 y byddwyr peth i chi. Fy oedd yn cyfrwyng wych yn resynol y attacking yn 해� brands y cart progressing a lot yr ystyrdd o Wcoverb wrongsiau? Ie! Fy oedd yn iddi'r own cyffredin ingredients y gwrdd riddymu llotig ar hyn, mae ein bod yn ei cymorth cofio gwyllgor. Rwyf wedi gai bro主 i iech Daleabyd yn cwestiynau ein busbl yn niwed ysu'r Yo pearls yn hysti puisx yn y yrm Waite Lrys iawn, niwn gwneud y mediad? Rwyf wedi ei wgcito 밥ol. besmaker chwarae. I benefit to the health secretary for what she wants in setting the issue." For those who are not so familiar with the 5th health and social care partnership's proposal, we must close the city of St Andrew's community hospital based on primary care emergency services for the GP hours. The proposal tuwellhanded to the Mae'r cydwyllt gan y bydd hyn yn daith i'r holl o'r cydwyllt. Jogwch chi'n ddwyngol i'r hanfodol sy'n gweld iawn i'r cydwyllt. Mae'r ffurey yn Saindrwyr aethol yn ein cynnigau. Mae'r holl o'r cydwyllt i'r holl o'r cydwyllt. Felly, mae'r panellope Phrasar aethol iawn i Saindrwyr. Mae'n cydwyllt ar gyfer mwy o'r pethau i mewn i ddyn ni'n ei weithgau. maen nhw'n mynd i amser ar gyfer y gael sydd d brushingknor i'r leoedd mor hysbethau i Ngr-Cody. Darryl Wilson i Anstrather i fynd yn yr ystod iawn, unrhyw gofyn o bwysigol griff ond byddai'r cyffredig, ac mae'r cyffredig yn gweithio o'r ffórwelm. Mae'r cwmwneidio'r cyffredig yn yn agnorog o'i ddau i Anstrother a St Andrews. Ond, mae gweithio'r cyffredig o'r cwmneidio'r cyffredig o'r bwysigol, ond so many o'r cyffredig yn gweithio'r cyffredig. 2,300 cyffredig o'r cyffredig o'r cyffredig yn cyffredig. Mae'r consultaidd, yn fawr, yn gweithio'r cwmneidio'r cwmneidio'r cyffredig iawn o'r pethau ar derbyniadau gyda'r amdanoedd. A bod 9,500 agmaint o'r gwaith yn graff yn gweithwyrwyr. Mae cyflawni'r bod Saunandrúr is draws. Mae'n cerddawodau fel Cercodi bydd yn gwybod o'r centau gyda'r gwaith, ac oherwydd wrth iddyn nhw'n mynd yn bod y Gwyrdd Gwyrdd rydyn nhw, a'r gwaith yn gweld, oherwydd yma dyn nhw i ferfoshed braw iawn, a ymdeithas ychydig i'i Felly mae omosProacja neuesol i ciwg wrth cha Gong 아�debbol, a i ofol mwy ddigon counts iawn i hi-iysfaith eraill ei hunain i gwaith eraill, wedi ei eradig hundreds iawn i syniad hyn o aheaddiu ei credu chi thanksu ar-diwrs. Kickers Crosshospital suggestau a Dundeeawu yn y gallu elles почемуn cymdeithio i alfa lath o Saaf-faith. Aller время ban sef cyrel o'r ka flap кожa hydi diwrn yn ei wneud, ataun cael ei agitanc trafod o karcairolol réu extra. The minor injury unit at St Andrews is run by the primary care emergency service, so if PSS goes in St Andrews, so does the minor injuries unit too. That would be a double blow for the community. The GPs locally are prepared to provide a service. In fact, the rota at St Andrews is booked all the way up until Christmas and has been for some time. The new service might be different from the one that we have been used to. It might utilise the skills of other health professionals, but a local service is possible and is required. The Lewis Ritchie report highlights the need for a multidisciplinary approach and one that is person-centred. There is nothing in the Ritchie report that prevents the St Andrews facility remaining open. I would argue that it reinforces the case for St Andrews. There is a shortage of GPs—I would say that it is a legacy of poor workforce planning. Of course, there are more GPs, but more of them are part-time so that there is effectively a cut in whole-time equivalents of GPs, so that is creating this particular problem. There is an issue that needs to be addressed by the five health and social care partnership. People in East Fife understand that, but those problems will not be solved by the closure of St Andrews. I have mentioned before already that the rota at St Andrews is full until Christmas. There is no guarantee that those GPs who are currently providing the service in North East Fife would be prepared to make the long journey to Cercodi to support the new service, so we would end up with fewer GPs participating in the service as a whole if that change goes ahead. The newspaper report recently in the courier of low uptake of GPs for the out-of-hours service was for Dunfermline, not for St Andrews. With the uptake in St Andrews as healthy, it would be extraordinary perverse to penalise North East Fife for the shortages elsewhere in Fife. There have been flaws in the consultation process, including the impenetrable language, the three consultations bundled into one, and the ruling that the St Andrews option should be ruled out from the very beginning. I have to say that the officials at the Fife health and social care partnership have been responsive and sensitive throughout the process, despite those flaws. I thank them for that professionalism, even though I disagree with their recommendations. However, I have heard it said that people in North East Fife are just whinging and that they are wealthy so they can cope. Those people who hold those views are small in number, but they hold senior positions. My advice to them is to think very carefully. You have responsibilities for the whole of Fife, whether you like those parts or not. I was the member of Parliament for Dunfermline and West Fife before I entered this Parliament, so I understand the special needs of that part of Fife and other parts of Fife. They should not be ignored. North East Fife has needs too, and neither should they be ignored either. The case for the facility in St Andrews is strong. We have the need, with students and elderly people, that is a long distance to Cercodi and those roads are not in good condition. There is a clear demand, as demonstrated by the public meetings, but also the response through the petition. There is a demand in North East Fife, and GPs are prepared to step up to provide a service. There is a demand, there is a need, and there is a capability of the GPs to provide that service. There is a way to make that happen, and I urge the health secretary to provide her support to make that happen. I congratulate Willie Rennie on securing today's member's debate. This is not the first time that the issue has been discussed during the member's business, and, while today's motion focuses on St Andrews, out-of-hours closures have affected Unfirmland and Glenawthus in my constituency, as Willie Rennie alluded to. For the last 223 days now, our constituents have been travelling to the Victoria hospital in Cercodi, one GP out-of-hours service for the third largest local authority in the country. I spoke with my colleague Stephen Gethens, the MP for North East Fife ahead of today's debate. He told me that the out-of-hours service must be retained at St Andrews community hospital. North East Fife is a large rural area with many minor roads and remote communities like the East Newark. Many parts of North East Fife are a significant distance from Cercodi. North East Fife has a diverse population, including a higher-than-average elderly population and a large number of students without transport. There are real concerns about having to travel a significant distance when you are unwell. I agree with Stephen Gethens. My concerns about the closure relate to the process, as acknowledged in today's motion. The service fell over, almost overnight. That is not usual practice, and I am sure that the cabinet secretary would agree that it is not good practice. Fife's health and social care partnership then decided to consult retrospectively, three months after the closures had begun, and they added in community health and wellbeing hubs, and then they also added in community hospital and intermediate care bed redesign, all in the same consultation. I know St Andrews very well, and I know my constituency. Issues of rurality in the north-east do not impact on the people that I serve, but inequality does. Recommendation 7 of the Sir Lewis Ritchie review states that quality and safety implementation and monitoring of out-of-hours services should be assessed for their impact on health inequalities. No equality impact assessment took place before the closures on 9 April. I asked repeatedly the local health and social care partnership to share details of the EQIA. That did not materialise until, very quietly in August, it was retrospectively electronically uploaded. I would encourage all members with an interest in this topic to interrogate the quality of the EQIA in its present form. Page 1, question 2. Who is the lead assessor and their contact details? Blank. Age and disability are rated as medium relevance. Race, sexual orientation and religion are rated as low. Ahead of today's debate, I wrote to the director of Fife's health and social care partnership seeking clarity. Who did they speak to in those categories? How did they identify risk? When was this work completed? Those questions have not been answered. The EQIA document, currently online, states that it was started on 28 March, 12 days before the service apparently fell over. If the service had to shut on an emergency basis, how did the partnership have time to start an EQIA? The truth, of course, is that it was not conducted in March nor was it conducted in April, as the director confirms to me in his letter that the EQIA was not approved until 14 September. It seems to me that Fife's health and social care partnership started from a position and then worked towards it. In my view, the consultation has been flawed from the outset. Fundamentally, people did not understand what they were being asked about. Three different services were lumped together in a bid, I believe, to deliberately confuse the public. The use of jargon throughout the consultation documents is excessive, but jargon to phrases like why we need to change suggests that it was never about seeking the views of Fife's. St Andrews should be commended for their organised and tenacious campaign, but my constituency also organised. Stoud out public meetings, numerous constituent complaints, all just five years after my predecessor and the former Labour MP organised to fight against the same proposal. It should also be noted that the partnership did not conduct a transport appraisal, which means that my constituents now have to pay for taxis to access out-of-hours if they do not have a car, and if they cannot afford it, they need to ask. Dignity is at the heart of the Government's new social security system. Where is the dignity in being forced to pay plead poverty just to see your doctor? Today's motion is focused on St Andrews, and, as Stephen Gethnes has argued, the best outcome there is that services are retained at St Andrews community hospital. The GPs have pledged their support for retaining out-of-hours services there, but my constituents face very different problems than those in North East Fife, nearly one in three children living in poverty. In Levenmouth, we have some of the lowest car ownership levels in the country. Benefits cuts have stripped more than £1 million from the communities that I represent. If the IGP votes on 20 December to permanently close Glenruth's GP out-of-hours services, make no mistake, it will be the poorest who suffer. Willy Rennie is right to bring this issue back to the chamber today. The public consultation has been opaque from the outset. The EQIA is not worth the paper that it is written on. Our constituents deserve better in the 70th year of our national health service. The decision on closing GP out-of-hours services in St Andrews, Glenruth and Firmland is one that the IGP will take in a week's time. Although that is ultimately a local decision, I would very much welcome the cabinet secretary's views today on how we now move forward. I happen to think that this Parliament is at its best when, despite our political differences, we are able to argue very forcibly when one particular issue dominates our mailbags. I have to say that, in the last debate in this chamber, we had a very similar passion. I think that it is only right that we progress with that, because this is an extremely important issue, not just for St Andrews and the motion that Willie Rennie has brought, but for the whole of the kingdom. I thank Willie Rennie for bringing the motion to the Parliament, but he has also been very passionate and assiduous in his advocacy for keeping the St Andrews GP out-of-hours facility open. Those benches are very fully supportive of that decision. I pay tribute to the other members, to the SNP members, to the Labour members, to the Green members for their contributions to the debate. I know that the cabinet secretary herself is taking a keen interest in that, and, like Willie Rennie, I would urge that she is able to at least put some pressure on the Fife situation. It is not just about the IGB decision, which is on 20 December, but it is about the way in which we make decisions about our local health services. I think that that is part of a bigger picture, and I know that I have debated with the health secretary about the structure of IGBs and perhaps how we can improve some of that when it comes to the local delivery. It has to be about the safe and sustainable levels of staffing. It must be equitable, it must be fair, and that has to be right across the kingdom of Fife. We have to pay heed to the advice that the clinicians are putting to us. I know that it is a difficult balance when you come to what has been termed an unsafe and, I think, unsustainable situation by Michael Killett, who made that point that he thought that there could be improvements about the delivery. However, the GPs, in many instances, particularly in St Andrews, are saying something completely different. Certainly at the public meeting that I attended that Willie Rennie had organised in the first instance, that was a very strong message. I think that it is partly because of that very strong message that the campaign has had such a considerable uptake in the St Andrews community. There are a number of factors. I too have heard that comment that, because it is St Andrews, people are relatively wealthy and they can cope with it. Not only is that quite offensive, it is not true, because the demographic in St Andrews is a particularly difficult one, because it has a high demographic of elderly people, some of whom are not particularly well off, and it has a very high student population. The demands on that particular are very different from the ones that are in different parts of Fife. While we are being told that there is one part of the kingdom that is directing operations on that, I do not accept that. I think that that is part of a much bigger picture, and I think that what is happening in St Andrews is something that we need to see in the holistic right. The out-of-hours care is incredibly important for a whole host of patients. The town that has a large population of students and retirees has a particular demographic that, as I say, we need to be very careful about how we respond to that. We all know that it is critical that, in any health emergency, the patient receives treatment within that golden hour, the health professionals call it. The travel across to Cercodi or to Glenrothes or to Dundee is a difficult option, should the decision be to close it down. Thirdly, the residents of North East Fife were very barely represented in the 2007 options appraisal workshops when various discussions were taking place. I agree with Willie Rennie that some of the professionals have been listening, but I am not sure that the process, and as Jenny Gilruth has rightly set out in terms of the actual language of the consultation and the direction with which that has taken, has not been particularly helpful to the engagement of the public. As I see the argument at the moment, people are almost coming from different angles, and that is not helpful to finding a resolution. I am very conscious that the health secretary is very aware of that and is being as helpful as possible. Can I reiterate my thanks to Willie Rennie, but also to all the other members, who I think have been extremely honest and straightforward about this, and again, I think that it brings together this Parliament on what is clearly a very critical issue for all of us who are either the elected member for the constituency or for those of us who are list members. I thank Willie Rennie for bringing forward this debate to Parliament, and I also thank him for the fair analysis that he has given of the situation that we are facing. It is not that long ago that many of us were in the chamber to talk about the wider closure of our services across Fife in the debate that was brought forward by Jenny Gilruth. St Andrews is one of three, alongside Glenruthus and on Firmland, that find themselves facing an extremely uncertain future. I appreciate the particulars that are of the situation in St Andrews, due to the reasons that Willie Rennie outlined in his opening speech, and I welcome the opportunity for us to highlight them today. MSPs were informed of the closure of the three of our sites in April, and next week the IJB will make the decision on their future. The decision to move to contingency measures were due to nursing and medical staffing difficulties, leading to concerns over clinical safety. As we are on the brink of the decision, it is important to emphasise the consequences of any decision. The decision to close the three centres was only supposed to be temporary, a contingency measure that would last for three months. Yes, eight months down the line, there is little confidence that we will see a return to the services that we once had. It could be considered that a contingency measure was supposed to be temporary until services were resumed and that all three of our services could continue. However, disappointingly, the GP situation in Fife has continued rather than improved. I appreciate that the Scottish Government will highlight the new GP contract and the work of the university citizens in St Andrews and Dundee through the ScotGem programme. Those are all welcome, but there are no guarantees that that will solve the problems of out-of-hours provision. Certain areas of Fife are struggling to recruit GPs for during the day and never mind at night. In other areas, we are seeing more GPs go from full-time to part-time provision. Currently, a quarter of all practices in Fife are full, with all surgeries in Cercodi, all surgeries in Llogelli and four out of five surgeries in Dunfermlyn registering a full practice list. We also know that at least seven GP practices are experiencing long-term recruitment difficulties and two are considered to be in a high-risk situation. That all makes the possibility of recruiting sufficient GPs to out-of-hours service work even more challenging. Although statistics released this week by ISD Scotland have shown that there is a small rise in the number of GPs in Fife from this time last year, there are still fewer GPs from a decade ago. At the same time, the number of people registering with a practice in Fife is increasing. While Fife having fewer GPs treating more patients, there is bound to be an impact on services. Patients struggling to book appointments at their local surgeries may start heading to A&E, all of which out-of-hours GP services are meant to avoid. Others may decide to ignore the symptoms, powering through until they need further more urgent care. That is the potential to put significant pressure on the Victoria hospital in Carcoda, which is currently the only facility in Fife that is out-of-hours service, and as Willie Rennie has highlighted, Dundee's King Cross service out-of-hours is often at full capacity. We need to look at how to alleviate those pressures and not exacerbate them. That is why the decision to close St Andrews is all the more perplexing. I have attended public meetings in the area, including those organised by Willie Rennie, and I have spoken to local residents and the student representatives at the university. I know how valuable the out-of-hours service is and how the alternatives are simply unacceptable and unrealistic. The travel times for St Andrews are too long, the rurality of North East Fife is challenging and the demographics of the population demands local healthcare. St Andrews hospital was an busy out-of-hours service, and we are being told that there is a commitment from local GPs to run an out-of-hours service in St Andrews in the interests of their patients. NHS Fife makes the case that it needs to deliver for all of Fife and cannot accept a solution that would only serve St Andrews. I understand that its responsibility is to do that, and it must provide a service for the whole of Fife, so that it must have flexibility and be able to be tailored. I want to see a solution that retains all three out-of-hours services, which recognises the importance of local delivery and does not risk exacerbating the health inequalities that Jenny Gilruth has highlighted. However, until that can be delivered, we have to be open to alternatives. NHS Fife should be flexible about St Andrews. It needs to recognise the needs of its elderly population, its rural nature, its distance from Kirkcaldy and the student population that includes a large number of overseas students. Reopening St Andrews hospital does not take resources, GP resources away from other areas in Fife. There is a strong case being put forward to keep St Andrews service running, and NHS Fife must listen. I thank Willie Rennie for bringing forward the motion for debate here today. Much of what we discussed back in the October's members' business, brought by Jenny Gilruth, is relevant to the debate today. It is also good to have the opportunity to focus in particular on the situation in St Andrews and North East Fife. Liz Smith makes a very important point that I hope that the cabinet secretary will reflect on. That is genuine cross-party concern. We are bringing thoughts and concerns and what we have heard from communities into this chamber here, and hopefully with solutions as well. Following the emergency closure of their services earlier this year, residents from St Andrews and East Newk have endured journeys of up to an hour to access primary care overnight and at weekends. With the capacity issues at King's Cross Hospital in Dundee, it has only compounded the issue. I have received reports, and I am sure that many other members have, that there are patients who have had to take taxis and yet they still have not been reimbursed for these long and expensive journeys. I have also heard from students that they are relying on the goodwill of the university to pay for their travel costs to access these services. The area has a unique demographic, as members have already reflected. We have a significant ageing population, living alongside a growing student population, and that brings its own specific healthcare challenges. Young and transient populations are more vulnerable to sudden contagion incidents, not just the notorious freshest flu, but serious and sometimes life-threatening illnesses such as mumps and meningitis, which require a swift medical response. This unique demographic, however, also makes St Andrews an ideal place to trial new and enhanced ways to deliver out-of-hours primary care. Using a mixed multidisciplinary team of, for example, advanced nurse practitioners, paramedics and pharmacists, I was recommended in the 2015 Richie review. I have been calling for an assessment of this option for some time now, and I remind colleagues that it does not have to be an all-or-nothing scenario. There could be a model here that could retain these important services in the communities, and we can recognise the need for change, but at the same time retain a level of primary care locally, joining up with a remote-working GP and urgent care team based at the Victoria hospital. It is clear that the consultation on these proposals has been wholly inadequate, especially since the formal consultation began with the assumption that services in St Andrews would close. I recognise that the initial closure earlier this year was made in emergency circumstances, but I have heard from GPs and Fife who say that they were not even consulted before the closure was made and were not aware of the extent of the staff crisis for out-of-hours services. I commend the work of St Andrews community council, who has sought to ensure that local people are represented better in the decision-making process through a formal participation process. I would urge the IJB to grant this request ahead of next week's decisive meeting. The issue, however, is linked with the wider GP crisis that we face in Fife and across Scotland. The number of GPs in Fife has fallen since 2008, while the patient list has increased by nearly 11,000. 18 surgeries have stopped accepting new patients, while seven are struggling to recruit the GPs that they need to deliver a basic primary care service. When local doctors are under such immense pressure during normal surgery, it is entirely understandable that the out-of-hours service has reached crisis point. I would be grateful to hear from the cabinet secretary in a closing speech about what is being done to address this overall GP crisis and how the Scottish Government are planning to deliver more GPs for Fife. I look forward to hearing the outcome of next Thursday's IJB meeting. I hope that the board fulfills its duty to consider all options, to properly consult with the community and to ensure that they are providing the best possible care in the communities using a full range of medical practitioners that are at their disposal. I welcome the opportunity to take part in the debate this afternoon, and I congratulate Willie Rennie for bringing it to the chamber. Here we all are again, having to comment, condemn and debate yet another ill-thought-through proposal by Fife Health and Social Care Partnership this afternoon, which talks about the GP of our facilities in St Andrews. We have already heard that the primary care emergency services at hospitals in Llanrothys, Llanfrman and St Andrews have all faced difficulties in the last few months since they were shorted back in April. The area has a large number of students who depend on those facilities and an ageing population. That population deserves more and deserves better facilities than they have at present. I would also like to comment on the effects that took place. I put forward a motion back in April discussing and condemning Fife Health and Social Care Partnership for what they were doing. It was widely criticised across the community that the consultation process was completely and utterly unacceptable. That is rightly so. We have already heard that 6,000 people have signed a petition and more than 2,000 have submitted objection postcards. It would sincerely hope that the IGB would take notice of that. It would appear that they do not. We have all attended meetings across the region and we have all communicated with them, but they seem to be quite stuck in their ways about what they want to achieve. As some have already said, we seem to be moving towards the goal of achieving what they have on paper, not for what the community needs and deserves. The whole idea was supposed to be looked upon as a contingency to try and sort out situations and deal with problems in the region. That has not happened. It seems to be an exercise that we have all gone through. The community feels very let down by that process. We have all heard that King's Cross in Dundee and its out-of-house facility are often at capacity. That means that there are difficulties in ensuring that people from North Fife can be looked after and supported, or otherwise they have to go to Cercodi. We have already heard about the long differences and the difficulties of that cause. Last week, only the GPs in the area talked about what they could do to provide and what they might be able to support. That should be taken on board, but, once again, the GPs seem to be very blinkered at their attitude towards those consultations. I very much hope that the body will hear the views of local people that have been highlighted and look towards instating those vital services. I share the deep disappointment that Fife's health and social care partnership seem to have a lack of respect for the community that they are supposed to be representing. We already know that, in the previous secretary for health, she kicked things into the long grass. That was the way things were managed. I hope that the new cabinet secretary will look upon that and see it as an urgent opportunity. As you have already heard, across the chamber, members who are constituency or list members really understand that problem. I think that you are beginning to understand it, too. We have a massive problem and a major concern. We have already heard that there is and that there is an acknowledgement that Fife is facing recruitment and retention issues. What do we have to do? We need to do more. Stuart Rowley, we are aware, and Clare Baker has highlighted the short AGPs in Fife, which is critical. The cabinet secretary needs to look at that, but does he also understand that the Fife and Health partnership has continued to overspend its budget? I am told that the Fife and Health partnership is possibly running with an overspending of around £8 million at the current time. Does he think that there is a financial issue here that needs to be addressed as well? Alexander Stewart I acknowledge that there are priority issues with the IGB, and it needs to take on board what it has and what it is doing in the communities that it represents. I agree with Mr Rowley very much on that. As we have already heard, St Andrews is a growing location, and the other areas across the region—Glenorth is done firm—require the support mechanisms that are put in place to ensure that the public are being looked after. That situation should be continued and concerned, and the individuals across the region have the opportunity to ensure that that takes place. We must do all that we can to continue, because we are putting patients' lives at risk, and the Government and the Health partnership have a duty of care and responsibility to protect those individuals in the region. They must act upon it and act upon it now. Thank you very much, and I call on Jeane Freeman to close with the Government. Thank you very much. I also thank Willie Rennie for bringing this matter to the chamber and to all those who have contributed so far. I also make a point of thanking Mr Rennie, too, for his recognition of the professionalism of the health and social care officials and the way in which they have done it, and for his recognition that what may need to be delivered to meet the needs of citizens in Fife—not just in North East, but across Fife—is not necessarily what has been in place up until now. That is a very welcome recognition that, as we move the delivery of our health and social care services forward, we need to recognise that what has I been is perhaps no longer the right service to offer people. Access to urgent primary medical services outside normal GP surgery opening hours is a fundamental part of unscheduled care in Scotland. Around 4,500 patients are seen every month by the Fife out-of-hours service, with around 20 seen between midnight and 8am every single week. The reason why we have a difficulty in GP shortages in out-of-hours services in part comes from the 2004 contract that GP signed, which allowed GP's to opt out of working in the out-of-hours setting. Many of our GP's who, as they approach retirement, are using that to opt out of out-of-hours, many of them are retired, and new entrants to general practice have in the main chosen not to work out of hours. One of the things that we have talked about in this chamber before or have touched on is the new GP contract. The new GP contract reflects one important element, and there are many, in Sir Lewis Ritchie's review of out-of-hours services and out-of-hours care. That is that out-of-hours services require GP involvement. The new GP contract, aside from introducing that important multidisciplinary team and so on, brings GP's into general practice on the basis of a recognition that they are required to contribute to out-of-hours services. In Fife, the health and social care partnership has taken a number of steps to improve sustainability and resilience. It has introduced new pay scales for GP's to encourage the uptake of shifts as the norm. That has steadied the service to some degree. It has moved ahead with the advanced nurse practitioner training programme, training band five nurses up to band seven advanced nurse practitioners. Using the out-of-hours funding, they have recruited a further three advanced nurse practitioners to work alongside GP's, and they also have a paediatric advanced nurse practitioner. They are also working to look at the prospect of a salaried GP service, introduced as part of the overall GP provision. Tayside, who currently operates a 65-35 salary-to-sessional GP ratio, has managed to introduce that successfully. Fife is working with Tayside to see what lessons they might have to teach them that they could use. There is also a new GP clinical lead that they have taken on, and they are looking at introducing a GP on-call service. That would be a GP at home in order to offer clinical advice on call. I absolutely understand the concerns that members have expressed, and the concerns of people in Fife about the current situation. I do not believe that the consultation was undertaken in the manner in which it was in a deliberate sense in order to obfuscate and make it difficult for people to be involved. However, I understand why that is the perception. Out of our services, intermediate care, how we configure primary care, how we deal with unscheduled care are not unrelated matters. It makes sense to look at them in the whole, in the round. However, the manner in which it was undertaken, coming on the back of having to reduce out of our services for clinically safe safety reasons, almost inevitably, in my view, with hindsight, produced some of the serious perceptions that people have. I think that the chief officer in Fife and others recognise that difficulty. I also think that they recognise that, although they undertook a number of meetings, effective consultation and engagement is not just about the number of meetings that you have, it is about how easily you make it for people to participate. I will take you in a second. Before I go any further, I have to say that I am not singling out Fife here. This is an issue across our whole health service and our health and social care service, and I am not being unfairly critical of people because I think that folks do it with the best of intentions, but we need to be smarter in understanding how it feels to be asked to participate in order to have that engagement as genuinely productive as it possibly can be, and I am looking at that overall across the whole service. Liz Smith, thank you to the cabinet secretary. I think that there are very perceptive comments that you have just made. As you are quite right to say that this is across the country, not just in Fife, will the cabinet secretary acknowledge that, in terms of some of the language that Jenny Gilruth raised when she was making her contribution, made it all that more difficult for people who were members of the public to understand what was going on? That is something that could be looked at in the future when there are discussions about changes that have to be made. I think that that is absolutely correct. It is a widespread issue, and it has been with us for a while. It is about language. It is about how we run consultation events. It is about how we involve in a way that is genuinely meaningful to local people to have a say and that we are straight with them. Having a say does not necessarily mean that we will decide what you want us to do, but that we will come back and explain why not. I think that we have examples of doing it very well and examples of doing it not very well. There are serious issues that Ms Gilruth has raised about when the equality impact assessment was done and so on and so forth. I am taking this issue very seriously. I am sure that Mr Stewart has noticed that at least two of the health team are quite short, shall I say. Long grass is not particularly attractive to me because I disappear inside long grass. I am not a fan of it, but I think that we need to try and move ahead. The health and social care partnership undertook, in terms of the steps that we have to take, notwithstanding the important point about the quality impact assessment and the transport impact assessment, but undertook the process in a manner that complies with what is required. They did the option appraisal involving members of the public and so on. They produced a consultation document and ran a number of meetings. We should not be overly critical about the approach that they took, although we might have positive suggestions to make to them and others about the language that is used and some of the critical elements that need to be put in place. We now have, of course, a request quite rightly and entirely within their rights from St Andrew's. I also believe now from Glenrothes under the Empowerment Act to have recognition of participation. That request is not to the IJB—it is to, quite rightly, to NHS Fife. NHS Fife needs to look at that and consider it. They have already responded and asked for additional information. In my mind, what all of that means is that the IJB will not be in a position next week to make a decision, because that request has to be dealt with and heard and determined by NHS Fife in a proper and appropriate manner but without taking too long to do it. At the same time, it is important that the discussions that are continuing that have begun—I think that there have been three so far—with the GPs in St Andrew's that those discussions continue. The initial proposition from those GPs, as I understand it, was not accepted on the basis of clinical advice. We have clinicians disagreeing with clinicians—it is not unusual, it does happen—and they need to work that through, because I think that both parties genuinely want to find a resolution that is appropriate for North East Fife. I take your point about how in practice accessible it is to think about Tayside and the service over there. I also welcome the fact that St Andrew's university has acted to produce additional health facilities for students, but those do not cover out-of-hours. There are a number of areas that are being moved on—some of the remedial actions that I outlined, those continuing discussions with GPs in North East Fife, and now the requirement to take appropriately and seriously the two requests that have been received under the Community Empowerment Act 2015. Willie Rennie, just before I take you, Mr Rennie, it is just that we are running out of time, so it has to be like an exchange of a minute. I welcome the fact that she has indicated that the partnership will not be in a position to make a decision next week and that further discussions can take place. I think that that would be a great opportunity, because there is a willingness to try and find a solution here that works. If that is the case, I think that that would be very welcome news in East Fife, and I hope that the partnership is listening to the minister's advice. Cabinet Secretary for Health and Sport, I have only been informed very recently about that request. I have read the letter that has been received. I understand, as of this morning, that Glenruth has also made a similar request. I think that it is Glenruth's residence forum. My understanding and reading of the letter that has gone back from Fife to St Andrews is that the exchange of information needs to take place. Fife needs to consider matters, and they need to look at what Glenruth is saying to them, too. That all indicates to me that it is actually not possible to make a decision in a week's time. I will discuss further with the chief officer of the health and social care partnership in Fife what needs to be done and what the times might be. I remind members that, in terms of people who have to travel for what is the existing provision, the out-of-hours service will offer a home visit if travel is not possible. We should make sure that residents understand that, and I assure members in the chamber who have taken part in the debate and others that I will continue to keep a very close eye on that in order to make sure that we reach a resolution that, within the available resource and the challenges that are to be met, genuinely meets the needs of residents in north-east Fife and Fife as a whole for an adequate out-of-hours services to meet their needs.