 The final item of business is a member's business debate on motion 11786 in the name of Jenny Gilruth on five out-of-hours closures. The debate will be concluded without any questions being put with those members who wish to speak the debate. Please press the request-to-speak buttons down, I call on Jenny Gilruth to open the debate. Ms Gilruth, please. Thank you, Presiding Officer. 2018 is a very important year for Glenawthus, marking the town's official 70th birthday. We share that special birthday with our health service, a national institution, so I want to begin tonight by thanking all the staff who make NHS Fife work, to the nurses, to the ambulance men and women, to the cleaners, to the administrative staff and to the doctors. Thank you. We value you. I am grateful for members from across the chamber for supporting tonight's motion. Changes to Fife's GP out-of-hours services issues are not happening as a result of a Scottish Government decision, however. That responsibility rests with Fife's health and social care partnership. Tonight's debate is therefore an opportunity to share what has been happening locally in Parliament, but I would nonetheless welcome the minister's views on how we can now move forward. Every year, more than 850,000 people will use GP out-of-hours services in Scotland. Over half of those people will be seen in some sort of primary care facility, with just one in five visited in their own home. The most likely people to use GP out-of-hours services are those over 75 or under five, perhaps the most vulnerable in any society. On 4 April this year, elected members across Fife were contacted by the director of Fife's health and social care partnership to inform us that services had fallen over. Essentially, there were no longer enough GPs to staff out-of-hours. That led to the start of contingency measures. In my constituency, the closure of Glenrothes hospital's GP out-of-hours services from 12 midnight until 8 am and in Dunfermlyn and St Andrews, GP out-of-hours services also closed and patients were told to travel to the Victoria hospital in Cercodi. What was meant to be a temporary closure has now been on-going for 197 days in total. Given that Fife's health and social care partnership took the decision to extend the contingency period, it will be a new year before the service is fully operational again. If, indeed, that ever happens, because despite a backdrop of closure, the partnership then took the decision to engage in a retrospective public consultation on transformative change. The public consultation document, which was produced in July, some three months after the closures began, included GP out-of-hours redesign but also community health and wellbeing hubs and community hospital and intermediate care bed redesign. That has caused understandable confusion, given that the focus is now not simply on GP out-of-hours and the clunky nature of analysing the provision of three separate services has meant that the vision for the partnership remains unclear. Although the consultation has, belatedly, given an opportunity for Fife's to voice their concerns, it is retrospective public consultation engagement rather taking place during a closure period. That, in my view, has compromised the consultation from the outset. I am not against transformative change agenda and I know through my own work as a former member of the Parliament's Health and Sport Committee that we need to work smarter, but I continue to have concerns that Fife's health and social care partnership are using the closure of GP out-of-hours services as a chosen horse for something quite different, particularly because, in April 2018, Fife actually had one more GP than the equivalent this time last year. That is not simply about numbers. In 2015, the Scottish Government commissioned the Richie review into primary care out-of-hours services. Two of the guiding principles of which are that out-of-hours services are person-centred and intelligence-led. Furthermore, the review made a specific recommendation regarding health inequalities, saying that the design and implementation of all GP out-of-hours services should demonstrate how they are ensuring equity of access and outcome and that quality and safety implementation and monitoring of out-of-hours services should be assessed for their impact on health inequalities. Fife's health and social care partnership did not complete any equality impact assessment before deciding to close GP out-of-hours services. It should have assessed how closing local services would impact on the poorest communities. Despite numerous requests from my office for that information, it was only after I raised concerns with Health Improvement Scotland in July that an equality impact assessment was very quietly uploaded online and backdated. Reducing health inequalities is however a key deliverable in the Scottish Government's 2020 vision for health and social care, which states that we will refocus our efforts on health inequalities, particularly in the context of benefits cuts, which will impact on those most at risk of ill health. Perhaps Fife's health and social care partnership should have looked at the impact of benefits cuts on my constituency. Had they bothered to do so, they would have found that welfare cuts have hit Glenrothes harder than any other area in Fife. Over £1 million has been lost in benefits payments to the vulnerable people that I represent. My constituency is already being disadvantaged by the political priorities of Westminster. Removing healthcare access for the poorest is only going to make this worse. However, it is not just benefits cuts, it is hard real poverty. In 2013, the Glenrothes and Central Fife constituency had the worst child poverty figures in Scotland outside of Glasgow. Five years on, and it is a year of young people, our town is 70. What value are Fife's health and social care partnership placing on the next generation and their access to healthcare? NHS Health Scotland says that there are fundamental causes that drive health inequalities, including societal values to equity and fairness and political priorities and decisions. Although the closure of Fife's GP out of our service was not a decision taken by the Scottish Government or, indeed, by this Parliament, it is reflective of a decision taken by health and care officials locally. Fife's health and social care partnership did not and have not completed any transport appraisal. My constituents fear that they will be unable to afford the taxi fare to Kirkcaldy in the early hours if they need it. Even worse than that, the transport system that exists requires patients to ask for financial help if they cannot afford a taxi. That is completely undignified. The rationale for GP out of ours closures back in April was predicated on clinical advice. Politicians cannot argue with clinical advice, nor do I believe that we should. The clinical advice was for a temporary closure. The clinical advice said that patient safety would be compromised due to staff shortages, but the clinical advice did not assess patient safety the other way round. What about the mum who cannot afford the taxi to Kirkcaldy, the elderly man who has no car, the chronic asthmatic who cannot travel? That decision will widen health inequalities because it will be the poorest who suffer. From elderly residents to the parents of children with serious medical needs, worries were raised that residents in Glynothus and the surrounding villages would become isolated from round-the-clock healthcare at the various public meetings that I spoke at. Our national healthcare service was founded in 1948, the same year that the first turf was being cut to build Glynothus, from the cradle to the grave free at the point of need. For Glynothus to lose GP out of ours services in our 70th year would be a travestay for the people that I represent. I look forward to the outcome of the public consultation with the wellbeing of the kingdom's most vulnerable in mind. I am confident that Fifei's health and social care partnership will come to the correct decision. Thank you very much. I call Mardou Fraser to be followed by Claire Baker. Thank you, Deputy Presiding Officer. Can I start by congratulating Jenny Goh-Ruth on securing this debate this evening for raising what was a very important issue for her constituents in Glynothus and for all those right across Fife who are similarly affected? Because, while Jenny Goh-Ruth quite understandably concentrated on the issue in her Glynothus constituency in her comments, this is an issue that reflects and affects the whole of Fife. There have been public meetings held in Glynothus, in Dunfermlyn, in St Andrews, which have been attended by large numbers of local people. My Conservative colleagues have also attended all of those. Liz Smith and myself attended a public meeting hosted by Willie Rennie in St Andrews earlier in the summer. You could tell from the attendance at that meeting just how important this issue was to the local community. I understand that there was a more recent meeting that Mr Rennie hosted that was even better attended than that one earlier in the summer. I could not be there that evening, but what I saw in terms of press reports indicated how much public concern there is around this issue. For people living in places such as North East Fife or indeed West Fife, the problems of distance to travel to Cercodiere are perhaps even more acute than they are for Jenny Goh-Ruth's constituents in Glynothus. I think that that is where the real public concern arises around the question of how do you access services, particularly out-of-hours, when they are a long distance away from where people live. There is a whole range of risks that are identified by the proposals from the Fife, Health and Social Care partnership. Will there be more ambulance call-outs as a result of the fact that people will have to travel further to access GP out-of-hours cover? Will there be more people attending A&E as a result of the fact that they cannot access those GP out-of-hours services? Those are questions that I do not think we have had as yet adequate answers to. There are real practical issues for those who do not have access to private transport. If you are living in a rural part of West Fife or a rural part of North East Fife, how do you get to Cercodiere after 11 o'clock at night and before 6 o'clock or 7 o'clock in the morning when public transport commences? I do not think that we have had adequate answers as to how those questions will be addressed from the local health partnership. There is a particular issue in North East Fife here, because the doctors currently operating out-of-hours in the community hospital in St Andrews have offered in many cases to continue to do their shifts, but thus far it has been the case that the health and social care partnership has told them that unless they are prepared to relocate to Cercodiere, their services are no longer welcome. That is deeply unfortunate, because where have you got people who are trained GPs prepared to offer service locally? A local Biscope solution should at the very least be explored by the health and social care partnership, rather than simply saying that if they are not prepared to work in Cercodiere and not prepared to make themselves available, we do not want to hear from them. We do not want your services at all. It is unfortunate that we could not try and find a solution, at least for St Andrews and North East Fife, with the available GPs because of an attitude being taken by the health and social care partnership. There are two broader issues that I want to touch on very briefly if I can, Deputy Presiding Officer. The first is that this problem that has been identified is not a problem that is unique to Fife. It is happening elsewhere in Scotland. It happens elsewhere in the region that I represent. The minor injuries unit that currently exists in Creef and also in Lockery are facing problems because of their difficulties in attracting qualified staff and therefore having to restrict their opening hours. The issues that Jenny Garuth quite fairly raises are being reflected elsewhere. That comes back to what is the fundamental issue here, which is workforce planning, because we simply do not have enough GPs available to fill the vacancies right across the country. I think that there is an issue here for the Scottish Government to address in terms of better workforce planning. In particular, should we be capping the number of university places available for Scottish domiciled medical students when we have that demand for more doctors and more GPs, we know historically that we have not been meeting that demand with those who are training here in Scotland. It is time to rethink that whole issue. I agree with Jenny Garuth that the health and social care partnership in Fife needs to think again. More than 6,000 people in Fife have signed a petition calling upon them to do that and they should listen. I thank Jenny Garuth for bringing forward this debate, which is of interest to all MSPs representing Fife. Jenny Garuth has set out many of the concerns about the decision to close the overnight out-of-hours service in Glenrothes, Dunfermyn and Andrews, with the service between midnight and 8 am now only available in Cercode. MSPs from different parties have shared platforms at local meetings hearing the concerns of our constituents about the decision. To start at the beginning, MSPs were emailed on 4 April, right at the start of Easter holidays, by the director of health and social care. To be told that, as a contingency measure, the out-of-hours services were suspended at Glenrothes hospital, Queen Margaret in Dunfermyn and St Andrews hospital in response to nursing and medical staffing difficulties. Since I have been elected in 2007, NHS Fife hold regular meetings with MSPs, and I cannot recall—I may be wrong on this but I cannot recall—the extreme pressures on out-of-hours services being raised with us prior to the decision being made. At subsequent meetings to the decision, we have heard how precarious the service has been in recent months, and yet the possibility of contingency measures were not discussed with MSPs or the public. There was no opportunity for scrutiny. Moreover, the decision to suspend those services is not risk-free. The additional pressure at the Victoria hospital in Cercode, which is already the A&E site, needs to be closely monitored as it faces additional pressure. The difficulties that health boards are facing in recruiting and retaining GP and primary care staff are well known. In Fife, a number of GP practices operate closed lists, and a number have had to come under the control of NHS Fife. There are too many practices that are relying on local cover and described as in a high-risk situation. Work should have been well under way to bring forward solutions that would have seen those hospitals remain open overnight. I have heard GPs say that they were not aware of the precariousness of the service and were not consulted, so something has gone wrong in communication. The immediate concerns raised by constituents are over the difficulties that centralising the service presents. Quite simply, the distance involved in travelling to Cercode in the middle of the night are significant for the majority of my constituents. If you do not have a car, there is no public transport and you will struggle to get a taxi at these times. Never mind having the money to pay for it. Say that you are a single parent or elderly or vulnerable, how are you supposed to get to Cercode? We did not hear significant enough assurances from NHS Fife and the IGB that that would be dealt with and that concerns over travel would not act as a deterrent for someone who needs to see a doctor. In general, those points about an equality impact assessment are fairly made. That was supposed to be contingency for three months. However, at the end of that period, the fundamental issues of staffing had not been resolved and the contingency continued, which is now consumed by the joined-up care consultation that is just closed. There are three issues that I want to additionally raise. I attended a public meeting in St Andrews, organised by Willie Rennie. As Murdo Fraser has described, with commitment from local GPs, St Andrews hospital are able to run an out-of-air service. NHS Fife argued that they need to deliver for all-of-life and are refusing to accept a solution that should only serve as St Andrews. I would like to see them be flexible with St Andrews. A strong case is being made at the combination of the student population—many of them are overseas students—an elderly population, and rurality justifies the continuation of out-of-air services, and a resolution should be worked on to achieve that. Secondly, the issue of governance. The IGB took the decision to suspend those services based on clinical advice. I fully accept that patient safety must be paramount, and that safe staffing levels must be maintained. NHS Fife are actively avoiding taking any responsibility for this decision, although it is based on clinical advice. The IGB has delegated powers over GP provision, not devolved powers. I understand that Audit Scotland is considering the roll-out of IGBs and that governance is a key area of concern, also raised by the health committee in the Parliament. The decisions of the IGB are dependent on the workforce decisions that have been made by NHS Fife when it comes to clinical staff and decisions, and the GPS situation has been facing a tipping point in Fife for the last few years. NHS Fife cannot hide from those decisions. Finally, I recognise the arguments from the Government that the new GP contract will improve the situation, and I am aware of the work that is being undertaken at St Andrew's and Dundee universities to increase GPs through the ScotGem programme. That is positive, and we need imaginative solutions to how we increase GP numbers, which is at the heart of the situation. However, we should never have got to the situation in Fife where we are closing health services that risk exacerbating health inequalities because we do not have enough GPs and primary care staff to deliver a service. I have to say that all this has come about during the past 11 years of an SNP Government that could be seen to have taken its eye off the ball before this crisis has been looming. Thank you, Deputy Presiding Officer. I thank Jenny Gilruth for bringing forward this motion tonight. I also thank her for reminding us in her opening comments that the changes in the service delivery will take away the dignity of some of the most vulnerable people in our communities. It is important that we listen to their voices in terms of how we deliver a service that is fair and equitable. I would like to focus, in some of my comments, on the national context for GP out of our services. Closure to services in Dunfermling, Glenrothes and St Andrew's is an issue of great importance and concern to our constituents, but it is not a situation that is unique to Fife. It is deeply affected by the shortage of GPs in Scotland, which was blamed for the emergency closures back in April, but it is also part of a national strategy to change the way that primary care emergency services are delivered. The Richie review, published in 2015 by the Government, warns that, in the current form, out of our services across Scotland are, and I quote, fragile, not sustainable, and may worsen rapidly if we do not rise to the occasion. It stated that patients should no longer expect to see a GP for urgent care, and instead it should be delivered by a multidisciplinary team, which could include nurse practitioners, community nurses, paramedics, pharmacists and other allied health professionals as well as GPs. It also recommended that those multidisciplinary teams be co-ordinated to a central urgent care resource hub. If they are delivered in their entirety, the recommendations in the Richie review could significantly strengthen out of our provision in Fife and improve patients' access to and experience of care. It is important that we need to accept that the status quo might not be the best option if we are to move forward in a meaningful way. That being said, I am highly critical of the options that are laid out by the Fife health and social care partnership in their recent consultation. I made that clear in my submission earlier this month, drawing on the experiences that I have heard in public meetings. They seem to only be delivering half of the Richie report recommendations, jumping at the opportunity to centralise service delivery without putting in place a multidisciplinary team to help to deliver those services in the community. The consultation emphasises the low numbers of people using the overnight services between midnight and 8 am, but then uses that to justify complete withdrawal of services at Glenrothes and St Andrews, including evenings and weekends. On average, nearly 150 people a day use the weekend service, so to leave people in Glenrothes and North East Fife without any kind of local service for a full 62 hours from Friday night until Monday morning is simply unacceptable. The health and social care partnership needs to go back to the drawing board and look at how it can use a multidisciplinary team to retain some level of service locally. That might look quite different to how it does now. Perhaps with nurse practitioners delivering care during the daytime, with remote access to GPs based in Cacoddy, it could be ambulances being used as urgent care centres in rural areas, or patients being referred to a community pharmacy for consultation and prescribing. All those were proposed in the Government's Richie review, but were not considered in the recent Fife consultation. I urge my fellow members to fully engage with all the options and not just cling to the status quo. We will not solve the crisis and GP recruitment any time soon. In the meantime, we need to understand what kind of care the most vulnerable in our community needs and how we can realistically deliver that. That requires further work on all sides. I hope that the Fife health and social care partnership will come back to the table soon with a workable solution. Deputy Presiding Officer, I congratulate Jenny Gilruthorn on securing this debate. I think that she set out the circumstances of the consultation very well. If I can gently disagree with her on one thing, she did say that there was an increase in the number of GPs in Fife. Perhaps there are, but the whole-time equivalence has certainly gone down, and that has led to that problem. The circumstances that we are dealing with, by 2021, I think, were expected to be 800 short GPs nationwide. Otherwise, I agree with Jenny Gilruth's analysis of the situation. I think that we need a change of heart by the Fife health and social care partnership. That is a big issue in East Fife. 2,300 people have filled out postcards from the East Newke, led by a campaign from the community council, and Daryl Wilson, who did a tremendous job. Over 6,400 people have signed my petition, including students and people from right across the community. People have been coming forward offering to collect signatures for that petition from all parts of East Fife. The public meetings have been absolutely packed to the gunels. People from every part of the community have been there. There are more people at the public meetings in East Fife than anywhere else in Fife. That reflects the fury, the anger that exists in East Fife about this situation. If I can just make a special plea for East Fife, the large number of students, the mixture of a large number of elderly people, the remote community, the rural community, the long roads, the distant in Cercodi is quite a problem for many people to get to. The taxes are incredibly expensive to get down to Cercodi in the middle of the night. We need to consider that when we are considering what kind of services we should be providing in East Fife. There is a general feeling in East Fife. If a service is going to be cut, it is going to be cut in East Fife first, and that is not acceptable. It is certainly a feeling that is strongly felt in East Fife, and I hope that the Fife health and social care partnership reflects on that. We are supposed to have a back-up from Kings Cross in Dundee, that people in Newport and Taiport and the north end of East Fife can nip over the tae to receive the service from Kings Cross. However, there are already capacity issues within Taeside, so that is not always guaranteed. Apparently, people from St Andrews at night time can get access to Kings Cross if the capacity is available. Generally, there is confusion about where people are supposed to be going, whether it is Cercodi or Dundee. We need clarity about that. However, when they say that we can access the services from Kings Cross, the GPs will not be doing home visits from Taeside to that part of Fife, they will have to come from further west, and the distances therefore apply equally in those circumstances. The GPs, as Murdo Fraser rightly mentioned, are prepared to step up to provide a service. It might be a different type of service, but they are prepared to participate in a service for East Fife, and they should be taken up on that offer. I know that there are discussions about that under way. Finally, the consultation process was wholly inadequate. I do not know who made the decision to wrap the three consultations into the one, but that was a poor decision. The jargon was riddled throughout the document, and it was difficult to find a link to complete the consultation. There are a lot of intelligent people in St Andrews—many academics—and I have had several of them coming to me and saying, look, I have two, sometimes three degrees, and I have found it difficult to complete the consultation document. It is pretty clear that, despite the advice that they received from various parts of the health service, the consultation process was inadequate. My final plea is to the health minister that, if the Fife health and social care partnership does not make the right decision on this and does not reflect on the huge opposition that there is from East Fife, as well as other parts of Fife, that it should step in and make sure that it makes the right decision. I call Annabelle Ewing to be followed by Alexander Stewart. Mr Stewart will be the last speaker in the open debate. I, too, would wish to congratulate my Fife colleague, Jenny Gilruth, on securing this important and timely debate this evening on the position of out-of-hours primary care in Fife. As Jenny Gilruth has set out very clearly the background to the issue, I will not go over at the same ground, but I can say that I, too, as MSP for Cowton Beath constituency raised concerns when the initial announcement was made out of the blue in April of this year that such out-of-hours care would be offered only at one site, that of the Victoria hospital in Kirkcaldy, as opposed to over the four sites being used prior to that announcement. I also wrote to the director of the Fife health and social care partnership, Michael Kelly, and, indeed, had several discussions with him on the matter. I raised in those discussions a number of issues, including to do with capacity at the Victoria and to do with transport, and I asked what arrangements were in place for those who did not have access to a car, or those, for example, who are lone parents with other children at home, as well as a sick child needing medical attention, or those, indeed, as Jenny Gilruth referred to with long-term conditions such as chronic asthma. The information that has been forthcoming on those points to date, I would have to say, has not been exactly clear, and, as Jenny Gilruth mentioned, no transport appraisal has appeared to be commissioned. However, that is all the more pressing as we look to the recent NHS Fife consultation on, as has been said among other issues, out of our urgent care redesign in Fife. As has been mentioned, essentially two options have been put forward with the status quo. That is what was in place before April in terms of the position that pertain for some years, before those contingency arrangements came forward, and the status quo has been rolled out apparently by clinicians on sustainability grounds, we are told. Although I can well understand the frustration of those in other parts of Fife about the approach being taken, and we have heard about that tonight in very clear and cogent terms, as the constituency MSP for Cowton Beath, I would have to stress the importance of maintaining the footprint of the Queen Margaret hospital in Dunfermline. Over recent years, we have seen a considerable expansion of services being offered at the Queen Margaret, which has been to the benefit of my constituents, and of course, in particular to the constituents of my colleague Shirley-Anne Somerville, the MSP for Dunfermline. I feel sure that local people would not wish to see the trend for expansion impinged upon to their detriment. Hence, in the context of at least the options that are being proposed by NHS Fife at this time, it would seem to me that option 2 is the preferred option, as opposed to option 1. That would see both Victoria and the Queen Margaret open overnight for out-of-hours urgent care, and hence would offer a better service to my constituents. However, the important issue of transport still remains to be clarified, and I note in this regard at page 18 of the consultation document that Fife Health and Social Care partnership with a view to ensuring that people have equal access to urgent care will, and I quote, develop a procedure to support people who have difficulties getting to an appointment. I am seeking clarification, as to what exactly that means, and I would ask the minister when winding up to confirm that he will seek appropriate assurances from Fife Health and Social Care partnership on this very important matter of transport that has been raised by every single member who has contributed to this debate. Finally, I note in the consultation that particular reference is made to the position importantly of paediatric services, with the point being made fairly about the importance of the immediate and direct access to specialist support if that suddenly becomes necessary given that children can become very unwell very quickly. The support is available at the Victoria, but not at the other sites. That issue has not been explored in detail in the consultation document, and in particular what impact that could have on the viability of the NHS and the health and social care position with regard to the viability of option 2. However, I would have thought that it would be possible, if deemed appropriate, to separate paediatric out-of-hours from other users as necessary and to still see the two sites being used for overnight appointments in general. I agree that the way in which the matter has initially been dealt with by Fife Health and Social Care partnership has not been optimal to say the least. However, we need to see longer-term out-of-hours arrangements in place going forward. As far as my constituents are concerned, it would be vital that we do not see the excellent role of the Queen Margaret hospital in the community diminished in any way. I also congratulate Jenna Gruth on securing this member's business this evening. It is vitally important. We have heard from many speakers this evening that the passion that they feel about the whole process is important. We have already heard that the primary care emergency services with reference to Glenrothes, Dumfirmas and Andrews services were suspended due to the lack of GP and staff shortages. That has already been found out in this evening's debate about where we are with that whole process, ensuring that we have enough cover to ensure that we have growing communities across the Mid Scotland and Fife area. The meeting that I attended in Dumfirmas, there were some very passionate individuals who gave very articulate views about their opinions about the partnership. The partnership individuals sat there, and I must admit that they gave relative lip service to their views and opinions. I do not think that that went down very well either, because they did not feel that the consultation that they were having was actually being listened to. I found that disappointing. I have heard from the other meetings that took place across the region that similar views were expressed, and similar individuals felt that that was much more of a fate to complete than a delegation and a process that was being challenged and looked at. As I said, those meetings were very important and continued to be very important, because it is the only way that some of those individuals have an opportunity of engaging with the entire process, and that is vitally important. We have the confidence of engaging. Every MSP that spoke in this evening has talked about the partnership's ability or lack of ability to manage the situation for them and their constituents across the area, and that has to be taken into account. The partnership itself said that that was happening because it could not ensure patient safety. That was the reasons that they were given, but, in reality, patient safety is being compromised all over the region if they are not able to access that. We have heard tonight about transportation issues, and the minister, I hope, does come back and tell us exactly what is happening on that situation, because to ask individuals to go a long distances to Kirkcaldy or to areas in Dundee is totally unacceptable. We are just about to go into the winter situation, and our climate, as we know, can be very volatile. In the evening, and asking individuals to go those journeys, that could become quite treacherous for some of them. The anxiety that they would engage is also a big problem going forward. The whole area of consultation on the whole aspect has been mismanaged extremely by the health partnership, and it has put huge difficulties on the region. The fact, as I said, that the decisions seem to have been already taken, and people believe that there is not really a consultation taking place and that the possibilities for what is going to happen next are really detrimental to the communities that we all represent. A lot has been said already about this this evening, and the Government has already acknowledged the fact that it is facing recruitment and retention issues. However, it needs to come up with solutions to ensure that those retentions are dealt with. As I said in Glenrothes, I have done it with Fermanis and Andrews, that we have that opportunity to ensure that individuals feel that their priorities are being listened to, because the status quo that we have at present is totally unacceptable. We cannot continue to have those facilities closed and asking individuals who may have conditions to go full lengths. The partnership has to sit up and listen, because at the moment, as I said, I believe that they are not. The discussion that I have had with some clinicians is that they know best in this situation. We all expect our health service to provide the services for individuals to ensure that we are given the services that we require, but they have to see that this is not a situation that is going to be resolved without them having to make big changes for the communities that we represent. Thank you, Mr Stewart. I now call Joe FitzPatrick to close for the Government minister, please. Thank you. I start by adding my congratulations to Jenny Gilruth for securing this debate and echo her thanks for everything staff in our NHS do for us in Fife and right across Scotland. Access to urgent primary medical services outwith normal GP surgery opening hours is a fundamental part of unscheduled care in Scotland. The services there for people who become unwell when their GP surgery is closed and their illness cannot wait until their surgery reopens. Around 870,000 patients use out-of-hours services each year across Scotland. In Fife, around 4,470 patients are seen every month in the out-of-hours service and an average of 20 seen between midnight and 8am every week. I recognise that across Scotland there have been some difficulties in sustaining the out-of-hours service and it is important also to recognise that general practices are not a nine-to-five business. How did we get where we are at? It is not just about GP numbers. There was obviously some discussion, and Claire Baker mentioned some of the actions that the Government is taking about tackling GP numbers. However, the root of the problem is a consequence of a change to the GP contracts that were negotiated way back in 2004 that made working in out-of-hours setting non-mandatory. Over time, GP's have decided that when they are coming into the service they do not want to work in out-of-hours service or those who have continued to work in out-of-hours service times kept up on them and many of them, a significant number, have retired from general practice. I am extremely grateful to those GP's and other clinicians who do work in out-of-hours service. As a number of members have noted, in 2015 we commissioned Sir Lewis Ritchie to carry out a national review of our out-of-hours service, the report that he published pulling together transforming urgent care for the people of Scotland. The review considered how best to deliver out-of-hours primary care services in the light of the challenges of Scotland's ageing population and as health and social care services are integrated. The review highlighted that a multi-disciplinary model should be adopted in the service, design and delivery of urgent care in the community and that it provided a foretaste of the direction of travel and how primary care would be delivered in out-of-hours. The report outlined the expectation that GP's will no longer be the default healthcare professional that is seen by patients for urgent care. However, GP's will, of course, continue to play a key and essential part of urgent care teams providing clinical leadership. As Mark Ruskell said, the proposed model of care is one that is clinician led supported by a multi-disciplinary team, including GP's, nurses, community pharmacists, paramedics and other specialists, recognising that patients will be seen by the most appropriate professional to meet their urgent care needs. I turn now specifically to the out-of-hours services in Fife. In April this year, Fife's health and social care partnership took the decision to reduce their overnight services provision from three centres in the filming of Rotheson, St Andrew's, to one centre for overnight operating from the Victoria hospital in Cercodi. That was not a decision for this Government or for this Parliament. The partnership has set out that it believed that the decision had to be taken quickly. I understand that the partnership has conceded that the nature of implementing the contingency measures for the provision of the overnight element of out-of-hours GP services felt sudden. I think that that has been replicated by members across the chamber who feel there was a lack of consultation around that. Maybe that is a lesson that the partnership will be able to hear from today's debate. As the chamber will be aware, it subsequently extended the contingency arrangements to the end of January next year. I appreciate that there have been many concerns locally about the contingency measures and the consultation exercise about the future of the service. In response, the partnership has said that the consultation had been considered by them since 2016-17, when the partnership completed an options appraisal exercise. They tell me that included workshops with members of the public in Fife. That was intended to look at the future of the service using the latest data and evidence. The next phase of the planning by Fife, health and social care partnership was a consultation exercise to share the decisions about the option appraisal exercise. At best it was unfortunate timing that the decision to implement contingency measures happened just as the consultation was announced. The partnership has repeatedly sought to provide assurances to this Government that no decision had been made at that stage about the outcome of the public consultation. I understand that the consultation period ended on 8 October and that the responses are being analysed. It is important to enable the local consultation process to run, as I am not in a position to comment on any likely outcome at this time. I understand, however, that draft proposals will be taken through the partnerships, governance committees during November. The reports and final proposals will be considered by Fife integration joint board at its meeting on 20 December. The Scottish Government has been very clear that we expect NHS boards and health and social care partnerships to ensure the delivery of safe and sustainable services across the locality that they serve, and they need to do that in their own. The points made by Willie Rennie and Murdo Fraser are important. If there are options there, they should be fully explored. I understand that the option that Willie Rennie mentioned, as he himself said, was still under discussion, so I certainly hope that that has been considered seriously as part of the on-going solution. Jenny Gilruth, Clare Baker, Mark Ruskell, Annabelle Ewing and Alexander Stewart, apologies if MDL has mentioned that, but they all raised the important issues such as the impact of the contingency measures on the ability of people to access services, particularly those that have limited access to travel options. I am clear that those are issues that I believe that the partnership should carefully consider as its plans for the future. I would once again like to thank Jenny Gilruth for bringing that to the attention of the chamber, and I hope that I have been able to provide some reassurance that the Scottish Government takes these matters seriously, and that we expect decisions by partnerships to follow meaningful community engagement. Thank you. Thank you. That concludes the debate and I close this meeting.