 board. ederim gan ein bod yn ei ddweud o'r ddweud o'r ddweud o Ff1416 4 yn y cyfnod Pratysia Fhergason aillai GPD Yn Ynryd Fethfyrd. Mae dydd yn chi meddwl i ddweud i gyd yn tyfu'n gweithio, ac i finno allu'r bwysig o'r ddweud i gilydd, no unig yn ddweud i gyd yn ddweud i ddweud yardwg i ddweud i ddweud i ddweud i ddweud i ddweud i ddweud i ddweud i gyd yn ddweud i ddweud i ddweud i ddweud I look forward to open the debate. Seven minutes please, Ms OGs. Thank you Presiding Officer. I begin by also thanking those colleagues from across the chamber who signed my motion and made this debate possible. General practitioners at the deep end are those who work in the 100 most deprived populations in Scotland, based on the proportion of their patients with post codes in the most deprived 15 per cent of Scottish data zones. I apologise now, Presiding Officer, that my speech has an awful lot of statistics within it, but I think that it does help to emphasise the case that I want to make. Those statistics show that people living in such areas are likely to attend their GP more often and will need longer appointment times because they are likely to present with more than one health issue at a time. That in turn means that GPs with even a small or average-sized patient list are likely to have a greater workload than their colleagues in more affluent areas simply by dint of their geographical locations and the health issues that their patients have. To understand the situation, it is helpful to compare those statistics again. Across Scotland, the average prevalence per 100 of congestive obstructive pulmonary disease, or COPD, is 2.21. That is 2.21 patients in every 100. In the Balmor practice in Pawsal Park in my constituency, that jumps to 4.18 in every 100. But at the other end of the scale, in a relatively affluent area like Hindland in Glasgow, the figure is only 0.63. At 0.63 in Hindland, it is 2.21 on average across Scotland, and in a particular practice in my constituency, it is 4.18. The same level of statistics for smoking-related ill health show that 24.87 people per 100 is the average figure for Scotland while Balmor has 29.17 and Hindland has just 13.6. It is no wonder that GPs in practices like Balmor are frustrated and angry about their predicament and that of their patients. It is widely recognised, Presiding Officer, and has been for a very long time, that men and women in the most deprived fifth of the population will die 10.4 and 6.9 years respectively earlier than those in the least deprived fifth. But the fact that disturbed me most and one that was new to me, I have to confess when I read it first and which has been the catalyst for my motion and for this debate, is the difference in healthy life expectancy or the estimate of how many years people are expected to live in a healthy state. If we look again at the most deprived fifth and the least deprived fifth of the population, the two ends of the extreme, the figures could not be more stark. The healthy life expectancy of men and women in the most deprived fifth ends 20.8 and 20.4 years earlier than those in the least deprived. That is potentially 20 years of productivity lost for individuals and their families. It is 20 years possibly of pain or discomfort and it is potentially 20 more years of stress and anxiety. That is not right and it cannot be acceptable. Practices like Balmor provide their patients with an excellent service and the team of doctors, nurses and the pharmacist work together to ensure that they continue to do so. They are struggling to do everything that they want to do and everything that they are expected to do within their existing resources. In summary, we have a situation where GPs at the deep end are dealing with patients with higher levels of multimorbidity at a younger age and those patients need longer appointments and more follow-up and support. However, the average spend per annum in those practices is £118 per patient per year compared to the Scottish average of £123 and £127 per patient per annum in the most affluent fifths. If those GP practices have no additional funding to recognise the difficulties and the problems that they face in their patients, it stands to reason that the staff in those practices are working longer hours in more challenging circumstances and that that will eventually affect recruitment and retention. There is even a name, Presiding Officer, for this phenomena. It is the inverse care law and it states that, and I quote, the availability of good medical care tends to vary inversely with the need for it in the population served. In their submission to the consultation on a fairer Scotland, the GPs at the deep end stated that this is, and I quote again, not a law of nature, however, but a long-standing man-made policy that restricts access to care based on need. Presiding Officer, it is surely time to end this situation and to recognise that we have a particular set of circumstances that puts huge demand on the deep end practices and everyone who works in them. We surely have to find a way of funding GPs that does not adopt the one-size-fits-all approach. We have already witnessed GP practices without those problems and issues, experiencing problems with recruitment and retention of staff right across the country and its sheer dedication and commitment that is keeping many of our GPs in post at the moment. The First Minister's announcement yesterday of additional funding for GP training is very good news, but how long will it take to filter through the system and to make a difference? We need more action now to avert the escalation of this crisis. In July of this year, the Balmor practice sent an 11-page open letter to the health board and I am sure that the minister has had an opportunity to see that for himself, in that they detailed the problems that they face and they also made some suggestions as to solutions. Fortunately, the health board has now decided that it will give them some additional support and help, and that again is welcome, but it is not a long-term solution and it seems to me that it is long-term solutions that those practices need. In closing, I can do no better than to quote again from the submission that the deep end practices made to the Scottish Government's consultation on a fairer Scotland. A document that actually did not talk about its particular predicament in any case, but it said, and I quote, "...equitable access to emergency care has been a shining example of the NHS commitment to comprehensive healthcare based on need and free at the point of use. A similar commitment is needed to reduce inequitable access to non-emergency care, especially general practice, and also to reduce social variations in access to specialised and centralised services." Surely that is a sentiment that we can applaud, Presiding Officer, and one that our policy and our funding should support. Many thanks. Now, moving swiftly on, Colin Bob Dorris, to be followed by Dr Richard Simpson. Tight for time today, four minutes please. Thank you very much, Presiding Officer. I welcome the debate this afternoon as an opportunity to draw attention to the significant pressures that are being experienced by Balmor practice in Pawsall Park. I have heard some of that already. I have not signed the motion itself because I do not accept part of the proposition made in the motion that, in relation to deprivation levels that funding distribution arrangements take no account of the additional burden that this places in staff and resources. I do however welcome the debate around whether sufficient account is taken of deprivation levels, and I commend Patricia Ferguson for putting many of the statistics on the record here this afternoon, which needs further interrogation. I want to focus on Balmor practice. Balmor practice in Pawsall Park has made a powerful case to NHS Greater Glasgow and Clyde for additional resources in relation to the processions that that practice is under. I, too, following a meeting with the GPs there, have corresponded with the health board to make the case for additional resources. I have also drawn the matter to the attention of the Scottish Government, and I welcome that the Cabinet Secretary for Health and Well-being has agreed to meet with me to discuss some of those concerns. I welcome the additional locum cover that is being provided to Balmor practice by the NHS. That cover amounts to three half-day sessions by a locum GP for a 12-week period. The additional support will, and I quote from correspondence that I have received from the NHS, fully explore the issues raised by the practice and together take steps to ensure the contigued viability of the practice. In fully exploring those issues, I would urge the NHS to properly consider the high level of patients with complex health needs and significant multimorbidities, as well as the profound health inequalities that exist. It is also worth highlighting the many asylum seekers that have enriched Pawsall Park but who often also have complex health needs themselves. I would like to highlight two additional matters before looking at a positive and constructive way forward. First, the locum GP support is welcome, but for understandable reasons of continuity of care, often locum GPs do not see them as clinically challenging and complex patients when they are providing cover. Those patients would see their regular GP. We must ensure that any exploration of the demands placed in Balmor practice takes account of the data and reality of resident GPs that are there. I echo the point that Mr Doris is making about continuity of care. I am sure that he will agree with me that the fact that another GP has resigned from that practice makes that situation all the more critical. I thank Mr Sferden for making that point. If a time constraints will not allow me to develop that particular point further, that is a point well made. Secondly, the additional locum GP support will end just before Christmas. In other words, it will be thrown just as the peak winter pressures are about to be placed in Balmor surgery. I would hope that Greater Glasgow and Clyde continue with additional locum cover support into the new year while analysing the findings of the review of Balmor practice. I make those points to NHS Greater Glasgow and Clyde. I would like the Scottish Government to consider making similar representations to the health board. The Scottish Government has recently announced an additional £60 million for the primary care development fund as to ensure the quality of care in general practice. That has been delivered following discussions with the BMA and the Royal College of General Practitioners. Given that some of that cash will seek to support, develop and test new ways of working in order to improve services, I would ask that consideration is given to working with Balmor practice to fund any new ways of working on a pilot that could be taken place within the postal park. The practice has already developed new models of working, including greater role for pharmacists, the assistance advice bureau is also present there, and addiction workers as well as a range of community nurses. I believe that working with Balmor practice, including if there is sufficient locum cover to allow the resident GP partners to develop new services and new pilots is essential, and we have a good use of government and health board money for the new ways of working that we all want to see. Can I finish off by thanking the practice manager, Susan Finlay, for taking the time to speak to me this morning? Susan, along with Drs Alison Reed and Lindsey Crawford, as GPs at Balmor practice, have to deal with the day-to-day realities of working in this cold face of a wonderful community, but one with huge challenges. I am delighted to be part of this debate because I think together and constructively we can build a better way of delivering the health service for the constituents that we all want to represent to the best of our abilities. Thank you, Presiding Officer. Dr Richard Simpson, to be followed by Dr Nanette Milne. Deputy Presiding Officer, I would like to congratulate Patricia Ferguson on obtaining this important debate. As I always do, Minister, I want to begin by giving credit to the Government for providing the funding to the deep end group in order that they can meet. This type of getting together by doctors from the 15 per cent most deprived practice in Scotland has in itself been beneficial in reducing the isolation that is often felt by general practitioners. Recognition that they should have problems that they share is actually a good starting point, and it is very clear from the extensive publications from this group that their view has a wide resonance not only in Scotland but across the United Kingdom. Minister, the unpalatable fact is that the inverse care law to which Patricia Ferguson referred, which was propounded half a century ago or almost half a century ago in Wales by Dr Tudor Hart, is alive and well in Scotland's general practice. The inverse care law, in essence, is the provision of resources, is an inverse proportion to the levels of need. As Patricia Ferguson has illustrated, the level of need is beyond question, with significantly higher levels of physical and mental ill health, a shorter life expectancy and, as she indicated, the period during which people have to put up with ill health is very much longer in this group. In the very first session of Parliament, the health committee interrogated what was then known as the Arbathnaught Committee about the basis for allocation of NHS resources. Deputy Presiding Officer, I would like to ask the minister in his response to indicate whether the successor committee, known as the National Resource Allocation Committee, has now taken into account not just population, not just the elderly, not just deprivation but the actual need, which can now be largely determined by the far better recording of epidemiological data, something that the Arbathnaught Committee could not achieve. In my view, it is long overdue for health boards to be instructed to ensure that resource allocation to primary care is based on need. It is clear that the poorest desile has doubled the mental illness, much greater numbers of physical illness, and a feature of the poorer areas is that greater prevalence of mental illness. Twice the number of face-to-face consultations for mental illness, three times the prescribing of antidepressants. The fact that there are more resources allocated to practices with much lower levels of deprivation is utterly appalling. The challenge of multiple morbidity and social complexity, shortage of time for the GPs and their staff, reduced expectations that result from that, lower enablement, poor health literacy, increasing practice stress and very weak interfaces with the rest of the services are all collectively in the deep end publications. The only move that the Government have so far taken as far as I know, and the minister can correct me, is to fund the recruitment of a small number of liaison workers. Now, this is no doubt helpful because it has been demonstrated recently by deep end sponsored research that the significant needs for benefits advice, for example, to ensure that there is maximum amount to uptake is vital. That study was actually done in Postal Park, but not in the Balmoral practice. Minister, every practice in the deep end group should be supported by someone helping with benefits advice and the maximisation because this is about social medicine as well as physical and mental health. The GPs need to have an understanding of the conflicted, fragmented benefit system, and we will need to understand the new systems that will come in with the transfer of powers that it proposed in the Scotland Act. Scotland has had the tube in breast with an equality of GP prison in that every area has had GP available, but this is no longer the case. We are now facing a crisis that the Government is beginning to appreciate. If we see more practices like the Balmoral one with GPs resigning, methyl and my practice in my constituency area is just closing, then we are going to have real problems. The announcement of 100 more GP trainee places is welcome, but there is a 20 per cent vacancy rate in the current trainee places and most of those are in the west of Scotland, so that is really not going to help. Presiding Officer, I close with the fact that we did an FOI very recently, and what we asked the health boards was, have you undertaken and do you have a risk register in relation to the risks that are being faced by your general practices? The minister only three said yes. Only three. If the health boards do not assess the risk register of their GPs, then we are in much trouble as the Government's previous denial of the problems in general practice. Thanks. Before I invite Nanette Milne to speak due to the number of speakers wishing to speak in this debate, I am minded to accept a motion under rule 8.14.3 that the debate be extended by up to 30 minutes. Ferguson, would you please move such a motion? Thank you very much. The question is, do we agree that the debate be extended by up to 30 minutes? I do. Many thanks. I now call Dr Nanette Milne to be followed by Jim Hume. Thank you, Deputy Presiding Officer. I realise that this is a very serious issue in Patricia Ferguson's constituency, but it also gives us the opportunity this evening to look at the wider problems associated with GP practices in patients in deprived areas. I never congratulate Patricia Ferguson on bringing forward this debate. I think that all of us would agree that general practice in Scotland faces challenges ahead with factors such as the growing shortfall of GPs to look after an increasingly elderly population with complex comorbidities. Added to that, of course, is the number of GPs set to return the next five years without being able to attract their replacements and many who are qualified moving abroad to practice. We start with a situation whereby, if not a crisis, there is a serious problem with overworked GPs and understaffed practices. It is clear that this is magnified in areas in which there is manifest deprivation. As Patricia Ferguson has said, in places such as Pusall Park and other parts of Glasgow, Glasgow University's research into general practitioners that depend throws up some very concerning facts and figures regarding life expectancy and the broad health and wellbeing of people in the most deprived areas of our society. The fact that men live over 10 years less and women nearly seven years less than the Scottish average in the most deprived fifth of the population is something that needs to be addressed. So, too, as I already stated, is the case that, in the most deprived fifths of the population, men and women spend twice as long in poor health before they die, with 23 years compared to nearly 13 years for men and nearly 26 years compared to 12 years for women. Clearly, those statistics have a huge knock-on effect on GP services, where poor health obviously leads to greater demands on local surgeries. However, the real problem lies with the difference between demand and unmet need. In giving evidence to the Health and Sport Committee regarding health inequalities, Professor Graham Watt from GPs at the Deep End told us that the challenge lies in defining the extent of unmet need within the primary care system. In deprived areas, there are people with conditions often of a specialist nature which are not dealt with, either through individuals not seeking help or through specialist services being seen as remote. I thank the member for giving way. Perhaps he will forgive me for that. Can I ask the member whether he recognises one of the significant issues that Balmoral practice and postal park raises for additional pressures is the consequence of UK welfare reform and the additional burdens that places on those GPs? I am sure that welfare changes have an impact on people in certain areas. I am not going to go into detail on the UK welfare reforms. In those areas, there is a need for specialist services to be local and readily accessible. There are distinctive problems with the physical and mental health of vulnerable children and families in very deprived areas, where the contribution of health visitors is vitally important. Unfortunately, in such areas, the uniform health visiting service, designed to provide support to all families regardless of circumstance, is under serious pressure because of a very high volume of vulnerable people requiring support, coupled with difficulty in recruitment. This will be compounded next year when the name person role is introduced throughout Scotland and not just in deprived areas as a result of the Children and Young People Scotland Act. In areas with a high instance of socio-economic deprivation, it is realised that new approaches and different skills may be required to help people to address social issues and gain more control over their own health and well-being, and, to this end, the Government-supported national links worker programme is being delivered in seven deep-end practices, including Possible Park, which, hopefully, will show the way to best meeting the challenges presented by the current health inequalities in Scotland. Patricia Ferguson's motion emphasises that the present funding distribution arrangements take no account of the additional burden placed on staff and resources in the deep-end practice. Of course, I accept that, and that resource distribution is a significant factor. However, any potential redistribution across Scotland would have to take account of the fact that deprivation is not confined to west-central Scotland, but it also exists even in parts of prosperous cities like Aberdeen and is significant in a number of our rural communities. Of course, demands on health services are increased in communities with a growing elderly population, where dementia and comorbidities are an increasing problem. I absolutely understand the issues that are concerning Patricia Ferguson. The funding and provision of primary care services is of concern to all of us, and I hope that the minister will address those points in his contribution this evening. I thank Patricia Ferguson for bringing this debate forward. It is a good opportunity to remind ourselves that focusing solely on the people in the most deprived areas is only a starting point. We also need to look at the resources that are available to them in their communities. We all know that GPs are, in most cases, the first point of contact. They deliver 90 per cent of patient care in the NHS. A bit, of course, just receive less than 8 per cent of the NHS budget. However, the group of GPs that we are talking about tonight is a special group in general practice. General practitioners, literally at the deep end in their work in the 100 most deprived communities in Scotland, who, until 2009, had never been convened or consulted by anyone. Of course, let us not forget other hardworking staff in those practices such as our nurses. I welcome the creation of this group by Professor Graham Watt. There are harwing facts out there about the environment that the group of GPs have to work in. They provide care for a population with 20 per cent more mental health problems and co-morbidities than in the least deprived areas, a gap that has widened since 2008. Alcohol-related illness and ramifications of unemployment combine to create an unfolding epidemic, as the Royal College of GPs put it. That is an epidemic that has failed so far, and I do not think that there has been enough progress in tackling that epidemic. Yesterday, the long-term monitoring report of health inequalities revealed that between women in the most and least deprived areas, there is a 22.5-year healthy life expectancy gap, and that is 24.3 years for men. The principle on which the NHS was founded that good healthcare should be available to all, regardless of wealth, has clearly failed to translate into an effective policy. There is a plea for care to be delivered proportionately on the basis of need, as expressed by Professor Graham Watt, is what we should be striving to provide. However, I regret to note that it is opposite of what is actually happening. A constant reduction in GP funding is a percentage of the total NHS budget since 2007, and this year another £21.7 million left the primary and community care services. Next year, the well programme will have seen its funding phased out completely, a programme that targets middle-aged men in the most deprived communities in Scotland get a health check to prevent heart disease and diabetes. That is the two biggest killers in Scotland. Last night, of course, the First Minister made a commitment to increase training places for GPs by 100 new positions. I welcome that, of course. However, the First Minister made no reference to the already understaffing of GP practices in the deep-end areas. The fact is that practices serving the most affluent 20 per cent of the population have twice the number of GP trainees than the least affluent 20 per cent. Unless the Government commits to changing those facts, it will maintain the imbalance and inequality between communities. I believe that members tonight have made a point of that the GPs at the deep-end are calling for exactly that the Government must allocate the right type of amount of support and resources to practitioners, not based on financial ability but based on the needs of the population. The solution for GPs at the deep-end is easy, of course—nobody is saying that they are, but they are there, and we need to enable GPs to achieve them. Thank you very much, Presiding Officer. I thank Patricia Ferguson for taking this debate to the chamber. I have two practices in my constituency. I am not sure if they fall within the deep-end 100 or not, but they serve areas of deprivation in the city of Aberdeen, Woodside and Northfield and Maastricht, which have more than 30 per cent of their patient cohort from the most deprived areas of the city. Much has been said about pressures in relation to GP practices widely and in relation to the deep-end. I have experienced that in my constituency with the announcement by the Bremen Medical Group that they were going to withdraw from the provision of general medical services. The six-month notice period that they had to comply with gave a very tight timescale to put in place a solution and resolve matters. The new dice medical practice, which has opened up in response to that situation, is now in place and is seeing patients. One of the things that I have written to the cabinet secretary about is whether that six-month period needs to be looked at again, particularly in situations where it does arise, to allow health boards and others to have a longer period of time to be put in place the required solutions to service communities with a general practice should that need arise in future. One of the things that is driving some of the decisions by GPs in terms of retirement, and I have had that from a number of GPs in my constituency, is around pension changes and the fact that it has become more beneficial to GPs to take their retirement earlier in order to get a better pension as a result of changes that have been made. I think that that is something that perhaps needs to be looked at as well, but obviously those powers do not sit with this Parliament. One of the other issues that has been raised is about how we attract more young graduates, more young medical students to view general practice as a career option. One of the GPs in Aberdeen, Chris Provan, who leads on general practice for NHS Grampian, is a very good and enthusiastic advocate of the benefits of general practice and the benefits of being a family doctor. That is something that needs to be got out there more. We often hear about the pressures facing general practice and nobody would deny that those pressures exist, but we also have to ensure that the message gets out there, that there are a number of rewards that come from entering general practice. If we do not balance off that message, then we do not sell it as an opportunity for young graduates to move into general practice and we do not do enough to promote it. One of the other things that we need to look at as well is how best we structure health services. The work that the Scottish Government is doing around that is something to be welcomed. I also think that there are examples out there, and the minister has been to my constituency. He has visited the middle field healthy who is a nurse practitioner-led service in the middle field, which is one of the most deprived communities in the city of Aberdeen, which is helping in that area to support the work of the general practice at Northfield and Maastricht by seeing patients, by offering advice and support to patients and, therefore, reducing some of those pressures and also improving the health and wellbeing within the local community. It is also about how we engage organisations from the third sector, and Home Starter, an organisation that I would readily accept, have an important role to play and do play an important role. Home Starter and Aberdeen are currently working with families to encourage, for example, home cooking and healthy eating and demonstrating how that can be done and also how it can be done within limited financial abilities that many deprived communities have. All of those things working together can support the work of general practice but also reduce some of the burden on general practice, because one of the things that we want to ensure is that when an individual sits in front of the GP, they are there because it is the GP that is the most appropriate person to see them, not because they have come to the GP because they feel that is the place they need to go to, and working with other organisations and other health professionals is the answer to this. There are examples out there, and I think that we need to look at those examples and ask ourselves, firstly, can those examples be transplanted into other areas? If the answer is yes, why has it not already happened before now? Good. Thank you so much. I now call on Margaret McAllister to be followed by John McAlpine. Thank you, Presiding Officer. I would also like to congratulate Patricia Ferguson for securing this debate this evening on depend general practices and healthy life expectancy. In bringing this debate to the chamber, she has not only allowed us to delve into issues concerning the health service and health inequalities, but she has also allowed us to put on record our appreciation for the hard work and dedication of all those who work in those practices, serving some of the most deprived and excluded communities in Scotland. As the motion makes clear, patients in the area served by those depend practices will have a lower than average healthy life expectancy. We need to think carefully about how our public services deal with that kind of inequality. How do practices and front-line services cope, and how do we as a society ultimately overcome inequalities in health? I want to draw the chamber's attention to the work of the Socialist Health Association in Scotland, and the report into health inequalities commissioned by my party colleagues. The uncomfortable truth that is documented in that report is that, still today, a boy born to a family from Lindsey can expect to live until he is 82, while a boy born in Calton, just eight miles away, has a life expectancy of 64. The progress that we have made as a nation simply is not enough when poverty and inequality take so many people from us so soon. The life expectancy gap between the righteous and the poorest in our society is a stubborn and stark reality of health inequality in Scotland. It should shame us and it should offend us, but it should also motivate us to close the gap. The inequalities in health and wellbeing, which the people who are served by those depend practices experience, are created and influenced by a number of economic and social factors, insecure employment, family income, housing conditions, a sense of social coherence or lack of it. We cannot tackle health inequalities if we do not reduce the social risk factors that slide behind them. That is as much about education, welfare and housing policy as how our health services are organised and configured. The health and social care alliance are quite right to call for a cross-portfolio response to health inequality. It is a call that I would associate myself with today, and Patricia Ferguson is right to. We will struggle to deliver at the level of service people and communities like Poso Part need and deserve if the burden on general practice keeps on mounting up. I welcome the recent efforts to understand and quantify the additional pressures that deep-end practices face. I accept the consensus view that inequalities rooted in multiple deprivation require a multi-layered response. I am personally interested in the national links worker programme, which some of us have received briefings about, and the work on new models of primary care for communities in the greatest need. I would simply echo the sentiment of the motion before us and suggest that we should do more to understand the financial consequences of health inequalities for our public services. Deep-end practices are in the front line and the struggle against vicious health inequalities, and we must give them our support. I, too, would like to congratulate Patricia Ferguson on securing the debate. We can all sign up to supporting GPs' independent practices, and in particular praise the work of Glasgow University in drawing attention to many of the challenges that they face. However, as a representative of a rural constituency south of Scotland, I do not wish to take anything away from the very concentrated levels of poverty and associated ill health and mortality that dealt with by deep-end practices in particular postcodes in urban areas. However, I would be remiss in my duty to my own constituents if I failed to point out that rural poverty is also a serious problem encountered by GPs there, too. Often, a few GPs in Dumfries and Galloway currently need to replace 19 per cent of the 132 strong GP workforce in the region, and that is in addition to 12 vacancies that exist at the moment. I very much welcome the measures that the Government is taking to address GP shortages such as its plans to increase training places by a third and, of course, the 8 million increase in funding for primary care. Yes, I will. The problem is that there are 20 per cent vacancies currently, so announcing another 100 is not really going to be very helpful. It is very welcome, but if there are 20 per cent vacancies already. John McAlpine? I said to it that we are looking to replace going forward 19 per cent. That is not vacancies at the moment, and that is going forward, and that is referring to Dumfries and Galloway as a whole. However, I know that the Government, and I am sure that the minister will say more about this, is working very closely with GPs. As I am sure that you are aware, the challenges in GP recruitment are very complex. I want to talk today about the motion, specifically about the distribution of funds. Although I said that I do not want to take anything away from the particular challenges that are faced by practices in urban areas, it is really important to talk about poverty that affects all parts of Scotland. Dumfries and Galloway, for example, wages are lower than the Scottish average. The population is older with the health problems that it associates with. One specific thing that I want to address today is fuel poverty, which sits at 45 per cent of all the homes in Dumfries and Galloway. That compares to 36 per cent in Glasgow and 26 per cent for other urban areas such as Renfrewshire. The Economy, Energy and Tourism Committee this morning heard from witnesses at its fuel poverty session that the index of multiple deprivation that many have referred to today does not really accurately reflect or identify some of the types of poverty that exist in rural areas. For example, the committee was told that having access to a car often means that a household scores lower on the deprivation index. In the countryside, a car can often be an absolute lifeline, the only way to get to work. That can result in families experiencing more severe poverty because, in order to run the car, they have to make even more cuts to essentials like food and heating. The committee this morning heard about the role of the GPs and the NHS in providing indicators that identify deprivation in a rural context. With regard to fuel poverty, which has serious health implications, we also heard that quality advice on the ground from people who are trusted is one of the most effective ways to deliver home insulation programmes and other improvements that are offered by the Scottish Government that can lift families out of poverty. Obviously, there is a really important role here for GP practices, particularly GP practices in rural areas suffering very extreme levels of fuel poverty. That is obviously something that, again, I would emphasise that it is not just urban areas that face these very significant challenges. It should be said that, while our witnesses this morning praised the efforts of the Scottish Government, such as the HEAPS programme, to address the fabric of buildings, a key driver of this kind of poverty and indeed all kinds of inequality are outwith the control of the Scottish Government. Several witnesses said that the £350 million tax credits already being felt by families in Scotland was plunging more people into fuel poverty. We need to support everyone who is in need, whether they live in urban and rural areas. We must recognise that GPs in every part of Scotland are dealing with the consequences of inequality, which, of course, are being exacerbated by the welfare reforms over which we have very little control. I congratulate Patricia Ferguson for bringing forward this very important motion that focuses on healthcare in the most deprived general practice populations. The general problems of general practice that we debated on 1 September are highly relevant to that. For example, we know about the recruitment and retention problems. Richard Simpson has reminded us that trading place vacancies are running at 20 per cent, particularly in the west of Scotland. We know that much of that is related to the whole issue of increased workload. Again, in the debate on 1 September, it was described how that was partly related to the shift towards primary care, although not the percentage of resources, unfortunately, towards primary care. Many of us spoke about demographic change as a key factor and more people with complex medical conditions. In that debate, quite often, we focus on complex medical conditions in relation to older people, which is important. However, we are reminded of today that, often, those conditions affect younger people, particularly in the most deprived communities. That is why healthy life expectancy is right up there in the title of the motion today, the years of good health. As Patricia Ferguson reminded us right at the beginning, men and women in the most deprived fifth of the population, healthy life expectancy ends, in fact, 20.8 years earlier for men and 20.4 years earlier for women than in the least deprived fifth of the population. That is perhaps the most shocking and important factor to remember from the debate. However, of course, it is the consequences of that that has been highlighted by Professor Graham Watt and his colleagues in the deep end practices. They have highlighted several aspects of that. Obviously, they have more patients with complex comorbidities. There is a whole issue of unmet need in those communities, but one of the key issues that is highlighted is simply lack of time. He has stated that, since 1948, the NHS has supplied GPs in the same way that bread, butter and eggs were rationed in World War 2. Everybody gets the same. In severely deprived areas, that results in a major mismatch of need and resources without sufficient time to get to the bottom of patients' problems, hence the swimming pool analogy in which GPs at the deep end are treading water. The NHS should be seen at its best when it is needed most. That is the strong message that comes out from the deep end work. There must be funding changes in the health service that shift a higher proportion of resources to primary care in general, but within that health boards have to ensure that the way that they distribute money takes account of deprivation. That is an absolutely fundamental shift that has to take place if we are serious about dealing with the profound problems of health inequalities in Scotland. Of course, doing more in primary care will not solve the problems of health inequalities on its own. We all know about the upstream influences related to life circumstances that are in fact the primary cause of health inequalities. We also accept that there have to be lifestyle initiatives in order to address the problem, but the role of health services is also absolutely crucial. That is why getting more resources into practices where the most deprived is absolutely essential for dealing with health inequalities. Of course, it is not just GPs, and we have to remember the role of other health professionals. I am particularly thinking of nurses here because we had a debate about nursing at the edge where we talked about the particular role of nurses dealing with individuals in the most deprived circumstances. We need to have resources to primary care in those areas that go to the whole primary healthcare team. My final word is here as someone who has been a strong supporter of community health projects for a long, long time. I think that their work—I always mention the Pylton community health projects and my own constituency in this context—should be recognised and valued. However, the general message is that deprived communities in general must receive more resources to deal with the profound health inequalities that are manifested in them. Many thanks. I now call the minister to make the closing speech on behalf of the Government. The minister is seven minutes away, so he is wiped. Thank you very much, Presiding Officer. I begin by joining with others and thanking Patricia Fergson for securing this debate. I want to make it clear that this Government attaches the highest value to Scotland's GPs and the work that they do. In particular, I think that it is appropriate, as Martin McCulloch invited us to do, to place our thanks in particular to those GPs who are working on the deep end practices. I have been able to meet representatives of the deep end practices before. On more than one occasion, I have been hugely impressed by their commitment to their patients. I think that it is well for us to reflect on the fact that many actively choose or have chosen to work in the communities that they serve because that is what they wanted to do. They recognise that they are communities that require support. The Government wants to ensure that local community-based services are delivered by the appropriate range of health and social care professionals working together. More effectively, that comes with a commitment to invest in Scotland. We are spending this year £12 billion on our health services, which some £770 million is invested in general practice. Some members, Patricia Fergson and Richard Simpson, have raised issues around funding for general practice in deprived communities. It is important to place on the record that there is a recognition of the additional needs of patients in areas of deprivation and the calculation of funding to GPs for the provision of core services. That is shown in the waiting given to reflect deprivation. The allocation formula does take out of deprivation. The Government will shortly publish statistics showing off funding to GP practices in Scotland for 2014-15. I would urge members who take an interest in those matters to take a look at the figures in that regard. We will be investing, or recently announced, £60 million to the primary care fund, which was mentioned by Bob Doris, to transform primary care, building on great examples that exist across the country of providing care for patients at or near home rather than in hospital. The fund will also help to address immediate workload and recruitment issues through long-term sustainable change. Dr Milne has suggested that we would all here accept that there are challenges in general practice. There are challenges in general practice. The Government knows that GP workload is increasing, as is the complexity of healthcare and where more is being delivered outside hospital settings resources have not always followed. We understand that GP services in some places are stretched and that, at the same time, communities rightly expect more of their health services. Our plan is to transform our approach to primary care to ensure that, in future, people see the right professionals more quickly. That is why we will continue to work with Scotland's GPs to design that new future. That is why a review of primary care out of our services was commissioned. That is why we need to redesign primary care in a collaborative and inclusive way, transforming and invigorating the workforce, creating new roles and supporting communities to innovate so that services are available where people need them, where people require them. Our challenge is to evolve our health service to best meet the needs of an older population who will often have multiple complex conditions, while ensuring that we drive down health inequalities found in our most deprived communities. There was some focus, understandably, on the situation at the Balmor practice in the north of Glasgow, with both Patricia Ferguson and Bob Doris. In particular, the issue should be acknowledged that Greater Glasgow and Clyde Health Board have already begun to address the issues that have been raised in order to ensure that the practice in Balmor is sustainable over the medium and longer term. I will be expecting them to engage closely with GPs and local communities as they begin to develop sustainable future-proof primary care services. Indeed, Mr Doris mentioned the fact that he has written to the Cabinet Secretary for Health, Well-being and Sport, and in her reply to him that she was clear that she will use every avenue to encourage the board to work closely with the GPs in the Balmor practice to address the issues that she has highlighted and ensure that, when she meets the Cabinet Secretary, Mr Doris will be able to raise the issues that he has brought forward in the context of this debate. Overall, health in Scotland is improving and people are living longer, healthier lives, reducing the health gap between people in Scotland's most deprived and affluent communities. That is, of course, one of our greatest challenges at the root of the issue, and that was alluded to by members taking part in the debate as an issue of income. Inequality, we recognise that this problem cannot be solved with health solutions alone. As Joan McAlpine and Mark McDonald mentioned, the UK Government's welfare reform programme presents the most immediate threat to health inequalities in our action. To tackle health inequalities, of course, the Government has responded and will continue to respond to mitigate the worst effects of welfare reform wherever we can, but we also need to look, as I have alluded to, to the further support that we can provide to practices at the deep end, as Dr Simpson mentioned. The Scottish Government has provided consistent financial support for the deep end project via locum-funded meetings and conferences, and support for other projects in the deep end, one of which Dr Simpson and Dr Miller and Mark McCulloch also mentioned the series of deep end projects leading to the establishment of the five-year link workers programme. I understand the desire to see that rolled out further. Of course, it is right that we assess its full efficacy and seek to learn from that programme. Members can be assured that we will do that, and we will continue to support other innovative projects in the deep end practices. We know that we need to continue to innovate and look at the future of primary care. We know that one size does not fit all that. That is why we wish to test and seek to use new models of care, including those that might be delivered by multidisciplinary teams in a community hub type arrangement. There are good models out there. I was very delighted to join my friend Mark Macdonald in the visit to Middlefield, the healthy poos, which was a very impressive arrangement. We need to see professional collaborating across the boundaries of primary and secondary care. Does all that have time? Yes, of course. I think that we would all recognise that this is not a problem just for GPs. It needs the kind of multifaceted approach that Mark Macdonald described. However, the problem is that, if you look at Balmor practice, for example, it already has a pharmacist, it has already applied additional nursing staff, it has already got links with the financial inclusion service, it has signed up to a new alcohol initiative and it now has a drop-in clinic on a Monday to sweep up those people who have not seen GPs over the weekend. However, it is still at breaking point and one and a half sessions per week for eight weeks and a review team is not really going to get them over the hurdle. They need a bit more help than that. What I have put on record quite clearly is that this is a priority area for the Government in terms of general practice, generally reforming it and making sure that it is fit going forward with respect to Balmor practice specifically. This is something that the Cabinet Secretary is aware of, is a matter ultimately for the health board, but we are clear as an administration. We expect the health board to engage positively with the GPs at Balmor and indeed the wider community to ensure that it has a sustainable future. Let me come to close. I think that it is important that we do what we can to talk up Scotland's general practice to encourage more doctors to stay within the profession. Of course, we had the First Minister's announcement just the other day and also we need to try to ensure that medical students choose their career in general practice because it is one that deserves to be admired and respected. That is particularly true in Scotland's most deprived communities. There are challenges before us in primary care, but members here and the wider public across Scotland can be absolutely assured that this Government is determined to meet those challenges going forward. Thank you very much and thank you all for taking part in this important debate. I close this meeting up on one.