 I choose the meeting to order. I welcome everyone to the 9th meeting of the Public Petitions Committee in 2019. Before we commence, I want to welcome Lynn Russell as our new clerk and to wish Sarah Robertson every good wish and her new post in the environment committee, as the clerk's Public Petitions Committee over the last period. We have one item in the agenda this morning, which is the consideration of three continued petitions. The first petition is petition 1698 on medical care and rural areas lodged by Karen Murphy, Jane Rental, David Wilkie, Louisa Rogers and Jennifer Jane Lee. I welcome Rhoda Grant MSP for this agenda item. Having received submissions from the Scottish Government, Scottish Rural Action and the petitioner, there remains a number of issues that require further scrutiny, including the Rural GP Association of Scotland's resignation from the Remote and Rural Working Group, the calculation of the Scottish workload allocation formula and the implication of the new GP contract in rural parts of Scotland. At our previous consideration of this petition on 4 April 2019, we agreed to invite the Cabinet Secretary for Health and Sport to provide evidence on the matters raised and the submission that we received to date. I welcome today Janet Freeman. The Cabinet Secretary is accompanied by Sir Lewis Ritchie, chair of the Remote and Rural Working Group and Richard Foggo, director of population health from the Scottish Government. I thank you all for attending this morning and I invite the Cabinet Secretary to provide a brief opening statement after which we will move to questions. Thank you very much, convener and members. I thank you for the invitation to be here today. Let me begin by thanking the petitioners for bringing this important issue to the Parliament. The services that they and indeed we are talking about are critical to the communities served. The focus of the petition is on two main issues, first, the new GP contract and its impact on rural general practice, and secondly, Sir Lewis Ritchie's short life working group. I want to make brief remarks on both of those issues. The new GP contract negotiated with the BMA is Scotland's first standalone contract and has been in place for one year now. In that time, I know that some fundamental questions have been raised about whether the new contract values rural general practice and whether it ultimately threatens rural general practice. It is important that I state very clearly at the outset that we value rural general practice and I do not believe that it is threatened by the new GP contract. Of course rural general practice faces challenges, some of which are shared like recruitment and retention with practices in more urban areas and some of which are unique, not least the remote geography and what that implies for GP practice. However, the new contract does not cause those challenges but is expressly designed to address them. The new contract does two things. First, it seeks to develop a new role for the GP as the clinical leaders in the community that they serve, leading enhanced more integrated teams to ensure that we continue to deliver the right care for patients at the right time. Secondly, it responds to the serious challenges identified by the GP profession of both increasing workload and risk, in particular the risk of owning property and employing staff. On both these points, I believe that all GPs, whether urban or rural, can see real benefits from the new contract. The low role of clinical leader in the community, the expert medical generalist, is a role already fulfilled by many rural GPs. In that sense, the contract is intended to enhance and not diminish rural general practice and recognise the work that they do. The issues are whether the measures that we are taking to reduce workload and financial risk, which include a new workload formula and bigger teams employed by health boards diminish that role. I am absolutely clear that the GP contract and the associated primary care improvement plans have to allow for flexibility to suit local circumstances, in particular in rural communities. I want to stress that there have been no changes to the GP contract in relation to services such as vaccinations. In a rural GP practice, if a rural GP practice wishes to continue to deliver vaccinations or other services set out in primary care improvement plans, then it can do so, and GP practices continue to be paid to deliver the service. We are also offering the opportunity to GPs to benefit from support from health boards if that improves outcomes for patients. While flexibility is important, I also believe that it is wrong to suggest that a team-based approach does not suit rural communities. So, for example, in Western Isles an integrated approach to vaccinations means uptake of flu vaccine among primary school pupils has increased from 67 per cent to 74 per cent since being transferred from GPs to school nursing teams. We have heard a number of concerns about the Scottish workload formula, which is a substantial component in determining the level of funding a GP practice receives. First, it continues to be said that rural practices have lost funding due to the new contract. That is categorically not the case. We invested £23 million to ensure that no practice loses funding. In addition, we have increased the overall value of the GP contract by £23.7 million, an increase of 3.46 per cent, which rural practices also benefit from. Secondly, it is said that because we are having to protect the funding of rural general practice, we do not value it. However, my point would be that you protect what you value. I know that there is concern that protection might be removed at any point, so rural general practice has been more fragile. Funding protection has been a feature of the GP contract since 2004. It was not an issue with the previous contract, and I do not believe that it should be an issue now. I cannot envisage a situation in which a Government of any political persuasion would remove this and thereby threaten rural general practice. The NHS depends on quality general practice. Finally, it is claimed that, while the new formula better captures the variation in GP workload, it does not include the effect of geography on costs and so does not reflect the reality of rural general practice. However, the funding steps that I have outlined mean that this change to the formula does not impact on the funding that practices receive. Transparency is key to understanding the effect of geography on the cost of providing primary care services and the actual cost of running a GP practice, be it in an urban or rural setting. As part of the contract that we have agreed with the BMA, all practices will provide income and expenses data. That will significantly improve our understanding of the cost of delivering services across Scotland, including in our rural communities. Development the Parliament has explicitly welcomed. Once we have that information, we will be in a better position to refine the formula as necessary in the course of action that we will take into phase 2 of the GP contract. We recognise GPs in remote and rural communities, work hard in exceptional circumstances, and I would like to assure the committee that the fundamental aim of the working group, which Sir Lewis chairs, is to ensure that rural GP voices are heard and to bring about agreed actions on strengthening the implementation of the contract in remote and rural areas. The contract also impacts on patients and the wider primary care team, so there is both patient and multidisciplinary professional representation. Since its inception, it is fair to say that Sir Lewis has worked tirelessly towards building collaborative and trusting relationships, and I know that he will be happy to answer any questions that the committee may have. It has, with its team, travelled extensively across Scotland, engaging with GPs, health boards, colleagues and rural communities to hear their views. I am very grateful to him for joining us this morning in order to deal with any issues directly that you may have. There have been concerns, but because the representative of the rural GP Association of Scotland has resigned that rural GPs are not represented on the group. Although we sincerely hope that RGPASS sends another representative, I want to assure the committee that there are a number of rural GPs on the group and that the rural GP voice is being heard while discussions continue in order to resolve the issue with RGPASS and, I hope, see them return to the committee. We are taking a truly transformational approach with the new GP contract. Our aim is not only to preserve general practice, as the cornerstone of our health service in Scotland, but to ensure that it flourishes and strengthens. I believe that achieving that is possible by taking professionals and patients with us, building relationships and directly recognising that one size does not fit all. As with everything worth doing, there is always room for improvement. We remain open to looking at how, in the immediate term, but also in the second phase of the GP contract and the negotiations around that, some of the issues that people remain concerned about can be considered fully and steps taken to resolve them. Finally, I am grateful to the petitioners for taking the time to ask the questions, to challenge constructively and to allow me, at least in this part, to explain our intentions behind the contract. Before I go on to my substance of the question, I want to ask what island proofing and rural proofing was done on the offer before the negotiations started? I asked Mr Fogle who led the negotiations for us to answer that. There were two phases to the proofing, which happened before the more recent requirements around statutory island proofing. The early stages of policy development, we engaged through a series of roadshows and engagements around Scotland on the broad policy intentions. I am looking more at what kind of process, as opposed to conversations that you had, given that there is a statutory responsibility now to do island proofing, but from that I think that people would accept their rural proofing. What was done to test the offer before you even took it to a place to consult on it? That was the second phase. Once the policy propositions were worked up, that went into the negotiating space, which was supported by evidence gathered through various reviews in relation to the formula. There was significant expert advice taken to turn the policy propositions into the contract propositions. When we look at the paperwork, presumably we can see that those are the propositions. That is what it will mean in an urban setting. That is what it will mean in a rural setting. That is what might happen in an island setting. That is all laid out before you go into negotiations. The policy propositions are subject to a quality impact assessment, which includes an assessment of the impact on rural communities. Explain why the evidence that we have received is that this settlement means moving resource, or greater resource, of what is now available. Let me put this a different way. Urban areas do better out of the contract than rural areas and better off areas within urban areas do better than poor areas. How could that possibly be if there was an equality impact assessment and a policy before you went into negotiations? It is worth saying just how complex the GP contract is and just how many considerations have to be balanced. As the cabinet secretary said, the BMA acknowledged that a lot of those required judgment calls in balancing a number of different competing factors. I should say two things. One is that no issue was specifically discussed more thematically in the negotiations than the impact on rural communities. Secondly, we were in a position where looking at all the different issues that we had to consider, we were absolutely clear that some of the fundamental propositions, in particular protecting income, were critical to ensure, for instance, that there was no loss to rural communities. Protecting income is not the same as enhancing income. Do you accept that the consequence of the contract of the funds that are available disproportionately go to urban rather than rural areas and within that disproportionately to more prosperous areas than poor areas in urban settings? I think that there is a difference between two things. One is that our explicit intention to frame the negotiations and the outputs in that way, and the answer to that is absolutely not. There was no explicit judgment. The formula element in particular does balance and rebalances based on objective evidence in relation to deprivation and age, which reflects an objective assessment of the impact of an ageing population and inequality in the Scottish population. That has a particular set of impacts in terms of urban and rural communities, but we came at it through the demographics, not through the nature of the communities impacted. You and I wouldn't be so hard-hearted to suggest that you would willfully want to spend money on better off people than poorer people, but the evidence would suggest that that has been the consequence. If an equality impact assessment stroke, rural proofing had been done, that would have been evident. Are you saying that that was a trade-off? It was an acceptable trade-off that the consequence is that deep-end surgeries in places like Glasgow would do less well than better off surgeries and that rural areas do less well than urban areas? If the starting principle was that income needed to be protected, the question is if we applied the formula without that protection and then I think your questions would be absolutely valid. You don't accept the evidence that we've been given that the disproportionate benefit goes from poorer to better off and from rural to urban. You don't accept that. I want to ask about the letters from the Rural GP Association of Scotland, which was submitted to us. It was sent to the rural short-life working group announcing the resignation from this working group. I'm sure that you'll agree that that's a serious matter. In connection with this matter, during the general questions on 4 April 2019, the cabinet secretary stated that, Salinas Ritchie has acknowledged the concerns raised by RGPS members and has agreed to hold further discussions in due course towards their continuing involvement in implementing the contract in our remote and rural communities. Can I confirm first that that working group cannot change the contract offer? What the working group can do is raise directly with me issues where they feel that the current phase 1 of the contract requires modification and where they will want to have a direct input into the negotiations around phase 2 of the contract. They can raise issues with me. Remember that the contract is a product of negotiation between the Scottish Government and the BMA. Any modification to phase 1 of the contract, any changes that might be necessary at this point, have to be subject again to negotiation between me and BMA. What the group can do, and Salinas Ritchie, I'm sure, will want to comment on this, is to raise directly and evidence to me issues that are raised with them that they conclude should be looked at further by Government and the BMA. Will you consider changing the terms of reference of the short-life working group? We've already had that conversation and we continue to have it with Salinas. Will you change the terms of reference? As you know, convener, I am always open to improvements. In that case, if that were something that those who have resigned were expressing concern about, would that mean that you'd be willing to look at what their objections were in order to bring them back on board? I mean, I hear what you say, but there are other rural people who could represent, but clearly there's an issue of folk who are serious about trying to represent rural GPs who have resigned. If that were something that would help, would you be willing to look at that? Before I ask Salinas to comment on this, the other folk, as you put it, who are on this group, are representative of the experience of being a rural GP, and therefore their views are valid and are important. Your suggestion was that although people had resigned, it was okay, because there were other people there who came from a rural experience. I'm asking you, are you willing to look at the terms of reference in order to bring those representatives back in who have also thought so seriously and strongly about it that they resigned? Before I bring Salinas in, just for clarity and for the record, I didn't say it's okay that RG Pass has resigned because we have other rural voices. I said that it was important to understand that there were rural voices on the committee and that we were working to see if RG Pass could return. I'll now ask Salinas to bring you up to date with the work that he's undertaken in that regard. Can I ask you then what is the extent of rural GP representation currently on the group? There are about 10 general practitioners on the group, and initially the group was made to consist only of general practitioners and officials. One of my first requests was that we include a multidisciplinary component, and we have a Norse and an allied health professional on the group. We also have public representation. I was keen to make sure that that was built in at the start. I was also keen to move forward very quickly to try and get some advice around how the public should best engage in developing primary care through the implementation plan. In other words, I did not see this group as only being comprised of general practitioners because the future of primary care is not just confined to one discipline. It is a multidisciplinary endeavour. In relation to the resignation of David Hogg, I found that to be deeply regrettable in spite of my best efforts. What we are talking about is a contract that will transform general practice in Scotland because it needs to be transformed because of the changing needs of society. The problem of transformation is that it is usually neither easy nor quick, but there are things that can move ahead more quickly and more pressingly than others. Your point convener about the reference of the group, as well as the membership that I have requested both through the Government through the civil service and SGPC, the BMA, to look again at the terms of reference of my group. It has been defined in the media as a task force for primary care. In its current form, it certainly is not that, but I do think that the terms of reference need to be modified and modified in conjunction with the community that we serve. I have asked that that should be considered and I understand that that is being accepted and will be considered. I just say that the terms of reference will be considered at the group's next meeting at the start of June, which I also intend to attend. I accept that we need change and that change is complex, but do you share the concerns that I have—I cannot speak with the rest of the committee—that those who want to deliver that change, who are absolutely the most committed, who argue that the GPs are serving that community and the teams around them, are expressing grave concerns about that contract? That is why the short life working group was established. I and my colleagues have been travelling, as the cabinet secretary said, extensively throughout Scotland. If I am asked to lead an important endeavour, one of the first things I do is try to listen to those who are active delivering on the front line. We have been doing that and will continue to do that because I find that listening to colleagues and observing the care that they deliver informs improvement, not necessarily by questionnaires and by emails. I prefer to go out there. I heard consistent concerns about being undervalued, about the new contract not helping uncertainty in terms of future planning. That is the feedback that I have been giving both of the Government and we have been discussing in the short life working group. That is a diagnostic phase, if you like. If you use the medical analogy, first of all, what is wrong here? That takes a little time to assimilate, but then we need to get to the treatment phase. I am hoping that the meeting on 4 June, which will be a workshop meeting, will not be a committee meeting. I hope that we will be bringing other voices in so that we can look at all of the issues and determine a way forward. I have had a number of meetings with Scottish Government civil servants and the SGPC, the BMA, to map out the near future. I am sure that both the BMA and the Government will produce a joint statement following the workshop in June to give clarity about the next steps. I have committed to writing a report of progress in relation to implementation of the new GP contract by the autumn. I will hope to lay out problems and examples of best practice. Those are emerging in the early days, but they need to be assimilated and spread where good and lessons learned where things have not worked and also be appropriately communicated. If I may just say that the word communication is all important in this matter, I will pause there. It is always encouraging if a doctor accepts that something is wrong and is willing to make a diagnosis. I think that that sense that perhaps there is an acknowledgement that there is something wrong here is a good starting point at Ryan Whittle. Good morning, Secretary Sir Lewis, Mr Fogl. Can I start with a clarification on the line of question that the convener was pursuing here? Do you accept that there is a migration of GPs from rural to urban, especially to the better off areas? I am not aware of any clear objective evidence to support that. I am not saying that that is not the case, but I have not seen objective evidence to support that. What there is, and I do accept, which is why we have taken a number of steps, are issues around the recruitment and retention of GPs in remote and rural practices. I think that we have been gathering evidence to suggest that there is that migration, however. If that is the case, and if you have that evidence, I would certainly welcome sight of it, so that we can consider that in terms not only of our current implementation of phase 1 of the contract, but also as we enter into negotiations for phase 2. It would also be something that Lewis would be interested in. It also plays to our wider workforce. If that evidence is there, I would be very happy to see it. I think that, in that respect, most of us have got mailbags where we have GP surgeries struggling in our areas, and they are actually moving to an urban setting. A lot of GPs are doing that, so I think that we could quite easily gather quite a bit of evidence to suggest that that is the case. In the words of the petitioner, Scottish Rural Action highlights that there are serious GP and other health worker recruitment and retention issues in rural areas. In which measures have been taken to address the concerning and costly issue, I think that it is common sense that GP contracts need to be attractive. Why was the technical advisory group on resource allocation, which provides advice on all resource allocation decisions in the NHS, specifically prevented from providing an opinion on the impact of the Scottish workforce allocation formula, when it is obvious that it would disadvantage rural practices and that already had difficulty in recruiting? I am going to ask Mr Fogo to give you a more detailed answer to this, but I think that I would say two things. One, it was not, from my understanding, specifically prevented, as you describe it. Secondly, TAGRA is there to discuss resource allocation. What we are talking about in the GP contract is about pay. It is not easy to straightforwardly combine the two into one area, but TAGRA did have a role here and I will ask Mr Fogo to describe that to you. As the cabinet secretary has set out, TAGRA does have a role around resource allocation. A difficulty that we have acknowledged both ourselves and the BMA is that there is a complexity around GP funding, which is that the GP funding covers the amount of money that we believe is right to provide and underpin GP services in those communities. That funding also provides GP pay, so the negotiations that we have with the BMA are effectively a pay negotiation, which also takes up the question of resource allocation. The pay negotiations are, as you would expect, confidential. That has a very particular impact on the transparency of those negotiations and our ability to get back to the points that were raised by the convener earlier for us to engage openly with the public and with others in relation to that. However, in this case, TAGRA were involved in the evidence gathering that allowed us to review the original Scottish allocation formula. At a number of meetings, TAGRA received updates as to the development of that work and received the outputs to that work. TAGRA were involved in the gathering of evidence, and at the point where a decision had to be made about the application of the formula, that was a matter for negotiation. The Scottish Government and the BMA have accepted that in future it would be better if resource allocation could be separated from considerations of GP pay. That is an explicit aim of phase 2 of the contract. If that were to happen, then, as with board allocations, we could have a higher degree of transparency around the allocation formula for general practice and therefore TAGRA may have, under those circumstances, a clearer role. However, the combination of a pay negotiation, which is confidential and essentially so, and the consideration of how we allocate resources added a complexity that made it difficult, ultimately, for TAGRA to offer its definitive advice. I will ask the committee to keep me right here, convener, but it is our understanding that your assertion of the involvement of TAGRA goes against the evidence that we have. If I could ask that perhaps we could get some follow-up on that. Make one for the clarification. If the question is, were TAGRA asked to advise on the final decision to apply the new formula to the GP contract, then the answer to that is no. That was informing your decision what you were going to offer. My understanding is that TAGRA was stood down from being involved in this from 2016, so they would not have seen any of the detail after that. The evidence of the review of the initial Scottish allocation formula was available to TAGRA, then we established an expert advisory group separate from TAGRA to offer us advice about the development of the new formula. And they didn't get the further information and were stood down from a process that they would normally have been involved in in the past? TAGRA would not necessarily have been involved in that and they were not explicitly stood down. We established an expert advisory group specifically to allow us to deal with the evidence in the context of the negotiations. Why is the Scottish workload allocation formula analysis based on data from a small group of highly unrepresentative practices that stopped collecting data in 2013? If I set that in context, those PTI practices stopped receiving funding at that stage because the Scottish Government considered the data to be useless. That issue is raised in a further petitions PE1698D in PE1698E, yet it remains unexplained why that data was used. The Scottish Rural Action notes that the community response to the concerns expressed by rural GPs has been significant and should not be ignored, yet it remains unanswered and ignored. I don't believe that it is ignored. My understanding is that the most up-to-date data that ISD had ended in 2013 and ISD then stopped collecting the data because they had to take the time to build a new platform called SPIR. Now that that is moving to be in place, that, together with the objective data that we touched on earlier about costs and expenses and so on, will now feed into phase 2 of the GP contract, which will, on the basis of that more up-to-date data, allow us to review the formula along with the other matters that need to be discussed at phase 2. The beginning of which, my understanding is that the data on expenses and costs and so on will be available to us from November of this year. The rest of that supplementary information, perhaps Mr Fogo wants to take us through. We did go out to seek further data that would allow us to form a more refined judgment. We ultimately went out to 600 GP practices asking for them to provide us on a voluntary basis the data that would allow us to refine our assessment. We only had 109 responses to that, and that was therefore not able to provide us with a robust enough basis to update the PTI information. I should say that the PTI information is the most robust information that we have to hand, and that the data and assessment used was refined, methodologically improved. We changed the census date, we moved to a data zone approach, so there were a number of methodological improvements to our assessment of that data. A second point that I think I should make is just to be very clear. The assessment of workload is not tracking real activity or real GP workload. There is some suggestion in submissions to this committee that, for instance, in areas that are under doctored or whether there are issues in which coding and consultations have reduced in some way that will have a direct impact on GP funding. Again, that is a misunderstanding that I would be happy to correct for this committee in relation to the methodology of the formula. The formula does not track actual consultation rates or read codes. It looks at the population that those practices serve, it adjusts for the age, sex and other characteristics, then it forms an assessment of notionally how many consultations would a population with those characteristics generate, and that generates a factor which then allows us to determine the allocation of resources. The fact that, for a period of time, fewer consultations happened or a GP was on leave or there was an error in the coding system, all those things are accounted for. The 2013 data was sufficient for us to form judgments, but, as the cabinet secretary said, we have an ambition to have a much more up-to-date and transparent data set. We have secured, through the contractual negotiations for the first time, a contractual obligation on GP contractors to provide that data. Therefore, we will not have 109 practices, but we should have the data from all 950 practices. The assertion that the Scottish Government considers the data to be useless, you would disagree with that? Absolutely, I would not understand what regard it was useless. I'm just saying that that's what the evidence that we are taking, that's what the suggestion is, and also the suggestion here. I think that what concerns me is, we're bringing forward here the petitioner's concerns, and the Scottish Rural Action Group here are saying that the concerns expressed by GPs have been significant and remain unanswered, and the only answer I'm getting back from you is, that's not true. To be fair, I think that you're getting a bit more than that's not true. We're getting an explanation of how we worked on the basis of data that was 2013 data, recognising that that was not as adequate as we would wish it, and then undertaking a number of methodological and other changes and checks to try and get it to the place where we could sensibly rely on it, whilst we take forward into phase 2 more objective and up-to-date gathered data. The choice at the point of phase 1 of the contract is to say, the data that we've got is 2013 data, that'll no do no matter what we do with it, so how do we go forward when we actually have a contract that has to be negotiated? What Mr Fogle has described to you is how efforts were made to ensure that, using the 2013 data, it was improved in order to be as robust as it could be made for the purposes of phase 1 of the contract, but phase 1 of the contract also includes now an obligation on all 950gp practises to provide up-to-date data for us so that we can use that in phase 2. Why did Deloitte not make the effort to obtain more up-to-date and representative data? I think that the cost of obtaining fresh data set would not be prohibitive. The contract was introduced with haste and concerns about the SWF dismissed with the cause for the concerns not addressed, as Scottish Rural Action is saying here. Scottish Rural Action considers that threat to health services needs to be addressed transparently and urgently yet the Scottish Government again is saying has yet to respond to that question. I think that that is an unfair claim by Scottish Rural Action that the Government is not responding to the concerns of the delivery of rural healthcare. I am not going to repeat and recite all the various steps that we have taken, nor what we have said clearly this morning that there is more work to do to ensure that the contract adequately reflects the needs across all our communities in Scotland. To say that we are not doing anything is both untrue and unfair characterisation of our current position. I do not think that they are saying that you are not doing anything. What they are saying is that you are not responding and informing. A characterisation that I would not accept is in relation to our attempts to secure additional data. Just to remind you what I said, we went out to 600 practices to ask for that data. We indicated that we would cover the cost of collecting that data. Only 109 practices responded insufficient in rural communities. I would note that that would have been an opportunity for rural general practice to provide us with the data that underpins their assessment. Despite offering to pay for the collection of this data, I note the point that is made that it would not have been prohibitively expensive. Indeed, it would not have cost anything because we were prepared to subsidise it. I am afraid that general practices were not able, for many reasons, including their hard pressed and workload, to come forward with the data. I would like to correct one point, which was that we made no attempt to update the data available to us. We made every attempt to do so, but, unfortunately, general practices did not feel able, despite the offer of payment, to provide us with the data on a voluntary basis. We have had to make it a contractual commitment on GP contractors that they provide us with that data, which is in line with what the Parliament has said previously in relation to transparency around GP funding. It would be interesting to find out why such a low response rate would be interesting. Did you ask them why they did not respond to clearly this issue? We returned to GP practices on numerous occasions to seek further volunteers, as I say, ultimately 600 practices, including a subsidy for providing the data to ensure that it was not financially penalising practices to provide the data on numerous occasions. We, Deloitte and others, the BMA, through their own local contacts, encouraged, indeed, exhorted their local practices to provide this data, understanding, in particular in rural communities, that if rural general practices provided that data at that point, then we would have been able to make, potentially, a different assessment of where we stood. I know Sir Lewis Ritchie made the point that he prefers to talk to people rather than to email them. Have you had any direct conversations with rural GPs who did not engage in this process, which all seems terribly reasonable? My contribution to the formula is that the ISD stopped collecting the data in 2013 because it coincided with the replacement of a national GP computer system with commercial alternatives. As Mr Fogo says, there was not in place an alternative, and that has now been worked on. In fact, I flagged this some years ago that, as I knew that the national system was going to be disbanded, we had to have a robust alternative in place, and that has been worked up. I will stop on that, but what I will say about formulas is that they do not express the richness of general practice in the round, and I think, in particular, they do not account for the diversity of practice in remote and rural areas. I would be saying to the Government that any future development should be informed not just by formulas but by looking at what GPs do in remote and rural areas because they do different things. A GP in a remote and rural area can be a nurse if the nurse is sick, can be a paramedic if the ambulance is out of area, or attends to a road traffic accident. The diversity there is quite stark at times. For example, in a very remote island, a GP may work all day to keep a sick patient at home, avoiding an air evacuation. That happened very recently with one of my colleagues. No formula will account for that. Therefore, we need to be more sophisticated at looking at what our rural colleagues do, the diversity of what they do, how well they do it, and how best that needs to be done. We need to be resourced and supported. As I see it, I would like to shed a little light on that with my group. A very brief supplement. Having said that, I appreciate that, Sir Lewis. Was that not taken into consideration when first we were producing the GP contract at stage 1? We know that to be the case. Was that not taken into consideration? I can't answer that. Mr Fogol may want to respond. Absolutely, it was. There was a very active consideration for the reasons that Sir Lewis has stated, which are well known and a limit on any formula-based, weighted capitation formula-based approach that we actively considered in negotiations, removing small, remote rural general practices from the formula altogether. We actively considered it for that reason. I should say now that the reason that we decided collectively with the BMA not to proceed with that was actually for precisely the reasons that have now come to pass, that by separating out small, remote rural general practices from the overall body of the GP profession, our fear was that we would be portrayed as marginalising rural general practice. In fact, we made the decision to keep them in the formula precisely to ensure that they felt part of the overall GP profession in Scotland and to avoid marginalisation. We actively considered removing the small, remote rural general practices from the formula approach. I'm just trying to grasp this because, first of all, the knowledge that perhaps the metrics weren't taken into consideration or were right for rural practices, but also the information gathering from ISD had stopped. I think that Sir Lewis Ritchie said in 2013, plus there wasn't an uptake of giving information from the GPs that maybe there should be some sort of pause on this until there is the right information. I completely accept Sir Lewis Ritchie's points here about some of the issues that my own GP practices have in the constituency, such as was the Scottish Workload Allocation formula, did other factors such as taking into consideration providing health services to seasonal workers or tourists, has that been taken into consideration as well? Before I ask Mr Fogol to answer that specific point, I think that I should say two things. I think that your characterisation, if you like, if I'm right, and I think that your colleagues, I think that we would share this, is that there are a number of issues in the negotiation around phase one, which were not as ideal as we would wish them to have been. There are reasons for that that I think are understood. Attempts were made, for example, as we've discussed in some detail, around the data to ensure that notwithstanding the fact that it was a starting point was 2013 data effort was made to try and ensure that was robust for the purposes of the negotiation. Deloitte, of course, we're involved in that, as well as the other matters. I think that I want to make two points. In terms of the question about a pause, the fact that the contract is in phase one and phase two, in effect, allows us in phase two, which begins reasonably shortly, to take account of some of the issues that have emerged, so that we can consider, again, what more might be done with the formula and, indeed, perhaps revisit that difficult question that was there in phase one, which was whether or not to remove remote and rural practises from a formula and the decision made, as Mr Fogo outlined, of it. You can call it one way or the other. It is essentially a judgment call as to whether you risk people perceiving that they've been marginalised if you remove them or whether you retain it in one Scottish GP family, if you like, and then carry the risk of some of the issues that we are discussing emerging. The point that I'd make is that there isn't a formula that is set in stone. Equally, there isn't a formula that will ever be perfect, but the opportunity to review how adequate the formula is or isn't is there, and that's why the work of Sir Louis's group, consideration of its terms of reference, how that, along with more up-to-date objective data, is fed into phase two, is really important. It's important for us to understand that this is not a completely final, no change is possible, no improvement is possible position at all. There is consideration at this point as to whether or not in advance of phase two, not least in terms of reference of Sir Louis's group, but any other more pressing issues that we might move on in discussion with the BMA because I repeat that it is a contract, it is negotiated, it is a contract. The BMA is the other major player in this, it's not entirely at our hand, it has to be negotiated whether or not there are steps that we can take before the conclusion of phase two to address some of these issues. On your specific point about seasonal workers, tourists and so on, there is a particular position on that. Again, generally we must understand that the application of the formula in totality without income protection would have been inconceivable to us, and a number of the hypotheticals that are run seem to be suggesting that the application of the formula, which thereby would not reflect the complexity of rural general practice, would result in an underfunding of rural general practice. The income protection is a critical component. The second point that I would make is that the existential threat to general practice presented to us from the BMA included workload. The question of why not pause was that two phase approach, which was to say that there were very many practices in Scotland, including some in rural general practice but elsewhere in Scotland, that were confronting a very serious workload challenge. It was the BMA's contention to us that, along with income protection, to ensure that no practice lost out, we needed to invest to capture that additional workload. Hence why we went forward with the workload formula along with income protection. The third point about seasonal workers, all practices, whether they are urban or rural, receive a fixed temporary patient adjustment for unregistered patients. We have committed to look at the ebbs and flows around patient lists, so whether that be increased registered patients or whether it be unregistered temporary, we have committed to look at that regime to make sure that it is up to date. Every practice in Scotland receives adjustments to accommodate for that. Whether those indexes are as up to date as they need to be, whether the regime is as good as it could be, we completely agree that if we had better data we would be able to form a better judgment on that. At the moment, GP practices are compensated to reflect those ebbs and flows. A number of the issues with regard to the Scottish Workload Allocation Formula I was going to ask have already been covered. However, I was interested to hear Sir Lewis allude to the situation in remote islands, and I should perhaps refer members to my register of interest at this point. Rydw i'r ddigon ni, dwi wrth gweithio'r ffordd, rydyn ni'n mynd i gwybod mor maenai gweithio'r gweithio'r縣dedd gwaith, cael ochr gwaith y teidw i nid i gafodd o'i fawr olygaith arlawn. Un o'u credu'r byw yw gweld mi o'r byw, sydd wedi eu gweld eu gweld maen nhw. The debate that was held was whether or not there was a risk that in removing remote and rural practices from the main formula that those practices would perceive themselves to be marginalised. That was an issue that was raised by the BMA and in the discussion that followed in terms of the negotiation, the final decision was taken not to risk that now. That doesn't mean that that is not an issue to return to. There are clearly improvements to be made, not least based now on the improved data that we anticipated to have in advance of phase 2, put contractually into phase 1, on some of the issues that have been raised, through yourselves, but primarily through Solucia's work and so on, to consider what modification can be made to the formula to better reflect those concerns and that variety of practice between rural and urban practices in terms of what GPs actually do. Now, whether or not that means you then remove remote and rural practices from the formula or whether you find other ways to adequately address that diversity is part of the discussion that goes into phase 2, informed and involving the views that come via Solucia's group but also others. That is why I said that my point is that no formula is set in stone. What we have at the moment clearly is not perfect. There are issues that need to be addressed. We need to look and see how best we address them. Do we do that by removing remote and rural practices? That question will be returned to you. There may be alternatives to doing that and we have to have that discussion and see. One of the responsibilities of a chair, apart from trying to care and support for those around the table—I have spoken regularly, including last night, with the chairman of our G-Pass and Actors' Scenar on a practice twice—I am deeply committed to getting all those voices heard. One of the things that we are doing, though, is that your opening comments, convener, was about my terms of reference. We have already covered that. However, as a responsible chairman, I would not just try and deal with what is in the tin lid of the remit but look laterally and try to think how we can do better than just addressing specific issues. In that regard, we have received an international literature review research of what might be best practice in other countries, which clearly also experience remote and rural situations. We can learn from others. It would be the guiding principle there. I am also asking the Government to sponsor a descriptor of what is distinct about general practice in remote and rural areas. We actually see what that richness is. We can look at that in greater detail and then move on that. On the international dimension, I am also garnering the opinions of remote and rural practitioners who have experience of developing models elsewhere. All of that I would like to see being included going forward, including the support of healthcare improvement Scotland and national agency and potentially others, including national services Scotland in terms of their programme support capacity. All of that I see is being on the table going forward to try to help our colleagues in remote and rural areas. I beg the question why this was not done at the beginning if we are committed to equality impact assessment and understanding of rural and island proofing. David Torrance? Good morning, panel. The wide range and additional medical services offered by many GPs in rural communities and the isolated nature of their allocation, why was this additional workload not taken into account during the Scottish Workload Allocation Formula analysis? To some extent, we have answered a large part of that. I should make the point that, although there may be justification in some of the propositions that some of what is being discussed now could have been better taken into account in the negotiation around phase 1, I think that it is fair to say that they were taken into account. However, what is important is that, as we implement phase 1 of the contract, we are open and willing to look at those improvements. That is in large part why Sir Lewis's group was not only established, but that he was asked to chair it, and that we are looking at strengthening and clarifying the remit of that group. In terms of how some of those issues were taken into account, I am happy to ask Mr Fogel to respond to that. I should say that, although our focus here rightly is on remote and rural general practice, some of the issues in terms of complexity of workload and demand on GPs applies in a different way, but none the less applies to our practices in more urban settings. The convener has already mentioned the deep end practices, they carry a slightly different name here in the east, but none the less they are practices dealing with a complex cohort of patients with many differing and demanding needs. The contract and the formula needs to be able to take account of that, too. I would not add much to that other than to say that some of that complexity is captured through other means of renumeration, so not all of it is captured through the GMS contract. A number of rural general practices carry other contracts to provide other services, including things such as community hospitals. I think that the general point has already been made that no formula is able to pick up on all that complexity. In relation to workload, absolutely, we would accept that the better dataset we have, the more able we are to pick up on our conception of workload. The consideration that we brought to bear, the comment was made that why did we not consider those things during negotiations. I can absolutely assure you that having been in the negotiating room for two years, all those matters were considered at some very considerable length, and judgments ultimately were made. We are open to revisit some of those judgments. Once we have that more up-to-date data, in relation to GMS services, we will be in a position to reflect on that workload. The judgment will then be that that is capturable through a formula, or indeed does it have to be handled in a different way. Complexity of general practice was the main consideration in relation to the formula, not just the complexity of rural general practice, which includes the logistical workload, the extra travel, all the other factors in relation to cost, but also the nature of consultation and engagement in clinical practice. Equally, there are other complexities in general practice that include, covered in the submissions, issues such as unmet need, which is incredibly difficult for us to capture in any formula, given its potential infinite nature. You have answered most of my question in the next part, but can I ask a Scottish Rural Action notes that recent decline in life expectancy in rural communities in the new west coast of Scotland to health needs assessment report? How would you respond to petitioners' concern that the Scottish workload allocation formula is adding to its inequality? I am sorry, could you just repeat that? The Scottish Rural Action notes that the recent decline in life expectancy in rural communities in the new west coast of Scotland to health needs assessment report. How would you respond to a petitioner's concern that the Scottish workload allocation formula is adding to its inequality? Well, I take an assertion like that very seriously indeed, and I would want to discuss with the petitioners in what way they think that the contract contributes to that situation, as opposed to a range of other matters that we are attempting to address through the health portfolio. It is a serious contention in terms of the workload formula having an impact on life expectancy of patients, and it would be a matter that I would want to seriously consider, but to understand the basis on which that assertion or that concern is being expressed. It is not immediately clear to me why that link would be made, but I do not know whether either Sir Lewis or Mr Fogol want to add anything to that. Again, we can provide this committee with considerable detail on the technical and methodological underpinnings of the formula, which includes the demographic characteristics of the population, including deprivation, age, etc. All of which are protected characteristics. That relates to the equality impact assessment. Again, judgments are formed. We are quite clear that we placed a particular weighting on age and deprivation in the assessment of the formula. We understood that the additional costs in the provision of rural general practice were mainly in relation to expenses and the costs of running those particular businesses and reflected that we would have to consider those costs in phase 2. I would be very happy to provide this committee with all the underpinnings, which sets out in incredible detail all the different component parts of the formula and how they capture the different demographics. However, I have no evidence that, given that the contract is only one year on, it is very difficult to see that we could, in any credible way, be seeing an impact on life expectancy at this stage. As the cabinet secretary said, that is a very serious point. I would imagine that it is quite early for there to be evidence of that directly, so we would be very interested in that evidence. I have evidence that the settlement disproportionately benefits better off areas in urban settings as opposed to poor areas in urban settings and disproportionately takes money into urban settings rather than rural settings. We accept that. We also have the body representing our rural GPs saying that there is a major problem here. I do not know whether the cabinet said to that particular assertion that it is clearly a very serious one, whether it would be possible to ensure that that conversation was held directly, and that is for you to establish yourselves. We would not want to engage with that, but clearly that is something that is felt very strong. Can I ask before I bring in Rachel two things? When do you think phase 2 will start, and other than through the efforts of Sir Lewis Ritchie, how do you hope to engage with our GPs to encourage their involvement in phase 2? As I said earlier, the data that will be gathered from practices that are now part of phase 1 of the contract should be with us in November of this year. We would expect phase 2 of the contract in terms of the beginnings of the negotiation, so there is a lot of preparatory work and discussion between November and that point, to be from the spring of 2020. Sir Lewis's report will inform what happens in November? Indeed. To answer the second part of your question, Sir Lewis's report will absolutely inform all that consideration. The primary way to engage our GPs in the work of Sir Lewis' group is taken forward by Sir Lewis. That is entirely proper. If at any point he thinks that there is value in a further discussion between myself and that body, then I am always open to do that. Last summer, I had a couple of discussions with David Hogg, but I am very happy to discuss them with him again. However, I would take Sir Lewis's advice on what is the best way to deal with that. The new GP contract, along with the memorandum of understanding, sees that health boards will take on some responsibility for secondary care services and non-core services, which will allow GPs to free up time for primary care. However, in rural settings, that is not necessarily happening. You mentioned some good figures, Mr Fogo, around the flu vaccine in the Highlands and Islands. I will pick that up if you would like to repeat it, but I wondered how vaccine transformation might be compromised because of the roll-out of those services and the geographical considerations that rural GPs have to take into consideration. I am speaking from experience, again, from having spoken to GPs in my area, where they believe that the vaccine transformation is not being delivered as they would like it. I think that Mr Fogo might want to add to that, and indeed Sir Lewis might want to make a couple of points. The first thing to say is that the alternative provision of immunisation programmes is an offer. It is not compulsory. For some remote and rural GP practices, the example that I gave was the Western Isles, where they feel that having taken up that offer there has been an improvement. However, I am equally conscious that, in other practices, they believe strongly that that offer is not one that meets the needs of their patients and they wish to continue to undertake that work themselves, and they are entirely free and able to do so. There is no compulsion here, and I think that it is really important that that is clear, because I understand that, and certainly some of our island communities have raised the point that it makes more sense for them to continue to do what they are doing than for a team to appear from the mainland in order to deliver that. That makes sense to me, too, if I am honest. I think that the important part is to be clear that it is an offer, and for some, certainly for some urban and town practices, not our cities but towns, it is something that GPs welcome and want, because they believe that it frees up more of their time to do some of the work that they and only they are clinically appropriate to be doing and to spend more time with patients, but we should see a mixed picture here according to what makes most sense for the patients in that practice and what is the safest thing to do. As long as it is being delivered and monitored, and I just wondered if you were monitoring that and had a sort of picture of how things were being perhaps transformed? We have the beginnings of a picture. I do not know, so there is a few options. I have to declare an interest in that I chair the Scottish Health Protection Network oversight group. Nested under that is, among other things, many other things, immunisation. I have agreed with my colleagues in that group that immunisation uptake rates is something that we need to be vigilant about. Any change that threatens the uptake of one of our crown jewels in Scotland, we need to take very seriously indeed. It is clear from my perspective and my colleagues that, even when the vaccination transformation programme is an advanced state, there will still have to be local delivery by GP teams in remote and rural areas. The issue for me is that it needs to be clearly recognised and we need to support that. It is not something that will just be subsumed into some central team. Having said that, I am aware that, in some places, for example NHS Tayside, where the vaccination transformation programme has been in place for several years, the uptake rates have increased in that setting and GPs are keen to see the job done well, in this case, by others other than GP staff. However, I cannot see that applying in remote and rural areas and we need to support that going forward. I think that all I would add, as the cabinet secretary has said, is that, at the moment, we have made no substantial changes to the contract in relation to vaccinations and GPs continue to be paid for that. There was some prospect that, no earlier than 2021 or phase 2, we would look at how much of the transformation had happened, but there was always an acceptance, as stated in the contract offer, that there would need to be flexibility around remote and rural. If I could just make one point, convener, on the vaccinations in particular, which I do know causes concern, it has been portrayed as a step taken to reduce GP workload and that, therefore, creates the risks that you have outlined. I should just say that that is a very narrow portrayal of what vaccination transformation is about and, as Sir Lewis has said, it has been under way in many areas for a while. Vaccinations are becoming more and more clinically complex and that interacts with the workload burden on Scotland's GPs. Future-proofing Scotland's vaccination programme, from a public health perspective, was a critical driver in that. There is a portrayal of this that we are prepared to sacrifice what Lewis describes as the crown jewels for the sake of some modest efficiency. I can absolutely, as the director of population health and, therefore, more responsible for policy on immunisation vaccination, say that there was a public health imperative behind us looking at how vaccinations were delivered. However, there are absolute backstops to say that no vaccination programme will be transferred unless it is safe to do so. I have listened with interest to the evidence and I suppose it has given me a better understanding of why rural GPs have such a lack of trust. What is very clear is that the formula was devised for urban practice and, indeed, ignoring the health inequalities that we face that Johann Lamont pointed out. There was an afterthought that their funding was protected because it was acknowledged that it would be cut if they were run through the same contract. The fact that it is being looked at again is not because that was recognised early on, it was because of the outcry of patients and rural GPs that this is now being looked at. I want to pick up some of the points that were made because I will dot about it because other people have asked questions. I can turn first to the formula and how you are gathering data. One of the things that was said in evidence today was that you were looking at, for example, the number of consultations. I have had the experience of both rural and urban GP services. I know that if I go to my GP in Inverness, I will get 10 minutes and there will be a queue of people behind me. I also know that, when I was going home and helping to look after my parents, the GP would travel a 40-mile round trip on single-track roads to do a consultation. If you say to a rural GP how many consultations did you do today? Well, I did maybe four or five and my urban colleague did 40. You know immediately that the formula is not going to work for you because it is going to look like you are not doing anything, so no wonder that they are not very keen to provide that data to you because the basis of which you are asking for it is not the premise that they are working on. I just make that point because I do not think that you can answer that now. I think that you maybe need to look at what information you are gathering and how you are gathering it. The other thing that Sir Lewis referred to this about GP's work in rural areas is that a GP could spend a day with a patient keeping them out of hospital but working with them at home. The same is true because they support rural hospitals as well as medical beds. I wonder how much cognisance has been taken of that. In evidence, you mentioned that rural hospitals came under a different contract, but do medical beds and hospital at home come under that same different contract? Mr Fogol will deal with a couple of your points. Before he does that, I think that it is very important for me to put on the record that protection was not introduced because there was some recognition that phase 1 of the contract and the formula was inadequate. Protection, as I said at the outset, has been there for rural practices since 2004 and clearly for that particular contract, which generally speaking my understanding as a majority of GPs were not content with and wanted to see significant changes, including GPs in our rural areas. Nor was the current phase 1 of the contract devised for urban and not caring about equality. I think that we have made it clear that that was absolutely not our intention nor was it the BMA's intention, the other partner to the negotiation and of course the BMA does represent GPs across a range of settings. Our acceptance that there are areas for improvement should not in my view be mischaracterised as an uncaring approach in terms of remote and rural phase 1 of the contract areas of improvement and areas to consider in phase 2 is simply a welcome recognition that there are in the implementation of the contract areas where we need to consider what further improvements should be made. On the point about consultations and about hospital beds and hospital at home, I will ask Mr Fogle to respond. I think that that would just build on responses to previous answers. There are always choices to be made about the methodology that we use and all I can say to you is that we absolutely did consider the complexity, as I have mentioned before, about the nature of the delivery of rural general practice. It gets back to a very, very basic point. The value of rural general practice is not expressed and can never be expressed through a formula. A formula is a device of which there are very many choices you might make about how to divide up your resources and that is not directly a way of expressing value. Those two debates make it very difficult for us to compare and to address some apparent inconsistency. The methodological point as to whether consultation rates are appropriate is absolutely part of our consideration about whether that is the best way to assess workload. We have acknowledged that it is not absolutely adequate for that reason. The broader point about whether or not that does or does not value through the formula rural general practice feels to me that I am very regretful that the connection between the methodological choices around the formula have been connected so directly with the question of whether or not we do or don't value rural general practice. Fundamentally, the point was income protection, which, as the cabinet secretary has said, has been a feature and has to be a feature of weighted capitation approaches and formula approaches. It is a standard feature of such contracts and previously, under the 2004 contract, it was not portrayed in the way that it is now being portrayed. The reflection for me is to what change has happened and again to look back and to look forward to making sure that in future we look at how we present that income protection and how it is understood. However, the connection between the methodology, which is very complex for the formula and the question of whether we value rural general practice, feels to me to be nowhere near as direct as it is being portrayed. If you are ignored, you feel undervalued and the first contract certainly ignored the work of rural general practitioners. If you put yourself in the shoes of rural general practitioners, you would understand why it came out as being undervalued. Can I move on to an answer given indeed about the protected salaries of rural GPs? It was Mr Fogo who said that it did not address things such as expenses, which made most of the costs of rural GPs. I find it difficult because property in rural areas is cheaper. Of course, there are more miles to travel, but the hours worked are the same, sometimes more, because you have to do your own out of hours. I cannot see how expenses would be the main difference in what would cost to be a rural GP and an urban GP. If it is helpful, just so that I absolutely can be as helpful as possible, why do not I provide you, based on the evidence base that we have, as much clarity as I can about the various differentials there in relation to the cost base in providing rural general practice, also the incomes, etc? I hope that it would be helpful to provide you with some data after this meeting that would allow us to be clear about that point. I think that there is quite a lot of complexity in that in relation to all the different factors. We have, based on the review work that we did, some evidence around the cost base. It is not adequate, as we have indicated, but I can provide you with a summary of that if it would be helpful. Can I turn to vaccinations? We are being told this morning that there is no change and GPs can go on vaccinating. I am assuming that that is up to a health board whether or not that happens. If there is no change, constituents are coming to me and saying that there is change. I have heard of constituents being told from not remote rural practices but rural practices outside Inverness, being told that they need to come in to the RNI in Inverness, which is an elderly people's hospital, to get their flu vaccine. Some of them are saying that they are elderly and frail. That means that they have to take a bus and there are maybe two or three buses a day, which means that they are spending the whole day in Inverness and many of them are not fit to do that, but they are being told that they must do that. I am concerned that you are telling us that there is no change. People are telling me that they cannot access their flu vaccine because they are not fit enough to spend a day in Inverness far less the affordability of travel. I think that the point was made is that there is no compulsory change. There is change and, as Lewis has indicated, that change is complex and I think that it is best. But who is initiating that change is what I am trying to get to. I do not think that it is the GPs. I think that it may be the health board. If they think that that is going to save them some money, they are not thinking about the patient experience. The contract offers the possibility of change, but the key element of that is that any transformation of the immunisation programme in any particular area or sub-area, if you like, of a health board, should be done in a way that is safe and should be done in a way that holds to one of the important elements of our health service and that it is person-centred. The board should be in discussion with GP practices about the best way to deliver immunisation programmes. If there are instances where the result of that discussion is one where patients are disadvantaged, we should know about that and we should take that up with the board to find out why that is the case, because it does not feel like it meets the criteria of safe and person-centred. Equitable is an important principle here and that is fair and accessible to all according to need. I would expect any development of a service, and it is getting increasingly complex, as Mr Fogo says, to be safe, effective, equitable with the accessible function in it and affordable, so it needs to make the best use of public monies. There is a little point in constructing an elaborate mechanism if it is going to be highly costly and not make use of best public funds. I would expect that to be configured into any change in regard to immunisation, but no one principle can be taken in isolation. They all need to be taken in combination and a judgment made in combination with those who deliver the service is the other point. You heard me mention earlier the communication issue, and I believe that that will be vital going forward. There is a lot of fog up uncertainty around right now. Frontline teams are not necessarily quite sure of what is going on at the board level and the IJB level, so we need to make every endeavour to chase away that fog. It will always remain in places, but we really need to change the weather. I think that you quoted figures for the Western Isles about school children, the increase of immunisation going up. Do you have the same figures for elderly people, and have you looked at immunisation across the board? You may not have those figures with you, but it would be interesting for the committee to have. We do not, but it is early days. We are very happy to keep you and the committee if it has an interest in the evidence that we have. I should say that the vaccination transformation programme is very complex and is being done in a way that is right down to the practice level. In other words, we are absolutely being clear at a very fine grain level about when those services can transfer. We are also doing it thematically, so we are looking at different vaccination programmes. It is very complex. You will find that in some areas they are transferring shingles and other areas they are not pertussis or flu. There are different things going on, so it is a complex picture. We sometimes have information from an area relating to one programme, but not to another programme or to another demographic. If you are interested, I can provide if it is specifically about the Western Isles or, more generally, when that information is validated and can be relied on, I would be happy to provide it to you. I think more generally, but you did quote from the Western Isles. I am slightly surprised that you gathered one set of figures, which in a way is a no-brainer. You know that most children go to school and they will all easily be captured. You do not have the same structure in place for an elderly population. If I were you, I would be more looking at the elderly population where you know that you are going to hit difficulties, rather than the ones that you know are probably going to work better. I take your point, but I think that because vaccinations and immunisation target a number of different groups and because the transformation programme is moving in different ways across the country, what I would be interested in is whether the transformation programme has improved uptake on the target group of people or not, or whether it has had a negative impact. It is not a picture that you can have with one set of figures for the whole of Scotland, but you need to look at where there is change and what difference is that change making for the different target groups, for the different immunisation programs. I would imagine that elderly people would be a target for free vaccines. Can I ask a couple of last questions? Those have been flagged up to me, so forgive me if I have got the technical language wrong, because I think that there is an issue about technicalities around that, which are leading to very strong messages about people being unhappy because of the consequences of choices that you have made when people are drawing those conclusions. I was advised that there was a shift from an excess cost of supply approach in rural practices to protected income and expenditure. The argument was put to me that the consequence of that was that, although people were told that income would not be protected and all the rest of it, that at some point in the future it is possible for the health board to come in or the partnership to come in and say that we are going to withdraw that money, and that is creating an insecurity in the system. I wonder if you want to comment on that. Secondly, the context for this is also that there is a recognition and a shortage of GPs. In that context, the attractiveness of a particular area to work and capacity to be supported in that work becomes another question. Therefore, people who are deeply committed to their local area as rural GPs are expressing anxiety about the sustainability of those GP practices in the future. I will answer that, but then I will also ask Mr Fogo just on the technical point about whether or not there was a shift from one approach to another. I am aware, and I understand notwithstanding the fact that the protected income element has been there since 2004, so it is not new. I am aware that there is a concern that, because it is described and viewed as that, it is vulnerable to being removed. I am tempted to address that. I think that more of the budget shifted over there. It is not that the model did not exist, but there has been a shift in the income of the GP in this contract, which makes more of their income vulnerable. I do not believe that to be the case. Mr Fogo may offer some more detail around that. What we are attempting to do is to maintain the financial recognition that our practices in remote and rural areas require to have a degree of income protection against any formula on the basis that it is difficult for a formula to completely reflect the nature of their practice compared to how a GP practices and the work that it does in more urban settings. I am keen with the Soluces group to look at how we can remove that concern around uncertainties to whether or not that level of income will continue, or whether it will be removed at some point in the future. That is part of the discussion that we are having. Was there a shift or not? I will let Mr Fogo respond to that. I think that a technical methodological change is being used to draw some quite profound conclusions, so just a couple of points that might help understanding here. Again, I am very happy to brief the committee on the technical aspects of that. On the fragility of income protection, it is no more or less fragile than any other part of the GP funding. GP funding is set on the basis of allocations from Scottish ministers approved by this Parliament. Can you explain to me why we shifted from excess cost of supply to a protected income? Why was that change made? Then we can work out whether it matters or not, but why was the change made? That is a technical methodological bit. The Scottish allocation formula in 2004 had two component parts. One was the workload component, and the other was the unit cost component. We gathered evidence on both. We published reviews and evidence. We had some evidence based on the imperative in negotiation with the BMA that there was a crisis around workload, and we had sufficient evidence to move forward with the workload component of the formula. We did not have sufficient data around unit cost, and therefore we proceeded with a single track formula removing for this stage and replacing it with income protection the unit cost component. I believe that that is perhaps the shift that you are talking about. I should say that that does not have a consequential impact as the way that you have described it in relation to then giving, for instance, boards any more leeway here to adjust funding. I should say that funding is set nationally. We do not commission GP services locally. The money flows through boards without boards being able to adjust the GMS component of that contractual arrangement. Although the board holds the contract with the GP contractors, the board does not get to adjust that set nationally through national bargaining. I think that there are two or three things going on in your question that are being conflated in relation to methodological adjustments to the formula, which we have explained at length, the limits of that and our prospects for improving it, a connection to GP funding, which overall the overall value of the contract increased during the course of the contract. It is not just that income was protected, but we added a further £23.7 million. That just proportionally went to prosperous practices in urban areas. No, the second uplift, which is that the contract uplift is separate from the income protection. Are you saying that all practices across the whole of Scotland have equal access and proportionate amount of that £23 million? What I am saying is that last year, two sums of £23 million—so £46 million in total—was put into the total value of the contract, partly to do income protection, but secondly to provide an uplift to all practices. Am I right in asserting that, of that new money, it disproportionately went to prosperous urban practices as opposed to deep-end practices in cities and to rural practices? I am not asking about income protection. I am asking about the new money, because one of the strongest arguments that has been made to us and I think that we found compelling was that, while rural GPs are saying that there is a problem here, we are not being listened to on issues that we are facing, the evidence that we suggest of the new money that came disproportionately went not to rural areas but to urban areas and not to poorer urban areas but to more prosperous urban areas precisely because of the formula or the choices that you made about what mattered most. People who live to a very old age, if that is a very important factor, those people who live to a very old age live in the better and more prosperous bits of our cities? Do you agree with that? Am I right in thinking of that new money that it disproportionately went to prosperous urban practices, not to rural practices and not to poorer practices? The cabinet secretary is quite right to have made this point earlier about the kinds of issues that are faced in areas of significant deprivation in the mon city, where people have comorbidity, where they have other issues that they bring with them and all those other challenges in their lives. Whereas somebody who, yes, has managed to reach the age of 90 and will have other things in their lives and deserve to be supported, but what the doctor is dealing with is quite different. The biggest question that I think we have to address here and it may be that I really appreciate the amount of time that the cabinet secretary has given to this. We'll need to reflect on what we've heard but I hope that you'll reflect on what we've heard. I think that there's a very significant question at the heart of this. Is it the case that the contract, as settled on a very small turnout of doctors, has to be said that disproportionately benefits more prosperous areas in urban areas as against poorer areas or rural areas? If that is true, then you haven't made an equality impact assessment and you haven't done an island proofing and you haven't done a rural proofing. The equality impact assessment and the work that was done on the basis of the contract, as it was negotiated, did not demonstrate that that would be the consequence of it. The two areas, primarily in the workload element of the contract, of the formula, is around age and deprivation. I'm asking you of the new money. Can you give us evidence that that new money went to disproportionately poorer communities and rural areas? My contention is that you can't. If you can, it's different to say that we've factored in those things. You may have factored in those things but the consequence and the argument has been put back to you and I've not yet had an answer to it is of the new money, where did it go? How did it break? How was it divided up? That's not about protection of income because I understand there's been difficult arguments in the past about changing formula and very often government of any colour will create a flaw so that nobody loses but actually they're losing because they're not gaining from the extra money that's made available. Of course we will provide you with, I think my hesitation is really just to say that the formula component and the income protection is only one small component of the overall contract value. So my hesitation around the word disproportionate is just to be very clear. Around that £23 million, which is not the only new money that was put into the new contract last year, along with the £45 million around the memorandum of understanding and the overall contract value, we would need to look at that in the round. So we will provide you with a look. I think that you should be able to say where the £23 million went and where did it go and in any assessment of fairness and equality was the money distributed in what might be regarded as an equal and fair way. It must be possible to do that. It went to the practices with the highest workload. Well, there's a massive question to be begged there because precisely, as the cabinet secretary has said, round workload is not number. Ten minute visits from did-a-da, 40 people who've really got no other issues in their lives but some particularly they need to have looked at in comparison with what's happening in our depend surgeries and what's happening in some of the complexes around our rural areas. I think that it doesn't stack up. We will provide you with all of that information, but workload isn't solely about how often or how many people are GPCs. It is also about the nature of the issues that the patient is presenting, which is how deprivation should be reflected in that workload. There is a phrase somewhere in which some of the campaigners around depend surgeries use, which is about the perverse allocation of moneys. It feels perverse to me that a poor community in Glasgow will get less money out of this process or a doctor trying to serve that community. Someone is doing a very good job and a very thorough and professional job in a more prosperous area, but I'm conscious that I'm taking up too much time. I think that's something that we would really need to get an answer on. I think that we would very much look forward to hearing what's going to come out of Sir Lewis's group. I think that I'm speaking for the committee, but I encourage that, at least, we're going to look at changing the terms of reference. The other area that I would like some more information on, because I think that there's a lack of clarity on it, is the role of TAGRA and why it was not involved in the later stages in this process. Everybody that I've spoken to has regarded them as serious people, doing a difficult job around resource allocation, and they cannot understand why they were not continuing to be engaged in the process and having an understanding of what the consequences of that would be. I think that that would be another area that we would want to look at, Brian. On your question, there can be no definition of workload. I think that we need to read the contract and look at that specifically and understand how that was defined. As the cabinet secretary has described, workload seems reasonable, but I want to see that that is reflected in the contract. We obviously need to think and reflect on the evidence that we've heard today, and I've already said how much I appreciate the amount of time that you have taken to be with us. I would be interested in hearing the response from the petitioners. Indeed, people who are involved in NGP practice more generally around what they have heard today, and I think that we would want them to come back to us as a committee. I understand and Mr Fogol has said that the intention was not to make them feel marginalised or excluded from the process, but the reality is that people feel that, and that is obviously an issue that has to be addressed. If it has been caused by inadequate rural proofing, island proofing, equality impact assessment, I do think that the Scottish Government needs to go back and look at that. Brian. There is undoubtedly a significant belief in the rural community that the GP contract treats rural practices unfairly. If we accept that as real, even if it is a perception, and given that there is a retention recruitment issue that is more acute within those practices, I think that it is reasonable to accept that urban practices will benefit to the detriment of rural practices. On the evidence that is given today and the evidence that we have received before, the consultation process has fallen short of what was needed, as well as the data gathering that has been implemented by the GP contract without that adequate data and consultation. I think that more effort had to be made in that. I think that, in the evidence today to be fair, the Scottish Government recognises that and knows that changes have to be made and that engagement with rural GPs and their understanding of their specific concerns is inadequate. However, the one that comes back to me is in the meantime. What is happening in the meantime? That means that the inequality continues until such times as that has changed, so I think that there is definitely work to be done here. The other work that we have done, we have heard from GPs about the pressures that they are under, and part of our inquiry is to support for young people with mental health issues, and to talk to doctors about the pressure on them in order to put them in consultation with young people who may be facing challenges in their lives. There is a general issue, which I think that I am right in thinking that the Health and Sport Committee is exploring around primary care. I would not want people to think that we are not respectful and valuing of our GPs generally when understanding that the pressures are under, but we would look forward to get a response back from some of the technical questions that we have asked. An update from the committee would be really useful and, of course, obviously to hear further submissions from those who have heard the evidence today. I am conscious of taking a great deal of your time, cabinet secretary, this morning. I thank you very much. Rachel, sorry. We will take a bit longer, and then I promise I will let you go. I do have general questions very soon, and I am number one. I will give you one minute. It is just really brief. I know that in the chamber, Miles Briggs had asked for a delegation, a cross-party delegation, to get together with the cabinet secretary following the next meeting, which I believe is on the 4th of June, with Salewis Ritchie. I remind you of that, cabinet secretary, that that would be very useful. Thank you very much. Thanks, and I suspend briefly to allow cabinet secretary and our colleagues to leave the table. If I can call the meeting back to order, the next item of business and agenda is another continuing petition. We should have been dealing with petition 1658, which is compensation for those who suffered a neurological disability following the administration of the ploserix vaccine between 1988 and 1992. However, I am conscious that we are short of time. We took longer on the earlier agenda item, so my proposal is that we defer this petition and deal only with the last petition on our agenda in order to ensure that we give proper time and attention to both of those. I would not want to think that we had, because the pressure is a time we weren't able to explore all those issues fully if that's agreed. In that case, if we can move to petition 1672, which is the Scottish Law Commission report on prescription, our final petition for consideration this morning is petition 1672 by Hugh Paterson on the Scottish Law Commission report on prescription. The petition calls for the Scottish Government to take remedial action in terms of the law relating to prescription and limitation. The Scottish Government has outlined what remedial action it is taking, which involves updating text to place on its website in relation to prescriptive periods, and also working with the Law Society of Scotland on any updated material that society places on its website. The petitioner considers that that is insufficient, suggesting that simply putting information on a website rather than hard copy quote does not address the issue. Members may recall that, at an earlier consideration of this petition, back in May 2018, the committee discussed whether there might be merit in some form of awareness raising campaign. That is reflected in the submission received from Tony Rossa. Mr Rossa also raises suggestions within his submission that a change in the registers of Scotland's systems and procedures is quotes both necessary and essential to protect donors. I wonder if members have any comments or suggestions for action. I note in the Scottish Government's response that it states that it will inform the committee once the updated material has been placed on the Scottish Government website. That was five months ago. I know that the Government's wheels can grind exceedingly slowly, but I would have thought that they could have got something up on their website within five months. Although I note the petitioner's dissatisfaction with that action, I have a lot of sympathy for the petitioner's stance. However, I cannot help but to think about Cavi Ademptor, let the buyer beware. While there is an issue with the 20 years, given that there is no intention to change the current situation, I would suggest that the committee closes the petition on the basis that the Government has no plans to amend the law of prescription. It would be possible. I think that the Scottish Government has been clear. It is quite difficult to provide information in a way that captures everybody who might at some point in the future be caught up in that. In closing the petition, we could agree to write to the Scottish Government and make the point to them that they made this commitment and they have yet delivered on it. That would perhaps at least satisfy the petitioner that that bit of the commitment has been made. I think that we are in having exactly those issues in our casework files. It is something that every single MSP will have come across in the building. It is just regretful that there is not a solution necessarily to it that can be implemented practically and easily. In that case, if the committee has agreed, we will agree to close the petition on understanding order rule 15.7. On the basis that the Scottish Government has no plans to amend the law of prescription but has agreed to update relevant guidance, we will agree to write to the Scottish Government to make the point that they made that commitment and we would be expecting them to fulfil that. We would want to thank the petitioner for bringing the petition before the Parliament and also remind them that they have an option of bringing back a petition at a later stage if they feel there are matters that they want to pursue further with the committee. I thank everyone for their attendance and I will close the meeting.