 Yr ystafell i gymdeithasol y byddiol yn yw y cyfnodfod yng ngyfgrifennidau, ond y Cymru, 389, yn y cyfnodd Alexander Stewart o NHS o'r ddifrwng gyda'r gyffredinol. Yr ystafell yn cyfledd o hyd i gael gweithio, rydych chi yn fawr i gyffredinol i gael y cyffredinol tastes. Thank you, Deputy Prime Minister. I am very grateful for the opportunity to open my member's business debate. The importance of…! out of our GP services can't be underestimated. Indeed, according to Healthcare Improvement Scotland, primary care out of services are a fundamental part of our healthcare. The service provides support to those who require medical assistance outwith normal GP surgery hours. This involves a number of healthcare professionals, agencies and support staff. They work together to provide a high quality of integrated services for patients, with many individuals going above and beyond to support these patients. I said in my original motion that the debate for healthcare improvement Scotland and many GPs have collectively acknowledged that the quality of safety of out-of-hours is extremely important. However, about four years ago, things appeared to slowly but surely be taking an about turn, Deputy Presiding Officer. Back in April 2018, I lodged a motion with deep concern as to the decision by Fife Health and Social Care Partnership to close the Glandwathus hospital out-of-hours services. During May that year, I sought assurances from the former health secretary that there were to be no further service reductions. The health secretary responded indicating that recent changes were a short-term measure to ensure that appropriate levels of patient safety were maintained. I also took part in Jenny Gorra's business debate on that very subject about Glandwathus. I well participated in Willie Rennie's business about St Andrews out-of-hours services. The primary care emergency services at these hospitals in Glandwathus, Dunfermlands and Andrews all remain closed for after they were forced to be suspended due to staff shortages back in 2018. Meanwhile, NHS Forth Valley has been escalated to stage 3 on NHS board performance escalation framework. All those concerns have sadly proven not to be in vain, Deputy Presiding Officer, as we are now facing grave issues in many of our out-of-hours services length and breadth of Scotland. Assurances were sought from the constituency member for Clackmannisher in Dumblane and the Clackmannisher Council leader in December 2021. A press statement was issued by them and they indicated that they had received assurances from the health board that they were committed to providing services in Clackmannisher. Deputy Presiding Officer, I have been contacted by a number of highly concerned, even frightened individuals about the possibilities of Forth Valley out-of-hours services and what is taking place. I am utterly shocked and dismayed to now see reports that this is being dismantled slowly but surely. Prior to the NHS Forth Valley control, Clackmannisher emergency doctor's services were working money to Friday and at weekends with two doctors and three doctors overlapping and other doctors on standby ensuring that there was receptionist, a car and drivers. Falkirk doctors were also working money to Friday and weekends with receptionist, drivers and two cars. Stirling doctors operated from Monday to Friday and weekends with rural Stirlingshire being covered by their own GPs. When the NHS Forth Valley took over the services, it had five GPs supplemented with local GPs covering a high-level and four GPs and four drivers. All centres were fully staffed seven days a week. After Clackmannisher, which I have also indicated, lost overnight a GP and the Student Forth Valley took over and that service started to be diminished. Once later, Clackmannisher was reduced to one GP an evening, with many patients having to travel to other centres when Clackmannisher's base GP was on visits. A freedom of information sent to me recently showed staffing levels fluctuating over the following years with Clackmannian centres being systematically run down since 2017. We were initially looking at what was happening in public holidays and shortages in weekends. They were running down continually and shortening opening hours at weekends, followed by regular weekend closures. Now we only see three evenings of fortnight. Despite claiming in the FOI that health boards would continue to deal with the three centres, I am repeatedly informed that there has been a removal of drug bags, drivers, cars and receptionists from Clackmannisher and Stirling over the past few months. NHS Forth Valley had five vehicles a few years ago, four of which were reduced to two, one in Llarbert and one car operating on other occasions. Moreover, on the days that Stirling and Allawa had no clinicians, there was no driver, no drug bags availability in any of those centres. Staffing levels are a fraction of the initial levels that were up to be indicated. Calls to Forth Valley via the NHS 24 line are triaged into the following areas, a doctor to be phoned, patients to be given centre attention within timescales of one hour, two hour or four hours, patients to receive home visits between one hour, two hour or four hours. During Covid, all those calls were triaged by NHS 24 and re-triaged to NHS Forth Valley. Deputy Presiding Officer, there is still this case today despite the pandemic being nearly but over. That is still the case that we have today. Now Forth Valley have adopted a policy of comfort calling by non-communist staff to apologise for the delays and ask the patient if they still wish to remain on the list. However, as we have seen historically over Forth Valley goes into escalation, that means that the standard diminishes. Indeed, on occasions we have gone into the black situation, which we know is the top priority, Cabinet Secretary, and there is no service at all. In conclusion, staffing levels and GPs co-operation is vitally important and Forth Valley ensured their patients that they would have a good service and they did have a good service at one point. Only now we find that one clinician on duty for a population of around 300,000 patients is causing real concern and is compromising patient care, Cabinet Secretary. Clinicians and drivers and receptions have all been cut despite there not being any drop in the demand. Indeed, Forth Valley has called the demand that is causing only in reality a quarter of calls that they cannot answer because they do not have the staff. This is a wholly unacceptable situation, and one that needs to be addressed by the Cabinet Secretary as a matter of urgency. I look forward to hearing his response in the summing up in this debate. GP out-of-hours services are vitally important, so the Scottish Government and local health boards need to strive to ensure that they are maintained, retained and sustained because at the moment they are failing patients and putting lives at risk. Thank you very much, Mr Stewart. I now move to the open debate. I call first Emma Harper to be followed by Tess White for around four minutes, Ms Harper. Thank you, Presiding Officer. I welcome the opportunity to speak in this debate and I thank my colleague Alexander Stewart for securing it. I supported this motion as it was quite positive, which is kind of different than what we've just heard in the contribution. I want to start by paying tribute to all of Scotland's GPs, as well as the support staff, the advanced nurse practitioners, NHS 24 call handlers and the drivers. As Mr Stewart's motion mentions, their work is absolutely crucial. Presiding Officer, the primary care out-of-hours services are fundamental part of our healthcare in Scotland, and the service provides support to those who require medical assistance out with a normal GP surgery hours. Out-of-hours involves a number of agencies and healthcare professionals working together to provide an integrated service for patients. The quality and safety of out-of-hours care is extremely important, and I agree that patients should have access to consistent, high quality standards of care across the country. The picture with out-of-hours care in Scotland is comparatively good one compared to other UK nations. Indeed, each year across Scotland around 870,000 patients use out-of-hours primary care services, resulting in just under a million consultations. Home visits account for one in five, which is about 187,000 contacts with out-of-hours primary care services, with over half of the contacts, that's 57%, taken place in a primary care emergency centre. Children under five, women in their 20s, people aged 75 and over are the most common age groups of patients contacting out-of-hours primary care services. Treatment was completed by out-of-hours primary care services for just over half of the patients who were in contact with them. Only 3 per cent of contacts with the services resulted in a referral to A&E or a minor injuries unit showing how out-of-hours services are helping to reduce acute hospital admissions. Those statistics are welcome, and they show the importance of the out-of-hours service as a way to reduce hospital admissions. They are also an important way of providing reassurance to the public that care will be provided out-of-hours GP hours. Andrew Bueist, the chair of the Scottish GP committee, recently wrote a blog, reflecting on NHS out-of-hours care in Scotland now, compared with previously in 2004, with that model. In the blog, Dr Bueist remarked how out-of-hours, which previously was solely doctor based and involved doctors driving long on-call hours, often driving themselves, has now been transformed into a model. Dr Bueist said in his blog, that when I think back to what out-of-hours was like before 2004, then what a luxury it feels like now to have a driver. He just sits back having read the patient's notes, he lets someone else worry about finding the right house and with the safety knowledge that when you are on the call there is someone outside waiting on you. He continued when he said, you work at your own pace alongside other GPs and nurse practitioners, all picking from a pool of patients who have been triaged by NHS 24 and given an appointment time slot. The cases were all appropriate, a mixture of children, coughs, urinary symptoms with occasional rash, chest pain or alcohol withdrawal. Compared to daytime general practice, he says, it was so much more straightforward, there was no shopping list, no paperwork. He said also, out-of-hours is part of general practice, we as GPs need to support it and not give it over to hospital care. Those words speak for themselves and while there is room for improvement in the out-of-hours service as there are in other parts of our healthcare system, I want to recognise the hard work of all the staff involved to make it what it is today. That is in contrast to the latest ask of the new UK Government Health Secretary Theresa Coffey by the Doctors Association UK. DAUK is asking for urgent action to address GP retention as they are predicting that 16 million people in the UK could lose access to a GP within a decade. In closing, I welcome the debate and the opportunity to speak highly about Scotland's out-of-hours sector. I thank Alexander Stewart for securing this time for the member's business on out-of-hours GP services. It helps to bring into focus how pivotal these services are in delivering primary care. When GP surgeries are closed during the evenings, weekends, festive periods and public holidays, that's as much as 70% of the week. A reminder that general practice is not just between 8 o'clock in the morning and 6.30pm but 24.7. It's important to emphasise at the outset that out-of-hours GP services deal with close to 1 million patient consultations each year. Those patients include people with long-term conditions, palliative care needs and mental health problems. For parents with babies and young children and for over 75s, the service is especially invaluable as it is for those in rural areas. In many parts of Scotland, the service is also desperately overstretched. Even before the pandemic, BMA Scotland's chair of the Scottish GP committee argued that the root cause was simply the fact that there are not enough GPs. There's not enough GPs working in Scotland and those who are face such demanding workloads that adding out-of-hours is just a step too far. This is an all too familiar theme. In 2015, the independent review of primary care out-of-hours services stated that, and I quote, serious GP shortages were compromising the sustainability of out-of-hours services which remain fragile and may worsen without resolute and urgent action. Time and time again, the Scottish Government has been warned about NHS workforce planning. Yes, by political parties, but more importantly by the people that matter on the front line. Chemnay Medical Group in Aberdeenshire has lost four GPs. In the Chemnay community newsletter, staff from the surgery described a creaking system where the pressures on clinicians have continued to grow, the demand for our time has rocketed and political promises of help have failed to materialise. They added that the national GP shortage is felt across Scotland, but particularly in the north-east. Breakin Medical practice, for example. Yes, I'll take an intervention. Emma Harper. I appreciate that you've allowed me to come in here. Would Tess White agree that the SCOT GEM programme, which is focusing on rural recruitment for GPs, do not think that that's something that's unique to Scotland and it's actually helping to get us GPs rurally? Yes, thank you for that intervention, Emma Harper. In the committee yesterday, we heard evidence that that was the healthcare committee, that it is a step in the right direction, but really it's only scratching the surface. It's still not good enough. We can't get enough GPs. Breakin Medical practice, for example, is surviving with two GPs and regular locums at significant cost. In the Burvey medical practice is struggling to meet demand and some surgeries haven't survived at all. I recently raised the example of Freikim Health Centre in Angus with the Cabinet Secretary. The GP surgery achieved a 95.46% positive score in the latest health and care experience survey. It was the highest across Tayside, yet it closed in May this year, displacing more than 3,000 patients. The reason for the closure, NHS Tayside wrote to patients to say that the main issue that is facing primary care and GP services is that there are not enough GPs. Deputy Presiding Officer, people in the northeast and across Scotland are paying the price for years of poor workforce planning by the SNP government. Now this government is playing catch up, pledging 800 GPs by 2027 in various phases, but it's abundantly clear that the NHS needs more GPs now to fill existing vacancies and to cope with increasing workload demands. The health secretary says he's working relentlessly on this issue and frankly we're tired of his relentless excuses. I thank Alexander Stewart for bringing this debate to the chamber. It is of course right that we recognise the absolutely vital contribution out of our GP services make to healthcare provision across Scotland. It is also right that we stress how important it is for all regions of NHS Scotland supported by the Scottish Government to ensure that out-of-hours GP services cannot only continue to operate, but continue to operate providing the highest levels of care. I think that if people are absolutely honest, if they look at their inboxes, constituents are telling us that there is strain on GP services and on GP out-of-hours services. However, Deputy Presiding Officer, it is important to note that excellent work goes on within our NHS staff in hospitals, primary care settings and in the community. The work that they do always goes above and beyond expectations, particularly in recent times, where people have needed that bit of extra help and the contributions, as mentioned in the motion of healthcare professionals, support staff, drivers and others must not be understated. Deputy Presiding Officer, primary care out-of-hours services are now embedded as a fundamental part of our healthcare provision in Scotland. Many of us remember our local GPs providing 24-hour cover where a variety of models were used, but if, like me, you lived in a rural area, your own GP and GP practice attended if you called a GP out overnight. Of course, since then, there has been wide variety of changes in out-of-hours services with them coming under the control of the health boards in 2004. In large part, as we have heard from other members, because of the increasing demands for services out-of-hours and the traditional models, we are just not able to cope with the service. However, it is important that we learn from the past. In my constituency, my own region, Malklin and Cachin, where I live, there are significant challenges facing GP services, such as in Balochmell medical practice, where I have had a number of residents contacting me, waiting significant lengths of time for appointments, facing challenges with administration of prescriptions, lengthy telephone queues when they phone up, appointments that cannot get an appointment with the GP, and residents are finding it difficult to balance their own lives and actually get a GP appointment. The pressure on day-to-day GP services is severe. Despite the best efforts of our workforce, they clearly need to be more supported. We must ensure that that pressure does not spill over further into our services, on which there is now a significant reliance to get some treatments. I repeat that we cannot forget the lessons of the past and we must ensure that there are sufficient resources to meet demand and to ensure that patients can access high-quality care in both the GP and the out-of-hour GP services. Deputy Presiding Officer, in the short term that I have left, I want to focus my attention on the work and commitment of all those staff groups under enormous pressure. It cannot be understated. Across my south of Scotland region, I have visited over the summer a number of services and staff groups working in a variety of settings within the NHS. It is not an exaggeration to see NHS staff across the board from nursing staff, porters, caterers, cleaners. Those working within GP practices are exhausted and demoralised and feel undervalued by the current Government and the structures in place. Staff need a proper plan for pay, for recruitment, for wellbeing provision and that includes those working in out-of-hour services. It will truly value our NHS and our NHS staff if that Government acts. In conclusion, Deputy Presiding Officer, I once again thank all those who contribute to the delivery of our out-of-hours GP services in my region, south of Scotland and beyond. The work that they do is invaluable to ensure that people's medical needs are met in those hours that perhaps others are brought at work. I thank the member for bringing the debate to the chamber. Thank you, Deputy Presiding Officer. Thank you very much. I call Brian Whittle to be followed by Monica Lennon in four minutes, Mr Whittle. Thank you, Deputy Presiding Officer. I also thank my colleague Alexander Stewart for bringing this crucial and timely debate to the chamber. Now, Deputy Presiding Officer, it would be easy to take this opportunity to just have a pop at the Cabinet Secretary and the Scottish Government and sit down. However, I think that there's a crisis here that goes beyond politics and pointscoring. I'm going to highlight what's happening at the coface which I'm sure won't be easy listening to the Cabinet Secretary because I'm sure he's fully aware of the acute nature of the challenges the health service faces and, therefore, he faces. I would say, Deputy Presiding Officer, that the level of GP services across Scotland is not uniform. I think that in my own area I have reports of good levels of GP access in Trun, for example. However, an extremely worrying is the inability to see a GP in parts of South Lanarkshire. I know of patients who have been attempting to see a GP at certain practices, calling up to be asked the nature of the issue, being told that a doctor will call them back only to get a text later that says they're only seeing emergency cases. I know of a constituent who's been attempting to access a blood test for over three months because of persistent worrying symptoms who has yet to speak to a healthcare professional. There is a chronic lack of GPs in certain areas which, of course, has a huge knock-on effect for the out-of-service GP services. If GPs can't cover daytime surgeries, how can they be expected to deliver an effective out-of-hours service? Furthermore, the private sector is reporting that their waiting lists are going ever longer, a symptom of those turning to the private sector because of a lack of access to NHS services. So what about those who do not have this route open to them? Especially post Covid, where we are learning about the inevitable backlog in non-Covid-related conditions such as cancers and elective surgery and dementia and so on. It is no wonder that A&E departments are under such pressure as a last resort to access healthcare. I listened to the Cabinet Secretary in the radio this morning, suggesting that one of the issues in the A&E waiting times was that people are arriving sicker than they did before. I think that this is a symptom of not being able to access healthcare when their condition was less acute. It is not just that, Deputy Presiding Officer. Consider that Scotland has been the unhealthy nation in Europe for some time. The highest levels of obesity, drug and alcohol deaths, diabetes, heart conditions, reducing life expectancy and so on. So it has to be a concern that, in the Cabinet Secretary's own words, patients are getting even sicker. The issues today are a symptom of policy decisions taken a decade ago or so. We have to accept that, cutting nursing mid-life places as well as putting a cab on Scottish applicants for medical school, which, of course, speaks to the shortage of GPs. The reality is that there are no quick fixes either. I think that there are certainly many things we could do to improve the situation while we look at the long-term strategy to support an NHS. Things like workforce planning, which has been a recurring issue since I was in this chamber, improving the working environment and conditions, helping our NHS staff to have the options of a healthier, more active lifestyle and so on. Long-term, I have been an advocate of planning to gradually move investment upstream into the more preventive agenda, thus improving the health of the nation with all the benefits to communities and society that that would bring. It's not about saving money, it's about gradually being able to redistribute that money into other areas of healthcare as progress is made. The problem, of course, is that deploying that kind of strategy takes way longer than a parliamentary term. I think that it's something that parliaments are just not good at. It's the biggest failing, in my opinion, of this place, having complete control of health with the ability to do things differently and to innovate, yet the Governments in this place have failed to do so. The strange GPs are trying to deliver out of our service as a symptom of this short-termism. Perhaps this is an opportunity for the Cabinet Secretary to look at the long-term view for once to the benefit and sustainability of our NHS. Thank you very much, Mr Whittle. I call Monica Lennon for up to four minutes. Thank you, Presiding Officer. I want to start by thanking Brian Whittle, who actually bumped into it earlier today and he told me about the debate that was happening. I wasn't due to speak to have another event tonight. For every single member of this Parliament, this is really at the heart of our inboxes, as Carol Mocken said. It's what people come to our surgeries about. Frankly, it's what we all fear, because we all rely on the NHS. We all have families who do so. I've been very grateful to have care for my GP during the pandemic, during even recent months. I know many, many people who've found it so hard to get that face-to-face contact, to even get through in the phone. I want to take the opportunity, like others have done so, including Emma Harper, to thank everyone working across health and social care, everyone in primary care, from the receptionist to the practice nurse, the GP, everyone, the NHS of a family, and every part of it needs to be nurtured and looked after. We do have a duty in here to give people confidence, to show that we value the workforce, and certainly not to scare people or give people a sense that they won't get support from the NHS. We all know constituents who have had to endure long waits for ambulances, have sat on the phone and tried sometimes dozens of times, sometimes hundreds of times to get through, whether it's to out of hours at NHS 24. That is the reality. It would be good to come in and keep it all positive, but we are living in scary times. We all do local pressurities, we all do social media. The word crisis is perhaps overused, but I fear that what we are seeing right now in our NHS has become the new normal. We have become so desensitised to words like crisis and catastrophe that it is really hard now to come in here and feel that our words actually have meaning. I do worry, as someone who lives in Lanarkshire and represents constituents there, that code black is becoming the new normal for us in Lanarkshire and we cannot allow that to happen. The cabinet secretary knows that I will work with him and his team and colleagues right across the chamber. Frankly, I don't care what party people belong to. This is bigger than any party logo or any sound bite because the reality is that many of us fear getting ill and many of my constituents in Lanarkshire cannot afford to go private and bypass the NHS. We have to fix this. There are immediate things that we can do and there are longer-term things, but we have to show our constituents the wider public in Scotland that we have a plan. We are happy to take an intervention yet. On the point that you have made, I wonder if you would agree that the new triage models that GPs are introducing, for example, advanced nurse practitioners, stabilising daytime services in a GP practice, goes some way to reducing the pressures on out-of-hours services, as was highlighted by a GP in my constituency recently. Monica Lennon. It is important to hear about good practice and what is working well, but when I listen to constituents of mine and people in my own family who work in the NHS, staff do not have time to go for a pee, never mind going and doing extra training. There are people who want to advance and stay in their NHS, but they do not feel valued, they do feel burnt out. While we have heard about additional recruitment, trying to find people, we are losing people. We are not retaining the talent, the good people that we have. Those are concerns that we all share. I will finish by reminding the cabinet secretary. I emailed him recently about the code black in Lanarkshire, and an offer from me on behalf of my constituents to work with him and his team. We need to pull people together, and hopefully in closing we will hear from the cabinet secretary that our date is in the diary and will be shared with colleagues soon. Thank you, Presiding Officer. Thank you, Ms Lennon. I now call on Humza Yousaf to respond to the debate, Cabinet Secretary, for around seven minutes. Thank you, Presiding Officer. I thank Alexander Stewart for bringing this debate to the chamber. I thank members for their contributions. I will try my best to get through as many of the concerns that have been raised. I start where most members did, and that is to thank all our GPs and all those involved in GP out-of-hours services right across the country. GPs, absolutely receptionists, AHP staff, all those people who make up the multidisciplinary teams right up and down the country. I am pleased that Monica Lennon mentioned the receptionist because we know that they have had a particularly tough time in GP practices up and down the country. It is why we ran the receptionist campaign, where receptionists are not gatekeepers trying to keep people away from the GP, but they are asking those questions to direct people in the right places. I know that that can be a really difficult job and our receptionist has done it fantastically well. In terms of some of the issues raised, I will certainly address very specific issues that have been raised by the member around Fourth Valley in just a second, but I will pick up on some of the more general comments first and I will come back to Alexander Stewart's specific points. Emma Harper was absolutely right to put some context around this debate in relation to out-of-hours. The transformation in out-of-hours, as described by Dr Bewist in that excellent blog, is really worth a read. That is not to sit on our hands and say, look everything is rosy. I am not suggesting that. I think that people in this chamber would know me well enough and have heard me enough times publicly, whether it was this morning on the radio or whether it has been in this chamber on many occasions, that I completely understand the level and depth of challenge and significant challenge our NHS in its broadest possible sense, and indeed social care are currently under. So nobody here, nobody in the Government, neither myself nor the First Minister in the many conversations I have with her about the NHS and under any illusion that somehow things are all rosy in the park. We know that there are significant, significant challenges, including in out-of-hours, but I think that context is usually important. If I may turn to the specific points that Alexander Stewart asked about, again, I will be absolutely candid and upfront the out-of-hours service provided in 4th Valley is not good enough. That is why I understand in the CEO's invitation, 4th Valley CEO's invitation, Sir Lewis Ritchie, who is, of course, an expert in out-of-hours services, has been asked to come back in to review that service. That review is due to start early next month, I think, on 5 October, and I would be pleased to furnish Alexander Stewart with more detail writing once that review, of course, begins to kick in if he wants. I know Sir Lewis Ritchie well, and his approach has always been a very open one with the elected members. I am sure that he himself would be happy to furnish Alexander Stewart with details of that review. In terms of action that has been taken, there is an improvement plan in place from 4th Valley, and all those actions we are monitoring very, very closely. They have recruited a GP to the out-of-hours service, but they have also recruited an additional two GPs onto the staff bank who will help to support that out-of-hours service. They are not site-specific, they will work across the three sites in 4th Valley. They also have a GP on-call to support that service, but it is not just about the GPs. It is important that they clearly are an out-of-hours service. 4th Valley has also recruited an ANP, and they are looking to recruit another ANP, too. They are also working with the ambulance service, and they are now providing a paramedic to support the out-of-hours service on Saturday and Sunday. Paramedic support for home visits in 4th Valley are working with SAS on advance paramedic practitioner appointments. Lastly, in terms of that improvement plan, I note 4th Valley also from 3 October, so just under a fortnight's time, there will be a pool of drivers who will be available to bring patients to the out-of-hours services, most notably to support people with no transport from socially deprived areas. I hope that that gives at least a flavour, at least some level of comfort and reassurance that nobody is sitting back and accepting the position of 4th Valley that there is action being taken. Again, I am happy to talk offline to Mr Struth if he wishes about more detail on what is happening in 4th Valley. In relation to GPs more generally, again, nobody is going to get an argument for me when they talk about some of the access issues to primary care that they are saying they are receiving from their constituents. I get it from constituents, family members, friends of mine, and I know that has been. An issue, particularly when we were in the teeth and the grip of this pandemic and the really difficult phases of this pandemic where, of course, IPC controls were at their highest and, therefore, of course, there were real challenges accessing GPs. There are still challenges and I raised this issue when I met with Dr Kennedy this morning, the new chair of the BMA, and we are going to have a broader meeting with more of his council members. He absolutely accepted that we would work collaboratively to increase where clinically appropriate more face-to-face. I think that nobody will be in disagreement about this. We all accept that that should be part of a hybrid model. We should retain the video consultation and phone consultation for those that want it. For some people, I prefer to use a phone consultation and have used it the last couple of times that I have been in contact with my GP. It means less inconvenience for me and disruption to my day. That does not suit everybody by any stretch of the imagination, so face-to-face appointments are very important. In response to a question from Kenneth Gibson a couple of weeks ago now, I made the point that there is more work to be done with GP practices around pre-bookable appointments, which I think could make a significant difference. I noticed that the Secretary of State in England was saying that some of those problems are shared right across the United Kingdom. In terms of Scotland's own record on GPs, again, I would not disagree that we do not need more. That is why we have that 800 recruitment target, but it is not waiting until 2027 for that 800. We are and will recruit now, so we have 277 recruited. Of course I give way to Brian Whittle. Brian Whittle. I appreciate the cabinet secretary giving way. He knows in the last time I had the health portfolio back then and was in the Health and Sport Committee. When we were 860-odd GP short, and the previous cabinet secretary came up with this, we were going to recruit 800 new GPs within the next decade. Audit Scotland said then that that did take into account those that would retire, and after that 10 years would still be over 650 GP short. I suggest perhaps that is going to get worse now. Perhaps it is time to maybe reflect and have a look again at that plan. Brian Whittle makes a good point and I thought his contribution was very good to, I should say, that this is not just about recruitment, but about the number of members who have referenced retention. There is no point recruiting 800 to a leaky bucket and you are losing that on the other end. Again, a lot of my conversation with Dr Kennedy this morning was about retention and I will say more certainly in the coming couple of weeks when I have a ministerial statement due on retention in particular and what we can do to support retention for GPs. That is in comparison to 78 in England, 18 in Wales and 75 in Northern Ireland. I am aware that I am over time so I will end by saying on Karen Watkins very important points around pay and on staff burnout and wellbeing. Let me see these out of the highest priority and I am getting round the table with trade unions again. I want to give a fair settlement one that is of course and has to be affordable within our health budget so that it is incumbent on us to come forward with an improved offer which our wellbeing is very high per agenda on Monica Lennon's point and I promise you that you know what I will end on this. Multidisciplinary teams are very important and we have recruited many staff over 3,000 staff since 2018 as part of the multidisciplinary teams Code Black can never be the new normal and I won't allow it to be the new normal and therefore the exit plan from Lanarkshire out of Code Black is exceptionally important. Forgive me if a date hasn't been given to her there's been obviously disruption because of events most recently but I would expect that meeting to take place and a date to be sent to her and other Lanarkshire MSPs very very soon because I know she wants to work collaboratively on this so if I can end by thanking our GPs and all of the staff involved in GPs out of our services for the phenomenal work that they do and the life they save when they have this Government's full attention but also appreciation. Thank you very much indeed Cabinet Secretary that concludes the debate and I close this meeting of Parliament.