 I think that we have to look at more imaginative and innovative ways and I'm happy to keep Alex Rowley posted on that progress. Many thanks. That concludes questions this afternoon and we turn to the next item of business, which is a debate on motion number 13416 in the name of Jenny Marra on health. I could invite those members who wish to contribute to this debate to press the request to speak buttons now please and a call on Jenny Marra to speak to and move the motion, Ms Marra. 14 minutes please. Thank you very much, Presiding Officer. Can I start this afternoon's debate by moving the motion in my name? I have approached today's debate. Indeed, the Labour benches have approached today's debate in a very conciliatory way, hoping to reach a consensus on the way we take forward the debate on our national health service here in Scotland. Last week, we were warned by the health professionals who spoke up so articulately that there was no place for political points scoring in this debate. In that spirit, I had drafted a motion that I had hoped the whole chamber could unite behind. Indeed, it was designed for the whole chamber today to unite behind. One that acknowledges the scale of the challenge, one that reflects the hard messages coming from our senior doctors and nurses in Scotland, and one that gives credit to the cabinet secretary herself for the constructive and positive tone that she has struck in response to them, especially in the newspapers on Monday. I have to express my disappointment that the cabinet secretary has sought to disregard the whole of our motion in the way that she has and replace it with her own words, which on my reading make largely the same point as the original motion. She will no doubt set out her rationale for this in her own contribution, but I do feel that it is not necessarily got today's debate off to the best start. Delivering the healthcare that we want for the people of Scotland in a time of straight and budgets and an ageing population presents one of the country's biggest challenges. We recognise and thank in our motion the heroics performed every day by the hard working staff at every level of NHS Scotland and our care services, keeping us safe and well under trying circumstances. However, the people who are working on the front line deserve more than warm words from those in Parliament. They deserve the resources that they need to do their job. At the very least, they deserve to be listened to when they tell us that serious change is needed to preserve and sustain what was the key word last week in our NHS. Last week, an independent report commissioned by the BMA's Scottish Consultants Committee illustrated the full scale of the challenge. The report said that the balance had tipped too far towards financial decisions dominating over medical need, and this was linked, and I quote, politicians' promises to the general public to meet increasing demands from an ageing population for a better quality of healthcare without being able to fully resource such promises. In its conclusion, the BMA's report said that it had detected a strong note of pessimism, even fatalism, over how the healthcare system could be improved for the benefit of all stakeholders without substantial improvements in resources allocated to the NHS in Scotland. Those feelings have left unaddressed could have major consequences for patient care and the overall sustainability of NHS Scotland. A wake-up call indeed, Presiding Officer, but one that was followed just 24 hours later by another, this time from the medical and nursing royal colleges, speaking for the first time in a single voice with the building of a more sustainable NHS in Scotland report. They say that funding is unable to keep up with the pressures on the NHS. They say that tinkering around the ages is not the answer. They say that it is time for a genuine public debate on change. I would like to make a little more progress, but I will later. Those are significant and considered interventions from experts who do not use such strong language lightly, and when they do, it demands the attention of us all. I was really heartened to read the response on Monday by the Cabinet Secretary for Health and Sport in the Herald, where she welcomed the report from the royal colleges and said that she would listen to her concerns, as the First Minister did last Thursday. In her agenda article, the cabinet secretary said that she wants to look beyond short-term demands and foster a consensus around how we best manage our NHS to ensure that it meets the considerable challenges of the future. Indeed, in the amendment today, she has placed before us talks of fostering matured debate involving the public, health and care professionals and MSPs from all political parties, and she believes that this consensual approach to future changes in Scotland's beloved NHS will help to ensure that it evolves to meet the future needs of the people of Scotland. She is right if she believes that she cannot do this without working with the public, the professionals and, indeed, other political parties. I want to make it clear to the Government benches today that we stand ready to have that debate and work together to improve our NHS for everyone. Before I set out some ideas on how we can take forward that debate, I want to touch on the issue of targets, which the cabinet secretary raised herself this week. On Monday, she said that it was important that we rethink targets and how we must have the right targets. Many must have thought that the cabinet secretary had a crystal ball. On Tuesday, the Government missed its own target for accident and emergency waiting times of 98 per cent of all A&E patients within four hours. This is the 295th week in a row that this target has been missed in Scotland. The 98 per cent target has been revised down by the Government to an interim target of 95 per cent, but this week the figure was just 92.6 per cent. If we are still so far off the interim target in the middle of June, then it suggests that we have a serious problem. In the new South Glasgow University hospital, the figure was as low as 83.2 per cent. One of the success stories on Tuesday was NHS Tayside, which reached 99.1 per cent. A question mark now hangs over that number in light of the allegations made by a whistleblower who has claimed that those figures are being manipulated and that patients' safety is possibly compromised. I would expect the health secretary to establish an immediate investigation into those claims in order to restore confidence. I do believe, Presiding Officer, that the cabinet secretary's response this morning that she was assured by the health board that NHS Tayside was simply not good enough. Whistleblowers need to have the confidence that the Government will take them seriously. It is in patients and the public interests for those claims to be fully investigated, no matter any expected outcome. We believe that there is a place for targets in driving up standards and maintaining accountability for performance in our health service. However, without adequate resources, we cannot allow targets to drive perverse behaviours. I would support the cabinet secretary in looking to revise targets so that they are smarter, more sophisticated and drive the right behaviour. That should be part of the debate that we have on the future of the NHS. However, we should never lose sight of why we have these targets in the first place, so that early diagnosis and treatment can lead to improved results, and people should not expect to wait longer and longer when our health service should be improving. I believe that looking at targets can be part of that genuine public debate, and I would like to set out now some ideas about how we can have that debate to ensure that it delivers the results that we all want. I look forward to the cabinet secretary doing the same in her own contribution. I believe that a summit of all stakeholders, including the professional bodies and trade unions that spoke out last week, certainly the patient groups whose experiences are central to this, and the political leaders from across this Parliament in the interests of democracy and accountability of our health service. The consensus that already exists among those groups on an NHS publicly run and free at the point of need can be built on to agree a way forward to transform our NHS and deliver our shared ambition of a healthier Scotland. Of course, there is one stakeholder who we must involve in this process above all others, and that is the Scottish public. In doing so, I hope that we can learn lessons from the recent past in how we allow people to shape this debate. Politics, in many ways, has undergone something of a resurgence in this country, with the referendum reviving the tradition of town hall meetings, bringing to life street politics and unprecedented levels of discussion on social media. Thousands of people stepped up to have their say in the referendum because they knew they had a stake in the decision and in the outcome. What other issue could provoke such universal feeling in our country than the future of our national health service? I believe that we can take this debate to every town in Scotland as we set out the choices that need to be taken and listened to the views of patients and the public. The BMA report says that the public need to be involved in what is considered to be the difficult decisions about future investment in Scotland's NHS. Unless people are empowered to do this and appraised of the options and the consequences of decisions, we cannot expect to take them with us on any journey of change. Our efforts to bring about that change will not be successful. I will take it briefly. I thank the member for giving way. I wonder if she feels that one of the decisions that has to be made and which the public certainly needs to be involved in is to put more resources into preventative spend and perhaps less resources into hospitals. I think that there is a great consensus in all the reports that we have seen about the shift to preventative spend. I do not want to do that. We will approach that public debate with a programme of what we would like to see and to have been discussed, but I do not think that we can second-guess the outcome of that public conversation that the RCL called for last week. I think that the evidence, as the member knows, is there on preventative spend. I have every confidence that the people of Scotland will make the right decisions when presented with the facts about the health service. With the public engaged, the professionals consulted and the politicians in agreement, I believe that we could have a process completed within six months, setting out some guiding principles and changes going forward. We should take cognisance of reports and reviews that have been prepared in past years. We should take our present experience and focus firmly on what kind of health service we want for the future. Ahead of the Scottish Parliament elections in 2016, we could get agreement across parties on a road map forward so that, no matter what the result of the election, we can have confidence that our NHS will be moving towards a sound and sustainable footing whatever the political outcome or debate. The accusation from both the BME report and the royal colleges that in the past politics has obscured the health service and the best way forward is one that we should reflect on, all of us. I am sure that we can all think on examples where populism or political opportunity has overridden the desire to do what we know is best for our NHS and we all should take some collective responsibility for that. Given the scale of the challenge in reshaping the health service, we can no longer afford that indulgence. There is an opportunity now to move past that point in the best interests for the people of Scotland, the sick and the vulnerable. The cabinet secretary has so far responded in a positive way to those calls, and she can be sure that, as health spokesperson for the largest opposition party in this Parliament, I will do my job of holding her Government to account. When she and her Government get it wrong, it is our responsibility to stand up for those who suffer the consequences. However, where they are prepared to be brave and bold in making the changes that need to happen in the interests of Scotland, I will be the first to be in agreement with her, and that is the opportunity that this process presents. I hope that we will hear from the cabinet secretary her proposals on how we can have that engagement with the public and the professionals politicians for the good of the country's health. The challenge that we face is a tough one, but one that we should welcome. The fact that people are living longer is a triumph for society and for progress, and we should treasure those extra years with our parents and grandparents, whose experience and wisdom are irreplaceable. We should approach the task of reshaping our national health service for the challenges of today with optimism and ambition in the same way that those who created our NHS did nearly seven decades ago. I welcome the consensual tone from Jenny Marra. The amendments in my name seek to build upon that tone, and I hope that it will be received in that spirit. I will come back to dealing with the issue of A&E, which was specifically raised. I hope that I might get a little latitude to do that during my speech, because I think that it is important to set out some facts around that matter. However, I am pleased to update Parliament on my announcement on 22 January of a public debate on health and social care. I said then that, among many others, I would work with colleagues across the political spectrum to seek as much consensus as possible about the shape of health and social care by 2030. I am certainly open to all constructive ideas for the future, and I hope that we will hear some today, and make some initial progress towards consensus. I will continue to engage with colleagues across the chamber as I take forward more detailed work informed by the wider public debate. That debate will be based on this Government's solid record on the NHS. We have cemented universal provision, largely free at the point of use, rejecting the internal market and privatisation agenda. We have protected health funding in the face of a considerable challenge with the health resource spending increasing by more than £400 million to a record of £12 billion in this financial year. We have made a strong start on integrating health and social care with the roll-out of integrated joint boards with £500 million of investment to help them to develop the services that we know will make the difference to local communities as people take charge of their own health and wellbeing in more innovative ways. We are performing well above the developed worlds average in relation to access to healthcare, waiting times and planned care. Of course, we have more staffing than we have ever had before—up 10,500 staff. We have a good platform in which to build, but I am the first to acknowledge that the increasing demands on that system require that we look at new, more innovative models. I want to take this point to respond to the issue that was raised about A&E. Targets have their place, and I will certainly be up for a debate about targets. We have to get the right targets, but targets are important. If you look at where we have come from with targets, before there were targets, people routinely waited 18 months for an appointment, another 18 months for procedures, and I remember in the early days of this Parliament regularly raising cases like that. We have come a long way to some of the lowest waiting times that we have. We still have challenges in meeting some of those, and Jenny Marra raised the issue of A&E waits. I want to specifically respond on the Ninewells issue, because I cannot let that stand without responding to it, so I unfortunately have to take a little bit of time to do that. It is very important to remember about the Ninewells system that has been operating since 1998. The four-hour target was introduced in 2004, so it is quite wrong for anyone to suggest that somehow the Ninewells system has been developed in response to the four-hour target because it predates the four-hour target. The general medical council was, during its routine feedback from trainees, made aware of some of the issues concerning bullying that were raised last year. In response to that, they looked at that in quite some detail and, in fact, reported and concluded that they found no evidence that there was a culture of undermining and bullying in either the general surgery, trauma or orthopedic units. Overall, doctors in training were very positive about their experience at the hospital, but they encouraged improvements to be made. Those improvements have been made in ensuring that trainees can have feedback in a safe environment. However, when any concerns are raised with me, I always want to make sure that we have asked all the questions that we have seen for ourselves. That is why I have asked the chief medical officer to visit Ninewells on Monday and to see for herself and to investigate and to ask questions and to speak to staff concerned and the trainees. She will report back to me, but I think that we have to be very careful here in making sure that one of our best performing emergency departments in the country is not undermined and important to put on record that patient safety is not affected by any of those concerns, because I believe that patient safety is absolutely at the key to what they do in that fantastic hospital. I thank the cabinet secretary for giving way, and I thank her for her considered response to that. I welcome the fact that the chief medical officer is going to Ninewells on Monday. Will she agree with me on the principle that, when whistleblowers must have the confidence to speak out and have the confidence that what they say will be investigated fully and taken seriously? Of course. That is why we set up the whistleblowing helpline, but it does not mean that it is always correct and should always be considered to be correct, because it is important that we get to the bottom of it. However, there is, of course, an alternative view that the Ninewells emergency department is a good, well-operating department that takes patient safety very seriously indeed and actually works very, very well. What I want to make sure is that those concerns raised are investigated and that the issues that the GMC says have been addressed. I have obviously had to take some time, Deputy Presiding Officer, on what is a debate around the future of our health and social care systems, and I do not want to miss the opportunity to do that. There are a number of challenges facing us, whether that is the poor patterns of health, health inequalities, the rapidly changing demography, high levels of preventable diseases, the tight fiscal conditions—all of those are a challenge to our health and social care system. Of course, the Royal College's statement outlined in very clear terms the requirement for us to take that longer-term look and to develop new models of care that fit for the needs of the 21st century, and that is something that I am absolutely determined to do. That fully supports my view that the status quo is not an option and that we need to start planning transformational change now, and that is why I announced a national debate on how we might make greater strides to improve our health and social care by 2030. I want to give added focus to how we might tackle the country's poor pattern of health and health inequalities. I was heartened on that by the degree of consensus in the debate on health inequalities that Duncan MacNeill led on 26 March. That debate demonstrated that addressing population health and health inequalities vital to our economic success had to be across sector approach and it cannot be tackled solely as a health issue or by the NHS alone. I want that public debate to look at those wider issues as well. I want to explore how service users and providers can have joint responsibility for a healthier population, where healthcare services are matched by individuals actively promoting their own health and wellbeing. I want the debate to consider more coherent cross-sector working on population health with firmer links to housing, welfare and employability, for example, to support sustainable economic growth. I want to reinforce the focus on quality in developing policy and service delivery options, but I want a genuine debate about how models of care can be tailored to individuals' needs with success measured by improved patient outcomes, not adherence slavishly to processes. I want to make more progress in shifting the balance from hospital to primary care, to see more care and support provided at or near home where appropriate and to blur the boundaries between primary and hospital care and between mental and physical healthcare. We are already taking great strides. Our three-year GP contract has provided much-needed financial stability and reduced bureaucracy, prescription for excellence charts and a 10-year future for the pharmacy profession in Scotland. Integration of health and social care has provided a rich landscape for new models of care to meet communities' needs, but more volume and more complexity is already being seen outside hospital settings, although often resources have not followed. Primary care services are therefore stretched and communities have rightly higher expectations, so I want to transform our approach to primary care to ensure that people see the right professionals more quickly. That is why we will be creating a new GP contract in Scotland from 2017, and that is why I have commissioned Sir Lewis Ritchie to review primary care out of hours and that is why we need to redesign and modernise primary care in a collaborative and inclusive way transforming and invigorating the primary care workforce, creating new roles and involving the communities in how best to make sure that the vast bulk of our healthcare continues to be delivered in a more effective way within the local community. I will therefore seek views from as wide a base as possible on new models of care, including those that might be delivered locally through cross-professional community hubs with a shift to regional and national centres of expertise for some acute services, founded on quality and focused on improved health outcomes. I am very conscious that developing new models of care and creating new roles and opportunities will require carefully managed workforce changes and effective forward planning, not least because of the education and training pathways of the professions involved. I want to continue to enhance NHS Scotland's reputation as an exemplar employer, committed to supporting, developing and involving its workforce in line with the Government's approach to fair work. I pay tribute to the dedication, commitment and drive of all those who work in our health and social care systems. That workforce must have a key input to the wider debate, but it is essential that the public should have a stronger voice in shaping the future. My officials and I have begun the process of engagement that I announced in January through regular and tailored meetings with the professional bodies. I have met the BMA in February and again last week. I visited across the country to seek views on the GP contract. I have had wide-ranging meetings to discuss the development of a national clinical strategy, to underpin local, regional and national planning, and to discuss new models of care and initial engagement through the usual partnership mechanisms with NHS staff representatives. That has helped to shape the type of wider public debate that I will launch personally at the annual NHS Scotland event in Glasgow on 23 June, followed at 25 June at the Health and Social Care Alliance, Citizen Wellbeing Assembly in Edinburgh. Those events will reach out to health and social care staff across Scotland and to over 500 individuals who are disabled or living with long-term conditions and over 300 organisations who work with them. That will be the starting point for a wide range of national and local engagement activity. The Government is also working with COSLA, Health Care Improvement Scotland, the Scottish Health Council and the Health and Social Care Alliance to develop a new framework to gather the collective knowledge, wisdom and views of people with real experience of health and social care and to make sure that their voice is heard and understood. In addition to that, we will use media events, social media, digital platforms and existing stakeholder groups, networks and other mechanisms to take that conversation directly to communities and individuals. My ministerial colleagues and I will use portfolio events and travelling cabinets to seek the views and contributions to this debate, and I will be asking health boards to use local events to facilitate public discussion and feedback to me. Of course, I will laze personally with the Health and Sport Committee and, of course, the Opposition parties, reverting to Parliament as often as required. The level of open engagement will seek consensus on a reform plan for health and social care by 2016, with further engagement beyond then on into implementation. I hope that, in the spirit of consensus, as I move the amendment, this debate will form an important part of the early days of that piece of work. We very much welcome this debate. Like everyone here, the Scottish Conservatives greatly value the work and dedication of the staff in NHS Scotland and Scotland's care services. At all grades and in all professions, they perform a tremendous role and are rightly regarded as among our most respected and valued citizens. All those people and the patients whose health and wellbeing are their overriding concern are tired of hearing politicians scoring particular political points whenever the NHS comes up for discussion and of the scary stories that we see so often in the media. We all value our NHS and most patients have a good experience when in its hands. Almost all the letters that I see in our local press from patients are full of praise for the care and attention that they have received, and they are grateful for it. Of course, there are exceptions, and those tend to be the cases that come to our notice as politicians. We would be failing in our duty if we did not take those seriously and worked towards ensuring that such failures of the system are not repeated. However, we are all increasingly aware of the pressures under which the NHS is currently operating and the need to take action to ensure its sustainability as the population ages and expensive medical technology and pioneering medicines continue to become available for clinical use in a publicly funded system where money will always be tight and where every last penny should be used to give best value to service users. The acceptance that we need to look beyond short-term demands is welcome, and the new joint report from the medical and nursing royal colleges on building a more sustainable NHS in Scotland, together with the cabinet secretary's stated desire to foster a consensus to find a way of ensuring that the service can meet the very significant challenges ahead, are like music to my ears. For many months, if not years, Jackson Carlaw and I have been pleading in this chamber for some political consensus around the health service in Scotland. We did have some very fruitful discussions with the previous health secretary about various health matters, not least the need for more health visitors, which resulted in the announcement of an extra 500 of this grade of professional, and I'm very pleased that the current cabinet secretary is keen to follow that pattern, and I heard her suggestions with interest for future planning for the way ahead. Of course, we won't always agree with the means to an end, but if we can find a consensus on the way forward for the NHS in conjunction with all stakeholders, including patients, then I think that we can succeed. Only by having a common goal which can be worked towards whatever the political colour of the Government of the day will we overcome the short-term planning, which is currently a feature of political life. The Scottish Conservatives have been championing a long-term plan for a very long time, and the long-term economic plan under Conservative Government has meant that the Scottish NHS will benefit from an additional £800 million in the next five years. However, this money must be used wisely, and we have to take notice of Audit Scotland's warning that if we don't restructure the current running of the NHS, it will struggle to cope with future demands, particularly those of our ageing population. Audit Scotland tells us that the proposed integrated health and social care system is in jeopardy because the Government has so far failed to focus on long-term planning. Scotland does need a process that involves all political parties and that gets beyond the silo mentality that hitherto has hindered co-operation between different professional groups. That is why we were very supportive of the Public Body's joint working Scotland bill, which provides a legal framework for the integration of health and social care on which the future success of the NHS will depend. We should listen to the advice of the medical and nursing royal colleges and take very serious steps to move away from the traditional model of hospitals as the mainstay of the health service. It has been recognised for a long time that care in or as close to home as possible, far as long as possible, is in the best interests of the health and wellbeing of our population, many of whom are now living into advanced old age with multiple and complex health problems. This has been backed up by Mary Curie's recent report, indicating that the majority of those who die in Scottish hospitals would wish to die at home or in a homeless setting. Mary Curie has also found that 11,000 people living with a terminal illness in Scotland who need palliative care do not have access to it at the present time. Moreover, from a financial point of view, it has been shown that to provide palliative care when needed would generate net savings of more than £4 million annually in Scotland. Hence the charity's plea for a clear commitment in the Government's forthcoming strategic framework for action and palliative care and the end-of-life care to ensure that everyone with a palliative care need has access to it by 2020. I note from a previous debate that I think that the cabinet secretary is receptive to that. We hear increasingly of staff shortages in both primary and secondary care due to an ageing workforce and recruitment and retention problems. At all levels, we hear of the need to pull together and to work cooperatively along with patients to develop a sustainable service that will adapt to change and cope with the ever-increasing demands placed upon it. Given the high numbers of GPs and nurses who are set to retire in the near future and the fact that not enough young blood is coming in to meet the demand, together with quite serious problems in recruiting carers within many of our communities, precious on the NHS and care services will continue to grow unless we introduce new initiatives to sustain them. All parties agree that we need more nurses in midwives, for instance, although we differ on how to pay for them. It is well known in this chamber that we would pay for 1,000 more nurses by abolishing free subscriptions for people who can afford to contribute to their cost. We absolutely agree that there has to be new thinking on how to overcome existing problems and to deliver a sustainable NHS into the future. That will only be achieved if we put the outcomes for patients at the very core of our planning. All interested parties work together in an integrated way to make the best use of available resources to secure a viable future for a service that is treasured by every one of us. I will close by restating how grateful we are to the NHS and care services staff and emphasising our commitment to protect the NHS. To quote the medical and nursing royal colleges, the time for talking and political points scoring has passed. We need to take practical action now and together, and I look forward to that. We will support the motion and the Government's amendment. Many thanks. I now open the debate speeches of six minutes please. There is not a lot of time in hand. Bob Doris, to be followed by Lewis MacDonald. Thank you very much, Presiding Officer. I start by referring to targets in the NHS, which was a theme in a number of the opening speeches in this debate. Indeed, the briefing prepared by the royal colleges for today's debate specifically mentions targets. I will quote very sparingly from it at action point 2. It talks about a new approach to targets, and the briefing says that the current approach to setting and reporting on national targets and measures whilst having initially delivered some real improvements is now creating an unsustainable culture that pervades the NHS. I might not agree entirely with that, but they have got a point in relation to how sustainable certain targets are. I will say more about that in a second, but we should not be in denial about the huge transformational change that heat targets can deliver to the NHS. I particularly think of access to psychological services when Greater Glasgow and Clyde was up to two years at one point when I first became an MSP and that slashed down to something like 20 weeks or something. I wish to dug out the exact figure, but the heat target has been transformational and there is a balance to be struck by saying that we should not throw the baby out with the bath water, but they have a point and we should listen to it carefully. However, I have to say that it is not a new point because I do not like to steal the thunder of my convener on the health and sport committee, Duncan McNeill, because it is one that he has been making in relation to targets for a while and one that our committee has made in relation to budget scrutiny of the NHS when we looked at that in the health and sport committee. We heard only on Tuesday, just yesterday, that certain targets for certain procedures should drive the change to get just close enough by one or two per cent to meet a target, for it is not a clinical priority. However, let us be clear that it is a priority to the person who wishes the surgical procedure, but it is not a clinical priority. Actually, that waiting times initiative can cost three times as much had they just waited a few days or a few weeks later. That should be taken in mind as well. Just think about a 93 per cent success rate where the target is 95 per cent, and you wait a few days later and you could save a huge amount of cash, but you do not meet the target. Consensual tones have to be two ways because, as we heard in opening speech from Jenny Marra, the opposition will be terrier-like in the exposing of a Scottish Government that does not meet its targets, but it will not meongset by a handful of patients for a handful of days because that target was mixed. We have to have a two-way process in that debate in relation to work out which heat targets should be revised, where the cost-benefit savings and how that money will be reinvested. I think that the health and sport committee has a lot of good work on that in the past couple of years for a period of time now. I think that we have to look at some of the successes that there have been and admit where there are problems. For example, there are undoubtedly living problems recently with delayed discharge and, quite rightly, the Scottish Government was justiced for that when it appeared. However, the data still shows that it is down two thirds compared to when the Scottish Executive was in power. You have to give credit where credit is due, but, at the same time, you have to challenge the problems that are there and, indeed, change the structures as and when necessary. Just over lunch there, I chaired a cross-party group in rare diseases. I would like to make a couple of points that come out from that in relation to today's debate. For example, we are speaking about the new medicines fund that exists, and that is £80 million additional money, just recently doubled £80 million. In 2014-15, we heard at the meeting that 1,000 people have had medicines that otherwise might not have got if it was not for that fund. I think that our health and support committee has something to do with driving government policy in relation to that, but it is a real achievement. We also heard about specialist nurses and £2.5 million additional for specialist nurses, and, again, pay tribute to Gordon Eggman and the MND specialist nurse campaign in relation to that, which is £700,000 specifically going towards that. However, the reason that I am referring to that is that, although members of the cross-party group welcomed that funding, it will only scratch the surface of the need and the demand that is out there. For example, there are specialists in relation to Huntingdon's. There are 35 of them. For the genes complex needs network, there are five. For sick or ill disease, there are zero. Do we do that nationally, set those targets, or do we leave it up to local boards? I am minded that I was drawn to my attention that the moneys to fund that has been given to local boards to make priority decisions, and maybe that is something that we might have to review. However, that leads me to the key point that I wanted to make in this afternoon's debate, which is in relation to workforce planning. I met earlier on today with representatives of speech and language therapists who told me that what they really want to see is a needs-led, full-care journey planned out with multidisciplinary workforce planning, not just in the health sector and the allied health professional sector, but in the social care sector as well. As we are developing workforce and workload management tools for nurses, we have to get a lot better and I am a lot more clever at a matrix for doing that right across the health and social care sector. I know that the royal colleges have mentioned something in relation to that as well. Yes, we might need dramatic change, but I do not think that it is that dramatic. A lot of that appears to be on-going already, and the royal colleges are calling for things that I hope the Scottish Government has already been looking at. The final thing that I want to say—I always say that in these kind of debates—is raising the status, esteem and career pathways of care staff. I raised it in the last debate on health and social care integration. Let us make it a profession of choice for many young people coming out of schools and colleges. Perhaps they will release to college, perhaps after five years in the care sector, they will go straight into second year of a nursing degree or a second year of an allied health professional degree. It is a personal hobby horse of mine. I will conclude at that. I hope that the cabinet secretary will listen to that particular sales pitch for the care sector. Thank you. Thank you very much. The challenge of matching NHS resources to demand for healthcare is tough everywhere and no more so than in NHS Grampian. It is a service that I know well as a local MSP, as a former health minister and, of course, first and foremost as a local resident. My starting point, like most service users, is one of immense gratitude to all those who provide the service and to those who created the NHS in the first place two generations ago. Ten years ago, it was easy to hold up NHS Grampian as an exemplar of how health services should be delivered. Patients with routine ailments presented to primary care, not to A&E, and hospitals could concentrate on acute care. Budgets were tight then, as they are tight now, but Grampian was best in class when it came to getting value for money from the public pound. Since then, the challenges have only grown. Population has gone up faster than in the rest of Scotland. More people are living longer with a greater range of healthcare needs. Resources have gone up too, but not at the same pace. The National Resource Allocation Committee recommended changes to reflect population growth back in 2007, but those changes have not yet been implemented in full. Now, at the time of Grampian's annual review in January, ministers did provide an additional uplift of more than £11 million in the hope of reducing that shortfall to some £8 million, or 1 per cent, compared with what the NRAC formula then said that Grampian's funding should be. The Government's good intentions were welcome, but when the NRAC formula was recalculated to take annual population growth into account, the difference between Grampian's funding allocation and NRAC parity had gone back up to over £2 per cent, or £17 million, for the current financial year. I know that that is not what ministers intended, and that they were indeed seeking to get Grampian's funding to within 1 per cent of parity. I hope that they will try again, and I would urge them next time to allow for the predicted change in population in advance, so that the gap really can close to no more than 1 per cent in the next financial year. I take his point about population being important. Would he also accept that need and deprivation is very important? That is exactly what the NRAC formula is intended to reflect, is population growth, need and deprivation and urban and rural populations. The Government has signed up to the formula, and they now simply need to deliver it. Fully funding the health service in Grampian does matter. Whole-time equivalent nursing staff numbers went down by 465 between 2009 and 2013. There are still nearly 400 nursing posts unfilled. That is not just because of money, but extra funding would certainly help. The strain of making ends meet also contributed to the crisis of leadership within NHS Grampian, which reached ahead at the end of last year. A number of senior managers have left the board, a number of senior consultants may well follow. The root causes of this crisis were thoroughly investigated by two inquiries in 2014. Health Improvement Scotland looked in general at how secondary health services were delivered, while the Royal College of Surgeons was brought in to examine the professional conduct and standards of consultants in general surgery at ARI. Implementing the findings of his report is for NHS Grampian to do, and I understand that senior staff of his believe that good progress in that regard continues to be made. Incidentally, I am very pleased that the leadership of the local NHS is now settled after a period of uncertainty. In the very competent hands of Professor Steve Logan as chairman of the board, Malcolm Wright as chief executive and Dr Nick Fluck as medical director, Mr Wright's appointment on a permanent basis was confirmed only a few days ago and will, I think, be welcomed by staff across the service. The findings of the Royal College report, on the other hand, remain largely shrouded in secrecy. Only the recommendations have seen the light of day, even the conclusions on which they are based, have yet to be published. That is a pity, because I believe that the people of Aberdeen and Grampian deserve to know what the Royal College investigators found. Unlike his report, the findings of the Royal College investigation are not primarily a matter for NHS Grampian. Just as the investigation was undertaken by the relevant Royal College, so responsibility for dealing with unprofessional conduct by medical staff is a matter for the general medical council. The GMC will not refer to NHS Grampian before deciding whether or not disciplinary action is required in cases of alleged misconduct. The problem for staff and patients, however, is that it will take time for all of that to become clear. If this Royal College investigation had been undertaken in England, the duty of candor on NHS bodies would have led to publication of the findings of the report. Until that is done, it will continue to be all too easy for the vacuum to be filled with misinformation in place of facts. Given the Government's commitment to a duty of candor in the forthcoming health bill, I hope that the cabinet secretary will look again at whether there is a way of making the findings of this report public, to protect those who have done no wrong and to let patients know the full facts of the case. Professional reputations are at stake, but there is clearly a balance to be struck in the public interest. There is a very important debate to be had about the future of the NHS across Scotland. I hope that it can continue to be progress in addressing all the issues that are facing the service in Grampian as well as elsewhere, so that the NHS in Grampian can play a full part in that national debate and in delivering for local people. Many thanks. I now call Linda Fabiani to be followed by Jim Hume. Thank you very much, Presiding Officer. I really welcomed the text of Jenny Marra's motion when I read it last night when it was published. Of course, I welcomed the very consensual and positive contribution that she generally made. It was good to see that. It is quite clear that that position is one that people are coming to, as outlined in the amendment by the cabinet secretary. Many are recognising that patients, public professionals are recognising that across the board we really need an honest conversation on the long-term future of our national health service to make sure that it can meet the considerable challenges of the future. That is something that is often said and it concerns me sometimes that we talk about challenges. It also sounds hugely difficult, but some of those challenges for the future of the NHS are extremely positive and should be viewed so because many of them result from people living longer and from the advent of much improved medical solutions right across the board. I think that what is very important, too, is that in that discussion we should not lose sight of the considerable progress that our NHS has in fact made in recent years. We should not lose sight of the high-quality care that is delivered every single day by the vast majority of doctors, nurses, ancillaries, assistants, ancillary staff and, of course, administrators who help the wheels to turn. We have excellence to build upon. The cabinet secretary outlined record funding, staffing and other improvements moving towards the agreed 2020 vision for our health service. That vision for health and social care has prompted the fundamental shift to move towards more preventative healthcare and care that allows people to remain in their own homes, which is where people generally want to be. On that issue, we should always remember that part of the integrated care is also respecting the needs of carers, of whom there are so many carers in Scotland this week. In my constituency of East Kilbride, of course, there is an award-winning NHS Lanarkshire integrated care team at Stirling work, but we still have a long way to go. There are issues to be tackled, including bed blocking, home care packages, better working within health boards between departments, for example primary care, acute care and mental health services. We need better working between health boards and local authorities. That has begun, of course, with the Public Bodies Joint Working Act 2014, but it is not easy. Our public institutions are renowned for a fortress mentality that can lead to intransigence. I do not just say that lightly. I say that in the following years of parliamentary experience in various committees. I do not have time to go into it all, but I do remember that it was in the last Parliament, being part of the finance committee, where we did a very in-depth inquiry into preventative spend and it was striking just how intransigent some of our public bodies are in terms of looking after their own budgets. If we can get beyond the silo mentality that the net mill spoke of in and between our public bodies, surely we can get beyond the silo mentality amongst political parties. I am heartened by what I heard in the chamber today. I hope that Jenny Marra and her colleagues would take that in the spirit that is intended. I hope that it finally marks a move away from the SNP-bad approach that seems to have dominated Labour thinking for quite a time. Successfully managing the NHS in public hands requires agreement across the parties as well as across institutions about some of the key priorities and principles. The SNP Government has made clear that we agree with the fundamental principle that NHS services should be free at the point of need. The Labour Party has made that clear as well. There may be discussion about what that actually means, but it is a very basic fundamental principle that we can all get very much behind. I would make a plea to Jenny Marra to spread her approach more widely across her party, because our experience recently in East Kilbride has not been encouraging in that respect. For example, Jenny's colleagues in East Kilbride condemn us for repairing a seriously run-down health centre, and then they condemn us for deciding to build a new health centre. Now that it is built, giving us a really hard time for daring to have artworks upon the walls, East Kilbride Labour seems to hanker after the days when all public buildings looked the same, and all NHS buildings had walls painted green and cream. However, I think that on a national level we are moving beyond that. I am also very pleased that on a national level and on a consensual level we are accepting a new approach to our targets being necessary. I also think that, over the years, the way in which we have looked at targets has not always been helpful. I do remember many being abandoned by previous Governments and others coming back. I would like to see continual monitoring that is quantitative and qualitative and constantly striving for improvement. I hope that, with that consensus that I spoke of, we can reach that for our health service. I, too, welcome this debate on health at a time when we often get narrowly focused and address only separate elements of the NHS. I believe, as RCN does, that it is time to develop a clear vision for a future NHS that is truly sustainable. The recent joint statement by the Royal College of Surgeons, the RCN and the Academy of Medical Royal Colleges on the need to re-examine and develop the sustainability of the healthcare system highlights that this debate is long overdue. We have, for a very long time, called for a more robust and overarching strategy that listens to experts and puts patients first. Marginal and piecemeal changes in things such as workforce development, access to psychological treatments for children and adults and primary care for the population are not the direction that we want to go in, spending money without recognising the important links between the different parts of the NHS system will only lead to further segmentation of the services, increase pressures on staff and eventually reach a breaking point. We know that health inequalities in Scotland exist and they are not just a matter of who has better access to a hospital. Those inequalities can be shaped by conditions of housing, by educational and employment opportunities that exist in each part of Scotland, and by the support that each person is able to access when those issues can lead to depression, self-harm, increased risks of dementia and many more ills in mental health. I want to point out once more the Lib Dem's call for equal treatment between mental and physical health. In this discussion about strained budgets, ageing population and the NHS's biggest challenges, the inclusion of mental health is of course crucial for any way forward. I do not think that we can begin to address problems when we have almost one person and four living with mental health ill health issues at some point in their lives and that includes our own NHS staff. I note the important work done by organisations such as CME to end discrimination with mental health, but even so, the fight against that stigma is still a long way from being sorted. The inability of so many people to express their need for support affects their productivity at work, of course, and can in turn touch on other aspects of their life, such as socialising and family relationships, and can lead to self-harm and at worse suicide if there is no support. Our future NHS needs a serious commitment from this Government to address a parity of esteem between mental and physical health. Instead, so far, we have seen a decrease in the mental health research budget, a barely increase in the children and adolescent mental health services budget and a continued vagueness in a pledge for parity of esteem between mental and physical health. It is important that we—yes, briefly. I thank Mr Hume for giving way. I know that he has raised this issue valiantly on many occasions and more power to his elbow for doing so, but I have to reiterate the point that parity between mental and physical health already exists explicitly in Scottish legislation. It was set out in the National Health Service Scotland in 1978. I have said that many times to you now, Mr Hume. I have replied that it does not repeat what has been done elsewhere where it actually states physical and mental health, and I will be happy to forward that to him yet again. I thank you for standing up at a big—we need to go with that one small step further. It is important that we address the clarion call once and for all that mental health is no less serious than physical health. Our hard-working staff, doctors, nurses, allied health professionals, consultants, clinicians, ambulance drivers, GPs, carers and so many more ensure that Scotland is on its way to a thriving health. They and the patients are the fountain of knowledge and expertise that we now have to listen to. That should drive the way that we think about achieving the healthcare standards that are striven for. The current targets and measures of treatment, effectiveness in the joint statements onward, while having initially delivered some improvements, are now creating an unsustainable culture, skewing priorities and unfortunately wasting resources. We hear GPs' concerns about being overwhelmed with so much work that it affects the quality of their time with patients. We see nursing so under staff that private agencies are costing us millions while that money could go to investing in the human capital that drives NHS forward. Instead, the Government has been acting in piecemeal and reactionary way rather than placing safeguards from the start. It now needs to also recognise the value, as I mentioned before, of preventative healthcare. We are at a point where we expect to see a lot of changes, of course, with the integration of health and social care. This is the opportunity to ensure that this major project is given all the right support with all the details that are addressed and relevant safeguards if we are truly to achieve a future-proof NHS. If we are to put our healthcare system on the right path, we need to have an honest debate to face the challenges. The Scottish Government now must listen to the people on the front line about their calls for this debate for change, a new approach to targets and new ways of delivering care. That is why we call on the Scottish Government to embrace the bold thinking of long-term solutions for the NHS. I look forward to being part of this debate moving forward, not just in this place but with the deliverers of our healthcare. The BMA was right to point out that research highlighting the frustration at the lack of opportunity to express its ideas and feelings and to participate in decision-making over issues that directly affected their working lives at the expense of effective and efficient patient care. That is so wrong that they should be driven to fuel that way. That is why we need a longer-term strategy for an NHS fit for the future. Now, I call on Dennis Robertson to be followed by Drew Smith. Thank you very much, Presiding Officer. Just yesterday, we had the directors of finance from some of our NHS boards in front of the health and sports committee. At one point, I started to feel very sorry for them. The reason I started to feel quite sorry for them was because of the complexity of their job, because there are so many people knocking on the door of the finance directors in our NHS boards. People quite rightly putting their case forward, just as Jim Hume did a second ago and the minister responded. However, that is where we have the issue, Presiding Officer, because everybody wants that slice of cake—everybody wants to be that priority. Quite rightly so, when people knock on the door. However, sometimes we need to listen. In the case of Mr Hume, when the legislation is very clear, he appears not to. However, here we are in terms of—I can take a brief intervention. You state that I am not listening. It is a fact that the Scotland Health Act states that there should be improvements in mental health, but it does not do the same as the Act down south, where it actually specifies the parity between mental and physical health. That is the point. Presiding Officer, it proves my point, to some extent, because we have interpretation. Coming together, when we are trying to make improvements, will be the issue. We have our nurses. They have a particular opinion, perhaps in orthopedics or in pediatrics. Or, in the specialist nurses, who feel that there should be more of them. We have our clinicians saying that, perhaps, they should have more facilities and more resources. I would suggest that they are probably all right, but at the same time, we need to look at ways in which we can improve what we have and maybe be smarter—I think that was the word of Jenny Marr saying that we should be smarter in the way that we actually provide the service. In some things, we have a finite resource. To do that, we then maybe just need to think how we then deliver our service. With the integrated joint boards, we have an opportunity to meet those challenges that are before us. That was a big concern when Jenny Marr said that it may be perhaps, after the listening, coming together in six months. I am not sure that we would have the answers in that timeframe. When I was looking at the business plans for some of the integrated joint boards, we were looking at a three-year business plan. We need to ensure that what we do, we do it in a manner in which we are going to get the outcomes that we desire. There is no point in trying to rush in to trying to fix something. It is not actually broken. It is not broken, but perhaps we just need to be able to oil the wheels, just that bit better. Everyone is an agreement, Presiding Officer. When we are talking about the health service, we need to ensure—I think that Bob Dorris did this when he mentioned the carers—that we have this dialogue—again, colleagues in the chamber have already said that. Jenny Marr? I thank the member very much for giving way. He made reference to the remarks that I was making about the timescale of the public conversation that the RCN has called for. We are looking for solutions, and solutions are always welcome, but I think that more of a priority—I would agree with him—is that we cannot rush to immediate solutions, but more of a priority—I think that the RCN is calling for—is a public debate on the principles, and perhaps considering a whole range of different issues such as resource shifts, such as different principles, and all of those things are not running to immediate solutions. Thank you, Presiding Officer. Again, here we are. It is about coming together and how we come together and what we discuss and what we interpret as possible outcomes. I think that we are all trying to say, Presiding Officer, that we want the best possible outcomes for all patients, regardless of age, because it is important. I certainly would like to see more of the services in our primary care, and certainly through the GP practices or specialist nurses or practitioner nurses or allied health professionals, because it is a switch in our culture, a switch in our thinking. For instance, most people might think that, when they have an ailment, they go and see their GP, but why do they go and see their GP? Why do they not go and see the community pharmacist? Why do they not go and see the practice nurse? This is about trying to get this change of thinking in our minds that we do not always have to go to the GP. Again, the GP does not always have to refer to the hospital, because there may be alternatives for those referrals. When we are looking at that and when we are looking at the changes that we are actually proposing, and the changes that I think that we all want to see is this integration, that perhaps the referral should not be to a hospital, but maybe it should be to some social care. We all, as patients, have a responsibility, Presiding Officer. We, as patients, have a responsibility for our own wellbeing. We do need the help of our professionals, absolutely, but let's try and help those who are providing the service for us. Let's try and help them by changing our approach and our attitude to the services that we richly deserve and the services that we need for the future. Thank you, Presiding Officer. Thank you very much. Colin Drew-Smith, to be followed by Kevin Stewart. Thank you very much, Presiding Officer. I am grateful to the Labour Front Bench for providing Parliament with time to discuss the situation in our national health service this afternoon. As a new member here, I spent some time on the health and support committee, and, like others, I became well used to the calls from health professionals and policy experts for a dispassionate evaluation of what is happening in our hospitals, and, most importantly, how we achieve the greatest possible consensus about how the service is reformed in order to meet the scale of the challenge that it faces. I believe that my party has consistently supported expert opinion and the need for a much broader political acceptance of both the facts and the forecasts about the NHS in Scotland. The truth is that continued piecemeal and short-term decision making have the potential to damage the long-term sustainability of many aspects of the service in a manner that would alarm the public, whose expectations are high and, like everything else in the national health service, are ever-increasing. We all receive regular representations from our constituents about their experience of local NHS issues. It is a fact of political life that the publicising of negative experiences will sometimes be uncomfortable for a Government, particularly if they have been responsible for the stewardship of the NHS for a decade, just as it has affected previous Governments. I suppose that the challenge for the Government, and I thought that the cabinet secretary set out her willingness to engage in that challenge, is to accept an honest appraisal of the record and to welcome a genuinely inclusive debate about the future, because that is not always the easiest thing to do. I think that there is a need to do it undistracted by the desire to defend a record in areas where it falls short. I have no problem with defending a record on things that have been achieved but where problems are pointed out, I think that we sometimes need to get beyond defensiveness about it. Whether or not, as Parliamentarians, we were elected here four years ago or 16 years ago, in some cases, we are at a point in this Parliament where we are sufficiently advanced through it. Across the parties, we all understand the scale of the demographic challenge, the technological advances and the budgetary pressure that has been faced by the NHS. The challenge is, I suppose, brought most clearly to us by our constituents, some of whom experience unacceptable waiting times or inequities in their access to treatments or refuse drugs or procedures that they might believe might be able to assist them. Therefore, it is right that, whether we are in opposition or backbenchers on the Government benches to raise these matters and to ask ministers to take responsibility and, of course, to pursue remedy, I do not intend to raise a whole number of issues that my constituents in Glasgow come to me with in this debate. I do not think that that is the tone of the debate this afternoon, but there has been problems, particularly in accident emergency services in the city. There is a situation at the southern general, which is important to point out. My party supported, the Government supported. We all want to see that new hospital succeed, but we have had concerning reports that go beyond teething problems at the new hospital. It was not Labour MSPs who said that, but staff and patients in the record, I think, just a few weeks ago said that the situation was akin to a war zone. I am not going to dwell on that, cabinet secretary, but it shows the level of concern that exists. To me, it suggests that some of the things that are being pointed out are really basic problems that we should not be experiencing in a hospital that has been at the end of the day 10 years in the planning. There must be lessons there, but that said, hospitals I do not believe are the place where the big changes are needed to get our NHS back on track and, more importantly, properly equipped for the future. We have challenges around the underfunding of social care, lack of time for general practice and, as others have said, including on the Government's mentions, sometimes we talk too much about the move to preventative health here rather than necessarily come forward with the examples of where and how it has been achieved. Those are the real problems, because the truth is that we all understand this across the parties that too many people are in our hospitals when they do not actually need to be. Arguments about which A&E departments are provided will not assist the doctors, nurses and, most importantly, the patients off tomorrow if we are not left with enough specialist staff or beds to support the quality of care that should be provided in hospitals. I believe that the calls from the RCN, BMAs, royal colleges, unison and, of course, patient groups are not going to go away. It will not be good enough in a second term. As I have to say, sometimes this happens. I appreciate that members on the other side will be concerned that we perhaps feel that the Opposition party raises concerns too much. The frustration on this side is that often those concerns are batted away. We see that anyone who raises these concerns accused of running down the staff or running down the service and that workers can then be used as human shields. None of that safeguards the principles that we all share in terms of the future of our national health service. The answer to specific problems in the national health service can also be the allocation and continual re-announcement of relatively small pots of money that seem to alleviate newspaper headlines more than they might do the actual symptoms of what the challenges are in the health service. I suppose that what I just wanted to say in conclusion goes to the point that I would do well is the point that we are now in a Parliament. I accept that it is Parliament's job to hold the Government to account, but I think that it is both the Government and Parliament's job to ensure that the country that we leave behind for those who come after us is better than the one that we live in ourselves. I think that that is the importance of this debate. It is about not just improving the NHS that exists today but ensuring that it genuinely is sustainable for the future, and I will leave my remarks there. Thank you very much, Presiding Officer. Thank you. I now call on Kevin Stewart to be followed by John Pendlin. Thank you, Presiding Officer. We all recognise that we all have a duty in this place to ensure that our national health service is fit for the future, and I am always pleased to have the opportunity to speak in NHS debates and to be able to recognise the hard work of all of the NHS staff who deliver vital services across Scotland. We are lucky to live at a time where people are living longer, where new medicines are being developed and coming online, and where breakthrough medical advances are happening at a fair rate. Unfortunately, we are also living at a time where austerity policies are the order of the day from the Treasury. Too often, our focus in these debates is on hospital and emergency care, and today, in my contribution, I want to concentrate on primary care and prevention, as this area will play a significant role if we are going to achieve the cabinet secretary's aim to look beyond short-term demands and foster a consensus on how we best manage our NHS to ensure that it meets the considerable challenge of the future. Beyond that, we also have to have the honest conversation that Linda Fabiani talked about in her speech. As MSPs, we all receive complaints and concerns from constituents about aspects of their NHS care and treatment, and, often, they are unhappy with specific parts of that treatment and not the whole package. As a percentage of cases that the NHS deals with, the number of complaints is relatively small, and we know that there is, in the main, high satisfaction rates. The bulk of the issues that I personally have to deal with in my time as an MSP are about hospital and emergency care, and in particular about areas of specialist treatment. I receive very few complaints about GP's or primary care, and, considering that last year, I believe that there were around about two million GP consultations in Grampian alone, it seems that the satisfaction rate with this service is very high indeed. Because of that, we rarely discuss this issue in this chamber. We know that GP numbers rose by 7 per cent from September 2006 to September 2014. We know that there was an increase in GP numbers. However, in a recent meeting that the cabinet secretary attended with members from the north-east, we heard from GP's some of the difficulties that they may face in the future if we do not start planning now. Number one in that list was recruitment and retention. There are also some worries about premises and whether they are fit for purpose. Obviously, there is the rising complexity of patient care and work. They were very practical in the discussions that they had with us, and gave suggestions about workforce planning, which I think that the cabinet secretary listened to in his tenure on board, and she has already mentioned the fact that work is on-going in that regard. Also, in terms of premises, we have seen some investment in Grampian to help in that regard. We have a pilot going on at this moment in the north-east, which is looking at some of the complexities of patient care and workload. I am very grateful to the member, and I am very interested to hear what he has to say about the meeting that he recently attended. Will he acknowledge that, in the context of Grampian, there are particular concerns around the future of primary care in the city of Aberdeen, and will he join me in urging the Government to look very closely at what it can do to address those concerns? The Government is looking very closely, and that is one of the reasons why the cabinet secretary attended the meeting that I have been talking about. She has given a very clear commitment to continue discussions. We can continue to talk down aspects of what is going on. I would rather talk up about the very good work that is going on at this moment, in combination between GPs, NHS Grampian and the Government in that regard. In doing that, I would also like to look at other aspects of life that have an impact on the health service that we do not often think about. I would like to see integration of health and social care of thought when it comes to certain issues, and in particular areas of strategic and local planning. Far too often, there is agreement to go and build huge amounts of new houses, but no thought whatsoever into how those people in those houses will be served by GPs and other health services. I think that we need to get much better in that regard. That is one of the reasons why we have a major problem in Aberdeen at this moment in time in terms of the amount of folk that we have compared to the amount of GPs that we have. In future, I think that we need to look very closely at that. I will be doing so in my capacity as convener of the local government committee. I think that this has been a pretty consensual debate, and I think that we all are almost in agreement on almost everything. What we all have a duty to do is to ensure that we have an NHS and a population that is fit for the future. I value our hard-working and dedicated doctors, nurses, lab staff, porters and other NHS staff. I also value their stand-up and precounted attitude, for it is often these health workers who highlight NHS problems, such as the 434 who complained about Lancer staff shortages in the course of one year. To attack MSPs who take up these issues shows contempt for the workers who raised them, and likewise, do not undermine the public concerns for they know and understand. It is not the frontline workers who are responsible, but those in charge of the NHS. So let's stop the diversity tactics, admit that the NHS has problems and address them. Yet, when I tried to do that, I was accused of scaremongering by NHS Lanetshire, even though I was using their own words, taken from their own documents. It's as if they don't want the public to know what we are talking about, but it's okay for Lanetshire NHS board to talk behind closed doors about the fragility of services such as A&E and their plans to close departments due to staff shortages, but it will be tied to anyone else who talks about it. It's okay for the board to see shortages highlighted in red namba, but not for us to repeat that they are high risk or to question flying locums in from all over the world. As for the board, it should be a scrutiny body, not a defence mechanism, but when I raise staff and public concerns and the chief executive accuses me of scaremongering, they say nothing. That doesn't encourage the public or indeed people to speak out. The board members are public appointments. They are supposed to represent the public. Instead, they dismiss legitimate concerns, rubber stamp proposals despite public opposition and are rarely heard speaking up except to defend crucial matters such as the chief executive's pay. However, it's not all about money and, cabinet secretary, you're well aware of the many problems that have beset NHS Lanetshire over the last year or so. An independent report that back whistleblowers who raised the alarm about the lack of suitably trained workers in neonatal services, the NHS claimed that this was being sorted, but other errors were left depleted. We see the impact of staffing shortages with Lanetshire sometimes having more patients waiting over 12 hours than the rest of Scotland combined. The rapid review of NHS Lanetshire highlighted the problems of Lanetshire's A&E services, or that Scotland highlighted NHS Lanetshire's repeated failure to meet outpatient waiting times and delayed discharge targets. Leak documents highlighted service configuration problems in Lanetshire, and mental health services are still dealing with problems after the controversial reconfiguration that was implemented when Alex Neil was cabinet secretary. A&E is still under pressure, and this will worsen, but the disintegration of GP out-of-hours services, which the NHS says, have reached a point where it is becoming extremely difficult to provide a safe service. As the cabinet secretary is aware, GP out-of-hours is a big issue in Lanetshire, not least because there were five centres until July last year when it was cut to three. Those are co-located within A&E departments, but according to five royal colleges is the best option where available. I am pleased that the cabinet secretary also described co-location in line with the work that we are already doing, and there is a good chance that the current review will recommend that. The cabinet secretary asked the board not to make permanent changes until the national review reports, but that appears to have been ignored with the board rebranding the permanent change as an interim measure. I hope that the member is going to be clear with the facts that there is an interim set of arrangements due to the patient safety concerns that we cannot ignore, but any permanent changes have to come to me for approval and have to be in line with the national review. I hope that he will accept that those are the facts of the matter. If it is an interim measure, why are the centres being moved from the hospitals against the royal colleges advice? Why are the interim measures identical to the board's proposed permanent solution? Why is NHS Lanetshire setting up a new centre as an interim measure with all the costs that it entails and even more costs if it has to move back again? That move does not make much sense unless it thinks that it is going to be permanent. That will reduce the service to two or even just one centre for the whole of Lanetshire based on consultation that has only offered those two options. There will be costs and disruption involved in changing and further costs have changed back, which makes people suspect that they want to make their so-called interim plan into a permanent picture. Now, if I've walked spot for wish of peace, the public were very angry and had some not very complementary things to see about the plan. I've already written to the cabinet secretary, asking her to intervene and now ask her publicly to ensure that NHS Lanetshire is not allowed to subvert her previous requests. So, in conclusion, I agree with the call for a wide-ranging debate about the future of our NHS. I've called for it locally and nationally, but we shouldn't get away from the urgent action that is also needed. There are certain key words and phrases in this motion, for example, the future sustainability of the NHS and looking beyond short-term demands, which I absolutely agree with and I hope that we are all signed up to these concepts. I would add one other phrase, which again I hope that we would all believe in, which is preventative spending. The reality is that there will never be enough resources to do all that we want with the NHS, and as the statement reminds us, new drugs and new technologies can be very expensive. There is no limit to the resources that could be spent, so there will always be difficult choices as to what we prioritise. That is particularly the case in the present time and in the near future, when resources are not likely to increase substantially. Of course, we could reduce resources in education or housing and transfer those to health, but I do not sense that there is a huge appetite for that in any of the parties and we have not heard anyone say that today. I was interested in the quote of Theresa Fife, director of RCN Scotland, when she said that putting more and more money into the current system is not the answer. Therefore, presumably what we are debating today is how we use resources within the health budget in a better way, and no one is seriously suggesting that there could be greatly increased resources. Action 3 in the statement talks about supporting people to live at home or in a homely environment, and I think that we probably are all signed up to that. It goes on to say that there has not been enough progress towards this, and I quote, instead, the focus has remained firmly on the traditional model of hospitals as the mainstay of the health service. This needs to change, end of quote. I have to say, I tend to agree with this. In the finance committee, we have spent a fair bit of time over the last four years, and I think Linda Fabiani reminded us before that as well, considering the subject of preventive expenditure. I think that other committees are on board with us too, and even this morning we spent time at Edinburgh University discussing it. I accept that it can be hard to clearly define exactly what is and what is not preventive spending, as even one particular medical intervention can have both a reactive and a preventive element. However, it seems to me that expenditure in hospitals is primarily reactive rather than preventive. I think that we have to seriously consider reducing the money that we spend in hospitals and putting more resources into GP practices and other more preventive and community based solutions, which often anyway are less expensive per person than treating somebody in a hospital setting. Yet seriously making that kind of change would be very bold. If we reduced the resources available for hospitals, what would the reaction be from the public, the media and politicians? Such disinvestment has not been easily tackled anywhere else, and I think that there can be a way of thinking amongst the public that somehow hospital care is gold-plated and other locations are second rate. Yet we know for older people especially that they can be more likely to be confused if they are moved to an unknown hospital and potentially more likely to fall or pick up infections than they would be at home. The statement calls for professions, organisations, politicians, the media and the public to work together on this. Now, is that actually possible? Well, surely it has to be our aim. We know that if accident and emergency waiting times go up, at least the politicians, the media and the public will all get very excited about that, and often the response is more resources for A and E, but is that not actually a sign of failure in one sense? Surely too many people are going to A and E who may not need to be there and who would be better treated elsewhere, so should we not actually be moving resources from hospitals and from A and E into the community? I also think that Jim Hume's point about mental health comes in here because we do not hear the same immediate demands for mental health needs as we do for A and E. Even if it did mean allowing waiting times to rise temporarily, in the longer term that would give us more resources for GP practices, care homes and home care, the question is really how do we allocate those resources and I have to say that I do not think that bringing one patient into Parliament who has very expensive needs is the right way of pushing how we spend the NHS's money. While mentioning GP practices, are the resources going to the right places? If it really is the case that life expectancy reduces as you move west east in Glasgow and it has been suggested that that happens by two years per train station, is that not a sign that we are putting too many resources into the richer areas and not enough into the poorer areas? Should we then consider cutting GPs in the west of the city and having more GPs in the east? I can see that that suggestion would not go down well in certain quarters, but we are being challenged by this statement to do things differently, so surely at least that is the type of question we need to ask and the deep end practices that represent the 10 per cent of GP practices in the most deprived areas have been asking these kind of questions. I think that we are all very proud of the Scottish NHS, despite its faults. We want the best for it and the best for our fellow citizens going forward, but I believe that that is going to mean hard choices. If we want to invest more in one direction, it is going to mean disinvesting in another direction, so my question is, are we brave enough to do that? I welcome this debate because it gives the chance to talk about the challenges that have been brought to us by constituents, patients or workers in the NHS. I want to focus my remarks on the basis of the perspective of what is happening in NHS Lothian, because it is struggling with huge pressures. It has got people experiencing ill health as a result of deprivation, people with multiple and long-term health conditions, we have a growing population that is month on month growing and there is no sign of that changing. We have a changing population, if others have talked earlier, more older people living longer who will have many more contacts with our NHS, whether it is our GPs, our care system or indeed hospitals. There is also a challenge that we are now being asked to look at from the RCN, the Royal Colleges, who wants us to have a genuine public debate on the change that is needed. In following on from John Mason's comments, I think that from where I am looking at it, the challenge is that it is not just a question of moving resources from one place to another. It is partly about managing the transition that we now need. When I think about the massive uplift of health expenditure in the early years of the Parliament, it enabled us to do all sorts of new things. Going forward, there is clearly not going to be that same massive uplift, but it is not as simple as saying that you just cut in one place and automatically move to another. The transition is absolutely key. That is where I think that the GP practices are crucial. They are about how we manage demand. Many people's first port of call, if somebody is going to the A&E when they could have gone to the GP, is a failure. It is a waste of resource, and that is an illustration of the problem. We have a constant pressure on waiting times in Lothian, and we have a care crisis. It was estimated this week that we are adding something like 5,000 hours of home care that are going to be needed every year. That is on top of already stretched services. Having tracked NHS Lothian for the past 16 years, I have watched the challenge growing as we have more people. I take part of the point that John Mason is making about moving resources on the grounds of inequality in terms of health. We also have a challenge about people, regardless of their income, who are going to need healthcare, so it is a bigger problem. We have a GP crisis that sees us with shortages that are hidden by locums. We were told at a meeting with the City of Edinburgh Council in NHS Lothian last week that, over 73 GP partnerships, six are unstable at any one time. As I mentioned earlier in the question time, we have 26 GP practices that are currently closed to new patients. There is a huge problem at the entry point to most of us to our NHS—our GPs. There simply is not the access that we need, and that does need new funding. We have also got a problem because the employment model has changed. With more and more women working as GPs, they are not wanting to do the same kind of traditional career structure. That means that we need new GPs and we need more training for new GPs. There is another factor to that. I know just from my personal experience of more and more GPs who are leaving or going part-time in their 50s. If all our careers are going to be lasting until we are 67, just thinking about that, that is a 40-year career in general practice. With the pressures that are now being added to GPs, that is simply not going to be sustainable for the long run. We need to find different ways to enable GPs to work. We need to find different employment patterns, but the system needs to assume that not everybody is going to be working the same kind of patterns that we have traditionally had. I think that a key to all of this is thinking more radically about GPs and supporting the development of GP practices to do different things, but to make that happen is going to need a transition. That £50 million fund that I mentioned earlier is key, and there is a question as to whether that will be sufficient. In addition to GPs, the care sector that is being mentioned by others is absolutely crucial. Part of our problem is that there are many, many patients stuck in hospital, particularly older patients, who, while their physical needs have been met and they are able to go home, do not have the care and support in their own homes. They do not have care homes to look after them. The particular challenge about that is that, for many older people, actually being in hospital for a prolonged period of time is, in itself, bad for their health. It may be bad for their mental health in terms of nutrition. They may not be getting the nutrition that they need, so we have got a multiple series of problems with people being stuck in hospitals. Again, that goes to GPs and to care home services. The challenge that we have is that I just do not see it realistically being a question of cutting back investment in hospitals and shifting all that investment instantly to care and GP services. We are going to need to have new investment as we manage this transition process, and that is challenging because the current model that we have in terms of public service and public expenditure is not going to meet that change. We have to have some really bold discussions here and some really honest discussions. It might be a question of looking at volunteers to help part of that process. For people with dementia, for example, there are many, many fantastic projects where people who are older themselves or people who are working part-time are actually providing a vital backup to our care services. There was a project that sirenians ran on dementia. It was on care for older people to reconnect them and they discovered a massive unmet need of dementia. I agree with the principle of what is being talked about here, but I would just finish on the point that, in some ways, it is a lot harder than people are saying. Having a genuine, honest debate, it is going to create a lot more challenges that we are going to need to address. The problems that we have currently got are already huge, so that needs to be added on top to the existing problems. Thank you very much. Thank you very much, Presiding Officer. I know that we are looking at today's debate, and I appreciate that we are looking at today's debate from what has been broadly a consensual approach. Given that I am famous for taking such an approach in my speeches, I will look to continue the theme. A number of suggestions have been made by members, and I think that I might contribute some suggestions of my own, because I recognise the pressures that the NHS faces. I think that we all recognise the pressures that the NHS faces. My colleague Kevin Stewart referenced the meeting that we held with NHS Grampian at which the Cabinet Secretary for Health and Sport attended to discuss some of the issues that are facing the primary care sector in particular in the Grampian area. In my constituency, recently, the Bremen Medical Group announced its decision to withdraw from the provision of general medical services as of 1 October, due to upcoming GP retirements and a difficulty in recruiting to the practice. A letter was sent out to the 8,300 patients of the practice of which I am one, advising to that effect. Discussions with NHS Grampian have established firstly that the patients will continue to have a GP service in the area. Discussions, I am aware, are on-going in relation to that, and there is a process that is being followed. One of the things that it is highlighted through and that I will continue to highlight with the health board is that, at a point at which a practice is facing pressures or deciding that the GPs are going to withdraw from providing general medical services and the practice faces closure. There is a need for on-going communication and collaboration with the practice itself, as well as looking to the future provision, because there are obviously issues around retention of existing staff and the two-pay arrangements that could be put in place, and there needs to be that on-going dialogue. What also highlights to me is that there is an opportunity to look more closely at what we are doing in terms of primary care and the way in which we are accessing primary care. I think that NHS Grampian has said that one of the things that they want to look at is a more confederated model. Instead of individual practices operating in small areas, which can obviously put pressure on GPs to take on partnership roles, looking at the possibility of a practice having a number of premises across communities delivering services, where you are only relying on a small number of the overall cohort of GPs to take on those positions. One of the things that has been highlighted is a difficulty in attracting— Microphone for Mr MacDonald, please. I am sure that you only missed a little bit of that quality contribution that I was making. To rewind slightly and start again, one of the difficulties that is being faced is attracting new graduates into general practice. I think that one of the reasons for that is the view that is held by graduates that they would be required to take on some of the responsibilities of partnership, which many of them perhaps do not want to take on alongside the role itself. On top of that, the fact that a larger number of general practitioners now are part-time and female compared to the previous model, where you had a larger number of male GPs working full-time, needs to change the way in which general practice is delivered. When we talk about pressures on accident emergency, we talk about people presenting an accident emergency who ought to be presenting at their GP surgery. We need to drill down a bit further and look at GP surgeries and where people are presenting at their GP surgery where they might be better dealt with by another health professional, for example nurse practitioners. I have highlighted in the chamber before the good example of the middle-field healthy who is in my constituency. I know that the minister, Jamie Hepburn, is going to come into my constituency to visit that facility next month, and I look forward to joining him on that visit. Also, pharmacists and other allied health professionals have a role to play. We need to ensure that there is an appropriate triage process in place. In many cases, when an individual phones up their GP surgery, they can be given an appointment with the GP without there being any examination of what the issue is that they wish to discuss. It is only at the point at which they are presenting to the GP in the consulting room that the GP might think, well, you should really be going to the pharmacist rather than coming to see the GP. We need to get better at how that is dealt with. The other thing that faces GP practices is certainly in my constituency, and I suspect elsewhere is the pressure of development as well as the pressure of demography. A large amount of planning applications are going in my constituency, which will add pressure to existing GP practices, which are already either at capacity or getting very close to capacity, some of which Daneston being one, which are operating within very constrained physical premises and do not have a lot of room for expansion or indeed any room for expansion. I think that we need to look at how we utilise both planning gain but also other funding streams to expand and develop practices and whether that needs to be done in a more collaborative approach. Finally, on the issue of the care sector, I thought that my colleague Bob Doris made some very important points about career pathways. We have seen in my constituency the Bucksburg care home being closed and abandoned by pepperwood care, the previous owners. I asked if NHS and the council would look at the possibility of establishing a step-down facility similar to that at Clashie now, which has helped and will help in dealing with delayed discharge. I was advised that the cost of bringing up to a suitable standard was too high and that it was not seen as a suitable facility for that. However, I do know that there are talks going on between Scottish Government, NHS Grampian and Aberdeen City Council about possible future uses for that facility, which will help to drive improvements in the care sector. I look forward to hearing more on that in the near future. I think that, in terms of the care sector, one of the things that we have to maybe look at is whether there is a way that we can develop a model and develop an approach that can chip away at what I see as the difficulties that have been caused by the genie being let out of the bottle, by the privatisation element coming into care home provision and whether there are ways of means that we can address some of the challenges that that is presented. I now call on Duncan McNeill after which we will move to closing speeches. Thank you, Presiding Officer. Like others, I welcome this debate today and welcome the cabinet secretary's commitment to a full public debate. It was something that I discussed with her and urged her to do, as I did speak to the previous cabinet secretary. I am encouraging this sort of debate for quite a while, so I am delighted that it has come also. A motion to the Parliament last week urged in this debate, and I am in the light of Bob Dorris's support for my motion. Consensus broke out there. I am confident that the Health and Sport Committee can play an important role in ensuring that we have the widest possible participation in this debate to meet the call made by the royal colleges. We bring about changes in the delivery of services in a sustainable way. I ask everybody in the chamber, because with a great consensual debate today it would be terrible if we split on the vote. I point out to those members in other benches who mentioned the importance of its sustainability. I think that there is only one motion that mentions sustainability. It is a slight tease, but it would be disappointing to get off to a bad start today, because there has been so much consensus in the fact that we would value this debate. We all know that the pressure has been on, and it has been on for some time. Indeed, John Mason left the chamber and so much agreed with his speech. One of the issues was that it is not simply about money. Simply protecting the budget does not solve the problems, nor did throwing money at the problems in the past. High bed occupancy rates, queues at A&E, unfilled vacancies and increasing work-in-hours challenges with providing A&E services out-of-hours have been with us for the past decade. We are all committed to the national health service. We know that at certain times it comes under pressure, but there seems to be a lot of it at this point. The members have been well. I thank the member for taking a brief intervention. The member agreed with me that every voice should be equal in this debate, so it does not matter whether you are a consultant, porter or nurse patient, regardless that every voice should be equal and heard in the same way. I think that the debate, if we had it, should seek the interests of the Scottish people, not vested interests in or without the national health service. I will come back to that. However, we have had single debates, time on time and inquiries and spent a lot of time on many of those issues individually. Here is the opportunity to have a debate about the whole system failure that needs to be addressed. A genuine public debate, as others have mentioned, John Mason, Sarah and others, will be a challenge. To sort this means that we will have to take sides on issues, whether that be the performance-related terror targets, as some people describe them, that drive so much in the health service, that skews away from looking at preventive measures. Preventive measures take longer and take time, but the pressure on the health board managers and the health boards themselves is to deal with the immediate situation, which is people waiting in A and E. Diverse our time and commitment in all of those areas in more way in one. However, we start off, as the cabinet secretary wrote in her article this week, that there is already consensus in his chamber across all parties, and Scotland's NHS should remain publicly on, publicly run, free at the point of need. Nobody would disagree with that principle. Indeed, it would be a good starting point, as it has in Wales about getting agreement with the principles. It is much more easy for people to agree in certain principles, and it is very easy to sometimes divide on target A or target B. The principles are good. We are all agreed in them. Let us build on some of those principles and hope that that can take us forward to achieve real change. Of course, the question about targets and the day-to-day running and whether we can get this debate going has got to be done with the recognition that we are facing immediate pressures and how we move on and deal with them. It has also got to be seen, if there is any criticism of the herald article. I think that it does what we all do. It focuses in too narrowly on the professionals and the health service as being a hospital. When we all know and our ambition is that more care is already taking place in the community, it will continue to increase care in the community. With the support of the national health service, but outwith what we normally consider the national health service, because we will need to deliver that care. We will support that move to in the home, closer to the home in the communities. Again, as I said with John Mason, he hits it right in the head. We have here a health service that is under tremendous pressure. The gold-plated health service is under pressure. On the other side of that, when more and more people have been dealt with in the community, it is not stress, it is adversarial, it is prone to the market. In some areas, it is driven by profit, which drives down, in some cases, a quality that impacts on the resilience of carers and diminishes the workers who are delivering that care in their communities. It is the exact opposite. None of those conditions would we accept in the health service. That must form an important part of our debate going forward. We cannot have two health services in Scotland. We recognise them in much of our policies as being the same. Health and social care should be one of our future principles going forward. I am not an evangelist. Sometimes, I think, can be slightly evangelical, but I am going to begin with a halleluia. Although there has undoubtedly been from the Labour benches in recent times, from Duncan McNeill, from Hugh Henry and others, a recognition of the need to move forward in a consensual basis, I hope that they will excuse me by saying that some of the debates that we have had quite recently, in fact, have been much more belligerent and antagonistic in their tone and, fundamentally, depressing in terms of the kind of move forward that we have to see. I hope that I am not being unduly cynical in observing that we are having this debate today one month after a general election and not one month before it, because it does seem to me that the exigencies of the political process in which we all apply our trade allow elections and the cut and thrust of elections and the preparation for the cut and thrust of elections to cut aside right through the type of conversation that everybody this afternoon says that we need to try and have and the consensus that we need to try and achieve if we are going to have a model for a sustainable health service in the future. A couple of years ago, Scottish Conservatives did say that we would have nothing to do with the English health service reforms that we believed in a publicly funded health service free at the point of need and delivery. Some were surprised. We did it because we recognised that the professional organisations, whether the BMA, whether the RCN, whether patients, whether people on the street said that they had had enough of this interminable antagonistic approach to health, which clearly was going to fall short of creating the kind of environment that is now going to be needed if that health service is going to be secured for the future. However, I do want to say one thing, and I hope that the cabinet secretary will take it a note. There is a distinction between consensus and a non-partisan approach to the health service, not being the same thing as the opposition agreeing with everything that the Government then says. I was a little dispirited last week when the First Minister at First Minister's questions when asked about health turned it around to say, and that is the end of the consensus, obviously, which the professional sectors are looking for. I thought that Drew Smith touched on that point. There is a duty and an obligation to raise concerns even while we try to arrive at that broader consensus on the way forward in the future. I agree with that, but I think that it is about how those concerns are raised and that there is always a balance to be struck as they are not. So when raising a concern about waiting times, for example, there is always the point to be made about the successes of the NHS. I think that that works both ways. There are ways of raising concerns but also not trying to undermine the fundamentals of our health service. I am happy to agree with that. Of course, that will be the test in terms of how we take those things forward. We have tried to contribute to the debate. Some ideas will be acceptable to some others not. We have talked about the need for a GP-attached, national and universal health-visiting service up to the age of seven because we think that that could help address health inequalities, particularly in areas of deprivation, and contribute to the broader success and the preventative agenda. We have talked about the reduction over time—because I do not want it to become a cause-celebrity on its own right—of the reduction in the number of health boards and ADTCs to try to evolve a more universal and, hopefully, less postcode lottery type of prescribing. We have talked about the need for—and this came up in several speeches this afternoon—in the investment in the development of a new model of primary care. We know that we have aging GPs, but we also know that if we want to stop people going into hospitals and to A and E facilities in particular, we have to have a model of primary care that actually works. That may mean moving to a more rural type model with larger practices or the confederate model that was talked to. I cannot just remember by who—I think that it might have been Mark McDonald—but we need to see that evolve. Perhaps when we revisit the contract with GPs, get away from paying people to do things irrespective of whether that is where the priority should lie and come up with a model that recognises the challenges that we have going forward. The member would agree with me that what Wales is doing—which I will refer to my summing up—of supporting 63 GP clusters is exactly the sort of confederative model that you have now referred to. I have talked as well that we need to find a way of encouraging people to understand their responsibility for their own health. The cabinet secretary was not terribly keen on the idea of an individual health statement, which I canvassed before, but perhaps we do need it. It is something of a national emergency, I think, the whole sustainability of our health service going forward. I do not mean that it is a crisis, but we want it to avoid ever getting to that, to maybe each health board sending out an annual report to every household identifying the real priorities, strains and consequences of not looking after your own health to individual households. If we have an ageing population and we want them to enjoy a healthy old age, then everybody has to understand that what they do in their 20s, 30s and 40s will have a direct bearing on the quality of life that they might expect to lead later on. We have to find ways of keeping people out of hospital. When this Parliament was founded, diabetes type 2 and dementia were hardly registering as issues. They are now enormously financially burdensome in the health service. What issues are we not even aware of today that may be a similar and equally complicated burden in the health service in just 15 years from now? That whole plan has to take place. I thought the contributions from Dennis Robertson, Sarah Boyack and John Mason not touched on those themes in different ways. However, I want to finish by saying, slightly disagreeing with Nanette Milne, which is a bit controversial. Nanette Milne said that she was confident of success. I am less sanguine. I have got to be honest. I think that, as I said earlier, the exigencies of our political process are the worst enemy of what it is we say we are trying to achieve today. There is an election next year. Are we really saying that all through the winter and the run-up to that election, we are not going to fall back into that trap of shouting at one another about what is happening in health? If the Government at Westminster says there will be more funding coming, I will be going to say, oh, no, it won't. It is going to be incredibly difficult. That debate that the cabinet secretary has talked about, I want to hear more about the how of that. We have got to get not just talking, but agreeing as well what the shape of that discussion should be and how we all sign up to the conclusions of it at the end, too. I am not sanguine about it. I am not roasted into spectacles about this. I think that it is going to be difficult, and I think that we are all going to have to work extremely hard if we are going to succeed. The problem is, the real problem is, we have to. I thank Jenny Marra for securing this debate on what is one of the nation's greatest assets and one which is so important to everyone who is required to use the services offered by the NHS across Scotland. I also thank members for their varied contributions to today's debate, and, in particular, for the wide appreciation that has been expressed by many members for the magnificent work and the dedication that has been shown by those who work in the national health service in Scotland. I thank those who are working in our NHS. I also welcome the many constructive comments from the royal colleges, but it is important that, as we engage in this process, we hear from everyone, including members of this Scottish Parliament, the public and anyone who can contribute to progressing our national health service. We have heard about the joint statement that was issued last week by the Royal College of Nursing and the Academy of Medical Royal Colleges regarding the sustainability of the NHS in Scotland, calling for a bold, visionary and collaborative approach between Government, public and professions to secure a better future for our health services. We, as an administration, welcome that contribution from both the Royal College of Nursing and the Royal Colleges. We should not, however, lose sight of the considerable progress that the national health service has made in recent years in Scotland, delivering high-quality care every day in NHS as high, record high funding, record high staffing and, historically low, waiting times, a world-leading patient safety programme in a clear 2020 vision. Nonetheless, we must be prepared to look beyond that horizon and consider the way forward for the NHS into the future. To that end, the cabinet secretary set out in Parliament earlier this year in January the need for change to meet rising demand and an ageing population and for a wider debate on the future of health and models with care and explained our commitment to working with patients and families, health professionals and clinicians, the health and sport committee of this Parliament opposition parties, everyone that wants to contribute to help shape the direction of our NHS and clinical strategy for the next 10 to 15 years. The cabinet secretary reiterated that comment today, and she set out our desire to foster consensus around the way forward in the Herald newspaper today, which was welcomed by the RCN and the Royal College of Surgeons. Applying for the future must include key elements such as determining what capacity is required where and what the workforce will need to look like to deliver those new services in a different way. The role of the professional bodies in the Royal College will be key to informing that work. We agree that the NHS and social care services need to continually innovate and adapt to meet public expectations and the changing nature of the demand placed upon them. Government legislated to bring forward health and social care integration with full implementation to be in place by April of next year to help to underpin the shift from acute to community delivery of care. We support integration, committing over half a billion pounds of Government investment over the next three years, including £300 million in care fund, £30 million for telehealth projects and £100 million for delayed discharge. Having mentioned delayed discharge, Sarah Boyack raised concerns about delayed discharge. I know that she has a long standing interest in that. She has raised it in the chamber with me before tackling delayed discharge, which is part of the rationale for introducing the integration of health and social care. I can report to the chamber across. We have seen a reduction in people delayed more than three days from 947 on October 2 to 646 in April, so it is clear that progress has been made. The Cabinet Secretary for Health and Sport spoke of the work that is being undertaken on primary care, the new GP contract that there will be. Professor Lewis Ritchie's work on it, out of ours, serves to know that many members take a great interest in that, particularly when John Pentland raised the issue of out-of-ours services in the NHS Lancery, who will understand that. I also take an interest in that matter, too, as a representative of a constituency that is covered by the NHS Lancery. He asked for a commitment from the Cabinet Secretary for Health and Sport today that the NHS Lancery's model for out-of-ours must correlate to the outcome of Lewis Ritchie's national review and recommendations taken forward by the Scottish Government. I would point out that the Cabinet Secretary made that clear commitment to him in her intervention on him, so, hopefully, that serves as an indication of the Scottish Government's commitment in that regard. Many members spoke about primary care, Mark McDonald and Kevin Stewart, in particular spoke about the situation in the north-east of the Cabinet Secretary's meeting up there. I say to Mr McDonald that I look forward to joining him on my visit to his constituency. The new models of primary care being looked at are at an early implementation stage in primary care settings, mainly GP surgeries across the country. What those projects will have in common is that they are bottom-up tests of change across a wide range of communities in Scotland. The learning from which we will influence the future shape of primary care is a critical element of making our 2020 vision for integrated health and social care rule, and they will inform the work going beyond the 2020 vision. We want a new emphasis on care delivered in the community, something that has been expressed as desired by most members in the debate. We want to see that emphasis on care delivered in the community by multi-professional teams that best meets patient needs and will be working with the professions to deliver us. How that shift is better achieved by a key element of the discussions with the professions that the Cabinet Secretary will lead. Bob Doris spoke about the opportunities for young people through the National Health Service, the NHS in Scotland benefits from a varied employee base. The employment of young people represents a great investment in the future. Boards, at the moment, are asked to deliver a national target of 500 new modern apprenticeships by August 2017. Mr Doris also raised the issue of ensuring better career pathways to the NHS. I agree that that has to be part of our thinking going forward. Jim Hume, as he does regularly to his credit law—I do not always agree with every element of it—he raised many issues around the future mental health service, and much of which I agree with. The need to tackle stigma is very important, and that is why we continue to fund CME. He did raise the issue again about the parity between mental and physical health. I reiterate the point that such already exists on a legal basis through the 1978 act. I would also point out that we have recently announced an additional £85 million on top of the £15 million that was previously announced last year for mental health. That new funding will focus on a variety of areas, including further investment to child and adolescent mental health services to bring down waiting times, improve access to services, and in particular psychological therapies. The focus on community settings is again on better responses to mental health in community and primary care settings, including promoting wellbeing through physical activity and improved patient rights. In a net million raised the issue of palliative care, the Scottish Government has committed to the development of a strategic framework for action, providing a focus to support high-quality palliative and early care. By the end of this year, I will ensure that that is available to all members of the Parliament. Lewis MacDonald raised the issue of NHS Grampians funding. I would point out that, in this year, NHS Grampians resource-based budget has increased by 6.7 per cent above inflation and the largest increase of any mainland board. However, in terms of the issues that he has raised about, the NRAC formula more generally is something that this Government is willing to look at. Of course, it is not possible to respond to every issue that has been raised in this debate, sadly, Presiding Officer, but I very much welcome the fact that we have had this debate. I welcome the fact that it has been a consensual type of debate. We will continue to work with others in this chamber and, most crucially, of all the professionals and the public to ensure that we continue to enjoy a world-class national health service long into the future. Many thanks. I now call on Dr Richard Simpson to wind up the debate. Dr Simpson, you have until almost five o'clock. Presiding Officer, I draw members' attention to my declaration of interest in respect to my membership of the BMA and of the Royal Colleges of General Practices of the Country. In supporting the motion in Jenny Marra's name, can I begin by saying that we really are disappointed that the consensual approach in our motion seems to have required such an extensive amendment by the Government? Indeed, I am disappointed by Mr Hepburn's summary at the end, which did not seem to address the motion at all. I very much welcome John Mason's support for the sustainability aspect of our motion, which has been deleted by the Government amendment, and his very measured contribution, with much of which I agree. Although I very much welcome the tone of the Cabinet Secretary's contribution and some of the things that she has said, the commitment and moves to a full, inclusive, open debate, I wonder if she would like to make a unique move in this Parliament, which follows something in the Welsh Assembly, which is a recognition that our motion, because it contains sustainability, should now be passed tonight. Rather than having her amendment defeated—which it probably will not be—she might withdraw the amendment, which actually happens in the Welsh Assembly. However, I do not believe that anyone looking at our national health service in Scotland today can come to any other conclusion about two things. One, that it has made very significant advances over the last 15 years. All the measures that we introduced and the SNP have continued and amplified and brought in new measures on have led to huge improvements in our service. The other thing is that, without the extraordinary efforts of our staff, often than above normal duty, our service today would be in serious difficulty. That is not the debate in which to elucidate the long list of problems that are self-evident to any reasonable observer. Although, in opposition, we must, as Lewis Macdonald illustrated, ensure transparency and open discussion, and, as John Pentland referred to with the problems with the Lanarkshire health board, this is vital. However, I have to say one thing, that the continued mantra from the Government that there are, and I quote, more staff in post, more operations and more procedures being undertaken than in 2007, is really getting a little tired. It is, of course, true, and I have just welcomed the advances that have been made. However, given the increases in population, given the increases in challenges, there is no doubt that there are serious stresses within the system. Presumably that is why, when I laid out in my opening speech the fact that there was all of this additional capacity and staff, I then went on to make the point that, of course, the increasing demand on the health service is why we need to have this debate, because it is difficult for the NHS to keep up with that demand. That is exactly that point. I accept that, but the point is that that is not the defence of the problems that we are currently facing. We recognise the increases, but the challenges actually exceed the increases in staff that we have had, and that is evidenced by the vacancy levels that we have at the moment. The increase in the complexity of problems with which our older population of presenting demonstrated by a recent Canadian paper has doubled in the last eight years. That is a huge increase. We have got real problems with waste within the system in both resources and time. We have new medicines and new procedures. We have increases in numbers with cancer and large numbers with dementia combined with physical illness. Following the lead of the Government's own Campbell-Christy report, we called in 2011 for a Vedrage-style review, a full review of the situation. We were told that that would be too slow and it would not be worthwhile. Four years on, if we had that review, we might have actually completed it. Now, let us look at what has happened in Wales, which both this Government and the Government in London have criticised for their performance. However, what they did was to establish the Bevan commission, and in December 2011 that became established, and they worked out four core principles for the Welsh NHS. They have suggested that some of the objectives of their Welsh national health service will be to fit the need and circumstances of the citizen with the citizen, to maximise the limit of resources, skills and financial resources that can be drawn upon, to actively avoid waste and harm, to abandon treatments or care that provide little or no benefit, and to reduce variation, something that I go on about in this Parliament quite a lot, adopting evidence-based medicine at scale and pace. They have got four principles that they have established. Now, they have taken the time to do that, and I think that our debate has to start by really establishing the principles of a sustainable NHS going forward. Now, there are things that I think we can do. Let me just give some examples at the coalface. For example, is a blood test or another test necessary in the first place? If it has been done, does it really need to be repeated? I personally had a whole raft of blood tests done the other day simply because the consultant couldn't access the results done in another hospital with the same managed, within the same managed care network. I agree with some of what you said, but you make it sound as if there has been no action in the last four years. Can I ask whether the member has held off from health and social care integration legislation or self-directed support legislation that this Parliament and our committee passed for that review? Those are two good things that should shape any future debate that this Parliament has passed. I have said earlier on that I have no doubts about what has been achieved and what is being achieved and the actions that are being taken, but that does not alter the fact that we are talking about sustainability in the long term and simply to put together health and social integration. As Duncan McNeill made clear news speech, it is not sufficient if we don't address, for example, the workforce problems. I was going to give just some very quick illustrations, Presiding Officer. One is about the blood test. The junior doctor has done a report showing massive numbers of unnecessary tests that have been done. They are being ordered simply because it is easy to tick all the boxes. This is an expensive waste of time. Multi-packs are opened and one content is used and the rest are discarded. Patients are followed up unnecessarily when new examinations are required and a phone call would do. How often are the patients travelling long distances when a video consultation would suffice, particularly on follow-up? How often are patients treated with invasive procedures or given expensive medicines, which only extends life by a very short time, and this is done without proper discussion and consideration for what the patient might actually want. Those are just some examples of things that I have seen and heard recently. One example in the last week was where a living will was ignored by the doctor in the hospital, not because they chose to ignore it, but because the living will had not been communicated to the hospital doctors. Those are just some examples of the cold-face changes that could be arised. The point that I want to make is that it is going to be great for us to have a debate, and I think that Jackson Carlaw is right to say that we need to be sanguine about where it will go with the election coming up, but we need to have that big debate, we need to have that open debate, but actually unless we engage everybody at the cold-face, public, patients, families, carers, professionals at all levels, in incremental change in the health service, then we will not achieve what we are trying to achieve. A number of speakers spoke about targets and for 18 years we have been driven by targets and it has been appropriate that we should have been. They have been hugely useful and should not be abandoned, but, as Jenny Marra said, we really think that we need to have a rethink about them. As Bob Dorris said, the report to the health committee heard on Tuesday was that the incremental costs of meeting some of them, particularly the 100 per cent treatment time guarantee, is absolutely massive and it is a question of whether that is a worthwhile expenditure. We need to look at where targets are vital and where they are overly expensive and could be adapted, but we will need to do that in a cross-party debate because otherwise we will continue to attack the Government for continuing to meet targets that they have set, which I do not think is actually very helpful, but it is something that oppositions have to do in holding Government to account. Kevin Stewart and others, Mark McDonald in particular, focused on primary care as being key and they recognised the problems on retention and recruitment in Grampian. This is the developing crisis across Scotland, Sarah Boyack illustrated the situation in Lothian. I have been warning about this for some years. I think that we do need to have a full debate on primary care. It is fundamental and key to the delivery of a modern health service and the system that we develop, whether it be clusters, use of advanced nurse practitioners, is also critical. Dennis Robertson and others referred to the use of other practitioners. We have developed things in Scotland with this Government and the previous Government on the use of pharmacists. It is quite unique, different from England and very important, but we must go further. Advanced nurse practitioners are now being used in primary care. That is important. We need to deal with physician assistants, whether they can make a contribution. We need to see about optometrists and others what contribution they can make to the situation as a whole. In conclusion, we now have a consensus of the Government and other political parties on a collaborative and co-operative public service without clinical privatisation. We now, finally, after some years have the BMA and the RCN and medical raw colleges on board. I believe that the public is also on board and we need to divide collectively with equal voices across all these groups managing vested interests, developing an NHS fit for the future, which, as Duncan McNeill said, is also having to continue to tackle the day-to-day problems, but unless we actually look at the long-term future and do so in a consensual way, then the NHS could indeed be something that fails, and that is nothing, something that none of us absolutely want. As Jeremy Manor said, this party has been ready for some years for our part and I welcome the Government's stated intention now to lead an inclusive national debate. Thank you. That concludes the debate on health. The next item of business is consideration of business motion 1-3-4-3-4, in the name of Joe Fitzpatrick, on behalf of the Parliamentary Bureau, setting out a business programme. Any member who wishes to speak against motion should press a request to speak button now, and I call on Joe Fitzpatrick to move motion number 1-3-4-3-4. Thank you. No member has asked to speak against the motion, therefore I now put the question to the chamber. The question is that motion number 1-3-4-3-4, in the name of Joe Fitzpatrick, be agreed to. Are we all agreed? The motion is there for agreed to. The next item of business is consideration of five Parliamentary Bureau motions. I would ask Joe Fitzpatrick to move motion number 1-3-4-3-6 on designation of a lead committee, and motion number 1-3-4-3-7 to 1-3-4-4-0 on approval of SSIs. We have done block. Thank you. The questions on these motions will be put at decision time to which we now come. There are four questions to be put as a result of today's business. The first question is that amendment number 1-3-4-1-6.2, in the name of Shona Robison, which seeks to amend motion number 1-3-4-1-6, in the name of Jenny Marra, on health, be agreed to. Are we all agreed? Parliament is not agreed. We move to vote. Members should cast their votes now. The result of the vote on amendment number 1-3-4-1-6.2, in the name of Shona Robison, is as follows. Yes, 77. No, 39. There were no abstentions. The amendment is therefore agreed to. The next question is that motion number 1-3-4-1-6, in the name of Jenny Marra, as amended on health, be agreed to. Are we all agreed? Parliament is not agreed. We move to vote. Parliament is agreed. The motion is therefore agreed to. The next question is that motion number 1-3-4-3-6, in the name of Jofus Patrick, on the designation of a lead committee, be agreed to. Are we all agreed? The motion is therefore agreed to. I propose to ask a single question on motions number 1-3-4-3-7 to 1-3-4-4-0 on approval of SSIs. Any member objecting to a single question will be put. Please say so now. Nobody objects. The next question is that motion is number 1-3-4-3-7 to 1-3-4-4-0, in the name of Jofus Patrick, on approval of SSIs, be agreed to. Are we all agreed? The motions are therefore agreed to. That concludes decision time. We now move to members' business. Members shall leave the chamber. We should do so quickly and quietly.