 The next item of business is a debate on motion 4324 in the name of Shona Robison on the Scottish patient safety programme. I would invite all members who wish to speak in this debate to press their request-to-speak buttons now. I call on Shona Robison to speak to and move the motion. I am delighted to have the opportunity to share with you the many successful initiatives being rolled out to continue to improve patient safety in Scotland. I want to thank all staff who are involved in this very, very important work. When we launched the Scottish patient safety programme, it was ambitious and unique in the world. No country had ever decided to tackle patient safety head-on in this way. Eight years on, that is still true. We remain the only country in the world with the level of ambition that I will describe today to strive for zero harm across our NHS and social care settings. Don Berwick, president emeritus and senior fellow institute for healthcare improvement, said recently, that what I love about what Scotland has done is that it has done it scientifically. It has done it through developing the capabilities of the country to be a learning nation to actually improve things. That is how you have done brilliant work in patient safety. Our initial focus, understandably, was on acute hospitals with the aim to reduce mortality by the end of 2012. The work has expanded to include safety improvement programmes across six strands—adult hospitals, healthcare-associated infections, maternity and children, medicines, mental health and primary care. This morning, I visited the Public Dental Service Centre in Glenrothes, one of the practices that is participating in the Scottish patient safety and dentistry pilot. The aim of the dentistry programme is to improve quality and safety in general dental practice through a collaborative approach. Dental teams now see many more patients who are on high-risk medications such as antiplatelet drugs or anti-quaglants. For this reason, the work has focused on reducing the potential impact of dental treatment on this group of patients. I am delighted that Healthcare Improvement Scotland is further investing in dentistry, extending the testing phase and developing a plan to spread the learning. The expansion of work into dentistry, community pharmacy and nursing homes means that we have SPSP work in all healthcare settings. From our largest hospital in Glasgow displaying real-time safety data in each ward to small GP practices in Fife discussing patient safety at staff meetings, the Scottish Government's position on patient safety is clear. It is and will continue to be of paramount importance in the daily work in healthcare settings throughout Scotland. Today, the Care Quality Commission down south announced that there is a clear need for change in the NHS in England, including the need for safety to remain central, with many trusts failing to learn when things go wrong. That is why Scotland's unique national patient safety programme is internationally renowned and has made patient safety in Scotland the global benchmark for safe care. Since its launch in 2008, the SPSP has contributed to a significant reduction in harm and mortality through a national collaboration to improve the quality and safety of care. A number of factors have been key. We have built capacity and capability within clinical and non-clinical roles to develop and apply quality improvement methodology through testing of focused safety interventions to understand and deliver reliable evidence-based processes. We have used data to support improvements that are shared through national and local forums and networks. The data is on the walls in our healthcare facilities for all to see. We have tested and implemented leadership activities, providing strong organisational support for safety such as executive safety walk-arounds. Doing all of those things has helped to create a culture within care that is more open, transparent, learns from success and failure and continuously improves. Crucially, within that culture, individuals and teams have risen to the challenge and continually work to improve safety. The programme has sought to engage front-line staff in improvement work by promoting the application of a common set of tested evidence-based interventions. That comes from a common improvement model based on the Institute for Healthcare Improvement model. However, we recognise that in order to meet the increasing demands being placed on our health service, we must reform as well as invest and work to accelerate the shifting balance of care. That is why we have committed to introducing a national and regional workforce planning system across the NHS in Scotland. The national plan will look to strengthen and harmonise workforce planning practice, take full account of the future demand for safe and high-quality services for Scotland's people, accurately identify gaps in supply and help to deliver the vision set out in the national clinical strategy. The plan that is currently being consulted upon and which will be published in the spring of this year will take full account of the many demographic and other influences on our NHS workforce and enable us to continue to deliver a safe and sustainable NHS. We have also committed to enshrine safe staffing in law, placing the nursing and midwifery workforce planning tools on the statutory footing. The safe and effective staffing legislation work is progressing and the consultation period will begin in early spring of this year. A crucial element of the programme is that the changes are led by the staff who are directly involved in caring for patients. They can then monitor and see the improvements through the collection of real-time data at the individual unit or ward level. We know that many countries around the world, including Norway, Denmark, Sweden, Australia, Mexico, Chile and Tanzania, have looked at the Scottish model. They are keen to emulate what we have been able to achieve for the people of Scotland through the Scottish patient safety programme. Many have begun to do so. Just this month, Singapore is visiting to learn from our approach. The Scottish surgical checklist introduced under the safety programme has been praised internationally by renowned experts such as Atul Gawande. The simple but powerful technique has been adopted across Scotland. It uses techniques developed in the airline industry to ensure that the safety of every surgical procedure is checked and assured every time. We continue to strive to improve further. This week, the chief medical officer's annual report was published on realising realistic medicine. The report sets out an ambition to put the person receiving health and care at the centre of decision making and encourages a personalised approach to their care. It aims to reduce harm and waste, tackle unwarranted variation in care, manage clinical risk and innovate to improve. Those are essential to a well-functioning and sustainable NHS. In response, Sir Muir Gray, who is the director of the national knowledge service and the chief knowledge officer to the NHS in England, tweeted that NHS Scotland is the future of healthcare, so good praise indeed and we will take that. Patient safety goes beyond the programme itself. Our diabetes improvement plan includes actions to improve the quality of care of people living with diabetes who are admitted to non-diabetes wards in hospital by improving their glucose management and reducing the risk of complications such as foot ulcers. Only this week, we have written to the chief execs of NHS boards to begin the national adoption of two important diabetes initiatives. To support this, the Scottish Government will fund 1,000 hypo boxes to be made available in acute wards across Scotland. That will ensure a standardised and improved approach to the management of low blood glucose and will improve patient care. It is important to share with you some of the specific improvements that have been achieved across the country. The primary care programme launched in March 2013 has been successful in improving the care that is delivered by health and social care partnerships. That includes general and dental practices, community pharmacies and care homes. One programme's aim was for 95 per cent of primary care clinical teams to be developing their safety culture and achieving reliability in three high-risk areas by 2016. Also, if we look at the mental health programme, an increasing number of wards and units are showing improvements. That includes a 78 per cent reduction in violence, a 57 per cent reduction in the use of restraint and a 70 per cent reduction in self-harming. Speaking about the identification of physical conditions for people in Scotland with mental illness, Francis Simpson, the chief executive officer, supported in mind Scotland, said recently, among the most supportive has been the Scottish patient safety programme team, whose staff would have opened up access to hundreds of health professionals across the country for the equally fit message. I thank the cabinet secretary for taking that intervention. In terms of maternity and children's care, in the fourth family royal hospital laboratory, it was recently revealed that stillbirths were disproportionately higher than national average, but those deaths do not seem to be counted in the mortality rates according to the national records of Scotland. I wonder if you could make any comment on that. I can say to Elaine Smith that there has been an 18 per cent reduction in stillbirths, and a lot of that work is due to the patient safety programme, working with front-line professionals in changing some of the practices. However, there is more work to be done, and that is why, of course, we have had the review of maternity and neonatal services, which makes a number of recommendations that we will be taking forward to further improve that. I think that we should recognise that that has been a significant improvement, but there is more work to be done. I just want to turn briefly to the medicines programme, which aims to bring together improvement activity related to medicines from acute care, primary care, maternity and children's service and mental health, providing a unique opportunity to consider the safer use of medicines from a whole-system approach, focusing on the patient as they move between care settings in home. The first key area of focus for the programme is medicine reconciliation. That focus is on reducing harm from medicines across transitions of care by ensuring that medication is accurately checked and prescribed. Finally, I am delighted to report that the hospital standardised mortality ratio, which provides details of unexpected hospital deaths, continues to decrease. As that was the primary aim of the programme, the continued reduction in those figures is a real success that I am proud to celebrate. The latest available hospital standardised mortality ratio figure that was published last month indicates that it has reduced nationally by 8.6 per cent since 2014. That is well on track to reduce further to 10 per cent by December 2018. Similarly, national data published at the end of 2016 indicates that there has been a 24 per cent reduction in surgical mortality, a 21 per cent reduction in sepsis mortality, an 18 per cent reduction in stillbirth, as I mentioned earlier, a 93 per cent reduction in healthcare-associated infections and a 78 per cent reduction in ventilator-associated pneumonia rates. I recognise the very significant challenges that are facing our health and social care system in terms of our ageing population and the increasing numbers of people living with multiple and complex conditions. For that reason, we need to maintain momentum and continue to improve quality of care. We must apply our successful improvement approaches to allow us to continue to deliver today and into the future better outcomes for the Scottish people. I move the motion in my name. Thank you, cabinet secretary. I am going to call on Donald Cameron to open for the Conservatives to move the amendment 4324.1 in his name. Just to let all members know, there is plenty of time members who may take their time over the remarks this afternoon. I am delighted to open the debate for the Scottish Conservatives, because it is a clearly very important one to have. I am pleased that we are finally having it since it originally appeared on the business bulletin several weeks ago. As I have said many times in this chamber, on issues across health and beyond, those benches will act as a strong opposition, scrutinising the actions of this Government at all times. We will critique the Government when we feel that it is not performing to stand as expected by the people of Scotland. Similarly, we will welcome positive achievements that make a real and tangible difference to people's lives. With that spirit in mind, we on this side of the chamber fully support the Scottish patient safety programme, its aims and objectives, and we will continue to support it as its remit grows. That means ensuring that every Scottish citizen who enters a hospital, whether that be for an out patient appointment, for minor treatment or for a longer stay, should all have a right to outstanding treatment, professional care and above all else, know that they are safe from further illness or complication where it can be prevented. The need for every patient in our health service to be safe is obvious and paramount. Context is important in understanding why the Scottish patient safety programme came into being in the first place. Before it was introduced, it was recognised that hospital deaths were too high and that the number of people succumbing to infections or other complications was excessive. In fact, the Scottish patient safety programme acknowledged that there are many severe risks that exist in Scotland's hospitals. In 2008, it was estimated that around 2,000 falls occurred in Scottish acute hospitals every month, accounting for a third of all reported patient safety events. In 2011, NHS statistics showed that around 22 per cent of all healthcare-acquired infections were urinary tract infections with 4 per cent of patients developing life-threatening bacteremia or sepsis as a result. Those statistics range over different timelines and different conditions, but all highlight that there are always risks in hospitals, proving the need for a monitoring body to ensure that those can be reduced as much as possible. Given the original aims of the Scottish patient safety programme, when it was first established to oversee reductions in infections, life-threatening developments and sadly deaths in acute hospitals, there have been many successes that must be welcomed and I am happy to welcome. Since 2007, there has been a 16.5 per cent reduction in hospitals' standardised mortality ratios, and it is good that the up-to-date information that the cabinet secretary just provided confirms that it is on-going. However, in plain English, there are now fewer avoidable deaths in Scotland's hospitals, which is testament to the hard-working commitment of our NHS staff, and we should all welcome that. The remit of the programme has indeed expanded over the past 10 years to include the monitoring of healthcare-associated infection, maternity and neonatal services, safer use of medicines, mental health services and primary care services. On primary care, there have been many notable achievements, including the fact that 93 per cent of all GP practices now regularly participate in the Scottish patient safety programme's safety climate survey. That allows practices to monitor performance against other practices, allowing patient safety to develop within a practice and to check not just safety within a practice but the perception of safety within a practice. I will talk briefly on maternity services as I know that other colleagues will elaborate further on that area, but since 2007 it is notable that still birth rates have fallen. There are a lot of achievements to praise, and I cannot stress enough that we on these benches, and indeed everyone across this chamber, I am sure, supports our NHS front-line staff and the phenomenal work that they carry out in keeping patients safe in ever-changing and difficult circumstances. However, it is also right that we talk about what we need to do better in order to ensure that the aims of the programme are fully met and continue to be met. Whilst many of the overall statistics are delivering better outcomes for patients, there remain inconsistencies in the performance of individual hospitals. My own local hospital, the Belford in Fort William, had significantly higher mortality rates than the national average in the first quarter of 2016. Dr Grace Hospital, the Inverclyde Royal, the Royal Exandria, the Vale of Leven, were all recorded as being above the upper warning limit for these ratios in the most recently available information. The cabinet secretary mentioned the chief medical officer's report this week. In that report, the chief medical officer also noted that between 2011 and 2015, E. coli, for example, has risen by 5.2 per cent year on year and that half of the near 4,600 cases of E. coli in 2015 were associated with healthcare. Public confidence is important, and that remains an issue. As last year's inpatient experience survey notes, one in five people say that they had experienced problems during their hospital stay and nearly a quarter of people felt that their condition worsened while they were in hospital. It is clear that while much progress has been made on patient safety, there is still a lot to do. Any debate on patient safety must consider current levels of NHS staffing, and it is here that I have to adopt a more critical tone. It is no coincidence that every Opposition amendment today mentions staffing. Those amendments were lodged without any collaboration. Across the chamber, there are clearly huge concerns around that. We need to ensure that the great work that has been carried out by NHS staff is supported and aided by ensuring that the NHS has the right number of front-line staff to deliver those changes. NHS staff cannot be expected to achieve and deliver a Scottish safety programme and its targets when there are so many unfilled vacancies across the board. We have been consistent in our calls for a solution to this crisis and have highlighted it time and time again. That is why we have lodged our amendment to the motion. The terms of the Government motion are entirely laudable, but given the crisis in staffing, we cannot simply leave matters as they stand. It is only realistic to expect progress. Yes, indeed. Thank you. I thank the member for taking that intervention. Would the member accept that the NHS staffing rates are at the highest that they have ever been and that this Government has increased staffing rates across all the staffing groups in the NHS? Donald Cameron. I have said many times that it is not enough. The professional body says that it is not enough simply to say that we have record numbers of staff. There are record numbers of people getting old in Scotland and we need sufficient numbers. Those are not just the cries from opposition parties. Some of the major professional bodies have voiced real concerns. BMA Scotland said that staff shortages could lead to a system breakdown and that the NHS is being stretched to a breaking point. The Royal College of Midwives said that, due to higher birth rates and a lack of recruitment, Scotland's maternity services are beginning to buckle. The Royal College of Radiologists said that Scottish radiology is on the brink of collapse. Crucially, they say that patient safety is at risk. We welcome and acknowledge the work that is being carried out by the Scottish patient safety programme to uplift standards and to share best practice. We recognise and support our NHS staff as they work to implement the changes that are required to ensure that all of Scotland's patients receive quality care. However, we also believe that in order for those results to continue to improve and come to fruition, the Government must commit to ensuring that staff vacancies are filled so that those expectations can become a reality. I move the amendment in my name. I thank the cabinet secretary for bringing this debate forward and to say that we will be supporting the Government's motion today. There is a lot to welcome in terms of the Scottish patient safety programme, which it has delivered for Scotland. On that, we should pay tribute to all the staff and the management who have helped to deliver the patient safety programme and thank them for the work that they are doing on the front line to support people in our national health service. Like Donald Cameron, I welcome the improvements in the mortality rates, the reduction in hospital deaths and the very welcome reduction in hospital-acquired infections. I am sure that everyone across the chamber will want to welcome them. I will come in a moment to talk about some other challenges that are associated with patient safety, but I want to once again take the opportunity to thank not just all those staff members who are involved in the patient safety programme, but our NHS staff right across the national health service who go above and beyond to deliver care for people right around the clock all year round, whether that be in primary care, whether that be in acute care, social care or specific services around maternity services or mental health. I genuinely thank you to each and every single one of them. I have to reflect, Deputy Presiding Officer, that we have had a lot of challenges around the national health service since this parliamentary term began. There are still some severe issues around the decisions that the cabinet secretary has made, the mismanagement of the national health service in many ways that has left our NHS staff overworked, undervalued and underresourced. Although I again say that I welcome the motion and we have always supported the motion, I think that the cabinet secretary should not simply be patting herself on the back but should look at the genuine challenges that we face. I welcome the fact that we finally have a meaningful debate on the NHS in Government time, but I would also hope that we could have a meaningful debate on the new health and social care delivery plan, which is a strategic approach for the NHS for years to come, or a meaningful debate on access to new medicines, or a meaningful debate on the maternity and neonatal review, or a meaningful debate on what is happening in our social care sector where we see continued cuts to local government budgets and meaningful local cuts to social care budgets. I listened to the cabinet secretary mention service reform, and I also read with interest the cabinet secretary's comments in the Holyrood magazine in relation to service reform. I have had Opposition members sitting in that very chair that you are sitting in, and I put those issues to them. They will sit in here and agree with me, but on the floor of Parliament you get into a different territory and they will say something entirely different. That is simply not true. Shona Robison is 100 per cent wrong, and she perhaps inadvertently, but I suspect not, is trying to mislead people about service cuts, because not once has the cabinet secretary met me or any of my front-bench colleagues. I cannot speak for any of the parties to imprive it to outline specific service changes that she proposes, and not once has she had the courage to come to this Parliament and make the case for the specific service reforms that she proposes. The only debate that we have had on service reforms has been in opposition time in which the cabinet secretary attempted to deny that any service reforms even existed, and on that day she even lost the vote, too. Why does the cabinet secretary not be brave enough to come to this Parliament in future and make the case for the service reforms that she supports rather than simply hiding behind the health boards? However, there are wider issues here, too, that also impact on patient safety. It is very clear that the resource is not meeting demand. How is that going to improve patient safety? Across Scotland, health boards are being held accountable for delivering improvements in healthcare and improving patient outcomes, but they are also having to make cuts year after year, forced upon them by the cabinet secretary. Cuts are more than £1 billion in the next four years—£1 billion of cuts. How is that going to improve patient safety happily? For the member, given the rate, with all due respect to Anna Sarwar, I am sure that he would accept that even the Tories and their manifesto for the election in May promised more for the health service than the Labour Party did. Therefore, instead of making all those chuntering noises about spending, if he could come up to the plate with real money from the Labour Party, that would help everybody in that regard. If every single thing that the cabinet secretary would suggest was not opposed by people and by way of reform, that would also help the process. I thank Bruce Crawford for that intervention. Perhaps as the chair of the finance committee he perhaps should have read Labour's budget amendment, which talked about how we use the tax powers of this Parliament to invest more in our NHS but also to use the tax powers to stop the cuts to local government, meaning cuts to social care, which also impact directly on the NHS. All I will gently say to the SNP benches is that you can repeat a line as offerings you like. It does not make it true. The reality is that there are cuts happening across health boards under this Government. We have also seen a complete failure to workforce plan with vacancies right across the NHS. More than 2,500 nursing and midwifery vacancies, including mental health nurses. It means that only a third of NHS staff feel that there are enough of them to do their job properly, and 9 out of 10 nurses say that the workload is getting worse. How is that going to improve patient safety? In primary care, we have one in four of Scotland's GP practices reporting a vacancy, asking staff to do more while they oversee the worst workforce crisis since devolution, leading to the chair of the BMA to warn that it will lead to personal breakdown and then system breakdown. How is that going to improve patient safety? We have cuts to local services across the country with maternity wards, a pediatric ward and intensive care neonatal units under threat. How is that going to improve patient safety? We have had the worst audit Scotland report since devolution, with seven out of eight, let me just finish this point, with seven out of eight patient standards failed, including A&E, cancer treatment and mental health. How is that going to improve patient safety? Shona Robison, back to the neonatal report. That report was a report of experts, including input from bliss, which is very much led by patient safety. Is Anna Sarwar saying that that report is wrong, and he knows better than the experts who have recommended those changes? Absolutely not. I welcome the Bliss Scotland report, but if you look at the findings in Bliss Scotland report, that is not a record to be proud of, cabinet secretary. That is a record to be ashamed of, because it talks about three quarters of units not having enough nurses or staff to meet minimum standards. The cabinet secretary wants to congratulate herself on the fact that three quarters of units do not meet minimum standards. Again, how is that going to improve patient safety? We have seen continued cuts to social care budgets, meaning that we have got chronic problems with delayed discharge, over half a million bed days lost in one year alone, with patients trapped waiting to go home. I asked the cabinet secretary how that is going to improve patient safety. We have audited Scotland again in a separate report, saying that now the spiralling costs of private agency spend means that we are now up to £175 million a year. Agency staff are likely to be more expensive than back nurses and also pose a greater potential risk to patient safety and the quality of care. That is audited Scotland saying that, not me. How is that going to improve patient safety? I explored the patient safety programme webpage, and I found an interesting article in that webpage, which I referred to a meeting of senior national health service managers in Greater Glasgow and Clyde. They posed three questions at this meeting. Remember that this was part of the patient safety programme. The first one is, why is the largest health board in Scotland in persistent financial overparity despite extensive efforts to overcome this via efficiency savings? That is civil service speak. Secondly, how will it be able to squeeze into a smaller bed complement with the new hospitals on the south side when demand is exceeding supply? Thirdly, why is the compliance before our accident emergency waiting time the worst in Scotland and deteriorating? Those are all serious questions. In closing, I ask the cabinet secretary if she really wants to improve patient safety, get her head out of the sand, address the workforce crisis, stop the cuts to local services, stop the cuts to NHS boards and actually meet patient standards across the country. I formally move the amendment in my name. To speak to and move amendment 4324.3, you can have a little extra time. The Scottish Liberal Democrats are absolutely happy to welcome this debate today, and we will be supporting the Government motion and all Opposition amendments. As a platform that aims to improve safety and harm reduction in any landscape where care is delivered, the patient safety programme sets an international standard. It successfully delineates an approach to safety from birth through to death, and at every stage and transaction in the delivery of health and social care in our society, I welcome the opportunity afforded in this debate to scrutinise its merits in granular detail. The welfare and safety of our citizenry must always be the alpha and the omega of our responsibilities as legislators, and the delivery of health and social care represents the largest such landscape in which we must, as public servants, discharge that duty. Since its inception, the safety programme has delivered groundbreaking interventions and the dissemination of best practice at every level of care in our society. From the prevention of sepsis, as we have heard, providing a whole systems approach to infection control and underpinned by robust data analysis, which is building a structured approach to all frontiers of patient safety. In a press release that programme was released in early 2015, it stated, patient safety problems exist throughout the NHS, as in all large complex healthcare systems in the world. However, it is not staff negligence but the systems, procedures, environment and constraints that are faced by healthcare professionals that lie at the root of most safety problems. I think that all of us share the sentiment that our health and social care staff represent some of the finest professionals in Scottish society. However, a structural problem exists that can run contrary to the efforts of the patient safety programme that visits symptoms on every aspect of our health service and that impacts on the work of the patient safety programme. Problems in workforce planning create a blockage that impedes patient flow through primary, acute and, ultimately, social care at every stage in the health journey. A shortage of GPs—and we know that at the end of this decade, we could have nearly 1,000 fewer GPs in our society—will require appointment delays, which in turn can see conditions become more acute and result in hospital admissions, where early intervention could otherwise have been prevented. That, in turn, exerts upward pressure that manifests in every other part of the health service. In coupled with the postcode lottery that is around the availability of adequate social care packages, that can lead to delays in hospital discharge, which we have heard from anasawa on a monumental scale. A recent volley of information requests issued by my office discovered the extent to where patients, in some cases, are staying in hospital for as many as 500 days beyond the point at which they are declared fit to go home. Shona Robison I hope that Alex Cole-Hamilton was copied into the letter that I sent to Willie Rennie on that subject. The cases that were highlighted, many of them were very complex cases where there were, for example, waiting for a house to be built or some very specific packages, and people who were readily able to be discharged from hospital. Would Alex Cole-Hamilton recognise those very complex cases that he is referring to? Shona Robison Alex Cole-Hamilton I thank the cabinet secretary for her intervention. I am delighted that she raises it, because when I raised FMQs we did not get to cover the fact that our specific FOI requested information on people who are left in hospital beyond the point at which they are declared fit to go home. It is entirely because of the social care package being unavailable, not because of houses being built and not because of very specific secure care needs. I am really glad that we have got the opportunity to thrash that out. I would like to return to a more consensual tone, but that presents an immediate challenge for patient safety programmes. We know that prolonged stays in hospital increase patient exposure to things such as pressure sores and hospital-acquired infection, even though we have heard how well we are doing in reducing that. Put simply, Presiding Officer, if we can get the workforce planning right by extension delayed discharge, we can take a giant leap forward in improving patient safety. I welcome the steps that are outlined by the cabinet secretary towards a plan in terms of workforce planning. The loci of the programme rightly extends beyond the traditional institutions in which health and social care are delivered, with the advent of new initiatives such as hospital at home and the decades-old approach to care in the community. We must turn also to ensure that patients are kept safe in any setting where they receive care. First and foremost, this must follow a proactive, preventative approach in which we can anticipate and mitigate risk from any outset. In December, I had the great honour to chair the older people forum in this chamber. It was a fantastic event—a very robust, vibrant exchange of views. In one session, I asked everyone about what they were most worried about and what was the thing that they were most concerned about. I was very surprised to learn that fear of falling outstripped crime, loneliness and money worries against everyone present. Given the commonality of falls and the direct causal link between falls and senior mortality, there is a great desire among older citizens for us policy makers to take action. That is why, Presiding Officer, I am calling for the Scottish Government to develop a national falls strategy, building on the work of the full prevention framework of 2014. That would include comprehensive training for all care staff, the employment of technology, a full suite of marketing and awareness, and raising materials to help older people stay safer in their own homes or in any setting in which they receive care. However, simply full prevention is one of the most important steps that we can take in promoting patient safety. The final area that I would like to cover, Presiding Officer, is around mental health and the mental health specifically in the work of the programme. Its inclusion is of course welcome, but it stands alone as a separate thread. To my mind, that stand-alone nature undermines the fact that it has a causal relationship with every aspect of patient safety. It is right that we should focus on physical safety, but there has to be an element of mental safety for our patients as well. At the moment, the patient safety programme focuses on restraint and seclusion and an understanding of risk factors, but it should also focus on prevention of mental ill health as well as a vital aspect of improving patient safety. In its work around safety and maternity, for example, it should look to the dissemination of best practice and roll out perinatal mental health specialist support teams across all of our health boards and share that knowledge. After all, one in five mothers will experience mental ill health as a result of pregnancy, and yet only five health boards have dedicated perinatal mental health teams. Similarly, in some cases where mental ill health strategy is a factor in patient care, any risk assessment around patient safety must include the likelihood of self-harm or suicide prevention. I am coming to a close now. That is why it is fundamentally important that the safety programme dovetail with a nascent mental health strategy and the successor to the suicide prevention strategy. We must be justifiably proud of that. It is an international standard, as I have said, and we should be proud of this patient safety programme, which is groundbreaking in so many ways. I certainly come to this chamber not to bury it but to praise it and to see it enhance it. Therefore, I move the amendment in my name. Twenty years ago, I was involved in the improvement of safety in the perioperative environment in the United States. It was a collaborative approach with the United States Institute for Healthcare Improvement. For example, I taught best practice and standardised approach for surgical counts of swabs, needles and instruments so that retaining or losing a surgical instrument inside an abdomen could be avoided. There is a growing implementation of non-technical skills to safeguard patients as well, and that was adopted and promoted in the USA as well as here in Scotland. Situation awareness, good decision making, flattened hierarchy, leadership and a good approach to teamwork and communication. In Scotland, that research has been procured and then continued by Professor Stephen Ewell and others at the IPRC in Aberdeen. As a clinical educator for NHS De Friesen Galloway, the training programmes that were initiated by myself and my colegs for healthcare support workers and nurses had a specific focus on safe, effective person-centred care. I collaborated with colleagues regarding verbal handover from the anaesthetists to the post anesthesia recovery room nurses so that clear plans of care were identified and documented. I provided education about deep venous thrombosis prophylaxis and prevention of central venous access line infections and medication safety so that the right patient, the right drug, dose, route and time are achieved for improving our safety of our patients. Quick snappy education sessions were also delivered using the one-minute education approach, and we used that for sepsis 6 as being only one of the items that we educated on. I could continue to give more examples of those seemingly small but immensely important measures that can make a difference between life or death. They are vital to the important improvement of both acute and primary patient care. I am pleased to be able to speak in today's debate, not at least as it enables me to say to this Parliament that my former colleagues in the NHS of De Friesen Galloway and across NHS Scotland deserve to be commended and congratulated for their on-going work to promote best practice using evidence-based care. Too often we hear nothing but negativity surrounding our NHS and I can tell you today that this has a very real effect on the morale of nurses and doctors. I was very proud that Scotland, the first country in the world to launch a national patient safety programme, it happened in 2008. The programme has been vital to delivering the highest quality healthcare services to the people of Scotland and it recognises world leading in the quality of healthcare that it provides. In fact, Barack Obama mentioned Scotland as one of the best health systems in the world when he was president. Since its launch, the acute adult programme has contributed to a significant reduction in harm and mortality to adult patients through measures such as those that I described above and many more. Since 2008, the scale and ambition of the programme has grown and the work that began in acute adult hospitals now extends to primary care, mental health and maternal and child health. There are many examples of cultural change brought about by the programme, notably in mental health settings where we have seen a real shift in the approach taken to the administration of psychotropic medication and improvements in how challenging behaviour is managed. The SPSP will be a service that continually adapts to meet our changing needs, embraces new technologies and approaches to care. We should be proud that, thanks to its implementation in Scotland, it plays a leading role in patient safety initiatives in Europe. NHS England officials have praised the programme, stating that they hope to use the experiences and learning to take forward in England. According to Mark Wittenberg, a clinical fellow at NHS England, the programme is unrivaled and contains much that should be replicated in England. The figures of 8.6 per cent reduction in hospital standardised mortality, coupled with the praise from bodies such as the OECD and NHS England show exactly why our Scottish patient safety programme deserves its international reputation as a world leader. I welcome the chance to speak in this debate on the Scottish patient safety programme, and the excellent work that our healthcare professionals do in ensuring the quality of care and the safety of patients is of the very highest standard. While it recognises the significance of the Scottish safety programme, I think that it is always incumbent upon the interested parties to continually examine the programme and look for ways to improve it and enhance it, and that includes in this chamber. In the short time that I have, I would, if I may, look to make two points. First, I would like to highlight that, delivering the patient safety programme, it is essential that we recognise that a key element in its effectiveness is the safety, health and wellbeing of the NHS staff themselves. We will have to recognise that the system is under quite a bit of stress, which has a detrimental effect on those who are working within that system. For example, with Ayrshire and Arran health board, there is a consistently higher than average Ameson T rate in the neonatal and midwifery section, sometimes more than double the national average, and this has been the situation for at least the last five years. This, of course, to me represents a department that is under quite a bit of pressure. Furthermore, we know that there is a growing issue of losing experience from the profession with some 1,200 midwives in Scotland over the age of 50 who are eligible for retirement at 55. This experience cannot be replaced by newly qualified staff, which have not addressed, could put staff in situations in which they have no experience and, crucially, without the support of more experienced staff. This has to speak to a heightened risk to patients, especially in emergency cases. I know that the Royal College of Midwives recognise that and are tempted to recruit experience from outside of Scotland. Indeed, the last time I spoke to the head of the Royal College of Midwifery a couple of weeks ago, she was at an event in London where they were actively promoting Scotland as a career destination. There is a general recognition that the new neonatal strategy announced by the Cabinet Secretary last week is a step in a positive direction. However, the workforce does not have enough capacity to deliver the strategy once again the safety of patients will be brought into question. Midwives want to get away from what the RMC described as conveyor belt care and into a more personal care where they can effectively address preventable health issues. That leads me to the second point that I would like to make. When things go wrong, it is crucial that NHS boards are in learning mode and they are able to scrutinise system failures as well as where clinical issues arise to ensure and enhance future patient safety. However, there is no national standardised process describing what constitutes a significant adverse event with the NHS trust reporting significant adverse events in widely varying numbers. What is more, when health improvement Scotland review cases it seems they do so under the instruction from the Scottish Government and when they do they can only offer recommendations. There is no regularity powers apart from in the private sector. We need to consider if those recommendations are implemented, how we audit the implementations and how it is further reviewed. In conclusion, in highlighting the importance of patient safety, we should recognise that the safety and working environment of our HEPs is crucial. Staff numbers are inevitably linked to the health and wellbeing of NHS workers and therefore speaks to the safety of patients. When considering patient safety, it is important that a national system for triggering a significant adverse event investigation is in place and allows for a consistent response that staff and patients feel comfortable engaging with and giving feedback to. Furthermore, any recommendations made by any review must be rigorously implemented and reviewed to ensure consistent learning continues to enhance the patient safety programme. Fulton MacGregor, to be followed by Elaine Smith. Thank you, Presiding Officer. I am pleased to speak in this debate and I will take the opportunity to remind the chamber that I am the parliamentary liaison officer to the health secretary. As has already been alluded to, the hospital standardised mortality ratios for Scotland has decreased by 16.5 per cent between 2007 and 2015, and now the latest published figures show that there has been an 8.6 per cent reduction in hospital standardised mortality ratios in Scotland's hospital since the baseline figure from 2014. Not only that, but a total of 10 hospitals have shown a reduction in excess of 20 per cent, including Munkmans hospital, which serves my constituency. I have a personal story here. In January 2000, my gran was admitted to Munkmans hospital and sadly passed away there after contracting pneumonia. Although she would want me to point out that the care that she received was tremendous, and there is no fault in terms of the staff at the hospital, it is heartening that statistics such as those, which inevitably she has won off, are decreasing over more recent years. Munkmans hospital over the last decade has regained its good name. It has absolutely shocked me over the past few weeks, including First Minister's questions last week for members of the Labour Party, calling the saving of the A&Es across Scotland, including the one at Munkmans, a 10-year-old story that does not want to be heard. That is something that has actually been niggling at me for quite a wee while, because I beg to differ with that and I expect that thousands of patients whose lives have been saved also disagree. I want to put on record today that Munkmans A&E is a vital service for my community, and the fact that it was saved 10, 20 or when it is 30 years should not simply be dismissed. Elaine Smith Thank you, Fulton MacGregor, for taking that intervention, but would he state just now on the record that the A&E at Munkmans is fully and properly staffed at the moment? Thank you, Elaine Smith, for her intervention. It is my belief that it is fully and properly staffed. I thank the member for that intervention. Despite the significant challenges of Scotland's public health record, Scotland's changing demography and the economic environment, the Scottish Government has set out a strategic vision for achieving sustainable quality in the delivery of healthcare services across Scotland. The 2020 vision that the Government has set out delivers a necessary strategic narrative and context for taking forward the implementation of the quality strategy and the required actions to improve efficiency and achieve financial sustainability. I welcome the Scottish Government's 2020 vision when everyone is able to live longer and healthier lives and ensure that we have a healthcare system where health and social care go together hand in hand and we continue to focus on prevention, anticipation and supported self-management. I think that it is critical to continue in pursuing the goal of providing the highest standards of quality and safety regardless of the setting with the patient at the centre of all decisions. It is therefore important that all forms of support across our communities are nurtured. On Monday, this week, I visited the Coatbridge meeting of Lanarkshire's carers group. I heard their first hand from all the carers about how much they valued that service and how worried they are about the pending cuts from North Lanarkshire Council and how that might impact how they care for their relatives. I think that it is imperative that we support across the board. I have also had contact with the St Andrews MS group, where the chairperson is a member of my constituency. He is also at present fighting for an increase in the number of specialist MS nurses across North Lanarkshire. I have submitted a question to the cabinet secretary to that effect, but that is yet another example of how we can support other groups that are trying to support themselves in this area. As we have also heard, the key part of this debate has been that the SNP Government has enshrined safe staffing and law and the consultation period will begin early in spring. The link between safe and sustainable staffing levels and high quality care is well established. It is vital to have the right number of staff in place, as others have said, with the right skills. I really welcome Emma Harper's contribution to the debate in bringing in her experience with that. Scotland has led the UK in the development of nursing and midwifery, for example, and the implementation of workforce planning tools. Progress has been made, but with changing demographics and in the face of Tory cuts, we must continue to work together and be innovative across all health services so that those that serve my community and all others across Scotland are the best that they can be. I call Elaine Smith to be followed by Mary Todd. Ni Bevan said that illness is neither an indulgence for which people have to pay, nor an offence for which they should be penalised, but a misfortune, the cost of which should be shared by the community. That was why Labour created our NHS and it remains one of people's most valued assets right across Britain. However, people expect it to be safe when using it, and so, whilst that unique plan is welcome, we must consider it closely and strive always for improvement. It is important to make it clear at the start that our hard-working NHS staff deserve our thanks for all that they do, but they are under extreme pressure. The use of agency staff has increased with spending and rocketing in the past four years, despite Audit Scotland warning that agency staff are likely to be more expensive than bank nurses and also pose a greater potential risk to patient safety and quality of care. I am sure that we can all agree in the debate this afternoon that improving our hospitals and keeping staff well trained and at safe levels takes investment and long-term planning and is something that we would all want to see. Under the plan, safer use of medicines is a worthy goal, but it is not well served by not providing people with correct medicines in the first place. The cabinet secretary has mentioned that on Monday, Scotland's chief medical officer, Dr Catherine Calderwood, said that doctors should spend more time listening to their patients to avoid unnecessary treatments. Dr Calderwood calls this realistic medicine, focusing on quality of life, not efficiency of treatments. However, it is not realistic for some patients if they cannot actually get the medicine that they need to live a normal life. I want to give an example of thyroid patients here who are mainly women. Far too many are not being properly diagnosed, they are being refused access to liothyrinine and they are forced into buying desiccated thyroid hormone over the internet and that is hardly safe and it is not putting patients at the heart of their own care. It is also common for some thyroid patients to be prescribed antidepressants, perhaps because their GPs do not have the time to listen to their patients and therefore cannot reach a proper, safe and correct diagnosis. That is an example where patients with chronic disabling and life-threatening conditions are being deprived of treatment due to cost or closed-mindedness on behalf of the medical establishment and NHS boards, as well as GPs being under immense strain. It is something that should be considered further. The Petitions Committee of the Parliament is considering it at the moment. Getting patients in and out of hospital safely and for the right amount of time is a key concern for patient safety. Labour obtained official figures back in January, which showed that 683 people died in hospital between the start of March 2015 and the end of September 2016 after being deemed medically fit to leave. Of course, we have promises to end the practice of bed blocking, but getting into hospital at the moment for desperately needed operations is a problem. In NHS Lanarkshire, there is an up to 24-week wait for an initial appointment for a hip replacement. That is 24 weeks in extreme pain for older people who will then have another long wait for the actual operation. That is despite the Government giving a 12-week guarantee, although I accept that it is not a legally binding one. What happens afterwards? I know that the figures may show a decrease, but I am becoming increasingly concerned about people that I am hearing about with acquired infections. I think that that is something that many people need to look at. I am also concerned about those who tell me that aftercare is poor, and that seems to be due to staff shortages and, in some cases, to low morale. Actually, a recent story, which was quite disturbing, was of a constituent who waited 30 minutes pressing her buzzer and then had to suffer the indignity of having to wait herself. It is also important to consider the kind of people who are dying in their hospitals and why and how we might be able to prevent that. We know, for example, that Scots from poorer backgrounds are 64 per cent more likely to die of cancer, and we know too that general health outcomes for those in deprived areas, specifically greater Glasgow region, are some of the worst in Europe, and those inequalities must be addressed. As well as tackling workforce planning, increasing patient safety in our hospitals requires us to ease tensions on the hospitals themselves, and that needs prevention, as has been mentioned before. The 2016 NHS audit report found that many NHS boards across the country struggled to achieve financial balance, and overall NHS Scotland failed to meet seven out of eight key performance targets. That is not exactly a picture of health, and it will only get worse if we do not continue to take action and continue to make improvements. I am absolutely delighted to be able to participate in this debate. As many of you will know, I worked as a clinical pharmacist specialising in mental health until my election last May. I can honestly say that in my 20 years of working in hospital, nothing has come close to the effectiveness of the Scottish patient safety programme in terms of change management. I hope that today's debate will provide reassurance to my Lib Dem colleagues that there is a step change occurring in mental health services already. The SPSP is about delivering reliable, safe care for every patient every time, 24 hours a day, seven days a week. As the cabinet secretary already mentioned, in mental health the safety programme supported improvements at a ward level, where there have been examples of reductions of up to 70 per cent in the number of patients who self-harm, 57 per cent in the number of incidents in which physical restraints had to be used, and 78 per cent in the number of incidents of physical violence in the ward. Those figures are absolutely phenomenal, and they come from some of the most disturbed words in Scotland. What is so special about SPSP? The methodology empowers staff to identify what is not working well, make changes and, while monitoring the impact of those changes by on-going use of data collection. Data is incontrovertible, which makes it really powerful for instigating change. Let me tell you about some of the progress that has been made at the hospital that I used to work at, New Cree's hospital in Aberness. Before I left, we had been using SPSP methodology for medicines reconciliation. It might seem simple, but the process of creating the most accurate list possible of all of the medications that a patient is actually taking and comparing that list against the records at transition points when errors are most likely to occur has dramatically reduced errors. The next focus of our attention was the use of as-required medication. This is where medications are used to alleviate symptoms of distress and agitation, so not a regular prescription. For some time now, coloured stickers were used in the notes to highlight the use of this type of medication—red for intramuscular injections, yellow for oral drugs. The stickers prompted staff to record how well the patient responded and the bright colours in the notes were a crude visual cue as to how well the patient might be. An audit of those stickers at New Cree's highlighted that over 50 per cent of the time when those drugs were being used, the patient only had a slight improvement or no improvement in symptoms, so discovering that an intervention does not work half of the time, of course warrants a response, and the pilot team proposed seeing if alternatives to medication might be of more benefit to a patient. All of the staff, including my pharmacy colleagues, had training on decider skills. The training was excellent and techniques are popular with the staff and patients alike, and clearly learning those skills, teaching those skills to patients, has the potential to have a much more lasting benefit than medication. Now, as well as the yellow-red sticker system, there is a green sticker that is used to record the score of the psychological intervention from both perspectives, from the nurse's perspective and the patient's perspective. I hope that that example demonstrates the power of this incontrovertible data to drive change. The fundamental issue with SPSP is that it empowers the staff at the coalface. My colleagues are increasingly turning to this methodology as the standard approach to problem-solving and process improvement. As I have mentioned before, this Government is enabling all healthcare professionals to develop and take on new roles. In order to support GPs and other primary care colleagues, the pharmacists at U Craig's have all trained as prescribers and they are taking their skills from the hospital, out into the community, and the SPSP methodology will be ingrained in that change to identify and improve any processes that are not working well. To sum up, let me finish by saying that Scotland is absolutely leading the way with the Scottish patient safety programme. Our ambitious and comprehensive approach to improving safety and quality of care might have caught the interest of the rest of the world, but it is the results that have made it really impressive. Alison Johnstone is followed by Clare Hawke. Government's motion today acknowledges the success of the Scottish patient safety programme. It also acknowledges the significant challenges that face the NHS. Given the scale of those challenges, we must take stock of approaches that do work, learn from them and build on opportunities to expand them. However, the amendments that are presented today all rightly address workforce shortages, which undermine the efforts of our NHS staff to provide the best possible care. Staffing levels are essential to patient safety and demand is often outstripping supply. The latest ISD figures show that many patients are facing unacceptable weights for diagnostic tests and treatment. I am worried that, while our health service is delivering very high standards of safe care to most patients, many others are being left too long without the care that they need. The Government points to its long-term strategy, but we also need urgent action to improve access to care for patients who need it today. We have been promised a new national workforce plan, but I am not wholly encouraged by recent signs such as the modest uplift to student nurse numbers. An increase of 142 student nurses is not ambitious enough, not when 28 per cent of nursing posts in the care home sector are vacant. Bliss Scotland's report on our maternity and neonatal services found that many of our neonatal units do not have enough nurses in posts and that most struggle to ensure that nurses get appropriate specialist training. That training and support is essential. We know that, when staff are well supported and their experience is valued, they can achieve fantastic results for patients. The patient safety programme has delivered some of the best examples of improvements in our healthcare system, and that is because it gives staff the opportunity to drive change themselves, as we have heard. Learning from this approach can help to make our hospitals and our community health services more attractive places to work in. Sometimes, NHS targets are criticised for creating perverse incentives, contributing to a tick box culture and putting processes, not patients first. However, the patient safety programme set ambitious goals, and it has surpassed many of them. Indeed, the Royal College of Nursing Scotland in its briefing for us in November last year said, there have been real improvements in the way health services are delivered in Scotland over the past 10 years, for example the patient safety programme. A 16 per cent reduction in hospital mortality, an 18 per cent reduction in stillbirth rates, a 21 per cent reduction in mortality from sepsis, colleagues have raised those, and they are clear and significant changes and improvements. All achieved by staff working together to review their practice, question their normal processes and develop safer alternatives. That is brave work, and I wish to thank all the staff involved in the pilots, collaboratives and improvement projects across Scotland. I am very glad that the patient safety programme is now moving into care homes. It has set a target of reducing harm from pressure ulcers by 50 per cent in hospitals and care homes by December this year. That will greatly improve quality of life for many people. We need to ensure high standards of safety as health and social care is integrated, and that is the kind of approach that we need. I want to see the successes of the patient safety programme reach even further, not just to care homes but to those who are cared for at home and in our communities. Very often people feel that a frail elderly relative would simply be safer in hospital, that that is the best place for them. They are more confident that risks will be minimised there. We need to take the patient safety programme's rigorous approach to improving the safety of vulnerable people cared for at home too. There are clear challenges there because at the moment social care staff do not have much chance to lead improvements to care services. They often have to work in relative isolation under pressure with few opportunities for training and development. One strand of the patient safety programme is its highly regarded fellowship programme, which allows clinicians to develop their leadership skills, strengthen collaborations and learn directly from international experts. It is crucial that we invest in our future clinical leaders. In the long term, we have to develop equivalent mentoring, training and expert support for our social care staff. Back in our hospitals, however, there are concerns regarding the ability of consultants to teach up-and-coming medical students, and that has implications for patient safety. It leads to the perception that Scotland is a nine-to-one country, and that is a reason that is cited by consultants who are not attracted to practice medicine. It impacts on their contribution to the NHS. However, one crucial aspect of the programme is that it encourages people to be open about failure. Today's debate has highlighted great successes, and we should be proud of the staff who led the challenging work, because they were not just looking for good news stories but examples of failure that others can learn from. Presiding Officer, I applaud all those who have contributed to the patient safety programme and its outstanding achievements. Clare Haugheyd, who is followed by Jeremy Balfour. I would like to refer members to my registered interests. I am a registered mental health nurse. I am proud to say that Scotland's health services are again leading the world in innovation. Because of the commitment that this Government has to this sector, we are rolling out new ways to deliver healthcare in the 21st century Scotland. The wider integration of health and social care, again spearheaded by this Government, acknowledges that taking care for individuals without looking at all of their needs can only get us so far. We recognise in Scotland that we need to have a holistic system to tackle problems that have multiple contributing factors, and the Scottish patient safety programme recognises that. I would argue that nowhere is this more in evidence than in the area of my own clinical practice mental health services. When we look to treat the person rather than the condition, we take into account their own experience of their illness, their individual strengths and what their recovery means to them. This approach is especially relevant to those receiving treatment from mental health services, as those patients frequently experience unique challenges—the challenges that the SP-SP tackles. It does that through five main work streams—safer medicine management, risk assessment, violence and restraint reduction, communication and strong leadership. The five prong process works by placing the requirement on healthcare professionals to systematically gather information on those key areas and to tailor their care for the individual accordingly and based on evidence. To deliver that, the patient safety climate tool was created, ensuring that patients' voices are heard when their care is being planned. That tool invites patients with mental illness to record their experiences of receiving treatment, from how they feel an award to how their medication is affecting them. Their experiences are recorded and the staff are committed to acting on that feedback that the patient gives them. For patients, that is an empowering experience, but it is more than that. That is an extremely effective system with its success borne out in the figures. There have been more than 600 patient safety climate tools and 3,000 staff climate surveys completed in the past four years. Those gather both the patients and the staff's feedback too. That is a huge amount of real intelligence on patients' experiences and the experiences of staff on the wards. That is already having a demonstrable effect on care, with participating wards showing massive improvements. As my colleague Mary Todd already alluded to, there are reductions in restraint of up to 57 per cent. There are reductions in the percentage of patients who self-harm of up to 70 per cent. There are reductions in the rates of violence of up to 78 per cent. Those are amazing figures that we can all support in this chamber. When violence drops to a quarter of existing levels and when self-harm drops to less than a third, that is a massive improvement in the lives of real people, both patients and the healthcare professionals who look after them. That presents a fantastic opportunity to improve mental health care nationwide and to share our learning internationally. Those numbers should be applauded and there is concrete evidence that using a human rights centred approach in mental health care just simply works. When we engage with patients, we use their feedback and tailor their care and environment appropriately to everyone involved benefits. When we empower healthcare workers to share their experiences, to learn from their patients and to tailor their approach, we ensure that care is personal and that outcomes are improved for everyone. We are fortunate with the devolved NHS that we can seek to implement those holistic human rights centred solutions to the specific problems that Scotland faces. With mental health wards already experiencing the benefits, I look forward to this approach rolling out to more services across the country. I call Jeremy Balfour to be followed by Richard Lyle and Mr Lyle will be the last speaker in the open debate. I declare an interest for having a number of family members who work in the NHS. The Scottish patient safety programme was launched in January 2008, a five-year national programme to reduce mortality and adverse events in acute hospital settings. Undoubtedly, there have been successes, deaths cut by 15 per cent, adverse incidents by 30 per cent over the last five years. The most recent phase of work was completed in March 2016. Again, reductions in harm were down, which can only be welcomed by everyone. The care provided by NHS staff is fantastic. We all agree on that. Just because sometimes we critique or comment on Scottish Government policy does not mean that we are attacking frontline staff. It is sometimes unhelpful for Government members to keep saying that we are attacking frontline staff when, in fact, we are pointing out what a good job we are doing in very difficult circumstances. I thank Mr Balfour for taking that intervention. Perhaps he and his colleagues might reflect on some of the language that they use in the chamber when they describe the NHS and use emotive language such as crisis and the effect that it has on the staff that are working in the NHS. There is nothing to do with the frontline staff—it is all to do with its Government and its lack of action. The Scottish Parliament has definitely helped to create a safer culture. By staffing levels play an essential part in patient safety. Coming across a range of clinical specialities, the NHS is facing a severe workforce and staffing issue. If we look at what is coming up in the next few years, it is likely that this is only going to get worse. A freedom of information request made by the Scottish Conservatives earlier this year revealed that dozens of adverse events are recorded every day in the dementia wards of Scotland's hospitals. Over 160,000 such incidents have occurred in the past six years. An under-pressure health service attempt to deal with an ageing population, with incidents raging from thaws to assaults and staff to self-harm and patients at leaving facilities. Much more seriously, bosses at NHS Greater Glasgow and Clyde said that adverse events had resulted in the death of 49 patients since 2011. Patients in dementia wards are among the most vulnerable in our hospitals and deserve the best possible care for their sake and for the comfort of family members. There is no question that wards dealing with dementia patients are in very challenging places to work. In such environments, many of those adverse incidents will have been unavoidable, but it is a credit again to front-line staff that we deal with these day in and day out. Patients in these wards and their families will be extremely worried at the sheer scale of those flashpoints. There are a significant number of incidents that will put down to staffing shortages or a lack of adequate resources and training. Again, that is not front-line services thought, it is Scottish Government's thought. We need to see a plan to make sure that our staff and hospitals are equipped for all the future challenges that they face. While SPS is playing an important part in improving safety and keeping patients safe, we need to make sure that our staff and hospitals are equipped for the future challenges that they face. I am delighted to be contributing to the debate on the Scottish patient safety programme as a member of the Parliament's health and support committee. Scottish patient safety programme is the first world-leading system of its kind to be implemented on a national basis, focused on advancing the safety and reliability of healthcare. The Scottish patient safety programme includes safety improvement programmes for acute adult healthcare-associated infections, maternity and children, medicines, mental health and primary care. The Scottish patient safety programme is an international benchmark for safe care. The programme demonstrates a key relationship between the Scottish Government, the NHS Scotland, towards a shared desire to provide safe care and reduce harm, as well as achieving sustainable quality healthcare for everyone throughout Scotland. In particular, healthcare improvement Scotland has partnered with the NHS to achieve the goals set out by SPSP to help NHS Scotland to deliver high-quality evidence-based, safe, effective and personal-centred care to scrutinise services to provide public assurance about the quality and safety of that care. The idea of the evidence-based care is reliant on close personal hands-on staff throughout the NHS in a variety of care settings all over the country. The attentiveness of each individual patient is what has allowed for continued reliability and improvement of routine healthcare systems and processes. The impressive work that is demonstrated by the NHS Scotland staff has progressed since 2008, despite demands raised by an ageing population in addition to integrating health and social care services. Since 2008, implementation of the Scottish patient safety programme has seen improvements in healthcare across all individual safety improvement programmes. For instance, the safety improvement programme for mental health has seen an increased number of wards and units showing improvements in rates of violence and restraint. From 2008 until now, there has been a reduction of up to 64 per cent of patient restraint, a 75 per cent reduction for patients who self-harm, and up to 80 per cent reduction in rates of violence. In 2012, the acute adult programme has done so well that the Cabinet Secretary for Health and Well-being expanded its aims on top of its primary responsibilities such as building capacity and capability within clinical and non-clinical roles. Those new aims were the further to reduce mortality in Scotland's acute hospitals and to further reduce harm experienced by patients in Scotland's acute hospitals, which has been achieved throughout continuous improvement. The groundbreaking work that the Scottish patient safety programme has achieved is unique to Scotland and the healthcare programmes internationally. It is aimed to reduce Scotland's mortality rates in a safe and effective way and has been incredibly successful thus far. In upcoming years, NHS Scotland and programmes such as healthcare improvement Scotland will face challenges concerning the wellbeing of Scots. However, the innovation and improvement approaches that the Scottish patient safety programme implements will make those challenges surmountable. Once again, this initiative is a perfect demonstrator of an incredible service that is the national health service in Scotland. I am proud that we here in Scotland not only continue to protect our NHS, delivering world-weaving healthcare but also that we are the pioneers of innovative approaches such as SP-SP. Once again, with any health debate, we wish to pay tribute to all who work in their NHS. In closing, I previously worked as a part-time out-of-hours driver for doctors in NHS 24. I have personally seen myself the excellent work done by all A&E departments in Milanochshire. We do have one of the best health services in the world. Since coming to this place in 2011, I have seen increases in health spending going up tremendously. Yes, there is more to do, but let's stop kicking the political health football. We have seriously got to look at what we are doing, what we are providing, how we can improve it, and how we will support our health providers. I, for one, have to say to our cabinet secretary that, as she and I know, she is totally committed to her brief. I thank her for it. Thank you very much, Mr Lyle. We have one culprit not in for the closing speeches, though I think that Annas Sarwar is holding his breath. He might have been summing up at one point for Labour. I note undoubtedly the SNP whip. We'll let Fulton MacGregor know that it would be good if he'd come in just to let us have his company in summing up when he's been in a debate. We move to the closing speeches. I call Alec Cole-Hamilton, please, to close for Liberal Democrats. Five minutes, please, Mr Cole-Hamilton. Thank you, Deputy Presiding Officer. We've had an excellent debate this afternoon. I think that there is a lot of common ground in terms of the recognition and support for the work of the patient safety programme. I wonderfully delineated in the excellent speech by Richard Lyle, who laid out, in granular detail, the successes and the huge advances in patient safety that the programme has delivered. I reflect on the fact that Donald Cameron mentioned in his opening remarks that the Opposition amendments are very, very similar today. That was entirely uncoordinated in respect of workforce planning. It shows the depth of political concern on this matter. While it feels like Donald Cameron, Anna Sawa and I have turned up at the same party in the same frock again, it demonstrates the significance that is attached by parties across the chamber to the staffing crisis in our NHS. It was echoed very eloquently by Alison Johnstone in terms of the Green Party perspective as well. We have heard it time and time again. Staff shortage is having a material impact on patient safety in our NHS and in our social care workforce, either because appropriate clinicians are not available or, if they are, they are worked to the point of burnout. Brian Whittle made excellent points in his speech on the impact that that can have on staff safety, particularly in respect of the staff absence, which can lead to exacerbating the wider problem. Fulton MacGregor recognised the importance of having a full complement of staff but did not pay heed to where we get them and how we address the crisis in our NHS. Cabinet Secretary, I thank her for that. In her opening remarks, she opened an avenue of the discussion that I had not considered. That was the reference to the excellent report published by the chief medical officer, Dr Catherine Calderwood, on realistic medicine. Clare Hall rightly points out the need for right-space patient planning. For me, nothing says that finer than the treaty that is housed in realistic medicine. As a liberal, this speaks to my core values that ultimately patients, when equipped with all of the information around their situation, will make decisions that are right for them and that will sometimes surprise their clinicians and choose less life-extending interventions in favour of spending their last few days in the comfort and dignity of their family home. I hope that we have opportunities to unpack further the intellectual arguments in this chamber over the quantity versus quality of life and the harm that too much focus on the former can do. Donald Cameron said that this unites the chamber and that the programme is internationally recognised. It really is. It outlines some of the context against which it was originally brought in and the measurable impact it has had not just on reducing harm but on the measurement of human lives saved and the reduction of preventable deaths, a theme that was then picked up by Jeremy Balfour. As Sarwar rightly pointed out and referenced the spectre of major service redesign and the potential impact that that might have on patient safety, should that not receive the full scrutiny of Parliament as we have voted for it to do so before. Elaine Smith also made excellent points about access to medicine and underscored with harrowing examples the blockage currently preventing patient flow through our health system, especially around the hundreds and thousands of bed days lost to delayed discharge. So much of what Elaine Smith said in her excellent contribution was particularly around the needs of older people. I very much hope that the Scottish Government will respond to my call for a national falls strategy in their summation this afternoon, because that was a theme that was touched on by Jeremy Balfour in his contribution about the needs of dementia patients and dementia wards and the distance that we still have to travel. I mentioned particularly the remarks of Marie Todd, who very kindly referenced our amendment, but said that there was a step change happening in mental health in this country. I take issue with that. She and I were attendees at the same mental health conference last week, where it was very clear that we are far from a step change in mental health. We are still lacking talking therapists in every GP surgery in the country, something that the Liberal Democrats will not cease from calling for, because that is the only way of delivering on the Scottish Alliance for Mental Health call for asking once and getting help fast—same to in terms of investment in CAMHS and other sectors in the mental health area. That said, I think that we are very well served in this chamber to have the expert professional knowledge of members such as Emma Harper, Clare Hohe and Marie Todd. In the spirit of cross-party consensus, I look forward to hearing their contributions and following their guidance in this area. They are right that the patient safety programme is something that is world leading and that we should all be justifiably proud. I believe that the Opposition's amendments today seek not to denigrate it but to enhance it. Thank you, Deputy Presiding Officer. During this afternoon's debate, members have all acknowledged the positive impact that the Scottish patient safety programme has had since its establishment in 2008. Richard Lyle, in particular, summarised the list of successes well. The cabinet secretary, among other things, highlighted the success of the surgical safety checklist where Scotland is leading the way, and that is something that we should all be very proud of. She stressed the fact that the encouraging outcomes of the programme has led to expanding recently to include paediatric and neonatal care, maternity, mental health services and primary care, increasing the positive impact of the programme on our health and wellbeing, such as improvements in mortality rates, stressed by the cabinet secretary and Donald Cameron. Alison Johnstone also rightly made the valid point that the programme had surpassed its initial goals. A number of members made important constructive suggestions of further improvements, such as Brian Whittle's point about consistency and the measurement of adverse incidents, and Alex Cole-Hamilton raised the issue of a national fall strategy. It is important that we build on the success of the programme. We know that the overall trend for premature deaths is one of steady improvement and life expectancy in Scotland has risen from 64 years for men and 69 for women when the NHS was established to 77 for men and 81 years for women today. That only paints part of the picture. Premature death is still much more common in Scotland than it is in England and Wales. Elaine Smith highlighted that there are huge disparities between deprived and more affluent communities. As the Health and Sport Committee's report on health inequalities said in 2015, a boy born today in Lindsay Eastern Batonshire can expect to live until he is 82, yet a boy born only eight miles away in Calton in the east end of Glasgow has a life expectancy as low as 54 years. A difference of 28 years is almost half as long again as his whole life. The solutions to this, appalling fact, cannot be tucked away in patient safety or indeed any part of the national health service are written off as a problem of individual behaviour. If we want to tackle health inequality, we need to be more serious about tackling wealth inequality. It is fair to say that every member today has rightly stressed the often heroic efforts of our health and social care workforce and the outstanding contribution that they make to our health and wellbeing. As Anas Sarwar said, there would be no patient safety programme without the work of our healthcare staff, but the truth is that there is not enough of them to keep doing what we need our NHS to do. It is not good enough for some SNP speakers to keep saying that we have more doctors and more nurses but fail to acknowledge that staffing levels are simply not keeping up with growing demand. We need an honest debate about the future funding and staffing of the health and social care sectors. We all accept that we have an ageing population and more people with complex care needs. However, despite a growing demand for services, local health boards are still being hit by significant health savings targets, £1 billion over the next four years, and that cannot be achieved without impacting on services. Those cuts come at a time when the NHS is struggling to recruit and retain staff, which is exasperated by the number of unfilled trainee and specialist posts. One in four of our GP practices reports of vacancy and we have a ticking time bomb of GPs queuing up to retire. The Royal College of General Practitioners has predicted that by 2020 Scotland will have a shortfall of 830 GPs, which we needed just to return to 2009 levels. It is not just in GP numbers that we have that crisis. Yes, it is a crisis. There are more than 350 consultant vacancies, nearly half of which have been vacant for more than six months. There are 2,500 nursing and midwifery vacancies, including more than 300 unfilled mental health nurse posts. The consequence of the failure of the Government's workforce planning is not only high vacancy rates and training posts that are unfilled across the NHS, but it is increasing the burdens on existing medical staff, which are adding to an already unsustainable workload. As Dr Peter Benny, the chair of the British Medical Association in Scotland, has warned, our NHS workforce is stretched to breaking point. Emma Harper shared her own invaluable experience, but she also touched on the issue of staff morale. Let's look at what really damages staff morale. The Royal College of Nursing surveyed its members and revealed that 90 per cent had said that their workload has got worse. That is what damages staff morale. NHS Scotland's own staff survey showed that only a third of NHS staff feel that there are enough staff to do their job properly. That is what damages staff morale. I had the sixth sense that Ms Harper was going to rise to that, but she did not let me down. The reason for staff morale is that it does not matter what a nurse does in a shift, she will always or he will always feel that they could do more. The surveys, I think, are sometimes not the best way to portray it. I am sure that Mr Anasarwar is helping you with the response to that right now. I hope that what Emma Harper will do is to read the surveys that have been published by the Royal College of Nursing. 90 per cent said that their workload has got worse. NHS Scotland's own staff survey said that only a third of staff felt that there were enough staff to do their job properly. What impacts on staff is the shortage of staff, the failure of proper workforce planning and the fact that we are asking our staff to do too much with too few of them. It is about time that this Government started to acknowledge that that was a problem instead of burying their head in the sand and pretending that we had enough nurses and doctors. In concluding today, Labour will back the wording of the Government's motion and will show us support for the patient safety programme. We will also back our hard-pressed nurses, doctors and all health and social care staff by backing the amendments and showing support for a staff team that is overstretched and under resourced by this Government. Thank you very much. Thank you, Deputy Presiding Officer. I am pleased to close today's debate for the Scottish Conservatives. The debate has been useful and there has been much consensus, perhaps not amongst the SNP and Labour members, but all of us can, I believe, support the aim of the patient safety programme to reduce mortality and adverse events in all NHS settings. Although we recognise that the Scottish Government has made progress, Donald Cameron is right to highlight the importance of staffing levels when it comes to patient safety. Other members have raised the legitimate issues around specific services, including maternity and neonatal care and pediatrics. I pay tribute to the points raised by my colleague Brian Whittle and Alison Johnson, who highlighted the key issues around midwife recruitment concerns that many of us are having told to us by constituents. The care of the elderly in hospitals has been mentioned by a number of members and is an issue that I am particularly concerned about. A recent freedom of information request shows that there are typically at least 3,000 examples each year of elderly patients in hospitals in my own region of NHS Lothian suffering falls in elderly care and dementia wards, and that a significant proportion of those falls are causing moderate or major harm to patients. We need to ensure that all those measures are put in place in elderly care wards to ensure that falls are minimised, including having enough staff on duty at all times to care for those monitoring patients. As well as causing bone breakages and fractures and affecting mobility, falls can destroy the confidence of our older people and make them less likely to undertake the physical exercise so important to maintaining the overall health of those individuals. Alex Cole-Hamilton spoke about preventing those falls, and I totally agree with what he had to say. The cost to the NHS of treating falls is also significant and investment in fall prevention can save really under pressure NHS resources, and we need to look at this. Technology will play a huge role in this. Just last week, I visited a company called Snap40, who is the doctor at your side. I welcome the fact that they will be undertaking two pilots in NHS Scotland, but the continuous monitoring device that they have developed can automatically identify the warning signs of health deterioration. I think that technology like that is something that we need to lead here in Scotland. As my party's mental health spokesman, I welcome the progress that was identified in the Scottish patient safety programme mental health phase report from last November, which covered 2012 to 2016 and has influenced the development of the mental health safety principles. As the cabinet secretary has said, there is some very positive data in this report, including examples of reductions in restraint of up to 57 per cent, a reduction in the percentage of patients who self-harm of up to 70 per cent, and a reduction in the rates of violence of up to 78 per cent. Mary Todd also said that—I support her on this—that we should pay tribute to all those who work in our mental health services and who have helped to achieve these important and significant progress in our mental health services. Although the work that has been undertaken focuses on our acute mental health service wards, we look forward to the roll-out of similar approaches to inpatient mental health services across Scotland. That will be challenging, but it is important, and I hope that the Scottish Government will really make sure that that is progressed within the mental health strategy. I also welcome the fact that the SPSP mental health work will also support the work of equally fit in reducing physical health inequalities for those suffering from severe mental illness, along with the support in Mind Scotland, CME and Bipolar Scotland. The need for the patient's safety programme to be supported at all levels of our healthcare provision across services is vital. From NHS board level down to local teams within hospitals and GP practices and community pharmacies clearly have a role to play in this, and I hope that that is something that will also be taken forward by the Scottish Government. It is important for all parts of our health service and NHS workers to share the aims of the safety programme, to share relevant information and best practice and work collaboratively. As Elaine Smith said, it is important to ensure that NHS staff are adequately supported to be able to implement the programme and encourage further development and training. It is also worth reflecting that many patients in the acute hospital setting can find this an incredibly disorientating environment and experience. On a recent trip to the Queen Elizabeth hospital in Glasgow, the health and sport committee saw what matters to you boards within the specialist dementia care unit, or at least one room that we visited. Those patient information boards provide the things that are important to individuals and are incorporated in the care planning and delivery process. What matters to you at a patient bedside is to display information at a glance and to actually have part of a conversation with the patient and their family. That has helped to personalise care, providing quick prompts to relieve distress for some patients and to act as an aid for non-permanent members of the care team on important issues to facilitate communication with patients, with information being updated as and when changes occur for that individual. I was particularly impressed with and hope will be rolled out as a national standard across Scotland. I also wanted to highlight the issue during the debate of hearing aids and reading glasses being lost. One of the issues that have struck me as a new MSP is a number of people who contact me to say that loved ones have had incidences where their hearing aids and reading glasses have been lost when they maybe go between care home setting and hospital appointments. I think that that is something that we need to look at because I know certainly in those cases it is really upset individuals and actually added to the deterioration of their health and it is something that I hope the Scottish Government will also really consider. Claire Hawke and Richard Lyle used this debate to actually talk about Opposition members talking down our health service and I have to say that that could not be further from the truth. I meet with NHS staff so often and see how often they are under—I do not have time. We have had enough of that today. The member said this last minute. To see those members of our health service under pressure, we have the right and we have them in mind when we come to this chamber with these debates to actually have to make be their voice in this Parliament. When the Royal College of GPs and RCN tell us that there is a crisis in this service, we have a duty to highlight that to this Parliament and we make no apologies for doing that because we support our NHS staff 100 per cent. As I have said in this chamber before, our NHS staff—the NHS does not depend on the SNP Government, it depends on those who work in our health service day in, day out and we need to make sure that voice is heard. To conclude, Scottish Conservatives welcome today's debate and support the aims of the Scottish patient safety programme to minimise adverse events and avoidable harm in the health service. We recognise that good progress has been made but there are still a lot of important improvements to put in place to ensure that patient safety outcomes are as good as they possibly can be. We look forward to the Scottish Government on providing the national leadership required to drive forward this programme and the funding to support all parts of our NHS to allow it to be put and to deliver best practice. I am pleased to close today's debate because, although we are not blind to the challenges, it is right that we pause to recognise the phenomenal improvements that are brought about by the Scottish Public Safety programme and Marie Todd and Emma Harper's professional analysis of this important and the impact of this important approach in their contributions today is compelling. In Scotland, we have, as the cabinet secretary outlined, 24 per cent reduction in surgical mortality, 21 per cent reduction in sepsis mortality and 18 per cent reduction in stillbirths, 93 per cent reduction in healthcare-associated infections and a 78 per cent reduction in ventilator-associated pneumonia. I welcome the largely consensual comments from members who have chosen to be constructive in their participation in today's debate. I want to single out Alec Cole-Hamilton, who made a very informed contribution. I recognise his continued interest in making improvements in mental health. Likewise, Miles Briggs, in his summary, points that I know will be taken on board by my colleague Maureen Watt, who recently announced the MCN on perinatal mental health, and which will be a priority in terms of the implementation of the recommendations set out by Jane Grant and the best start report. Although there are challenges around discharging, I think that Alec Cole-Hamilton and others did raise, there has been an 11 per cent reduction on bed days lost since 2011. Again, another point raised by Alec Cole-Hamilton and his comments that falls were more feared by the elderly than crime. We are making progress on this, and efforts across hospitals and care homes are taking action. For example, NHS Grampian has reduced falls by 14 per cent, and there has been more generally a reduction in falls right across the country. However, he and Miles Briggs and others are right that we need to continue to focus on that, which is why, in my portfolio, which also includes sport, it is also imperative that we do what we can to get our older population more active, so that they have the resilience to cope with the falls if they happen to them in later life. Again, I am happy to continue that dialogue with Miles Briggs and Alec Cole-Hamilton, and perhaps Elaine Smith, if that is what she wants to raise. I thank the minister for taking intervention, but in keeping older people more active, would you agree with me that up to 24 weeks for operations such as hip replacements is not acceptable? We have capacity in the world in Jubilee. I understand the points that she raises around NHS Lanarkshire. That is a point that we continue to engage with NHS Lanarkshire on to support and try to make better progress on some of those issues, but I think that the point that she makes is relevant. However, we are making sure that there is capacity in other hospitals to try to cope with some of that demand, but it is an issue that we continue to work through and we will continue to engage with her on those points in that local setting. I want to look ahead, however, to what is next for the Scottish patient safety programme. The teams in the Scottish patient safety programme are ambitious. They have reviewed the varied work and many achievements today. Looking forward, the programme will have a much wider focus on the overall patient journey, and that will ensure that sick patients are identified appropriately and timuously, that they receive their medicines safely and effectively, and that they move through their healthcare journey as safely as possible. During 2016, the content and delivery methods for the future programme were reviewed. That identified three core themes under which future work will be planned—prevention, recognition and response to deterioration, medicines and system enablers for safety. A greater focus will be placed on designing improvement activity across pathways of care, with a focus on NHS boards and partnerships setting their own priorities and outcomes to be achieved to meet their own local needs. Although improvements continue to take place in healthcare settings, improvement methodologies from the programme are also being applied across the public sector in Scotland, whether in education, justice or beyond. We are spreading our improvement approach beyond the boundaries of health and social care. I think that points touched on by Alison Johnstone. The Children and Young People Improvement Collaborative is essential to our work to make Scotland the best place in the world to grow up. It joins up the earlier's collaborative and the raising attainment for all programme to use quality improvement approaches to deliver improvements throughout a child and young person's journey to support positive experiences in the early years and educational attainments. I think that I might have to have an improvement approach to my own voice at this moment, as it is deteriorating itself. We can pause for a sip of water. We will understand. Our health and social care delivery plan, published on 19 December, sets out how we will further enhance health and social care services. Through this, the people of Scotland can expect to live longer, healthier lives at home on a homely setting. We will have a health and social care system that is fully integrated, focuses on prevention, anticipation and self-support management. It will make day-case treatment the norm where hospital treatment is required and cannot be provided in a community setting. It focuses on care being provided to the highest standards of quality and safety, whatever the setting with the person at the centre of all the decisions, and ensures that people get back to their home or community environment as soon as appropriate, with minimal risk of re-administration. Could members please—I mean, the ministers are struggling—women fully on through a bad cold and you're all chittering and chattering away, so stop it. Thank you, Presiding Officer, we're not at all. I very much only approach to this. So, in its ninth year, the Scottish patient safety programme continues to grow, to mature and to develop, to meet these new challenges in the new integrated environment. Increasingly, the emphasis will be on supporting NHS boards and health and care social partnerships to identify their local priorities, and the Scottish patient safety programme will act to tailor any improvement support required to meet those local priorities. Turning, however, to some further points raised by members, many members raised the issue of the workforce. While it is absolutely right to hold government to account and we would never deny any Opposition member to do that, we must also, though, be mindful of the words of Emma Harper and Claire Hawke, who made the point about the impact of consistent negativity on the morale of our NHS staff, who work daily on our behalf to help others, because this Government is committed to supporting and developing our workforce. Staffing has increased. Qualified nurses and midwives are up by 4.9 per cent. The cabinet secretary announced a 4.7 per cent increase in intake to pre-registration nursing and midwifery programmes for 2017-18, meaning 151 extra places, and that's the fifth successive rise and equates to 3,360 new places. We've committed to retaining the nurse student bursary, unlike in the rest of the UK. Thank the minister for taking intervention purely out of solidarity. I thought I'd give her a chance to also get a sip of water if she's struggling today. Can she address the point directly made by Dr Peter Benny, that if it's not the workforce crisis is not addressed, it will lead to personal breakdown and then system breakdown? We have the workforce plan that is coming out. Again, I would notice what Anna Sarwar announced at the weekend. Again, he's playing catch-up with action that this Government has already taken, and I think that she should take cognisance of that fact and the improvements that we have. He puts his hand up 10 years. The fact is that 10 years would have meant that Monklands A&E would have been shut. 10 years' clothes would have been air A&E, so I think that the record that we have today is a positive one, a good one, and we'll continue to govern effectively for our NHS. As part of the support to the workforce, Claire Hawke also made an important point about empowerment and the improvement approach and powers practitioners. The programme and the CMO's broadening of realistic medicine also means that we empower the patient to be in control of their own care, but we know that there are challenges, which is why we are developing a workforce plan and we'll continue to engage with other opposition members on the strategic future of the NHS where their voices are constructive. Bruce Crawford, however, intervened on Annas Starwar's contribution, or I think that he described it as chuntering, as he described it and asked a very simple question as to why they did not commit to more funding in their manifestos for the NHS. Presiding Officer, it was his party, the SNP that pledged the most financial support for the NHS, and it is this Government that has and will deliver on it. No matter how much the opposition don't like to hear it, unfortunately that uncomfortable truth for Annas Starwar is one that this Government will continue to repeat and keep repeating and continue to deliver for our NHS. Miles Briggs also mentioned, however, what matters to you, and I was desperately trying to find in my notes about when the next one will be. I'll get back to him on it because of the success that happened from last year, but to conclude, Presiding Officer, I want to again quote Don Berwick, who said, in my opinion, Scotland should be extremely proud of what it's done in the improvement of healthcare and extremely excited about what it can do now with ambition to make Scotland the healthiest country in the world. It may be the leading example in the world. On that point, I'll conclude, and I think that we should all, though, be grateful to the impact and effort and the dedication of our committed NHS staff for allowing us to be able to patrol case Scotland's NHS on that global stage. Thank you. That concludes our debate on the Scottish patient safety programme. The next item of business is consideration of motion 3924, in the name of Michael Matheson, on the UK criminal finances bill. I call on Michael Matheson to move the motion. The next item of business is consideration of three parliamentary bureau motions. I call on Jovis Patrick to move motions 4, 332, 4, 333 and 4, 335 on the approval of SSIs. Moved on block. There are six questions at decision time today. The first question is that amendment 432, 4.1, in the name of Donald Cameron, which seeks to amend motion 432, 4, in the name of Shona Robison, on the Scottish patient safety programme, be agreed. Are we all agreed? Yes. We're all agreed. The next question is that amendment 432, 4.2, in the name of Anas Sarwar, which seeks to amend the motion in the name of Shona Robison, be agreed. Are we all agreed? No. We're not agreed. We'll move to a vote and members may cast their votes now. The vote on amendment 432, 4.2, in the name of Anas Sarwar, is yes, 62, no, 61. There were no abstentions. The amendment is therefore agreed. The next question is that amendment 432, 4.3, in the name of Alex Cole-Hamilton, which seeks to amend the motion in the name of Shona Robison, be agreed. Are we all agreed? No. We're not agreed. We'll move to a vote and members may cast their votes now. The result of the vote on amendment 432, 4.3, in the name of Alex Cole-Hamilton, is yes, 62, no, 61. There were no abstentions. The amendment is therefore agreed. The next question is that motion 432, 4, in the name of Shona Robison, as amended on the Scottish patient safety programme, be agreed. Are we all agreed? No. We're not agreed. We'll move to a vote and members may cast their votes now. The result of the vote on motion 432, 4, in the name of Shona Robison, as amended, is yes, 62, no, 61. There were no abstentions. The motion, as amended, is therefore agreed. The next question is that legislative consent motion 3924, in the name of Michael Matheson, on the criminal finances bill, be agreed. Are we all agreed? I put a single question on parliamentary bureau motions 4332, 4333 and 4335. If any member objects to me doing so, please say so now. No. The question is therefore that we agree motions 4332, 4333 and 4335, in the name of Joe FitzPatrick. Are we all agreed? Yes. We are all agreed. That concludes decision time. I close this meeting of Parliament.