts to social care budgets, too.
The cabinet secretary mentioned service reform, and I read with interest her comments on the issue in
Holyrood magazine, when she said:
“I have had opposition members sitting in the very chair that you’re sitting in and I’ve put these issues to them and they’ll sit in here and agree with me but on the floor of parliament you get into a different territory and they’ll say something entirely different.”
That is simply not true. Shona Robison is 100 per cent wrong, and she is trying—perhaps inadvertently, although I suspect not—to mislead people about service cuts. Not once has the cabinet secretary met me or any of my front-bench colleagues—I cannot speak for the other parties—in private to outline the specific service changes that she proposes. Not once has she had the courage to come to Parliament to make the case for the specific service reforms that she proposes. The only debate that we have had on service reforms was in Opposition time, when the cabinet secretary attempted to deny that any service reform proposals even existed—and on that day she even lost the vote. Will she be brave enough to come to Parliament in future to make the case for the service reforms that she supports, rather than hiding behind the health boards?
There are wider issues that impact on patient safety. It is very clear that resource is not meeting demand. How is that going to improve patient safety? Across Scotland, health boards are being held accountable for delivering improvements in healthcare and patient outcomes, but year after year they are also having to make cuts that the cabinet secretary is forcing on them. There will be cuts of more than £1 billion in the next four years. How is £1 billion of cuts going to improve patient safety?
With all due respect to Anas Sarwar, I am sure that he would accept that even the Tories, in their May election manifesto, promised more for the health service than the Labour Party did. It would help everybody if, instead of chuntering about spending, the Labour Party stepped up to the plate with real money. It would also help if every single thing that the cabinet secretary suggests by way of reform was not opposed.
I thank Bruce Crawford for that intervention. Perhaps as convener of the Finance and Constitution Committee, he should have read Labour’s budget amendment, which talked about using the Parliament’s tax powers to invest more in our NHS and stop the cuts to local government, which would stop the cuts to social care that also impact directly on the NHS.
I gently say to members on the Scottish National Party benches that they can repeat a line as often as they like, but that does not make it true. The reality is that cuts are happening across health boards under this Government.
We have also seen a complete failure in workforce planning, with vacancies right across the NHS. There are more than 2,500 nursing and midwifery vacancies, including vacancies for mental health nurses. Only a third of NHS Scotland staff feel that there are enough of them to do their jobs properly, and nine out of 10 nurses say that their workload is getting worse. How is that going to improve patient safety?
In primary care, one in four of Scotland’s GP practices reports a vacancy, asking staff to do more while they oversee the worst workforce crisis since devolution. That led the chair of the BMA to warn that the situation would lead to “personal breakdown” and then “system breakdown”. How is that going to improve patient safety?
There are cuts to local services across the country, with maternity wards, a paediatric ward and neonatal intensive care units under threat. How is that going to improve patient safety?
Let me just finish my point.
We have had the worst Audit Scotland report since devolution, with seven out of eight patient standards failed, including those for accident and emergency, cancer treatment and mental health. Seven out of eight standards failed—how is that going to improve patient safety?
I refer Anas Sarwar to the report of the review of maternity and neonatal services—a report by experts that included input from Bliss Scotland and was very much led by patient safety. Just for clarity, is he saying that that report is wrong and that he knows better than the experts who have recommended those changes?
Absolutely not—I welcome the Bliss Scotland report but if we look at the report’s findings, it is not a record to be proud of; it is a record to be ashamed of. The report talks about three quarters of units not having enough nurses or staff to meet minimum standards. The cabinet secretary wants to congratulate herself on the fact that three quarters of units do not meet minimum standards. Again, how is that going to improve patient safety?
The continued cuts to social care budgets mean that we have chronic problems with delayed discharge. More than half a million bed days were lost in one year alone, with patients trapped in hospital, waiting to go home. I ask the cabinet secretary: how is that going to improve patient safety?
In a separate report, Audit Scotland says that the spiralling cost of private agency spend is now up to £175 million a year. Audit Scotland also states:
“Agency staff are likely to be more expensive than bank nurses, and also pose a greater potential risk to patient safety and the quality of care”.
That is Audit Scotland saying that—not me. How is that going to improve patient safety?
I have explored the patient safety programme web pages and I found an interesting article that referred to a meeting of senior NHS managers in Greater Glasgow and Clyde. They posed three questions at the meeting—remember, this is part of the patient safety programme. First, why is the largest health board in Scotland in persistent financial overparity—that is civil service speak—despite extensive efforts to overcome that via efficiency savings? Secondly, how will it be able to squeeze services into a smaller bed complement in the new hospital on the south side when demand is increasingly exceeding supply?
—and meet patient standards across the country.
I move amendment S5M-04324.2, to insert at end:
“; thanks Scotland’s health and care staff for all that they do, but understands from listening to the workforce that services are facing a situation in which demand is often outstripping supply, with rising vacancy rates in key areas, key standards missed and a situation that the BMA Scotland has described as being ‘near breaking point’.”
Thank you very much, Presiding Officer.
As a platform that aims to improve safety and reduce harm in any landscape where care is delivered, the Scottish patient safety programme sets an international standard. It successfully sets out an approach to safety from birth to death, at every stage and in every transaction in the delivery of health and social care in our society. I welcome the opportunity that the debate affords to scrutinise the programme’s merits in granular detail.
The welfare and safety of our citizenry must always be the alpha and omega of our responsibility as legislators, and the delivery of health and social care represents the largest landscape in which we, as public servants, must discharge that duty. Since its inception, the patient safety programme has delivered groundbreaking interventions and disseminated best practice at every level of care in our society. We heard about the prevention of sepsis through a whole-system approach to infection control, which is underpinned by robust data analysis that is building a structured approach to all frontiers of patient safety. As was said in a programme press release in early 2015:
“Patient safety problems exist throughout the NHS, as in all large complex health care systems in the world. However, it is not staff negligence, but the systems, procedures, environment and constraints faced by health care professionals that lie at the root of most safety problems.”
I think that all members share the belief that our health and social care staff represent some of the finest professionals in Scottish society. However, there is a structural problem that can run counter to the efforts of the patient safety programme and can visit symptoms on every aspect of our health service. That, in turn, impacts on the programme’s work.
Problems in workforce planning create a blockage that impedes patient flow through primary, acute and, ultimately, social care, at every stage in the health journey. A shortage of general practitioners—we know that by the end of this decade we could have nearly 1,000 fewer GPs than our society will require—leads to appointment delays, which in turn can lead to conditions becoming more acute, which then results in hospital admissions that earlier intervention could have prevented. That exerts upward pressure that is manifested in every other part of the health service, and which, coupled with the postcode lottery around the availability of social care packages, can cause delays in hospital discharge—as we heard from Anas Sarwar—on a monumental scale.
A recent volley of freedom of information requests that my office issued uncovered the extent of the problem. Some patients are staying in hospital for as many as 500 days beyond the point when they are declared fit to go home.
I hope that Alex Cole-Hamilton was copied into the letter that I sent to Willie Rennie on the subject, because many of the cases that were highlighted were very complex and related to patients who were, for example, waiting for a house to be built, or for very specific packages. Those people were not readily dischargable from hospital. Does Alex Cole-Hamilton acknowledge the complexity of the cases to which he is referring?
I thank the cabinet secretary and I am delighted that she raised the issue, because when I raised it at First Minister’s question time we did not get to cover the point that our FOI request was for information on people who are left in hospital beyond the point at which they are declared to be fit to go home, entirely because of the social care package being unavailable—not because of houses being built or specific secure care needs. I am glad that we have had the opportunity to thrash that out.
I want to return to a more consensual tone. The issue presents an immediate challenge for the patient safety programme, because we know that prolonged stays in hospital increase patient exposure to pressure sores and hospital-acquired infection—albeit that we are doing well in reducing the incidence of such harm, as we have heard.
Put simply, if we can get the workforce planning right and, by extension, reduce delayed discharge, we can take a giant leap forward in improving patient safety. I therefore welcome the steps that the cabinet secretary has outlined towards a plan for workforce planning.
The locus of the programme rightly extends beyond the traditional institutions in which health and social care are delivered. With the advent of new initiatives such as hospital at home, as well as the decades-old approach of care in the community, we must ensure that patients are kept safe in any setting where they receive care. First and foremost, that must follow a proactive and preventative approach in which we anticipate and mitigate risk from the outset.
In December, I had the great honour of chairing the older people’s assembly in this chamber. It was a fantastic event at which there was a robust and vibrant exchange of views. At one session, I asked everyone assembled what they were most worried about, and I was surprised to learn that, among those present, fear of falling outstripped fear of crime, loneliness and money worries. Given the commonness of falls and the direct causal link between them and senior mortality, there is a great desire among older citizens for us as policymakers to take action. That is why I call today on the Scottish Government to develop a national falls strategy that will build on the work of the falls prevention framework of 2014.
I would like to make progress, please, Emma. I am sorry, Presiding Officer—I mean Ms Harper.
The strategy would include comprehensive training for all care staff, employment of technology and a full suite of marketing and awareness-raising materials to help older people to stay safer in their homes or in any setting in which they receive care. Put simply, falls prevention is one of the most important steps that we can take in promoting patient safety.
The final area that I would like to cover is mental health—specifically in relation to the work of the programme. The inclusion of mental health is of course welcome, but it stands alone as a separate thread. To my mind, that stand-alone nature does not take account of the fact that there is a causal relationship with every aspect of patient safety. It is right that we should focus on physical safety, but there has to be an element of mental safety for patients as well. At the moment, the patient safety programme focuses on restraint and seclusion and an understanding of risk factors, but it should also focus on prevention of mental ill-health, as a vital aspect of improving patient safety.
In the work on safety in maternity, for example, the programme should look for dissemination of best practice, sharing of knowledge and roll-out of specialist perinatal mental health support teams across all our health boards. After all, one in five mothers will experience mental ill-health as a result of pregnancy, yet only five health boards have dedicated perinatal mental health teams.
Similarly, in cases in which mental ill-health is a factor in patient care, the risk assessment of patient safety must include the likelihood of self-harm or suicide. That is why it is fundamentally important that the safety programme dovetails with the nascent mental health strategy and the successor to the suicide prevention strategy.
We should be justifiably proud of the patient safety programme, because it sets an international standard, as I said, and is groundbreaking in many ways. I come to the chamber not to bury it, but to praise it, and I want it to be enhanced.
I move amendment S5M-04324.3, to insert at end:
“, and believes that action to reduce harmful and avoidable incidents would be strengthened by ending the NHS recruitment crisis, following warnings from frontline professionals that shortages pose a risk to patient safety, developing a national falls strategy and delivering a step change in mental health services.”
Twenty years ago, I was involved in the improvement of safety in the perioperative environment in the United States as part of a collaborative approach with the USA’s Institute for Healthcare Improvement. For example, I taught best practice and a standardised approach for surgical counts of swabs, needles and instruments, in order to avoid the retention or loss of a surgical instrument inside an abdomen. There is growing implementation of non-technical skills to safeguard patients. That approach has been adopted and promoted in the USA as well as here in Scotland. Those skills relate to things such as situation awareness, good decision making, a flattened hierarchy, leadership and a good approach to teamwork and communication. In Scotland, research on that has been procured and continued by Dr Steven Yule and others at the industrial psychology research centre in Aberdeen.
When I was a clinical educator for NHS Dumfries and Galloway, the training programmes that my colleagues and I initiated for healthcare support workers and nurses had a specific focus on safe, effective and person-centred care. I collaborated with colleagues regarding verbal handover from the anaesthetist to the post-anaesthesia recovery room nurses so that clear plans of care were identified and documented. I also provided education about deep venous thrombosis prophylaxis and prevention, central venous access line infection and medication safety, so that the right patient, drug, dose route and time were achieved, which improves the safety of patients.
Quick, snappy education sessions, for example on the sepsis six, were delivered using the one-minute education approach. I could continue to give examples of these seemingly small but immensely important measures that can make the difference between life and death. They are vital to the improvement of both acute and primary patient care.
I am pleased to be able to speak in the debate, not least because it enables me to say to Parliament that my former colleagues in NHS Dumfries and Galloway and across NHS Scotland deserve to be commended for and congratulated on their on-going work to promote best practice using evidence-based care. Too often, we hear nothing but negativity surrounding our NHS, and I can tell members that that has a real effect on the morale of the nurses and doctors.
I was proud when, in 2008, Scotland became the first country in the world to launch a national patient safety programme. The programme has been vital to delivering the highest-quality healthcare services to the people of Scotland and is recognised as world leading in the quality of healthcare that it provides. In fact, when he was President, Barack Obama mentioned Scotland as having one of the best healthcare systems in the world.
Since its launch, the acute adult programme has contributed to a significant reduction in harm to and mortality in adult patients through measures such as those that I have described, and many more. Since 2008, the scale and ambition of the programme has grown and the work, which began in acute adult hospitals, now extends to primary care, mental health and maternal and child health.
There are many examples of cultural change that has been brought about by the programme, notably in mental health settings, where we have seen a real shift in the approach that is taken to the administration of psychotropic medication and improvements in how challenging behaviour is managed.
The Scottish patient safety programme will continually adapt to meet our changing needs and will embrace new technologies and approaches to care. We should be proud that, thanks to its implementation, Scotland plays a leading role in patient safety initiatives in Europe. NHS England officials have praised the programme, stating that they hope to use the experiences and learning to take forward practices in England. According to Dr Marc Wittenberg, a clinical fellow at NHS England, the programme is “unrivalled” and contains much that should be replicated in England.
The 8.6 per cent reduction in hospital standardised mortality and the praise from bodies such as the Organisation for Economic Co-operation and Development and NHS England show exactly why the Scottish patient safety programme deserves its international reputation as a world leader.
I refer members to my declaration of previous business interests and to the fact that I have a daughter who is an NHS midwife.
I welcome the chance to speak in this debate on the Scottish patient safety programme and the excellent work that our healthcare professionals do in ensuring that the quality of care and the safety of patients is of the very highest standard.
Although we recognise the significance of the Scottish safety programme, it is always incumbent on interested parties, including members, to continually examine the programme and look for ways to improve and enhance it. In the short time that I have, I want to make two points. First, I want to highlight that, in delivering the patient safety programme, it is essential that we recognise that a key element in its effectiveness is the safety, health and wellbeing of NHS staff. In that regard, we have to recognise that the system is under quite a bit of stress, which has a detrimental effect on those who are working in that system. For example, in NHS Ayrshire and Arran, there is a consistently higher than average absentee rate in the neonatal and midwifery section—sometimes more than double the national average—and that has been the situation for at least the past five years. To me, that represents a department that is under quite a bit of pressure.
Furthermore, we know that there is a growing issue of experience being lost to the profession, with 1,200 midwives in Scotland over the age of 50 who are eligible for retirement at 55. That experience cannot be replaced by newly qualified staff. If the situation is not addressed, it could put staff in situations of which they have no experience and in which, crucially, they would be without the support of more experienced staff. That speaks to a heightened risk to patients, especially in emergency cases.
I know that the Royal College of Midwives recognises that and is attempting to recruit experience from outside Scotland. Indeed, I spoke to the chair of the RCM a couple of weeks ago at an event in London, where the organisation was actively promoting Scotland as a career destination. There is a general recognition that the new neonatal strategy that the cabinet secretary announced last week is a step in a positive direction. However, if the workforce does not have enough capacity to deliver the strategy, the safety of patients will once again be brought into question. Midwives want to get away from what the RCM describes as “conveyor-belt” care and move towards the provision of more personal care that allows them to effectively address preventable health issues.
When things go wrong, it is crucial that NHS boards are in learning mode and are able to scrutinise system failures and look at where clinical issues arise to ensure and enhance future patient safety. However, there is no national standardised process that describes what constitutes a significant adverse event, and the numbers of significant adverse events that are reported vary widely between NHS boards.
What is more, when Healthcare Improvement Scotland reviews cases, it does so under instruction from the Scottish Government, and it can only offer recommendations; there are no regulatory powers in that respect outside the private sector. If HIS recommendations are implemented, we need to consider how we audit implementation and how that is further reviewed.
In highlighting the importance of patient safety, we should recognise that the safety and working environment of our healthcare professionals is crucial. Staff numbers are inevitably linked to the health and wellbeing of NHS workers, and therefore to the safety of patients.
With regard to patient safety, it is important that a national system for triggering a significant adverse event investigation is in place and that it allows for a consistent response that staff and patients feel comfortable engaging with and giving feedback on. Furthermore, any recommendations that are made by any review must be rigorously implemented and reviewed to ensure that consistent learning continues to enhance the patient safety programme.
I am pleased to speak in the debate, and I remind members that I am the parliamentary liaison officer to the Cabinet Secretary for Health and Sport.
As has been mentioned, the hospital standardised mortality ratios for Scotland decreased by 16.5 per cent between 2007 and 2015, and the latest published figures show that there has been an 8.6 per cent reduction in hospital standardised mortality ratios in Scotland’s hospitals since the baseline figure in 2014. In addition, a total of 10 hospitals—including Monklands hospital, which serves my constituency—have shown a reduction in excess of 20 per cent.
I have a personal story here. In January 2000, my gran was admitted to Monklands hospital and sadly passed away there after contracting pneumonia. Although she would have wanted me to point out that the care that she received was tremendous, and there was definitely no fault on the part of the staff, it is heartening that the mortality statistics that I quoted, which must have included her, have been decreasing in more recent years, and that Monklands has, over the past decade, regained its good name.
It has shocked me in the past few weeks, including at First Minister’s questions last week, to hear members of the Labour Party call the saving of accident and emergency departments throughout Scotland—including the one at Monklands hospital—a 10-year-old story that does not need to be heard. That has been niggling at me for a while, because I beg to differ with that view, and I expect that the thousands of patients whose lives have been saved will also disagree with it. I want to put on record that Monklands A and E is a vital service for the community, and the fact that it was saved should not simply be dismissed, whether it is 10, 20 or 30 years later.
I believe that it is fully and properly staffed.
Despite the significant challenges of Scotland’s public health record, its changing demography and the economic environment, the Scottish Government has set out a strategic vision for achieving sustainable quality in the delivery of healthcare services across Scotland.
The 2020 vision delivers the necessary strategic narrative and context for taking forward the implementation of the quality strategy and the required actions to improve efficiency and achieve financial sustainability. I welcome the Scottish Government’s 2020 vision to ensure that everyone is able to live longer and healthier lives, that we have a healthcare system where health and social care go hand in hand and that we continue to focus on prevention, anticipation and supported self-management. It is critical to continue pursuing the goal of providing the highest standards of quality and safety, regardless of the setting, with the patient at the centre of all decisions.
It is therefore important that all forms of support across our communities are nurtured. On Monday, I visited the Coatbridge meeting of the Lanarkshire carers group, where I heard at first hand from carers how much they valued the service and how worried they are about the pending cuts by North Lanarkshire Council, which might impact on how they care for their relatives. It is imperative that we provide support across the board to such support services. I have also had contact with the St Andrew’s MS self-support group, whose chairperson is a constituent of mine. That group is fighting for an increase in the number of specialist multiple sclerosis nurses across North Lanarkshire, and I have submitted a question to the cabinet secretary on the matter. That is another example of how we can provide support to such support services.
As we have heard, a key point is that the SNP Government has committed to enshrine safe staffing in law, and the consultation period for that will begin early in spring this year. The link between safe and sustainable staffing levels and high-quality care is well established. As other members have said, it is vital to have the right number of staff in place, with the right skills; the debate benefited from Emma Harper’s contribution on that aspect, given her experience. Scotland has led the United Kingdom in the development and implementation of nursing and midwifery workload and workforce planning tools, for example.
Progress has been made but, given the changing demographics and Tory cuts, we must continue to work together and be innovative across all health services so that those who serve my community and all communities across Scotland are the best they can be.
Nye Bevan said:
“Illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune, the cost of which should be shared by the community.”
That was why Labour created our NHS, which remains one of the most valued assets of people across Britain. People expect to be safe when using it so, although Scotland’s once-unique patient safety programme is welcome, we must consider it closely and strive always to improve it.
It is also important to make it clear that, although our hard-working NHS staff deserve our thanks for all that they do, they are under extreme pressure. The use of agency staff has increased, and spending on that has rocketed over the past four years, despite Audit Scotland’s warning that
“Agency staff are likely to be more expensive than bank nurses, and also pose a greater potential risk to patient safety and the quality of care.”
I am sure that everyone who is taking part in the debate agrees that improving our hospitals, keeping staff well trained and maintaining staff numbers at safe levels takes investment and long-term planning, which is something that we all want to see.
The patient safety programme has the worthy goal of the safer use of medicines, but that goal is not well served by not providing people with the correct medicines in the first place. As the cabinet secretary mentioned, Scotland’s chief medical officer, Dr Catherine Calderwood, said on Monday that doctors should spend more time listening to their patients in order to avoid giving them unnecessary treatments. Dr Calderwood called that realistic medicine, which focuses on quality of life, not the efficiency of treatment. However, that is not realistic for some patients if they cannot get the medicine that they need to live a normal life. For example, too many thyroid patients, who are mainly women, are not being properly diagnosed or are being refused access to liothyronine, which means that they are forced into buying desiccated thyroid hormone on the internet. That can hardly be called safe and it is not putting patients at the heart of their own care.
It is common for some patients with thyroid illness to be prescribed antidepressants, perhaps because their GPs do not have the time to listen to them and therefore cannot reach a proper, safe and correct diagnosis. That is an example of patients with chronic disabling or life-threatening conditions being deprived of treatment because of costs, the closed-mindedness of the medical establishment and NHS boards, or GPs being under immense strain. That issue should be considered further, and the Public Petitions Committee is considering it.
Getting patients into and out of hospitals safely and having them there for the right amount of time is a key concern for patient safety. Back in January, Labour obtained official figures that showed that, between the start of March 2015 and the end of September 2016, 683 people died in hospital after being deemed medically fit to leave. Of course, we have promises to end the practice of bed blocking.
At present, even getting into hospital for desperately needed operations is a problem. In NHS Lanarkshire, there is a wait of up to 24 weeks for an initial appointment for a hip replacement. That is 24 weeks of being in extreme pain for older people who will then have another long wait for the operation, and that is despite the Government giving a 12-week guarantee, although I accept that that is not legally binding.
What happens afterwards? The figures may show a decrease in acquired infections, but I am becoming increasingly concerned that I am hearing about people with such infections, which may need to be looked at. I am also concerned about those who tell me that aftercare is poor, which seems to be a result of staff shortages and, in some cases, low morale. A recent disturbing story involved a constituent who waited 30 minutes, while pressing her buzzer, and who then suffered the indignity of having to wet herself.
It is important to consider the kind of people who are dying in our hospitals and how we might be able to prevent that. For example, we know that Scots who are from poorer backgrounds are 64 per cent more likely to die from cancer and that general health outcomes for those in our deprived areas—specifically those in greater Glasgow—are some of the worst in Europe. Those inequalities must be addressed.
If we are to improve patient safety in our hospitals, we need not only to tackle workforce planning but to ease the tensions that affect hospitals, and that requires prevention, as has been said. The 2015-16 NHS audit report found that many NHS boards across the country struggled to achieve financial balance and, overall, NHS Scotland failed to meet seven out of eight key performance targets. That is not exactly a picture of health and it will only get worse if we do not continue to take action and make improvements.
I am delighted to participate in the debate. As many members will know, I worked as a clinical pharmacist, specialising in mental health, until my election last May. I can honestly say that, in my 20 years of working in a hospital, nothing came close to the effectiveness of the Scottish patient safety programme for change management. I hope that the debate will reassure my Lib Dem colleagues that a step change is already occurring in mental health services.
The SPSP is about delivering reliable and safe care for every patient, every time—24 hours a day, seven days a week. As the cabinet secretary mentioned, in mental health, the safety programme has supported improvements at ward level, where there have been examples of reductions of up to 70 per cent in the number of patients who self-harm, 57 per cent in the number of incidents in which physical restraint has to be used and 78 per cent in the number of incidents of physical violence on wards. Those figures are phenomenal, and they come from some of the most disturbed wards in Scotland.
What is so special about the SPSP? The methodology empowers staff to identify what is not working well, to make changes and to monitor their impact by on-going use of data collection. Data is incontrovertible, which makes it really powerful for instigating change.
I will tell members about some of the progress that has been made at the hospital that I used to work at—New Craigs hospital in Inverness. At the time when I left, we were using SPSP methodology for medicines reconciliation. It might seem simple, but the process of creating the most accurate list that is possible of all the medications that a patient is actually taking and comparing it with their records at transition points, when errors are most likely to occur, has dramatically reduced errors.
The next focus of our attention was “as required” medication, which is used to alleviate symptoms of distress and agitation, so it is not a regular prescription. For some time, coloured stickers—red for intramuscular injections and yellow for oral drugs—had been used in patient notes to highlight the use of such medication. The stickers prompted staff to record how well the patient responded and the bright colours in the notes were a crude visual cue as to how well the patient might be.
An audit of the stickers at New Craigs found that, when such drugs were being used, more than 50 per cent of the time the patient had only a slight improvement or no improvement in symptoms. Of course, the discovery that an intervention does not work half the time warrants a response. The pilot team proposed seeing whether alternatives to medication might be of more benefit to patients. All the staff, including my pharmacy colleagues, had training on decider skills. The training was excellent and the techniques are popular with staff and patients alike. It is clear that learning those skills and teaching them to patients has the potential to have a much longer-lasting benefit than medication has. Now, in addition to the yellow and red stickers system, a green sticker is used to record the score of psychological interventions from the perspective of both the nurse and the patient. I hope that that example demonstrates the power of such incontrovertible data to drive change.
Fundamentally, the SPSP empowers staff at the coalface. My colleagues are increasingly turning to the methodology as a standard approach to problem solving and process improvement. As I have mentioned before, the Government is enabling all healthcare professionals to develop and take on new roles. To support GPs and other primary care colleagues, the pharmacists at New Craigs have all trained as prescribers and are taking their skills from the hospital into the community. The SPSP methodology will be ingrained in that change, to identify and improve any processes that are not working well.
Scotland is leading the way with the Scottish patient safety programme. Our ambitious and comprehensive approach to improving the safety and quality of care might have caught the interest of the rest of the world, but it is the results that have made it really impressive.
The Government’s motion acknowledges the success of the Scottish patient safety programme and it acknowledges the significant challenges that the NHS faces. Given the scale of those challenges, we must take stock of approaches that work, learn from them and build on opportunities to expand them.
The amendments that have been lodged all—rightly—address workforce shortages, which undermine the efforts of our NHS staff to provide the best possible care. Appropriate staffing levels are essential to patient safety, and demand is often outstripping supply. The latest Information Services Division figures show that many patients are facing unacceptable waits for diagnostic tests and treatment. I am worried that, although our health service is delivering very high standards of safe care to most patients, many others are being left for too long without the care that they need.
The Government points to its long-term strategy, but we need urgent action to improve access to care for patients who need it today. We have been promised a new national workforce plan, but I am not encouraged by recent actions such as the modest uplift in student nurse numbers. An increase of 142 in the number of student nurses is not ambitious enough when 28 per cent of nursing posts in the care home sector are vacant. Bliss Scotland’s report on our maternity and neonatal services found that many of our neonatal units do not have enough nurses in post and that most struggle to ensure that nurses get appropriate specialist training.
Training and support are essential. We know that, when staff are well supported and their experience is valued, they can achieve fantastic results for patients. The patient safety programme has delivered some of the best examples of improvements in our healthcare system, and that is because it gives staff the opportunity to drive change themselves, as we have heard. Learning from that approach can help to make our hospitals and community health services more attractive places in which to work.
Sometimes NHS targets are criticised for creating perverse incentives, contributing to a tick-box culture and putting processes, not patients, first. However, the patient safety programme set ambitious goals and has surpassed many of them. In its briefing for us last November, the Royal College of Nursing said:
“There have been real improvements in the way health services are delivered in Scotland over the last 10 years, for example, the patient safety programme.”
Colleagues have mentioned the 16 per cent reduction in hospital mortality, the 18 per cent reduction in stillbirth rates and the 21 per cent reduction in mortality from sepsis, which are clear and significant improvements. They have all been achieved by staff working together to review their practice, question their normal processes and develop safer alternatives. That is brave work, and I thank all the staff who have been involved in the pilots, collaboratives and improvement projects across Scotland.
I am glad that the patient safety programme is moving into care homes. Its target of reducing harm from pressure ulcers by 50 per cent in hospitals and care homes by December this year will greatly improve many people’s quality of life. We need to ensure high standards of safety as health and social care is integrated, and this is the kind of approach that we need.
I want the programme’s successes to reach even further—not just to care homes but to those who are cared for at home and in our communities. People often feel that a frail elderly relative would be safer in hospital and that that would be the best place for their relatives, because they are more confident that risks will be minimised there. However, we also need to use the patient safety programme’s rigorous approach to improve the safety of vulnerable people who are cared for at home. That poses clear challenges because, at the moment, social care staff do not have much chance to lead improvements in care services. They often have to work in relative isolation, under pressure and with few opportunities for training and development.
One strand of the patient safety programme is its highly regarded fellowship programme, which allows clinicians to develop their leadership skills, strengthen collaborations and learn directly from international experts. It is crucial that we invest in our future clinical leaders. In the long term, we have to develop equivalent mentoring, training and expert support for our social care staff.
Back in our hospitals, there are concerns about consultants’ ability to teach up-and-coming medical students. That, too, has implications for patient safety, and it leads to the perception that Scotland is a 9:1 country. That is the very reason that has been cited by consultants who are not attracted to practising medicine here, and it impacts on consultants’ contribution to the NHS.
Thank you. A crucial aspect of the programme is the way in which it encourages people to be open about failure.
Great successes have been highlighted in the debate, and we should be proud of the staff who have led this challenging work, because they have looked not just for good news stories but for examples of failure that others can learn from. I applaud all those who have contributed to the patient safety programme and its outstanding achievements.
I refer members to my entry in the register of members’ interests as a registered mental health nurse.
I am proud to say that Scotland’s health services are again leading the world in innovation. Because of the Government’s commitment to the sector, we are rolling out new ways of delivering healthcare in 21st century Scotland. The wider integration of health and social care—which, again, has been spearheaded by the SNP Government—is an acknowledgement that caring for individuals without looking at all their needs can get us only so far. We recognise that in Scotland we need an holistic system if we are to tackle problems with multiple contributing factors, and the Scottish patient safety programme recognises that, too.
Nowhere is that more evident than in what was my clinical practice—mental health services. When we look to treat the person rather than the condition, we take into account their experience of their illness, their individual strengths and what their recovery means to them. That approach is especially relevant for people who are receiving treatment from mental health services, because those patients frequently experience the kinds of unique challenges that the SPSP tackles.
The programme does that through five main workstreams: safer medicines management, risk assessment, violence and restraint reduction, communication and strong leadership. That five-pronged process works by placing on healthcare professionals the requirement to gather information systematically on those key areas and to tailor their care for the individual accordingly, based on evidence.
The patient safety climate tool was created to deliver that and to ensure that patients’ voices are heard when their care is being planned. The tool invites patients with mental illness to record their experiences of receiving treatment, from how they feel on the ward to how their medication is affecting them. Staff are committed to acting on the feedback that the patient gives them. For patients, it is an empowering experience.
However, it is more than that; it is an extremely effective system, and its success is borne out in the figures.
More than 600 patient safety climate tools and 3,000 staff climate surveys have been completed in the past four years. Those have gathered patient and staff feedback—a huge amount of real intelligence on patients’ experiences and the experiences of staff on the wards. It is already having a demonstrable effect on care, with participating wards showing massive improvements. My colleague Maree Todd alluded to the following: there are reductions in restraint of up to 57 per cent, reductions of up to 70 per cent in the number of patients who self-harm and reductions in rates of violence of up to 78 per cent. Those are amazing figures that all of us in the chamber can support. When violence drops to a quarter of the existing level and when self-harm drops to less than a third, that is a massive improvement in the lives of real people—patients and health professionals. It presents a fantastic opportunity to improve mental healthcare nationwide and to share our learning internationally. Those numbers should be applauded: they are concrete evidence that using a human-rights-centred approach in mental healthcare simply works.
When we engage with patients, use their feedback and tailor their care and environment appropriately, everyone involved benefits. When we empower healthcare workers to share their experiences, to learn from their patients and to tailor their approach, we ensure that care is personal and that outcomes are improved for everyone. We are fortunate, with a devolved NHS, that we can seek to implement holistic human-rights-centred solutions to the specific problems that Scotland faces. With mental health wards already experiencing the benefits, I look forward to the approach rolling out to more services across the country.
I declare an interest in that I have a number of family members who work in the NHS.
The Scottish patient safety programme was launched in January 2008 as a five-year national programme to reduce mortality and the number of adverse events in acute hospital settings. Undoubtedly, there have been successes, with the number of deaths having been cut by 15 per cent and the number of adverse incidents having been cut by 30 per cent over the past five years. The most recent phase of work was completed in March 2016, and reductions in harm were reported, which can only be welcomed by everyone.
The care that is provided by NHS staff is fantastic—we all agree on that. The fact that we sometimes criticise or comment on Scottish Government policy does not mean that we are attacking front-line staff. It is unhelpful when members of the Government party keep saying that we are attacking front-line staff when, in fact, we are pointing out what a good job they are doing in very difficult circumstances.
Perhaps Mr Balfour and his colleagues might reflect on some of the language that they use in the chamber when they describe the NHS—emotive language such as “crisis”—and the effect that it has on the staff who work in the NHS.
It is nothing to do with the front-line staff; it is all to do with the Government and its lack of action.
The SPSP has definitely helped to create a safer culture, but staffing levels play an essential part in patient safety, and currently, across a range of clinical specialties, the NHS is facing severe workforce and staffing issues. When we look at what is coming up in the next few years, it is likely that the situation will only get worse.
A freedom of information request that was made by the Scottish Conservatives earlier this year revealed that dozens of adverse events are recorded every day in the dementia wards of Scotland’s hospitals. More than 160,000 such incidents have occurred in the past six years, as an under-pressure health service attempts to deal with an ageing population, with incidents ranging from falls, to assaults on staff, to self-harm, to patients leaving secure facilities. Much more serious is that bosses at NHS Greater Glasgow and Clyde said that adverse events had resulted in the deaths of 49 patients since 2011.
Patients in dementia wards are among the most vulnerable in our hospitals and deserve the best possible care—both for their own sake and for the comfort of family members. There is no question that wards that deal with dementia patients are very challenging places in which to work. In such environments, many of the adverse incidents will have been unavoidable. Once more, it is a credit to front-line staff that they deal with such incidents daily.
Patients in those wards and their families will be extremely worried about the sheer scale of the flashpoints. A significant number of incidents were put down to staffing shortages or to lack of adequate resources and training. Again, that is not the fault of those on the front line, but of the Scottish Government.
Although the SPSP is playing an important role in improving safety and keeping patients safe, we need to see a plan to ensure that our staff and hospitals are equipped for all the future challenges that they will face.
As a member of the Health and Sport Committee, I am delighted to be taking part in the debate on the Scottish patient safety programme.
The Scottish patient safety programme is the world-leading first-of-its-kind system to be implemented on a national basis. Focused on advancing the safety and reliability of healthcare, the Scottish patient safety programme includes safety improvement programmes for acute adult care, healthcare associated infections, maternity and children’s healthcare, medicines, mental health and primary care. It is an international benchmark for safe care.
The programme demonstrates a key relationship between the Scottish Government and NHS Scotland, in the shared desire to provide safe care and to reduce harm, as well as to achieve sustainable high-quality healthcare for everyone in Scotland. In particular, Healthcare Improvement Scotland has partnered the NHS to achieve the goals that are set out by the SPSP to help NHS Scotland to
“deliver high quality, evidence-based, safe, effective, and person-centred care; and to scrutinise services to provide public assurance about the quality and safety of that care.”
The idea of evidence-based care is reliant on having close and personal hands-on staff throughout the NHS in a variety of care settings all over the country. Their attentiveness to each individual patient is what has allowed for the continued reliability and improvement of routine healthcare systems and processes. The impressive work that has been demonstrated by NHS Scotland staff has progressed since 2008, despite the demands that stem from the ageing population in addition to those that arise from integration of health and social care services.
Since its 2008 implementation, the Scottish patient safety programme has seen improvements in healthcare across all individual safety improvement programmes. For instance, the safety improvement programme for mental health has seen an increase in the number of wards and units showing improvements in rates of violence and restraint: since 2008 there has been a reduction of up to 64 percent in patient restraint, a 75 per cent reduction in patients self-harming, and a reduction of up to 80 percent in rates of violence.
In 2012, the acute adult programme had done so well that the then Cabinet Secretary for Health and Wellbeing expanded its aims, on top of its primary responsibilities, which included building capacity and capability within clinical and non-clinical roles. The new aims were to reduce mortality further and to reduce harm that is experienced by patients in Scotland’s acute hospitals. That has been achieved through continuous improvement.
The groundbreaking work that the Scottish patient safety programme has achieved is unique to Scotland among healthcare programmes internationally. Its aim to reduce Scottish hospital mortality rates in a safe and effective way has been incredibly successful thus far.
In the coming years, NHS Scotland and Healthcare Improvement Scotland will face challenges concerning the wellbeing of Scots. However the innovative improvement approaches that have been implemented by the Scottish patient safety programme will make those challenges surmountable.
Once again, the initiative is a perfect demonstrator of the incredible service that is the national health service. I am proud that we here in Scotland continue not only to protect our NHS and deliver world-leading healthcare, but to pioneer innovative approaches such as the SPSP.
I pay tribute—as I do in any health debate—to all the people who work in our NHS. I previously worked as a part-time out-of-hours driver for doctors in NHS 24 and have personally seen the excellent work that is done by all the staff in Lanarkshire’s accident and emergency departments.
We have one of the best health services in the world. Since coming to Parliament in 2011, I have seen health spending increase tremendously. Yes—there is more to do, but let us stop kicking the health political football. We have to look seriously at what we are doing, what we are providing, how we can improve it and how we will support our health providers. I, for one, am glad that the cabinet secretary is totally committed to the brief—and I thank her for that.
Thank you very much, Mr Lyle.
We have one culprit not here for the closing speeches—although, at one point, Anas Sarwar was holding his breath, too, hoping that he would not have to sum up for Labour. Undoubtedly, the SNP whip will let Fulton MacGregor know that, as he spoke in the debate, it would be good if he could come in—just to let us have his company—during the summing-up.
We move to the closing speeches now, and Alex Cole-Hamilton will close for the Liberal Democrats. He has five minutes.
We have had an excellent debate this afternoon. There is a lot of common ground in our recognition of and support for the work of the Scottish patient safety programme. That was wonderfully delineated in Mr Lyle’s excellent speech, which laid out in granular detail the successes and the huge advances in patient safety that the programme has delivered.
Donald Cameron noted that the Opposition amendments today are very similar. The references to workforce planning were entirely unco-ordinated, but they show the depth of political concern on the matter. Although it feels as though Donald Cameron, Anas Sarwar and I have turned up at the same party in the same frock—again—it demonstrates the significance that parties across the chamber attach to the NHS staffing crisis. Alison Johnstone eloquently echoed that point when she put forward the Green Party perspective.
We have heard time and time again that staff shortages are having a material impact on patient safety in our NHS and social care workforce, because appropriate clinicians are not available or, if they are, are being worked to the point of burnout. Brian Whittle made excellent points about the impact that that can have on staff safety, particularly the effect of staff absences, which, in turn, exacerbates the wider problem. Although Fulton MacGregor recognised the importance of having a full staff complement, he did not pay heed to where we would get that from and how we should address the crisis.
The cabinet secretary—and I thank her for this—opened up an avenue of this discussion that I had not considered by referring to the excellent report published by the chief medical officer, Dr Catherine Calderwood, entitled, “Realising Realistic Medicine: Chief Medical Officer’s Annual Report 2015-16”.
Clare Haughey—rightly—pointed to the need to have rights-based patient planning. Nothing makes that point finer than the treaty espoused in the CMO’s report. It speaks to my core values as a liberal that, ultimately, when equipped with all the information about their situation, patients will make the decisions that are right for them. Sometimes those decisions will surprise their clinicians, with their choosing fewer life-extending interventions in favour of spending the last few days in the comfort and dignity of their family home. I hope that we have opportunities in the chamber to unpack further the intellectual arguments about quantity versus quality of life and about the harm that too much focus on the former can do.
Donald Cameron said that those in the chamber are united in agreeing that the programme is internationally recognised. The member outlined the context against which it was originally brought in and the measurable impact that it has had in not just reducing harm but saving human life and reducing preventable deaths—a theme that was picked up by Jeremy Balfour.
Anas Sarwar rightly pointed out and referenced the spectre of major service redesign and the potential impact that that might have on patient safety. He asked whether that should receive the full scrutiny of Parliament, as we have voted for it so to do.
Elaine Smith made excellent points about access to medicine, underscored by harrowing examples of the blockage preventing patient flow through our health system. Indeed, thousands of bed days are lost to delayed discharge. Much of what she covered was to do with older people’s needs.
I very much hope that, in its closing speech, the Scottish Government will respond to my call for a national falls strategy. Jeremy Balfour touched on that in his contribution about the needs of dementia patients, dementia wards and the distance that we still have to travel.
Maree Todd kindly referred to our amendment but said that a step change was happening in mental health. I take issue with that. Last week, she and I attended the same mental health conference, at which it was clear that we are far from making a step change in mental health. We still lack talking therapists in every GP surgery in the country—and the Liberal Democrats will not cease from calling for that because it is the only way of delivering on the Scottish Association for Mental Health’s call for people to be able to ask once and get help fast. The same applies to investment in child and adolescent mental health services and other mental health services.
That said, we are well served in the Parliament by having the expert professional knowledge of members such as Emma Harper, Clare Haughey and Maree Todd. In a spirit of cross-party consensus, I look forward to hearing their contributions and following their guidance on the matter. They are right that the patient safety programme is world leading and we can all justifiably be proud of it. The Opposition amendments seek not to denigrate it but to enhance it.
During the debate, members have all acknowledged the positive impact that the Scottish patient safety programme has had since its establishment in 2008. Richard Lyle in particular summarised the successes well.
Among other things, the cabinet secretary highlighted the success of the surgical safety checklist, on which Scotland is leading the way. We should all be proud of that. She stressed the fact that the programme’s encouraging outcomes have expanded recently to include paediatric and neonatal care, maternity services, mental health services and primary care. That has increased the programme’s positive impact on our health and wellbeing by, for example, improving mortality rates, as the cabinet secretary and Donald Cameron stressed.
Alison Johnstone also made the valid point that the programme had surpassed its initial goals. However, a number of members made important, constructive suggestions for further improvements. I refer, for example, to Brian Whittle’s point about consistency in the measurement of adverse incidents and Alex Cole-Hamilton’s call for a national falls strategy.
It is important that we build on the programme’s success. The overall trend in premature deaths is one of steady improvement. Life expectancy in Scotland has risen from 64 years for men and 69 for women when the NHS was established to 77 for men and 81 for women today. However, that paints only part of the picture. Premature death is still much more common in Scotland than in England and Wales. Elaine Smith highlighted the fact that there are huge disparities between deprived and more affluent communities. As the Health and Sport Committee’s report on health inequalities said in 2015:
“A boy born today in Lenzie, East Dunbartonshire, can expect to live until he is 82. Yet for a boy born only eight miles away in Carlton, in the east end of Glasgow, life expectancy may be as low as 54 years, a difference of 28 years or almost half as long again as his whole life.”
The solutions to that appalling fact cannot be tucked away in patient safety—or any part of the national health service—or written off as a problem of individual behaviour. If we want to tackle heath inequality, we need to be more serious about tackling wealth inequality.
Every speaker has rightly stressed the often heroic efforts of our health and social care workforce and the outstanding contribution that they make to our health and wellbeing. As Anas Sarwar said, there would be no patient safety programme without the work of our healthcare staff. However, the truth is that there are not enough of them to keep doing what we want our NHS to do. It is not good enough for some SNP speakers to keep saying that we have more doctors and more nurses, but to fail to acknowledge that staffing levels are simply not keeping up with growing demand.
We need an honest debate about the future funding and staffing of the health and social care sector. We all accept that we have an ageing population and more people with complex care needs. However, despite a growing demand for services, local health boards are still being hit by significant health savings targets of £1 billion over the next four years. Those cannot be achieved without impacting on services.
The cuts come at a time when the NHS is struggling to recruit and retain staff, a problem that is exacerbated by the number of unfilled trainee and specialist posts. One in four of our GP practices reports a vacancy, and we have a ticking time bomb of GPs queueing up to retire. The Royal College of General Practitioners has predicted that, by 2020, Scotland will have a shortfall of 830 GPs—the number needed just to return to 2009 levels.
It is not just in GP numbers that we have a crisis—and yes, it is a crisis. There are more than 350 consultant vacancies, nearly half of which have been vacant for more than six months. There are 2,500 nursing and midwifery vacancies, including more than 300 unfilled mental health nurse posts.
The consequence of the failure of the Government’s workforce planning is not only high vacancy rates and training posts going unfilled across the NHS, but an increase in the burdens on existing medical staff, which add to an already unsustainable workload. Dr Peter Bennie, the chair of the British Medical Association in Scotland, has warned that our NHS workforce is
“stretched pretty much to breaking point”.
Emma Harper shared her own invaluable experience, but she also touched on the issue of staff morale. Let us look at what really damages staff morale. The Royal College of Nursing surveyed its members and revealed that 90 per cent said that their workload has got worse. That is what damages staff morale. NHS Scotland’s own staff survey showed that only a third of NHS staff feel that there are enough staff to do their job properly. That is what damages staff morale.
Thank you, Presiding Officer. On staff morale, it does not matter what a nurse does in a shift, she or he will always feel that they could do more. The surveys are sometimes not the best way of portraying morale. I am sure that Mr Sarwar is helping Mr Smyth with a response to that right now.
I hope that Emma Harper will actually read the surveys that have been published by the
Royal College of Nursing—90 per cent said that their workload has got worse. NHS Scotland’s own staff survey said that only a third of staff felt that there were enough staff to do their job properly.
What impacts on staff is a shortage of staff, the failure of proper workforce planning and the fact that we are asking our staff to do too much with too few of them. It is about time that the Government started to acknowledge that that is a problem, instead of burying its head in the sand and pretending that we have enough nurses and doctors.
To conclude, Labour members will back the wording of the Government’s motion and show our support for the patient safety programme, but we will also back the hard-pressed nurses, doctors and all health and social care staff by backing the amendments and showing support for a staff team that is overstretched and underresourced by this Government.
I am pleased to close the debate. It has been useful and there has been much consensus, although perhaps not between the SNP and Labour members. However, we can all support the aims of the patient safety programme to reduce mortality and adverse events in all NHS settings.
While we recognise that the Scottish Government has made progress, Donald Cameron was right to highlight the importance of staffing levels when it comes to patient safety. Other members have raised legitimate issues around specific services including maternity and neonatal care and paediatrics. I pay tribute particularly to the points raised by Brian Whittle and Alison Johnstone, who highlighted midwife recruitment, a key concern that many of us have been told about by constituents.
A number of members mentioned the care of the elderly in hospitals, which is an issue that I am particularly concerned about. A recent freedom of information request showed that each year in hospitals in my NHS Lothian region there are typically at least 3,000 instances of elderly patients suffering falls in elderly care and dementia wards, and that a significant proportion of those falls cause moderate or major harm to patients. We need to make sure that all measures are put in place in elderly care wards to ensure that falls are minimised, including having enough staff on duty at all times to care for and monitor patients.
As well as causing fractures and affecting mobility, falls can destroy the confidence of older people and make them less likely to undertake the physical exercise that is so important to maintaining their overall health. Alex Cole-Hamilton spoke about preventing such falls, and I totally agree with what he said. The cost to the NHS of treating falls is significant, and investment in fall prevention can save under-pressure NHS resources, so we need to look at that.
Technology will play a huge role. Just last week, I visited a company called Snap40 that is “the doctor at your side”. I welcome the fact that they will undertake two pilots in NHS Scotland. The continuous monitoring device that they have developed can automatically identify the warning signs of health deterioration. We need to lead on technology like that here in Scotland.
As my party’s mental health spokesman, I welcome the progress that was identified in the “SPSP Mental Health: End of phase report” from November 2016, which covers 2012 to 2016 and has influenced the development of mental health safety principles. As the cabinet secretary said, there is some positive data in the report, including examples of reductions in restraint of up to 57 per cent, a reduction in the percentage of patients who self-harm of up to 70 per cent, and a reduction in the rates of violence of up to 78 per cent. Maree Todd said that we should pay tribute to all those who work in our mental health services who have helped to achieve such significant progress.
Although the work that has been undertaken focuses on our acute mental health service wards, we look forward to the roll-out of similar approaches to in-patient mental health services across Scotland. That will be challenging, but is important, and I hope that the Scottish Government will make sure that it is progressed within the mental health strategy.
I also welcome the fact that the SPSP-MH will support the work of the equally fit project in reducing physical health inequalities for those who suffer from severe mental illness, along with Support in Mind Scotland, See Me Scotland and Bipolar Scotland.
The need for the patient safety programme to be supported at all levels of healthcare provision and across services is vital, from NHS board level to local teams within hospitals to GP practices and community pharmacies and I hope that the Scottish Government will take that support forward.
It is important for all parts of our health service and all NHS workers to share the aims of the safety programme, to share relevant information and best practice and to work collaboratively. As Elaine Smith said, it is also important to ensure that NHS staff are adequately supported to be able to implement the programme and encourage further development and training.
It is also worth reflecting that many patients can find the acute hospital setting to be a disorientating environment and experience. On a recent trip to the Queen Elizabeth hospital in Glasgow, the Health and Sport Committee saw a “What matters to you?” board in a room in the specialist dementia care unit. Those patient information boards show the things that are most important to individuals and they are incorporated into the care planning and delivery process. The bedside boards display information at a glance and form part of the conversation with the patient and their family. They have helped to personalise care by providing quick prompts for how to relieve distress for some patients and they act as an aid for non-permanent members of the care team, informing them about important issues to facilitate communication with patients. The information is updated as and when changes occur for the individual. I was particularly impressed with that and I hope that the initiative will be rolled out as a national standard across Scotland.
I also highlight the problem of hearing aids and reading glasses being lost. As a new MSP, I have been struck by the number of people who have contacted me to say that their loved ones have had their hearing aids or glasses lost when they have been taken between the care home and hospital appointments, for example. We need to look at that. In some of the cases I have dealt with, the individual has been really upset by the loss and their health has deteriorated. I hope that the Scottish Government will look at that.
I meet NHS staff often and see them under pressure, and I have them in mind when we come to the chamber for these debates. We have the right to be their voice in this Parliament. When the Royal College of General Practitioners and the RCN tell us that there is a crisis in the service, we have a duty to highlight it to the Parliament and we make no apologies for doing so. We support our NHS staff 100 per cent. As I have said in the chamber previously, the NHS does not depend on the SNP Government; it depends on those who work in our health service day in, day out and we need to make sure that their voices are heard.
The Scottish Conservatives welcome today’s debate and support the aims of the Scottish patient safety programme to minimise adverse events and avoidable harm in the health service. We recognise that good progress has been made but there are still a lot of important improvements to put in place to ensure that patient safety outcomes are as good as they possibly can be. We look forward to the Scottish Government providing the national leadership required to drive forward the programme and the funding to support all parts of our NHS to deliver best practice.
I am pleased to close today’s debate because, although we are not blind to the challenges, it is right that we pause to recognise the phenomenal improvements brought about by the Scottish patient safety programme. Maree Todd and Emma Harper’s professional analysis of the impact of that important approach in their contributions was compelling because, as the cabinet secretary outlined, there has been a 24 per cent reduction in surgical mortality, a 21 per cent reduction in sepsis mortality, an 18 per cent reduction in stillbirths, a 93 per cent reduction in healthcare-associated infections, and a 78 per cent reduction in ventilator-associated pneumonia.
I welcome the largely consensual comments from members who have chosen to be constructive in participating in the debate. I will single out Alex Cole-Hamilton, who made an informed contribution; I recognise his continued interest in making improvements to mental health services. Likewise, Miles Briggs made points that I know will be taken on board by my colleague Maureen Watt, who recently announced the managed clinical network on perinatal mental health, which will be a priority in the implementation of the recommendations that were set out by Jane Grant in “The Best Start: A Five-Year Forward Plan for Maternity and Neonatal Care in Scotland”.
Although there are challenges around delayed discharge, as Alex Cole-Hamilton and others mentioned, since 2011 there has been an 11 per cent reduction in bed days lost. Alex Cole-Hamilton also commented that falls were more feared by the elderly than crime, and we are making progress on that. Efforts are being made in hospitals and care homes to take action on falls. For example, NHS Grampian has reduced falls by 14 per cent, and there has been a reduction in falls more generally right across the country. Alex Cole-Hamilton, Miles Briggs and others are right to say that we must continue to focus on that, which is why, in my portfolio, which includes sport, it is also imperative that we do what we can to get our older population more active so that they have the resilience to cope with falls that may happen to them in later life. I am happy to continue that dialogue with Miles Briggs and Alex Cole-Hamilton, and indeed with Elaine Smith, who I see is keen to raise a point with me now.
We have capacity in the Golden Jubilee hospital. I understand the points that Elaine Smith raises about NHS Lanarkshire, and we continue to engage with that health board to support it in making better progress on some of these issues. Her question is relevant, but we are ensuring that there is capacity in other hospitals to cope with some of the demand, and we will continue to work through the issues and to engage with her on what is happening in that local setting.
I want to look ahead to what is next for the Scottish patient safety programme. The teams in the Scottish patient safety programme are ambitious. They have reviewed the varied work and many achievements to date. Looking forward, the programme will have a much wider focus on the overall patient journey. That will ensure that sick patients are identified appropriately and timeously, that they receive their medicines safely and effectively, and that they move through their healthcare journey as safely as possible.
During 2016, the content and delivery methods for the future programme were reviewed. That identified three core themes under which future work will be planned: prevention, recognition and response to deterioration; medicines; and system enablers for safety. A greater focus will be placed on designing improvement activity across pathways of care with a focus on NHS boards and partnerships setting their own priorities and outcomes to be achieved to meet local needs.
While improvements continue to take place in healthcare settings, improvement methodologies from the programme are also being applied across the public sector in Scotland, whether in education, justice or beyond, and we are spreading our improvement approach beyond the boundaries of health and social care—Alison Johnstone touched on those points. The children and young people improvement collaborative is central to our work to make Scotland the best place in the world to grow up. It joins up the early years collaborative and the raising attainment for all programme to use quality improvement approaches to deliver improvements throughout a child or young person’s journey, to support positive experiences in the early years and educational attainment.
I think that I might have to have an improvement approach to my own voice, which is deteriorating—
Our health and social care delivery plan, which was published on 19 December, sets out how we will further enhance health and social care services so that the people of Scotland can expect to live longer, healthier lives at home or in a homely setting.
We will have a health and social care system that is fully integrated and which focuses on prevention, anticipation and self-supported management. It will make day-case treatment the norm where hospital treatment is required and cannot be provided in a community setting; it will focus on care being provided to the highest standards of quality and safety, whatever the setting, with the person at the centre of all decisions; and it will ensure that people get back into their home or community environment as soon as appropriate, with minimal risk of readmission.
In its ninth year
, the Scottish patient safety programme continues to grow, to mature and to develop to meet these new challenges in the new integrated environment. Increasingly, the emphasis will be on supporting NHS boards and health and social care partnerships to identify their local priorities. The programme will act to tailor any improvement support that is required to meet those local priorities.
To return to some other points raised by members, many members raised the issue of the workforce. Although it is absolutely right to hold the Government to account and we would never deny any Opposition member the opportunity to do that, we must also be mindful of the words of Emma Harper and Clare Haughey, who pointed out the impact of consistent negativity on the morale of our NHS staff, who work daily on our behalf to help others. The Government is committed to supporting and developing our workforce. Staffing has increased. Qualified nurses and midwives numbers are up by 4.9 per cent. The cabinet secretary announced a 4.7 per cent increase in intake to pre-registration nursing and midwifery programmes for 2017-18, which means 151 extra places. That is the fifth successive rise and it equates to 3,360 new places. We have committed to retaining the nurse student bursary, unlike in the rest of the UK.
I thank the minister for taking an intervention, which I am making purely out of solidarity—I thought that I would give her a chance to get a sip of water, as she is struggling. Can she address the point that was made by Dr Peter Bennie that, if the workforce crisis is not addressed, it will lead to “personal breakdown” and then “system breakdown”?
We have the workforce plan, which is coming out. I noticed what Anas Sarwar announced at the weekend—again, he is playing catch-up with action that this Government has already taken and I think that he should take cognisance of that fact and of the improvements that we have made. He puts his hands up—“10 years, 10 years”. Under his party, Monklands A and E and Ayr A and E would have been closed for 10 years. I think that our record is a positive one and a good one and we will continue to govern effectively for our NHS.
In relation to our support for the NHS workforce, Clare Haughey made an important point about empowerment. The improvement approach empowers practitioners. The programme and the CMO’s broadening of realistic medicine also mean that we are empowering patients to be in control of their own care. However, we know that there are challenges, which is why we are developing a workforce plan and will continue to engage with Opposition members on the strategic future of the NHS, when their voices are constructive.
Bruce Crawford intervened on Anas Sarwar’s contribution—or “chuntering”, as he described it—to ask a simple question about why Labour did not commit to more funding for the NHS in its manifesto. It was this party—the SNP—that pledged the most financial support for the NHS and it is this Government that has delivered and will deliver on that pledge. No matter how much the Opposition does not like to hear it, unfortunately, that uncomfortable truth for Anas Sarwar is one that this Government will continue to repeat, as we continue to deliver for our NHS.
Miles Briggs mentioned “What matters to you?” and I was desperately trying to find in my notes when the next “What matters to you?” day will be, as last year’s day was such a success. I will get back to him on that.
I will again quote Don Berwick, who said:
“In my opinion Scotland should be extremely proud of what it’s done in the improvement of healthcare and extremely excited about what it can do now with the ambition to make Scotland the healthiest country in the world. It may be the leading example in the world”.
On that point, I will conclude. However, I think that we should all be grateful for the impact, effort and dedication of our committed NHS staff, who allow us to be able to showcase Scotland’s NHS on that global stage.