 The next item is a statement by Gene Freeman on St John's paediatrics services update, and the cabinet secretary will take questions as usual following my friend. I would encourage all members who wish to ask a question to press their request to speak button as soon as possible. I call on the cabinet secretary, Gene Freeman. I am grateful for the opportunity to update members on progress that is made on the provision of paediatric services at St John's hospital in Livingston. I want to begin by recognising the excellence and dedication of the staff who work there to care for and serve patients and families in the surrounding communities, the support that the service has from local parents and by emphasising my commitment to the hospital and its paediatric services. When I came to Parliament to update members last September, I gave a commitment that I would return in January to provide a further update. I informed members that I had asked the director general for health and social care and the chief medical officer for Scotland to review progress by the end of January this year. I also asked the chief nursing officer for Scotland to liaise with NHS Lothian and provide advice and support on the training and development of advanced nurse practitioners. I would like to record my gratitude to them for their support and their professional input. I will not rehearse again, Presiding Officer, the detail of why the interim service model has been implemented beyond one important point—that the decision was taken by NHS Lothian in the best interests of children and their families in the circumstances of that time. Within this interim model, the majority of children's services have been maintained at St John's. The children's ward is open from 8am to 8pm seven days a week, providing a short stay paediatric assessment service, with the paediatric ward remaining open for day surgery activity, as well as planned day case procedures and programmed investigations. The paediatric outpatient services, neonatal services and community child health services have all been unaffected. The assessment unit has seen around 3,560 children since July 2017, and there have been over 2,555 planned investigation unit attendancies. The emergency department continues to see more than 11,000 attendancies each year, and outpatient clinics have seen more than 4,000 new and reviewed patients. The board has evolved the interim model since it was first implemented, and that has seen a drop in the number of children who have been transferred but not admitted to the Royal hospital for sick children in Edinburgh. When the interim model was introduced in July 2017, the average figure was 12 children a month. Since March 2018, the average has been four, reflecting more confident triaging of patients. Additionally, although the original plan was for children to be redirected to the Royal hospital for sick children at weekends, the board has maintained a daytime weekend rotor on all but three weekends from July 2017 to date. A wide range of children's services continue to be available at St John's and the vast majority of children who require services locally receive them at St John's. However, I am acutely aware of how important the reinstatement of the full inpatient service is to the local community. I met a group of parents and misconstants on 29 November last year, where I heard first hand about their personal experiences at St John's and of the excellent care that their children received in the inpatient unit. I heard of the dedication of staff to the service and of their willingness to go above and beyond to provide care for the local population. I am grateful to all parents who attended for their openness and I understand the anxiety and share the concern felt by members and the local community to have the service fully reinstated. The Royal College follow-up report to the board in 2017 reiterated that its preferred option remained a 24-hour model, reflecting the population projections for West Lothian. In turn, the board has confirmed its absolute commitment to the reinstatement of the 24-7 model through discussions with Paul Gray, Dr Calderwood and Professor McQueen. The board has continued to work to develop and deliver that 24-7 service but one that is safe and sustainable. That requires a staffing rotor that ensures resilience to sick leave and any other short notice reductions in staff availability. It requires that the majority of shifts be filled by permanent staff so that rotas can be planned for six-month periods, and it requires a model that equates to having two tiers of trained staff to look after the children of West Lothian overnight that is consultant pediatricians supported by a second full rotor of other medical and nursing staff. The NHS Lothian paediatric programme board met on 9 January, when two interim options to enhance paediatric service provision were considered. The options were to reopen the inpatient ward for four nights a week, Monday to Friday, or to extend the opening hours of the short stay unit to 10 o'clock or midnight, seven nights a week. The programme board undertook assessments of both options in the context of the full 24-7 service reopening in October this year, meaning that those interim options would be required for no more than six to seven months. What emerged from the assessments was a clear preference for the reopening of the 24-hour inpatient service Monday to Thursday from 18 March. On the remaining three days, Friday to Sunday, the assessment unit will continue to be open from 8 am to 8 pm. That is achievable because of improved medical and nursing staff numbers. From a nursing position, the ward will be fully staffed overnight for four nights a week, Monday to Thursday, with a paediatric nurse in the emergency department for the remaining three nights Friday to Sunday, as is the current arrangement. NHS Lothian currently has three advanced paediatric nurse practitioners in post. Two are already contributing to the out-of-hours rotor, and one is expected to contribute to the rotor from March. That is an improvement on the position in September when only one advanced paediatric nurse practitioner was supporting the rotor. Of the three additional APNPs recruited last year, two will be ready to contribute to the rotor from October, and another will be available in 2020. NHS Lothian expects that the improved staffing position will support their commitment to reopening the inpatient unit fully in October 2019. The programme board felt that the reopening of the unit four nights a week would significantly enhance the service delivered at St John's through a reduction in transfers to the Royal hospital for sick children. Over the past 18 months, an average of 1.6 children a day have been transferred from St John's to the RHSC. The board would expect most of those children to be admitted to the St John's unit over the four nights that are open. There are, in addition, an average of four children who are transferred to the RHSC but not admitted, and the board expects that most of those children would stay at St John's. The board will monitor the arrangements and keep activity under review. It has also felt that the four-night interim arrangement would improve further recruitment efforts as it demonstrates the board's commitment to fully reinstate the 24-7 inpatient service from October. The board will go back out to recruitment for the two consultant posts that were not filled after their efforts in the autumn of last year. Advanced nurse practitioner posts will also continue to be advertised. NHS Lothian remains committed to where possible over recruit to both areas in order to build resilience and to mitigate the risks associated with the impact of sickness or any other absences or long-term leave. I know that members and the local community are anxious to know when the full 24-7 service will be reinstated, and I understand that. I believe that the board's decision to reopen the paediatric ward for 24 hours for nights Monday to Thursday is welcome, and I hope that it provides assurance to members and families that the full reinstatement of the inpatient service is on track to happen in October. The board's chief executive has sought to assure me that reinstatement of the full 24-7 paediatric service has the full commitment of the board and will continue to receive the highest level of priority. As I said in September, that too is and remains my commitment. We will continue to act, as we have done, to provide assistance and support to the board, monitor progress and work towards that delivery of 24-7 paediatric inpatient services at St John's from October this year. That remains my commitment and I hope that members see the progress to date as further assurance of that. Thank you, cabinet secretary. I encourage all members who wish to ask a question to press their request to speak buttons and a Colin Wiles Briggs. I thank the cabinet secretary for advanced sight of her statement today. The downgrading that we have been discussing specifically for families in Livingston is key, because we have now seen on three separate occasions in 2012, 2015 and 2017 services removed, and local families across West Lothian will rightly be cynical about their latest SMP promises. The main staffing concerns that are outlined in your statement point towards the summer months, which are traditionally very difficult to staff. Can I ask whether those steps on recruitment will be sustainable, because that will only be clear from your statement in the summer of 2020? How will the cabinet secretary guarantee that those proposals are sustainable going forward? Thank you to Mr Briggs for his response and for that question. Can I make it absolutely clear that we are not talking about promises here, we are talking about an absolute commitment, and since September I have done exactly what I said I would do, and that is to look to improve the existing service on the road towards full 24-7 opening. We are on track and I have returned to this chamber to report on that. I am disappointed that it is not particularly welcomed from those benches over here. How will I guarantee that it is sustainable and that it remains on track? I will do that with the professional judgment and the guidance of the Royal College and of that Pediatric Program Board, who themselves are committed to ensuring that there is a sustainable service. It would have been all too easy to come here with quick fixes in September, but quick fixes were not sustainable. There is no point in making promises to the parents that I met or to any other parents in West Lothian that I am not convinced that I can keep. I have kept them so far and I intend to keep them right through until October and beyond. Monica Lennon I also thank the cabinet secretary for advance sight of her statement. Anything that increases provision at St John's providing it is safe is absolutely welcome. It does still fall short of the 24-hour consultant-led pediatric care that the Royal College of Pediatrics and Child Health is needed. We know that more than 1,000 children have been transferred to Edinburgh since the out-of-hours closure in 2017, with all the extra stress and expense that that brings to our families. Does the cabinet secretary and the health board have any estimates of how many more children will have to be transferred between now and October? Although it is absolutely welcome that the cabinet secretary's commitment that the reinstatement of the 24-7 service is of her highest priority, she will accept that families have been let down by assurances before. Can I ask what contingency plans are in place at the 24-7 care, which is so badly needed, is not in place come October? I am grateful to Ms Lennon for her comments and for her welcome of the progress that we have made. I agree with her. We are not yet at the full 24-7 provision and I completely understand that that is not only what is required, but what parents have told me very clearly is what they want and rightly so. It is difficult to estimate exactly what difference that four-day 24-hour opening will make, because, as I am sure you will appreciate, cases come in and you cannot and they are not all the same. The board's expectation is that there will be a significant reduction over those four days in the number—in fact, no children unless they are very sick children—who would, in the full course of it, being open 24-7 would, in those circumstances, always be transferred to the hospital for sick children in Edinburgh. It estimates that very few cases are being admitted in that period who require the short stay, which is what the full pediatric service offered prior to the reduction that we have seen, that none of those children would need to be transferred. Children who require longer than 24 hours or are very sick and the longer than 24 hours would take them beyond the Thursday may have to be transferred to the sick kids in Edinburgh, but that will be on a case-by-case basis, obviously, and it is a clinical decision. The previous model was, by and large, children who require 24-hours admission and, obviously, for those four nights that would be open to them from March. On the point about what is the contingency plan, I intend, with the support of the director general and chief executive of NHS Scotland and our chief medical officer and chief nursing officer, to keep on track with the next step of progress, both when the unit moves to greater opening from 18 March and then the further steps in terms of recruitment and advanced pediatric nurse practitioner engagement all the way through to ensure, month by month, that we are making the progress that we need towards October. If it looks to me at any point that that is not likely to happen, and at this stage, remember that we have the pediatric boards assurance that they can make the October date, and we have the royal colleges support for the option appraisal and the work that they are doing, but if at any stage advice comes to me that suggests that that may not be possible, then you have my assurance that I would act quickly to try and see if there are ways that we can get it back on track and you have my assurance, of course, that I would keep his chamber advised of that. The cabinet secretary, I know, appreciates the extra travel, the stress and the expense that has been caused to families who have been required to travel to the sick children. I am pleased that we are seeing some progress, but I am sure that none of us are satisfied as yet, including the cabinet secretary herself. I would like to know if the hard-learned lessons of St John's will help to inform the legislation that is currently going through Parliament with regards to health care in Scotland. Does the cabinet secretary consider that over recruitment should become the norm so that we are never in a position like this again? I am grateful to Ms Johnson for her comments. Of course, the experience that St John's, as elsewhere in our health service, all goes to inform the propositions that we have put in terms of the draft legislation before Parliament, before the committee and the amendments that we have brought in our position on those other amendments. Of course, St John's is part of that mix. In terms of over recruitment, over recruitment works where a board understands and can demonstrate that, if they are over recruited in one area, they can nonetheless make good use of those skills and expertise elsewhere and that they have a sustainable model that takes account not only of planned events such as holidays but also unplanned events such as sickness and long-term leave. Over recruitment is not particularly new in the St John's case. It is used elsewhere in our health service. In terms of our overall discussions with chief executives of health boards, directors of nursing, medical directors and others, it remains a feature of those discussions to ensure that, where it is appropriate, it is the approach that a board adopts. I welcome today's statement and assure the cabinet secretary of the full support of those benches in seeing that service re-established to 247 coverage. The cabinet secretary referenced the fact that there has been a drop-off in the number of cases referred to the sick kids, something like 12 to 4 per week. Does she share my anxiety that it may be symptomatic of an understanding that the service does not exist in St John's to sustain children in this way, so people are going straight to the sick kids and as such is not a reflection of demand on the service. Secondly, if re-establishing the service is a 247 provision hinges on the appointment of trained APNs or two or three trained APNs, given that the margins are so tight, will that be impacted by staff sickness and absence? In that event, are there banks or locums that can be drawn down upon to relieve the pressure? I am grateful to Mr Cole-Hamilton for his question. I have no evidence that the drop-off in the transfer from St John's to Edinburgh is a result of anyone going straight to St John's, but it is the result of, as I said, a more confident triaging of patients at St John's as people understand better what they are there to do in terms of the particular services that they can offer within the restricted hours that it is currently operating in. That, of course, will translate itself now into that longer operational period for the children's ward at St John's. In terms of tight margins, that is actually the point about why we had to do the work to get to this point in order to be able to open 24 hours over those four nights, but no longer at this point. That is precisely to ensure that what we have is a sustainable model, and a sustainable model is one that is built on taking account not only of rotas and planned leave and planned holidays but, as far as it is possible to do this, based on the evidence that you have overall in terms of how your staff numbers work out, unexpected periods of—inevitably unexpected periods of sickness and periods where sick leave is lengthy. At the moment, what the board with our support has done and the paediatric board is in line with how the Royal College wanted us to progress towards, as Ms Lennon said quite rightly, their support for our 24-7 model. All of that is in line with that progression to ensure that we have that sustainable model. When we open for those four nights in the week, we do not have to close it because somebody goes off sick. That is partly how the model is being built. It is also what sits behind the proposition that the board has been delivering on as we described it over recruit. Angela Constance, to be followed by Gordon Lindhurst. Thank you, Presiding Officer. As the constituency MSP, I can indeed say that this is a very positive stride forward. It is not the final destination but good progress nonetheless that will be welcomed by West Lothian parents of school-aged children, including those in this chamber and, indeed, in the public gallery. However, what parents will want to know, particularly those that Ms Freeman has met and who have led a very positive campaign, and what they will want to know in detail is how the cabinet secretary and her team will continue to ensure that NHS Lothian do not rest, do not black slide and do not take their foot off the gas until our much-loved first class children's ward returns to a 24-7 service, given that it is not just the preferred option of the wider West Lothian community but also, crucially, the Royal College of Pediatricians and Maternal Health. I am grateful to Ms Constance for her support and for her comments, and I take this opportunity personally to welcome any parents from West Lothian who may be in the gallery and who I may have already met. As I have already said, the questions that Ms Constance raises are, of course, very pertinent ones, because that is in what everyone's minds and entirely understandably so. As I have already said, we will continue to act, as we have done, to provide assistance and support to the board, to monitor progress very closely and work towards that delivery of 24-7 paediatric inpatient services at St John's from October this week. The involvement that we have had and will continue to have with the board and the chair of the paediatric programme board, and with our director general for health and social care, and with the chief medical officer and the chief nursing officer since September last year, will continue. It has proved to be very helpful and it will continue right through. I have asked Dr Calderwood and Professor McQueen to maintain that involvement, to keep me regularly briefed on progress, to alert me. If at any point it looks like we may be going off track, so that I can be personally assured that we are putting in place all the steps that we know now need to be put in place in order to return from October this year to that full inpatient service at St John's. Gordon Lindhurst will be followed by Gordon MacDonald. Is the cabinet secretary able to tell us what effect partial closure has had on the ambulance service and has any assessment been made on ambulance response times and costs to the service? I am grateful to Mr Lindhurst for that question. I should say, just in response to that, that the ambulance service has been consulted on this proposed improvement and that is supportive of that. There has been, as I think we mentioned in September, additional payment made by NHS Lothian to the ambulance service to cover any additional costs that it had to meet in the period and where that continues through to October. That will continue to be met by NHS Lothian. The ambulance service, along with other referring services, will be notified well in advance of that 18 March date so that it can ensure that its staff are briefed and know where they should be taking patients, as parents and staff at St John's will themselves be briefed well in advance of that date. On ambulance response times, from the data that I have seen overall of ambulance response times, I have not identified any dip in response times that may be attributed to St John's. I am perfectly happy if it would be helpful to Mr Lindhurst to look further into that specific area of data and advise him of my conclusions from that in due course. Gordon MacDonald, to be followed by Kezia Dugdale. I welcome the commitment that the full reinstatement of the 24-7 paediatric service from October is receiving the highest level of priority. However, will the cabinet secretary detail how she will scrutinise and support the work of the paediatric programme board? I am grateful to Mr MacDonald for that. I understand from members their concern to make sure that, while progress has been made, nobody takes their foot off the pedal. In addition to my consciousness of members' concern, I am very conscious that parents of West Lothian will be scrutinising to make sure that we deliver on the final part of the commitment that I have made. As I said, I have asked Professor McQueen, Dr Calderwood and the DG for health and social care, chief executive of NHS Scotland, to continue their active involvement. It has been active involvement. It has not been arm's length or distant. It is active involvement with the programme board, with NHS Lothian's chief executive. We have made sure that, at that senior level in NHS Lothian, there is proactive interest in how those matters progress. All of that will be reported regularly to me with, as I said before, the commitment that I have made, that if at any point it appears to me that it looks to be going off track, then I will take steps to intervene as far as I am able to bring it back on track, but also to ensure that members of the chamber are kept up-to-date with our progress. Thank you, Presiding Officer. This is welcome news in West Lothian and, indeed, for any family with children that have ever required hospital attention. The cabinet secretary will be aware, though, that there will be a degree of scepticism about the announcement, given that the hospital has opened and closed three times since 2012. In that context, can I ask for her assurance that there will be a 24-hour paediatric service at St John's hospital for as long as she is health secretary? The final part is still going to be off a wee bit for as long as I was a health secretary. I am grateful to you for your question and for your support. You have my assurance of that. I made that commitment in September. I fully support a 24-7 in-patient paediatric service at St John's. I understand that that is needed now, that in terms of the oncology's work, the need for that is absolutely reaffirmed by the expansion in the number of families, welcomed families who are now moving into and will continue, I hope, to move into West Lothian and benefit from that area's significant advantages and a good standard of living. Therefore, I said in September that I would work with all those individuals that I have set out. I would bring in that chief medical officer, professionalism and experience, the chief nursing officer, director general. We would work with the paediatric programme board. We would work to the oncology's commitments. We have done so in order to reach a next step towards that full 24-7 opening in October. That is my commitment. It remains that, and for as long as I am health secretary, I will continue to want and to work towards sustaining a full 24-7 paediatric in-patient service at St John's. Emma Harper is to be followed by Brian Whittle. The cabinet secretary has been very definitive in her response to Miles Briggs about sustainability of the service. Can I just again clarify whether the board has sought to provide the cabinet secretary with assurances that the current staff and model will be implemented at St John's paediatric ward, will create a sustainable solution to ensure patient safety and will avoid any future disruptions to children's services? I am grateful to Ms Harper. Ms Harper probably knows better than just about any of the rest of us in this chamber about the importance of a sustainable rotor in our health service that takes account of all the issues that I have already set out in my answer. I am sure that she agrees with me about the significant value of advanced paediatric nurse practitioners and advanced nurse practitioners as a whole across our health service. That is why we worked in September to recruit additional advanced nurse practitioners to begin to bring them into the rotor. As we said, you will know that it takes a period of time to do that. We have now reached a stage where, with their engagement and with the other consultant and medical provision engagement that we already have, the rotor is sustainable for that four-night 24-7 opening of the inpatient ward at St John's. The next step is to continue to look to recruit two more consultants to continue with the additional recruitment of advanced paediatric nurse practitioners to bring those who are currently going through that training into the rotor at the point where they are clinically safe to do so. All of that work through takes us to a point where we can say that it will be 24-7 opening of that inpatient service from October. Brian Whittle to be followed by David Torrance. I ask the cabinet secretary how she will ensure that adequate resources will be made available to St John's to make sure that this crucial service overcomes the pressure on the staff that caused the initial restrictions in the first place. In truth, my understanding is that there was not a resource issue in the terms of pound notes that led to the situation that we are now working so hard to resolve and to ensure that it is sustainable going forward. It was a staffing issue and, yes, there is obviously a connection there in terms of resources, but the resources are clearly there in NHS Lothian and will be there in 1920, depending, of course, on what this Parliament does with our current draft budget in order to deliver on those commitments. I do not come to this chamber making commitments that I do not believe that I have the resource to deliver. Depending, as I said, on what happens with our draft budget in due course, I have the resources to deliver, NHS Lothian will have the resources to deliver and, consequently, St John's will have the resources to deliver. David Torrance to be followed by Mary Fee. Does the cabinet secretary share my concern that the end of free movement of people following Brexit would be harmful to future recruitment drives for clinical staff across health boards in Scotland? I share my concern. I will give Mr Torrance and the chamber the benefit of a couple of quotes from more than me, those who work and represent people in our health service. BMA council chair said that the only thing that is certain is how disastrous leaving the EU will be for the NHS, its workforce, its patients and the health of the country. Donna Kinair from the Royal College of Nursing said that our healthcare system is fast losing its most important asset, its staff. We already know that staff are leaving our health service, who are EU nationals. We also know from memory that 78 per cent of EU nationals who are doctors in the United Kingdom, who were asked, said that they found the UK Government's assurances deeply unconvincing, and just over 35 per cent of them planned to leave. Those are serious problems and serious matters that we have to try to address in how we take forward our health service, but more importantly, how we take forward our country. Mary Fee to be followed by Colin Beattie. The cabinet secretary has said that there are plans to recruit two new consultant posts, which were unfilled at a recruitment round last year. What additional steps are the board taking to fill those posts? Does the cabinet secretary have confidence that the posts will be filled before the service opens in October, and what impact will not filling the posts have on the service? The board is going out again to advertise for those posts. The board believes—indeed, it was a point made to me by the parents that I met—that the more we can do to improve the provision of pediatric inpatient services in St John's, the more attractive that becomes in terms of people looking to apply and to being recruited. We are hopeful that the next step that I have announced will assist in that recruitment exercise, along with our absolute commitments that we have restated. The move to the four-night opening makes good on those commitments. It will encourage individuals to think seriously about coming to work in what is an excellent hospital, providing very high-quality care. The board will go back out to advertisement and seek to recruit in those posts. In anticipation that there was a post to difficulty in the autumn recruitment where the two posts were not filled, the board looked to—with the paediatric programme board and the support of the Royal College—to realign what its model might look like. That has resulted in some of the additional advanced paediatric nurse practitioner recruitment that I spoke about in my statement. We continue to look for those two consultant posts. They are important for the consultant rotor, but in terms of going to the full 24-7 model, the additional steps that I set out in my statement, including the additional advanced nurse practitioner roles above what I said in September, helps to take us towards that sustainable model. Colin Beattie The cabinet secretary has outlined some of the challenges that are being faced in recruiting staff at present. Can she outline how NHS Lothian figures today compare with staffing figures in 2007? Thank you to Mr Beattie for that. In terms of NHS Lothian, since 2007, consultant numbers have risen by 54 per cent, emergency medicine consultants have risen by 252.7 per cent, qualified nurses and midwives up by 9.6 per cent and allied health professionals up by 18.8 per cent. Overall, staff numbers in NHS Lothian have gone up in total across all of those by 14.8 per cent. We continue to seek to recruit in order to deliver the quality service that families in West Lothian and elsewhere across Scotland deserve to have. Thank you very much, and that concludes our statement on St John's paediatric services. We are going to move on to the next item of business, which is a debate on motion 15609 in the name of Christina McKelvey on a Connected Scotland, the Scottish Government's strategy for tackling social isolation and loneliness. I invite all members who wish to contribute in this debate to press their request to speak buttons as soon as possible. Thank you very much.