 The next item of business is a debate on motion number 15172, in the name of Shona Robison, on redesigning primary care for Scotland's communities. Members who wish to take part in the debate should press their request speak button now, and I call on Shona Robison to speak to and move the motion. Ms Robison, you have up to 10 minutes. I'm pleased to have the opportunity to open this afternoon's debates and just want to move the motion in my name at the start of the debate. I want to take the opportunity to describe my longer term vision for primary care building on Sir Louis Rich's recent report and the many innovative new ways of working which have been developing across the country. First of all, I want to explain our delivery plan. I want to set out how we're going to make the vision a reality and how all parts of the system will need to work together to make it happen. First of all, I want to take the opportunity to thank all of those working in our health and care systems, particularly at this time of year, with the pressures that winter brings. I know that our staff work particularly hard over that period. Although we are talking about primary care today, I want to take the opportunity to also thank our hard-working health professionals working within our A&E departments, who have delivered on the four-hour target today. That is a huge achievement and something that I'm sure will be welcomed from all sides of the chamber. In our primary care sector, we have a huge number of people working very hard. I absolutely understand some of the challenges and will hear more of that this afternoon. What is important is that we are very clear on the way forward to ensure that our primary care services are robust, sustainable and able to change and develop to meet the changing demands that are going to be required as we go forward. Sir Lewis Rich's report on the out-of-hours primary care was published on 30 November. I warmly welcome the findings. Of course, we have announced an initial investment of £1 million to begin to test his new models of care, and I will come back to that later. Through our programme for government commitments, we identified 10 examples of test sites for change in primary care. Work is progressing across all those. For example, the Lothian-Headroom initiative is focusing on improving outcomes for people in economically disadvantaged areas of Edinburgh. I am also going to test two community health hub sites in Fife and Forth Valley, which will focus on the interface between primary and secondary care. Through trusting our GPs and delivering on our commitments, when I spoke at the RC GP conference on 1 October, I promised GPs that I would remove the outdated quality and outcomes framework, the co-off from their contract. I was delighted to announce this morning that, working closely with the BMA in Scotland, we have delivered on that promise and that co-off will cease to exist from April next year. That will help to free up more of the GP's time to be focused on essential patient care. We have moved to do some very quick developments, but there is obviously more that has to be done. We need to go further and we need to go faster, because Scotland is changing and people who need healthcare are also changing. We are living longer, which is a good thing, but all too often a longer lifespan brings with it more complex health needs and reduced quality of life. Meanwhile, people quite rightly expect to access the right care by the right professional quickly when they need it. I hear that our primary care practitioners say that they sometimes feel that they have too much to do and not enough time to do it. Statistics published today show that, while the number of GPs working in Scotland has increased by 9 per cent since 2005, the number of patients over 65 has also increased by 18 per cent over the same time period. Our out-of-hours primary care services are also relied on by hundreds of thousands of patients across Scotland each year, yes, of course. Dr Simpson? I welcome the publication of the figures today, but it is regrettable the fact that we do not have the full-time equivalent numbers, because the head count is something that is not reflected in the full-time equivalent. It is the full-time equivalent that really is critical. I wonder if she has that figure. Cabinet Secretary. No, but there is a survey, of course, that is going to be taking place, which I think will provide more depth of analysis of some of the data that Richard Simpson is referring to. Now, I accept that there are significant recruitment and retention challenges within general practice and that we need to build and maintain the workforce. That is why, from 2016, we are increasing the number of training places for GPs by 33 per cent. That is why we are investing in a programme to encourage GPs who have left the practice to return to the workforce with investment this year. Of course, we are investing in GP recruitment and retention more broadly in order to make general practice a more attractive career option. As we move forward into next year, health and social care integration is presenting us with a huge opportunity to do things differently. My vision is of primary and community care very much at the heart of the healthcare system, with highly skilled multidisciplinary teams delivering care both in-hours and out-of-hours, with a wide range of services tailored to meet the local area, with that care taking place within locality clusters, and with our primary care professionals, being involved in the strategic planning of our health services, and with the people who need healthcare being more empowered and informed than ever and taking control of their own health, able to directly access the right professional care at the right time and remaining at or near home wherever possible. We are already heading in the right direction. We know that up to a quarter of people who are seeing GPs are suffering from soft tissue injuries. That is why every person in Scotland can now call NHS 24 and get advice or be referred for physiotherapy if required. That is an example of the kind of change that we need across the system. I want to set out my plan for making the vision a reality. I mentioned earlier Sir Lewis Ritchie's review of out-of-hours care, and I want to record again my thanks to Sir Lewis for his work. I know that he worked closely with many stakeholders, including the BMA, the Royal College of Nursing, pharmacy representatives, NHS chief execs and others. Sir Lewis Ritchie told us that we need to do more and have better multidisciplinary working, with more investment in the workforce, more investment in infrastructure, and I drive towards changing the culture. He centred this around a model of urgent care resource hubs. He said that we need large-scale tests of change, moving quickly to a whole system change, and he is right. My initial £1 million of investment will allow us to begin the process of testing and will publish the national implementation plan in the spring of next year. That will coincide with the integration of health and social care, further enabling just the sort of joint working that we need. Our detailed budget plans will be published by the Cabinet Secretary for Finance and the Constitution tomorrow. I am not going to pre-empt that. I certainly would not dare. I can say that I am determined to see primary care expenditure rising. We have already announced a new £60 million primary care fund, and I want to go further than that. I want to see the balance of health spending changing over time so that a greater percentage of funding goes to primary care. That is not a short-term change, but one that will continue throughout the current process of transformation. From within the £60 million primary care fund, more than £20 million of that is going to provide a kick-start to some of the major tests of change that Sir Lewis said we needed. Some of the first things that we are going to do to test are fundamental changes to the GP contract. With our key partners across the Inverclyde health and social care partnership area, we are working to develop and test new ways of working. I hope very shortly to be able to announce to you the details of this work, which will draw upon the knowledge of those working locally to identify the changes that can be made. That will help us to realise our vision for the future role of GPs and others in primary care and ensure improved outcomes for everyone. That will make a difference not just in Inverclyde but across Scotland. Of course, we are investing £100 million for mental health over the next five years in the run-up to 2020, £10 million of that within a primary care setting, which could look at developing new ways of working, like the distress brief intervention. I want to move on to looking at changes that we are making affecting GPs and other parts of our valued workforce. We absolutely value family doctors incredibly highly. We want them to stay in the profession. As I have said before, the time has come to start talking up Scotland's general practice to encourage more doctors to stay and to ensure that medical students choose a career in general practice. I think that the future for GPs lies in them having high quality jobs focused on undifferentiated presentations or working out who may need further assessment, investigation or referral, caring for people with multiple conditions and quality and leadership. Other health and social care professionals will provide the care that they are best placed to provide. That future is a win for patients who get to see the right person at the right time. For all our healthcare professionals, we can make the most of their skills and knowledge. We have been working with the Scottish General Practitioners Committee to redesign the GP contract. I want to thank Allen McDever and his colleagues for their work. As I said earlier, we have now removed the co-off system as of 2016. We will take the opportunity that this process presents to focus on tackling inequalities in a more effective way. I know that that is shared across the chamber. We will have the first version of the new Scottish contract in place by April 2017. By then, we will have made significant progress to change the way that general practitioners work. We will remove the annual churn of contractual change and introduce the next version of the GP contract three years later, in 2020, when the transformation in the way that GPs work will be near complete. Our model of multidisciplinary working has implications right across the workforce for community nurses, advanced nurse practitioners, allied health professionals, pharmacists, practice staff and those working in new emerging roles. Our community nurses can, and in many instances are already, leading and co-ordinating both care management and specialist services. I want to see more of that. The chief nursing officer has recently begun work to transform and develop nursing roles so that they can meet the current and future needs of Scotland's people. Let us not forget the important role that pharmacists can play, not only as clinicians in their own right, but as a crucial part of that multidisciplinary working. Up to March 2018, more than £16 million will be invested from the primary care fund to recruit up to 140 additional whole-time equivalent pharmacists, independent prescribers, and those pharmacists will free up GP time to spend with other patients. We need to get the basics right, too, such as IT systems that are fit for the future and flexible premises. Over the period to March 2018, I have allocated £6 million of funding to the primary care digital services development fund, and that will be focused initially on increasing the availability and uptake of online appointments and repeat prescriptions. In summary, the transformational change plan is multifaceted. It is ambitious. It will take us a long way down the road that we need to travel. However, those changes will not achieve anything without the people who really make our Scottish NHS what it is. I want to end where I started by thanking all those involved in the journey so far. I also want to put on record my thanks to Richard Simpson. I had a very helpful meeting with Richard Simpson the other day, and he is someone who has brought a lot of experience in primary care to this chamber, and I think that that will be missed after the election next year. I hope, perhaps in some way, that he might continue to share his experience with us as we move forward with those important changes. Thank you very much, and I look forward to hearing what members have to say in this afternoon's debate. I now call on Dr Richard Simpson to speak to and to move amendment 15172.2. 10 minutes, please, Dr Simpson. Thank you, Deputy Presiding Officer. All of a sudden, can I draw members' attention to my declaration of interest as a member of the BMA and fellow of the Royal College of General Partitioners? This is a welcome debate, and I thank the cabinet secretary for her kind remarks. I am slightly regretting the fact that the first third of my speech is going to be quite negative, but the remaining will be quite positive, so if she could maybe just dwell on that for a minute. The Government motion does not recognise the extent of the urgency that the cabinet secretary has now put into her speech, and it remains a slightly complacent motion. The current national conversation, for example, is very similar to what Labour proposed in 2011. There is the Beverage Commission for the 21st century, although such a commission would have been more independent of politicians. Our proposal was rejected out of hand by the SNP on the grounds that it would take too long, yet here we are. My first call for a new GP contract was made in 2010, rejected not only by the Government, but the BMA. The reason for making that call at that time was twofold. One was because the Tory plans in England were creating a totally different approach to general practice with commissioning groups, but also in Scotland I was hearing anecdotally that the number of applicants for partnerships in general practice had reduced to a level that had not been seen since the early 70s. If we look at the Labour Government in Wales, it did set up the Bevin commission similar to what we were proposing, and the result has been that they now have 64 funded clusters. The Government will no doubt have studied the Labour Welsh Government's document, a planned primary care workforce for Wales, on the further development of those clusters. In Scotland, meantime, we have experienced an increasing population, as the cabinet secretary referred to, increased birth rate, increasing numbers of over 75-year-olds with multiple and complex conditions, increasing demand as evidence to growth year on year in GP consultations, and a largely unresourced transfer of work from secondary hospital-based care to GPs and an increasingly bureaucratic quality outcome framework. I am delighted that the cabinet secretary has agreed to remove early before the contract. That is a welcome move. The response of the SNP in the past few years to preparing for this transformational change is that we will all agree that it will be worthwhile to cut the nursing student intake. Nurses are going to be vital to this transformational change. They cut the midwifery student intake as well. I recognise that this is not an easy area. I think that the Government's establishment of the out-of-hours review by Sir Lewis Ritchie was a very welcome first step and has resulted, as is usual for Professor Ritchie, in a thorough piece of work with achievable objectives. I welcome the pilots that are going to occur, although I am slightly concerned about the level of funding that I have queried before. The Government's announcement of the £60 million funds for new models of general practice to be tested is very welcome. The 140 pharmacists are also welcome, although I would like to know how people apply. I am getting GPs phoning me up saying that we like one of those. How do we get them? I am finding it difficult to give a response to some detail as to exactly how they are going to be put in place will be welcome. I know that they are going into the two C practices that have been taken over and that does test the model and that is excellent. The other thing is, of course, that the delay in recognising and acting on the deterioration in general practice over the past five years in terms of recruitment and tension means that we urgently need further action now. Increasing the GP training places sounds very good, but is there a 20 per cent vacancies? I would really like to know from the cabinet secretary how she is going to actually get people into these posts since 20 per cent are currently this year unfilled. The action on the deep end practices is also something that is quite urgently needed. The cabinet secretary did allude to that in her speech, but I think that we do need a lot more detail. It is evident from the paper published last week about the discrepancy in funding for those practices, and I think that that really needs to be addressed as a matter of urgency. I am told that those practices, although they have not yet collapsed as some others have, are nevertheless extremely fragile and their sustainability is quite questionable. I have to say to the cabinet secretary that she gave me an answer to a written question about her risk register for general practice in which she believed—because I do not doubt her belief—that there was a risk register in every health board. I have to say that I have subsequently repeated my FOI. The first one said that there were seven or eight boards that did not have such a risk register, and I have to tell her that there are still three that do not have them. Greater Glasgow and Clyde have said that we will now start, but I have to say that is another recognition of the fact that the problem has really not been followed through on. I have some suggestions, and many of them are in the paper that I have produced, in which the cabinet secretary was kind enough to have some discussions with me, and I think that I have to have some more discussions with him. That is a labour paper based on our survey and review and consultation with GPs. The boards should now start to contract retained banks of GP locums and other primary care staff. Where are they to come from? There are a lot of seasonal doctors out there, and doctors who have almost retired to have perhaps a break to have a family, who could be recruited into a bank of locums to provide at least short-term cover for short-term absences of sickness. Evidence of this approach is already materialising, because with the Bannockburn practice closing, the practices in Stirling have rallied round, and the seasonal doctors there are providing some of the locum cover already. There is a willingness amongst colleagues to support other local practices and difficulty, and I think that that needs to be built on. We need a national performance list today, tomorrow or certainly this week. We cannot wait. That is in Lewis Ritchie's report, and it should be acted on now. Local performance lists to which doctors have got to apply to individual boards is outdated, outmoded and must be done away with. We should have a reversal in the cuts in the medical undergraduate places and establish a graduate entry medical course. That will take a little longer. The nurses, which I want to return to, are absolutely critical to this. We have a situation of 1,900 vacancies. We need another 350, although not all of them now, for the family nurse partnership, but that was the original number, and they are not all recruited yet. The RCN reckons that we need another 500 for the named persons situation. That comes to about 2,500, and yet there were 640 fewer nursing students enrolled in universities since the start of this Parliament. In fact, this is one area where the cabinet secretary is not able to stand up and say that we are doing better than Labour. The numbers are actually 476 down this year on the last year when Labour left office in terms of recruitment. We cannot actually have this transformational change without having an adequate number of students. The increase in the uptake of return to work for nurses is welcome, and I hope that that will be built on. I think that we need to have negotiations now if they are not already taking place and how to incentivise senior GPs not to retire. We need a modernisation now in the bureaucratic revalidation scheme. This is an intensely workload element and is particularly a problem for senior and experienced GPs who really do not need this level of revalidation. I would strongly suggest that we should have discussions with the GMC immediately about moderating this bureaucratic process. We need an immediate revitalisation of the GP retainer scheme. With the gender shift that we have had, one would have expected that there would be more retainer GPs and retainer schemes. It was originally called the women's retainer scheme when we were more or less PC and gender specific. However, the scheme has had a 40 per cent drop, and yet the number of women who are qualifying in medicine is up from 10 per cent in my time to over 50 per cent today. There should be post-registration work placements for every allied health professional. I know that the Government does not control the intake, but putting them into work placements now would help some of the elements that the cabinet secretary has mentioned. The essential workforce training contract measures must be underpinned by a national infrastructure programme using a combination of NPD and GP-financed backed finance. For example, the innovative scheme in Tayside to close the Aberfeldy community hospital but to open beds in a care home that they are going to build. That sort of combination might work in poetry where there are problems at the present time. Sterling's care village is another example of a joint NHS local authority venture, which is very welcome. Cabinet secretary mentioned IT, and improving the IT links to pharmacy should be an immediate priority, along with the links to optometrists who are now prescribing. The system of clusters advocated by the Royal Colleges nine years ago, endorsed by the King's Fund of Essential and reported by the Commonwealth Fund survey of 10 countries as being essential to greater satisfaction and delivery in general practice, those clusters need to be established quickly. I know that we have 10 pilots, but I think that we need to look at what has happened in Wales and try to adapt that. Presiding Officer, I only have about 30 seconds left. I can give you a minute or so. I still have a way to go, sorry. I can give you an extra minute or so. Oh, that is very kind of you. Thank you very much. Those practice or locality groups that are verisly referred to in different documents as clusters, networks, federations and family care partnerships are showing themselves to be absolutely crucial in delivery. The Tower Hamlets work has been extraordinary over the course of seven or eight years in the changes that they have made to one of the most deprived communities in the United Kingdom. We need to have support from specialist nurses, advanced practitioners, physician assistants, allied health professionals and pharmacists, covering conditions such as diabetes, COPD, asthma, heart failure, end-of-life care and polypharmacy. I would ask the Government in terms of looking at these clusters to publish the details of what they are doing so that we can have a full discussion on that and see how it is going. The objective, of course, will be to full a fully resourced shift in the balance of care from acute hospitals to a modernised, integrated community health and social care service fit for the 21st century, designed to reduce admissions and prevent a return to growth in acute beds. There are clearly funding restraints, but the next Parliament will need to consider how we address the reduction in the primary care share of the budget and the effect upon the infrastructure in the community of the capital cuts that we have had to sustain. Shifting the balance of care cannot be achieved without a significant shift in the balance of resource. I have one suggestion that does not involve money, and therefore I do not have to have approval from my Cabinet Secretary for Finance. That is the efficiency savings, which are still running at 3 per cent, although they are difficult. The non-recurring aspect of that part of that should be designated as being applied to primary care. That would achieve a shift because the majority of the savings will be from the major part of the budget, which is still in the acute sector. I do need you to close now, please. Finally, Presiding Officer, I hope that the Government will publish a set of principles with which it seeks to underpin any new contract. The task is a daunting one, but if we all work together, I hope that we will be able to achieve that transformational change. I move the amendment in my name. Thank you, Presiding Officer, for the time. Thank you. I now call on Jim Hulme to speak to you in move amendment 15172.16, Mr Hulme. Thank you very much, Deputy Presiding Officer. I would also like to associate myself with the words of the Cabinet Secretary regarding Richard Simpson. I hope that he continues to have an active part, and I am sure that he shall. I also want to start today by praising the extraordinary work that front-line community health and care services professionals put in day in and day out across Scotland. It is a timely debate to have today. We want to raise the importance of primary health services. There is a valued asset that needs urgent attention. We know that there was an investment of £40 million in the primary care fund, announced in 2014 November, but that took the best part of seven months to put words on paper and solidify that very action. That action turned out to be reducing the amount that would be invested on primary care from £40 million in 2015-16 to £16.6 million per year over three years. That aside, the cabinet secretary obviously wants to talk about redesigning primary care for Scotland's communities. The record shows exactly that. Sorry that we have to start slightly negative, but we will go on to be constructive. £26.5 million was cut from the primary medical services since 2009-10. Almost £30 million was cut from the total spend on GPs in that period of time. Out of our GP funding was cut from £95.7 million in 2008-09 to less than £80 million in 2013-14. Those are figures that the cabinet secretary provided to me just this month in a PQ. Clearly, a redesign is exactly what is on the Government's mind. However, I do not want that to be of the wrong kind. One thing that the Government acknowledges is the challenge in recruiting and retaining GPs, a challenge brought on by perhaps a lack of investment in primary care and to establish the recruitment practices that are needed. The chair of the Royal College of GPs said that there is no question that the consistent underfunding of general practice has contributed to the difficulties that the services face. RCGP has been warning for over two years. Now, if the results of year-on-year cuts the percentage share of NHS Scotland's funding allocated to the service, general practice which sees 90 per cent of all-patient contact with the NHS received just 7.6 per cent of the budget, such imbalance is a plan for failure. Today, we have new figures out that the average GP practice list sizes have increased by 10 per cent since 2007. Perhaps that goes some way to answer Richard Simpson's questions on full-time equivalents. It would be interesting to hear of the figures that the cabinet secretary does find on that very figure. We do not want to just play lip service, of course. There continues to be little success in attracting GP trainees in the necessary numbers, while I am sure to welcome the announcement of adding 100 more GP training places. I would also like to receive assurances from the Scottish Government regarding what plans it has made to fill those places. If the current places are not being able to be filled with GP trainees, as Richard Simpson says, what is the plan for the 100 additional places going forward? In September, the cabinet secretary told us that, in 2015, of the 305 GP speciality training posts advertised in Scotland, only 237 were filled. Research presented in the British Journal for Medical Practice shows that the majority of GP trainee places were, in the least, deprived 25 per cent of practices, with the most deprived 25 per cent having just over half that number. Those deprived areas are the areas where multi-mobidity and premature mortality are a real problem, where mental health problems are a fact and a third of GP consultations are a third, and where, in fact, funding does not match clinical need. GPs at the deep end want the flat distribution of GP resources throughout Scotland does not benefit those who are in need of GP care the most. That is the 8 per cent of the Scottish population living in the most deprived areas. Unless a drastic shift is applied to address inequalities in the current resource distribution methods, I do not think that we will see a change in the health inequalities themselves. Of course, I am not referring to throwing money at the problem and expecting solutions to just magically appear. I guided an educated approach that is needed that takes into account the needs of both practitioners and patients. A fully-resourced workforce that works in the right way and in the right place is a call also backed by the Royal College of Nursing and the out-of-hours primary care review. As the cabinet secretary will be aware, the report's recommendations 8 states that clearly that a national primary care workforce plan should be developed and implemented without delay. The redesign of primary care for Scotland's communities must be precisely this, a redesign for the communities. We are facing next year a project of an enormous scale, the integration of health and social services who will jointly manage £8 billion worth of assets and resources, a redesign that has to take into account the localisation of services and the ability of integration authorities to plan their workforce needs and be supported while doing so. The Ritchie report proceeds to point out the need for robust workforce planning to be urgently replicated at NHS board and integration authority levels to ensure a sustainable and empowered multidisciplinary workforce. The Scottish Government has to redesign services with regard as to the real needs of the populations in different communities across Scotland. Unless that changes in a way that enables and empowers practitioners to plan for their patients, we will see very little progress on reducing inequalities and putting our NHS on the right footing for progress—a strong, future-proofed NHS. I move the amendment in my name. I begin where the cabinet secretary did by paying tribute to the staff who will be working extremely hard over the winter and over the Christmas season. I know that I have remarked before that I very much doubt that they are watching our debate this afternoon. They will be far too harassed, and if they are not, I hope that there are better things to do in many respects. However, I hope that they understand that that tribute is heartfelt and well meant, because I think that over the last two or three winters we have come to appreciate that the demographics are changing so rapidly that if there is any major health concern emerges, a pandemic of any kind whatsoever, it places enormous strain on the hospitals and on our NHS staff widely. I have thought long and hard and decided not to table an amendment to this afternoon's motion and that we will support the Government's motion. I did so because there is no point in me going to meetings of nurses and allied healthcare professionals and doctors and saying to them that I am going to take the health out of politics and then coming along here and being highly belligerant about the position that we are in. There is a distinction between the day-to-day health issues, where I might have issues with the Government, and the strategic plans for the future of the health service, where I think that it is necessary that we stop being partisan and that we seek to find as much common agreement as we have. I begin really, I suppose, but I will, however, since it is Christmas, support Mr Simpson's amendment this afternoon, albeit that I have read his fit for the future document, and I am supporting your amendment, Mr Simpson, but there is a whiff of Labour said, Labour did, Labour thought, if only we would listen to Labour, yada, yada, yada, we would not be where we are today. I do not think that that entirely gives measure of the issue and the problem that we collectively face. I noticed somewhere in Professor Salou's Richie's report, which, although it is an out-of-hours care, I think its themes reach right across the whole primary care debate, but towards the back of it there is an age demographic laid out. I noticed that in 2039, when, if I were to have lived that long, and I've cheered the chamber up previously by making clear, carl all men don't, and I would be 80 years of age, there would be twice as many people of the age of 80 by that date than there are today. Whereas my sons, who would then be in their 40s, there will be just as many people in their 40s as there are today. I think that we constantly understate or fail to paint a picture which people properly grasp of just how huge a shift in the demographics of the Scottish population we have lying ahead. What a revolution is required in our whole approach to primary care, where so many of those elderly people are part of a detailed patient cohort and need so much individual attention and just that bit more time and the effect that that is having on primary care. I see one of the most encouraging things, though, is that you can get into that kind of approaching old man syndrome. I've spoken to people in the professions who say, oh, the trouble is, all these new doctors coming through now, they just don't have the same commitment and work ethic that we had when we came in. I mean, we believed that it was a vacation, we would work through the night if it was necessary, and this new lot, my goodness, you can scarcely drag them out of their beds to meet the shift that they're supposed to be on. And I was very encouraged last week to meet both the leader of the Scottish junior doctors and the leader of the Scottish junior student doctors, and I was enormously impressed to find absolutely that that is not the case. But what has changed is there is a different perception of the work-life balance across all of Scotland and the workforce going forward, and therefore we have to ensure that the contract renegotiation and the structure for GP primary care that we put in place is one that you can't dragun people into. It has to be one that we attract people into, and that's why the job that the cabinet secretary has ahead of her is so important. I have to say that Professor Sir Lewis Richie, when he says, the funding will not grow in line with the service demand, makes a very important point. There therefore has to be, and I'll touch on this as well in my closing remarks, there has to be so much more focus put into the preventative agenda which stops people having to see a doctor in the first place, so much effort that has to be put into the whole NHS asset beginning with community pharmacy care and the role that they can perform which potentially alleviates the pressure on GPs. I was very attracted by the whole resource hub and the emphasis Sir Lewis Richie puts on the definition of urgent and emergency care and our job as politicians and within the health service to educate the public to the difference because too many in the moment are dissatisfied rightly or wrongly with the, as they see it, the level of primary care provision and the opportunities that there are for that. It was very interesting to read in his report some of the patient responses as to why they don't access various services at the moment. Many of them are prejudicial rather than factually based but some real things that need to change there too. It was interesting to see that we are driving people to hospitals, not literally, but making them go to hospitals in their own mind rather than using the whole network that exists. It reminded me again that one of the things Scottish Conservatives have advocated is that along with the annual council tax bill there should be a health board statement in each region which details what has been happening in general terms with healthcare in that region, but also directing again as much as we can and educating people as to the correct access point for the service need that they have at any given point. I will come back later on to other points but I want to finish at this point by saying that this is the great strategic health debate and strategy decision that we have to make. It will I think dominate the next Scottish Parliament. It's worth and essential getting it right. Thank you very much. We now turn to the open debate. Speeches of six minutes please and I call Nigel Dawn to be followed by Margaret McCullough. Thank you very much, Presiding Officer. Can I start as some others have by thanking the staff who work in our health service? I'm very conscious that I speak here as someone who represents fairly widely-flung communities across Angus North and the Mearns and I shall speak from that position. I'm very conscious that the staff who work in my local facilities themselves have transport difficulties when everybody else has a transport difficulty. They also of course suffer health issues themselves and somehow or other in their various communities they make it all work and we're very grateful. I'd also like to thank Jackson Carlaw actually for his approach because I do have to say that I entirely agree with the idea that across Parliament we really should be able to agree on our strategic planning because quite frankly if we can't we've got it wrong. The timescales are just so long. The inertia in the system is just so big that we actually have got to get this right in principle and we've got to understand each other's position. Presiding Officer, my communities do have within them a number of hospital facilities which I sadly even in this time don't have time to discuss but what I would bring to the chamber's attention and to the cabinet secretary in particular is that folk like a local facility. Cabinet secretary, we're very well aware for example that Tobrikin infirmary is under some threat at the moment. It's next to a GP practice. The GP practice is for its own reasons not able to sustain that local cottage hospital or community hospital if I may use that. I want to talk about community hospitals because they are a necessary add-on to GP practices and I have I think five of them. My folk like a local community hospital, they are used to a local community hospital. They value therefore local hospitals but they recognise it has a cost and the costs are in two ways. First of all because there is a relatively low occupancy and sometimes these facilities are not even occupied. There is a significant unit cost if I may use that to describe how we look after a patient but far more importantly I think where staff are effectively underutilised they are also very rapidly de-skilled and I think that that is a point which health boards need to get across to the communities. It's a problem that we had and I met it first a long time ago when we were looking at ambulances up the rivers in particular up in Braemur and Balleta. You can have an ambulance at every stop but the people do so little they rapidly become de-skilled and that's one of the constraints that we need to make sure folk understand. If I then look at Sir Louis Rich's review I'd like to pick up on one or two of the important points that he raises. I'm sure others will pick out on many of them. The huge potential for shared records is one of the things that I'm seeing as an opportunity but also as a bit of a concern because sitting on the Public Audit Committee I do get the impression that sometimes records are not as shareable as they should be. The boundaries between health boards are we recognise artificial in the middle of my constituency they are calling arbitrary and we must make sure that the IT systems work in such a way that records can be accessible Sir Louis also talks about video links and recognises that there are often cultural barriers to the use of video links. It seems to me that the doctor can't come to your bedside it might be entirely reasonable to the nurse can with the appropriate video link. We don't seem to be making use of that as much as we should. Turning now Presiding Officer to what I see as the biggest risk. I commend the Cabinet Secretary and the Government for what they're trying to do but integrated integration joint boards do seem to me to come with a risk and I say that not alone but because the Auditor General in one of our very recent reports also takes that view. I have absolutely no doubt that everybody concerned wants to make them work but I do have a concern that when you get at a leadership level and at a governance level people who come from other organisations which may well have primary responsibility for some aspect of what you're trying to integrate then it's got to be very difficult for them to know which hat they're wearing at any point in time and for the integrated services to become the dominant factor in their thinking. It seems to me that the leadership of our integrated joint boards is going to be absolutely crucial. It's relatively easy to come up with a vision statement, a document but turning that vision into changed processes, changed expectations both from staff and patients and then changed satisfaction levels because the expectations have been absorbed is surely a huge concern. I'm hoping that we can find leaders who will make that work. I'm hoping that we can still in them the idea that this has to be for the whole population and not for the small section which they previously used to look after but I do want to be concerned Presiding Officer that we get that right and we get the governance right to say I have no doubt that the Government's intentions are entirely correct, I've no doubt that the legislation is right but leadership does seem to be crucial. Summing up Presiding Officer it seems to me that the doctors, the nurses, the pharmacist, the physiotherapists, the advanced nurse practitioners in particular district nurses, the social service and care workers who are going to be part of the integrated services that we rely on in future years come in well motivated. I am absolutely sure that people want to do a good job. I find it inconceivable that anybody goes into those caring professions not wanting to do a good job, not wanting to develop their skills and to provide. So all the Government has to do is to provide them with an opportunity to contribute. Our job I would suggest is to make sure that they can effectively to ensure that governance around them is going to be effective and I commend the Scottish Government's determination to make sure that they can. Thank you. I'm afraid there's not a lot of time in hand this afternoon to ask members to keep to six minutes. Margaret McCulloch to be followed by Sandra White. Thank you Presiding Officer. In beginning my contribution today I also want to put on record my appreciation for the hard work and dedication of GPs. We as a society depend on their skills, their experience, their hard work and their sense of duty towards others. They are an invaluable profession. They are essential and their dedication should be acknowledged by the whole Parliament today. Presiding Officer, before dealing with issues concerning reform and redesign of services I also want to draw the chamber's attention to the member's debate which Patricia Ferguson had secured at the end of last month. In that debate we heard about the challenges facing so-called deep-end practices where the consequences of the health inequalities are most acute and most severe. The life expectancy gap is a stubborn and stark reminder of the extent of health inequality in Scotland. The Labour amendment allows me to repeat the point that I made in the chamber last month which is that we need to do much more to understand the financial consequences of health inequalities for our public services and for health budgets and we need to properly support practices on the front line in our struggle with health inequality. There is no doubt that the causes of health inequality are complex. Tackling those root causes is not simply a question of resourcing GP practices, it is also a question of redistribution, regeneration, education and economic opportunity. However, the BMA and researchers from Glasgow and Dundee universities have shown that practices in the most deprived areas have 38 per cent more patients with multiple morbidities. They have also shown that the average spend per patient in those practices is lower than in more affluent parts of the country and GPs in deprived areas tend to have a higher workload. That is why so many of us have called on the Scottish Government to examine the allocation of funding. There is no doubt that our health services, including primary care, must overcome significant challenges if we are to make them fit for the future. There is a consensus on that point across the chamber in our healthcare professions and throughout the wider public sector. Demographic change arises in workload, developments in medicine and medical technology and pressures on funding all necessitate change in healthcare. There is also a broad consensus about the principles that should drive the necessary reforms, preventative spending, shifting the balance of care, delivering new models of primary care closer to the community while developing specialisms and expertise in acute settings, making better use of our pharmacists, our nurses and our allied health professionals. All of that is common sense, but none of that is new. Let me quote some recommendations from a report by one of the UK's leading health experts. In planning the future of the NHS in Scotland, we need to ensure sustainable and safe local services, redesign where possible to meet local needs and expectations, specialise where required to have in regard to clinical benefit and to access. View the NHS as a service delivered predominantly in local communities rather than in hospitals. 90 per cent of healthcare is delivered in primary care, but we still focus the bulk of our attention on the other 10 per cent. Preventative care rather than reactive management, development new skills to support local services, generalists as well as specialist nurses and allied health professionals as well as doctors. That could have been an extract from the minister's speech or from a recent briefing from the BMA, but it is not. It is from a report by Professor David Kerr, the Scottish executive, published over a decade ago. I do not believe that the pace of change that we have seen in the years since that report was published matches the scales of the challenges before us. If it did, then we would not be where we are now. 32 per cent are considered in return from general practice. 92 per cent say that the workload has negatively impacted on the care patients receive. Primary care share of the budget is going down. In acute care, we also have reports of a crisis in medical recruitment and in A&E. In NHS Lanarkshire, we are even seeing out of our primary care services centralised under a Government that promised to keep health local. The health board is not driving reform from a position of strength, it is reacting to a shortage of GPs who are willing to work in that service. It is all reactive and it has been for too long. I believe that many of the challenges in our health services today, whether in primary care or acute care, are related and have been foreseeable for some time. Negotiations over the new GP contracts are of the utmost importance, as are the questions of resources and training. I commend Richard Simpson's work on those issues. We need to shift the balance of care, but we cannot do it unless we support our GPs with models of care that are fit for the future. I thank the Scottish Government for the content of their motion and, in particular, the recognition that it is difficult and challenging to recruit and retain GPs. I welcome the cabinet secretary's commitment to tackling that. I would like to reply to Dr Simpson, who appears not to be here, but perhaps Margaret McCulloch. We have heard about the Labour Party in Wales as well. We should hear something about Scotland and what is happening here in regard to the care that we are providing. Basically, the notes that I took down before I came in here today are primary care in Scotland's outperforming other parts of the UK. I wonder why we do not mention that very often in a debate from the Opposition Labour Party survey in 2013-14. 87 per cent of people in Scotland rated the overall care provided by their GP surgery as good or excellent compared to in England, which was 85 per cent. I could go on about how good the health service here in Scotland is, but I am not going to be petty the way that the Labour Party appears to be petty today. I think that the earlier behaviours could probably look towards some form of health care for themselves rather than anything else, and I think that it was an absolute dereliction of duty to attack this Parliament and the Presiding Officer, but maybe they will grow up in time. I will leave that with the Opposition Labour Party and let them get on with it. If I could just go further on to welcome the report, in particular the report by Sir Lewis Ritchie, the review there and the 28 recommendations that he actually made. I think that it was Professor Mercer also. One of the recommendations is that recommendations 1 to 4 reflect the need for better innovative models. That is absolutely correct. Models of care will improve co-ordination and communication. That is really important communication. Recommendations 8 to 19, the need for comparing and pressing action to shore up and rapidly enhance the capability of an increasingly diverse and multidisciplinary workforce, which I think has been mentioned already also. We must work and learn together more closely and effectively around the needs of patients and carers. I think that that is really important. It is the patients and carers, and I emphasise the word carers. It has not been mentioned very much at all in the debate, but carers need help when it comes to health. Some of those carers are not in the best of health themselves, sometimes caring for elderly parents, sometimes caring for young disabled children. I think that carers are an important part of that as well, and we must, as I said before, work together. For me, the most important recommendation that Nigel Doan touched on in his contribution is the potential future roles of health and social care partnerships and integrated boards and integration. For me, that is absolutely the most important part of it. If I could just continue on that theme regarding social integration. South Lanarkshire was mentioned before, and Glasgow Health Board is my particular area. Throughout local authorities, we do not have a level playing field in regard to social integration and what it delivers. In my particular case in Glasgow, I have a huge workload of people who have actually been kept in hospital. I will not quote the patient's name, but I can quote this from Glasgow City Council. Social care, each area's service is giving a set target, numbers of placements that they can make in each month. That does not happen across the board, so while we are talking about social integration, to ensure that we do not have bed blocking, we do not have the NHS picking up the tab, that is not the way that it is supposed to work with integration. In Glasgow, it is working that way, and I think that it is absolutely sad in a way because people who should not be in hospital, who could be being cared at home are languishing in hospital beds and they are not getting proper care or treatment, which basically the hospital and the health service want to pick them out, because they think that they could actually benefit from staying at home or in a care home, and yet they may have the proof of it, placements that they make each month. I am sorry, I want to take an intervention. When we are looking at primary care and social integration, what do we have numbers from each local authority that they are working together? I know that in South Lanarkshire, they work very well. There is a very good practice in South Lanarkshire and also in West Lothian. Glasgow, for some unknown reason, seems to be lagging behind. I do not know the choice. I have certainly tried to ask, but I have not been able to get any answers, apart from the admission that they do look at targets each month. I would like the cabinet secretary to pick up on that particular one. I would also like to ask in regards to practices. In people turn up it, we had the report in the Equal Opportunities Committee about isolation and loneliness. There were cases where people, particularly elderly people, would turn up at doctor surgeries not because they were unwell but because they were no-one else to talk to and they were very lonely. We were talking about looking at someone such as a link worker, who could identify that, which means that, one, the doctor's time would be eased, and a link worker could point those particular patients to some form of voluntary service, because they are very important to the integration of health and social care. It could point them to something that they would get the benefit out of. It would be beneficial to their health both physically and mentally as well. I just wanted to, within this primary care, to put it down to the lowest common denominator, link workers to being involved in this also. I'm grateful to you, Presiding Officer. The report from Professor Sir Lewis Ritchie is a good one, and it makes sensible points about the reform of out-of-hours primary practice. I also agree with much that has already been said by some of the earlier contributors, including Richard Simpson, about the extent of the primary care crisis. That said, I will support the Government's motion in the Liberal amendment later. However, the points that I wanted to make are about GP provision more broadly than out-of-hours, and specifically the issue of GP provision for the poorest places. I am assisted in this this afternoon by an email that I received yesterday from a constituent in general practice in Glasgow with expertise in homelessness and addiction health services. Margaret McCulloch was right to raise the concerns that have been expressed throughout this Parliament by GPs at the deep end. That is a group that I have met with several times. I know that many members will have met them. I have always been somewhat of a loss to suggest what practical change is coming that resolves some of the problems those GPs face. The constituent that got in touch with me yesterday particularly wanted to highlight some comments by Peter Costin on behalf of the deep end, and I hope that it is helpful to the debate to hear some of them. At the beginning of this month, Professor Graham Wat published a paper in the BJA GP that showed that the poorest 40 per cent of the population, with 47 per cent more complicated multimorbidity—that is either five conditions or more—or the combination of mental and physical health problems received 8 per cent less GP funding per patient per year. That is not only a matter of social justice but has a profound effect on inflating the cost of running the national health service and indeed undermines the prosperity of the whole country. When those with the poorest health cannot access the same level of preventative and long-term care in the community that is enjoyed by the more affluent, they become sicker sooner and end up costing far more in hospital admissions and airy attendancies. If the average age at which the workforce develops long-term illnesses in some communities is 10 years before the age of retirement, then that has a devastating impact on both the local and the national economy. I was interested a few weeks ago when the First Minister's questions answered a question about that, and she said, I welcome Professor Wat's findings, which we will take fully into account in delivering a new GP contract for 2017 and the accompanying revised allocation formula. The new GP contract, on which we are in the early stages of negotiation, and which will take effect in 2017, gives us a good opportunity to revise the allocation formula to ensure that it reflects the varying needs of GP practices. The First Minister quoted figures that day showing that the least deprived 10 per cent of practices received a slightly lower level of payment per patient—£7.65—less per patient per year than the most deprived 10 per cent. That is only correct when you compare the extremes. Professor Wat's paper compared the poorest 40 per cent with the most affluent 60 per cent, i.e. he covered the whole of the patient population in Scotland. What the First Minister did not mention is that complicated multi-morbidity was twice as prevalent in the most deprived 10 per cent compared with the most affluent, and none of that is reflected in the way that general practice care is funded. Dr Costin has said that it is time to move on from debating points about small differences in funding and to recognise the huge differences in premature morbidity across the social spectrum, and the need to include that on a pro-rata basis in the new contract formula. That is not about necessarily taking funding from affluent areas to give to poorer areas, because all practices have common cause in highlighting that during the last decade there has been a 20 per cent reduction in NHS funding of general practice relative to the rest of the NHS budget. Quite simply, the focus of our national health service has been on additional investment in the most expensive parts of healthcare, i.e. acute care, while disinvesting in preventative general practice care. The GP contract and the change to integrated health and social care must rectify those mistakes and ensure that general practice as a whole is funded in such a way that we do not withhold care from the poorest in order to ensure that we can continue to provide care across all areas of the country. If we do not get that right, we will continue to fund an NHS that actually contributes to health inequalities and which becomes less and less sustainable in the long term. My constituent in Sandra White might be interested in talking about the reality of what is going on in the health service. My constituent is a GP in Glasgow working in an economically deprived area for 16 years, she says. In many ways I believe I provide a very good service when we have a high level of satisfaction amongst our patients. We recently surveyed patient calls and found that we had a 25 per cent higher demand for appointments than the number that is expected nationally. We also found that we were providing 10 per cent more appointments than the nationally recommended level, so it is no solution to her to expect those GPs working in the poorest areas simply to work harder. She goes on. Those are not the figures that worry me, however. I am especially aware of all the people who are not calling for appointments or have so many things to talk about when they see me that they neglect to mention those things that really matter, such as an early symptom of cancer. Many of my patients have learned to survive adversity by having very low expectations and by accepting that they are old when they are in their 50s. They are the people who are paying the true price and ultimately with their lives for maintaining the status quo. Unmet need is what we should be focused on. I certainly commend the work of the deep-end group to members this afternoon. Given that, unlike the Government motion, the Labour amendment mentions the issue of differential funding. I will be supporting Dr Simpson at decision time and I commend others to do so. We all know that there are significant challenges in delivery of healthcare, given the demographic trends that present us with an ever-aging and increasingly frail population. We celebrate a longer life expectancy, but we must show determination to boost poor statistics in relation to healthy life expectancy. Other members have mentioned that. We also know that the vast majority of older people wish to stay in their homes as they get older and more frail, with the support that is required for as long as possible. It is also true that, as part of that process, we also want to see a shift from the spend on the acute sector into the primary and community sector and care there. However, I can strangely commend a spend on what the first glance looks like an entrenchment of spending in the acute sector. I refer to the £200 million investment to enhance capacity at the Golden Jubilee hospital in Cloudbank and the creation of six elective surgical hubs across the country. As we have an increasingly ageing and frail population, the need for cataracts, surgery and knee replacements and hip replacements become increasingly important to sustain older people in their homes for longer. If we do not take the strategic decision now to increase capacity, whoever the Government is in five years' time or 10 years' time will be told that planning just was not in place five or ten years ago. That is something that has been taken, a decision that has been taken now and fundamentally is also connected to making sure that we can sustain people in community social care for longer. I would like to put that on the record. What I would note however is that, in the context of health and social care integration, how that interacts with the acute sector spend is something that we have to do better on. I note that only two of the integrated joint boards have acute sector spending as part of their combined budget. That is Dumfries and Galloway and that is Argyll and Bute. Maybe other integrated joint boards are missing a trick there. After all those integrated joint boards are going to be looking at rehabilitation and enablement services for older people in communities. They are going to be looking at slip, trips and falls prevention at home and the acute sector, whether it is emergency treatment through the door of A&E or whether it is early intervention and preventative surgical interventions through these new acute hubs. I think that there has to be a better integration of funding in relation to that. I do not think that perhaps we have necessarily got the balance right, but that is, of course, the decision for the integrated joint boards. I do accept that. I welcome the real progress that has been made in one element of Glasgow in relation to integration of health and social care. Sandra White mentioned a very specific example in relation to admission to care homes and in relation to qualifying for free personal care for the elderly. I recognise the issue that Sandra White has raised there, but in terms of delayed discharge, Glasgow has done very well in recent months. David Williams, who gave evidence to the health and sport committee this morning, was talking about that. He is the chief officer designate for the shadow integration board in Glasgow and also the head of social work for Glasgow city council. It shows that when there is a real focus and drive and determination on an integrated basis within the city that we can actually get it right. Indeed, there are exceeding targets there in some cases. We need health and social care integration to similarly improve community health and social care, alleviate pressures on GPs and see the development of integrated health and social care teams attentive to the needs of the community and shaped in a way that is meaningful to the integrated joint boards via locality planning. GPs are central to that process. I am delighted to see what is going on, and that is a significant achievement. However, what replaces it with the vacuum that is left and the negotiations that are taking place are just as important as the fact that that is going on? The new GP contract is indeed a real opportunity to direct funding as to where it is most needed. Will it allow us to focus on tackling health inequalities, particularly in our most deprived communities? Will the integrated joint boards be able to preferably, via a co-production model with GPs at the most local level, be able to shape a more localised model of GP provision and how that interacts with the wider health and social care integration within communities? Whether it is community pharmacists, physiotherapists, speech and language therapists, care-at-home staff, OTs, whoever it may be, whether it is nurse specialists, whoever it may be, they have to be part of a combined health and social care team. GPs have to have confidence in that combined health and social care team irrespective of whether they are employed by GPs, health centres, by the integrated joint boards or whoever. If they do not have confidence in those teams, they will continue to refer directly to the acute sector. That is part of the issue. We want GPs to have more tools in the box to refer to community disposals for health and social care needs. When people talk about that there is not enough going on, there is a huge amount going on and a huge amount of successes. I have not actually developed any successes within my speech, because I get the opposition to call that complacent, but there is significant structural change taking place and the benefits are starting to emerge. I am glad that there has been a significant degree of consensus within this debate, and I hope that that continues going forward. I am pleased that we have been given the opportunity today to have some discussion around the way forward for primary care in Scotland. Throughout my time in Parliament, we have heard of an impending crisis within the NHS as more people are living longer, with many in their senior years coping with complex health problems. The Scottish Government's 2020 vision is what we all wish for, to be able to live for as long as possible at home or in a homely setting, avoiding hospital admission and let rest. We really require specialist in patient care and then returning into the community as soon as possible with the support services that we need in place. The system is currently creaking at the seams due to doctors retiring early and ageing nursing workforce. Young medical graduates are unwilling to face the stresses of general practice and difficulty in recruiting the good home carers so essential if they fail elderly and sustain a reasonable quality of life within the community. I supported the 2004 GP contract because of the difficulty at that time in recruiting young doctors who were not prepared to undertake the 24-7 non-call responsibilities of their predecessors, but that has run its course and recruitment has again fallen. This time, because demands on the service are leaving GPs, it was too little time for face-to-face contact with the patients who really need their expertise and a workload that is stressful and leading to a less than satisfactory work-life balance. Because of the undoubted challenges that are facing the system, it has been all too easy for opposing political parties to attack the Government on health issues, which frankly, like Jackson Carlaw, I do not think is good for either patients or the NHS staff, who in the vast majority of cases provide a tremendous service for patients, most of whom are very grateful for the care that they receive, so I am glad that there now seems to be some consensus developing on the way forward. The excellent report that was published recently by Sir Lewis Ritchie on out-of-hours care gives an in-depth analysis of the current situation and a comprehensive assessment of what is needed for a sustainable and, I quote, seamless service that not only meets the needs of patients but also offers a valued working and learning environment for all those delivering health and social care services, whether that be the NHS, local authorities social services or the third sector. The thrust of the recommendations is that there is a need to develop multidisciplinary teams, including GPs, nurses, AHPs, community pharmacists, social care and other specialists, all working together to secure the best out-of-hours care for patients in urgent care resource hubs across Scotland. Sir Lewis's recommendations for out-of-hours care would sit very well with the daytime integrated health and social care service envisaged by most experts who have considered the issue. The Scottish Government's plans to transform primary care services in light of the demands of an ageing population and its health and social care services are integrated. I look forward to the Government's detailed response to the out-of-hours report early next year and to how it proposes to implement this nationally. I also look forward to hearing the detail of the new GMS contract currently being negotiated with the profession. I am, of course, pleased that the Government has now announced the end of the quaff, which has undoubtedly outlived its usefulness. The future of primary care is clearly at a crossroads at the present time, and the BMA and others point the way forward by stating that the role of GPs and other primary care professionals must be to make the best use of the unique skills of each, with a proposal that GPs become more involved in complex care and system-wide activities, and the more routine tasks become more reliant on other health professionals in the wider community team. As senior decision makers, GPs would be seen as the expert generalists in their communities, able to support their local teams where their specific expertise is required. As emphasised by the BMA, the core of general practice expected by patients and the basis for learning the necessary skills has to be personal contact with patients who are or see themselves as unwell. However, because of limited capacity, there will have to be a balanced struck between access to GP appointments, access to other health professionals such as nurses and community pharmacists, where that is more appropriate, and encouraging supported self-care, also where appropriate, and aided by the use of modern communication technology. For that to be acceptable to the public, effort will be needed to explain why those changes are required and how they will work. Practices would become the patient gateway to appropriate services, overseen and managed by GPs, to ensure that patients get the best care suited to their needs. For that to be effective, GPs must be at the core of health and social integration at locality level. Indeed, if they are not significantly involved and engaged with integration joint boards, then I for one cannot see integration being successful. At the present time, I understand that this involvement is patchy across the country. It is never easy to change the way we work, and health and social care professionals come from different cultural backgrounds. They will need support to learn different ways of working together, with mutual respect for each other, as they seek the best outcomes for the patients in their care. That is already beginning to happen, and there are many good examples of professional co-operation, not least in my own region. For example, the NHS Grampian out-of-hours model employs a significant number of advanced nurse practitioners, all of whom are or are training to be independent prescribers, who work in the main centre in Aberdeen, alongside GPs, with team members from the Scottish Ambulance Service, community psychiatric and district nurses, maricuri nurses and on-site pharmacy provision, and co-located with NHS 24. Different arrangements apply in the rural centres, where help is available from the main centre via video and telephone links. If primary care is once again to attract and retain young medical graduates, every indication is that we have to develop team-working, involving all health professionals, including nurses, HPs and pharmacists, working together with social care at the third and independent sector. If we can achieve that, and at the moment there is the will, but a long journey ahead, we can build a sustainable system of good care in our communities. I think that we are on the cusp of some very exciting developments in primary care. I am just sorry that I will not be in Parliament when they come to fruition. I am pleased to speak in this important debate, and I know from the Opposition Party amendments that the core of their argument seems to be about the allocation of resources. They want more resources allocated to primary care. I agree with them. It would be good to allocate more resources to primary care. It would be good to allocate more resources to healthcare in general. In fact, it would be good to allocate more resources to every aspect of expenditure devolved to this Parliament. That is why I am opposed and will continue to oppose the economically illiterate austerity policies of the Opposition parties. The fact of the matter, however, is that we are living in an era of austerity. We saw austerity under the previous coalition Government and Westminster, and now that the spending review has been published, we are seeing yet more austerity going on into the future. You might say that that is what the people voted for. That is what the people voted for in the recent Westminster election. That is their democratic choice, and that is indeed what the people of the UK voted for. It is not what the people of Scotland voted for. Overwhelmingly, the people of Scotland rejected austerity. And yet, thanks to that democratic deficit in our constitutional arrangements, Smith or NoSmith, Scotland Act or NoScotland Act, we are stuck with austerity. I remember, too, in the last Scottish election, that the SNP Government made a manifesto commitment to ring-fence health spending, something that Labour, the main opposition party refused to do. That is what SNP committed to do in this Parliament, and that is what we have done. The Labour Party refused to commit to ring-fencing the health budget, but neither did we do that. I wonder, Presiding Officer, if the member intends to address himself to the terms of the motions that are before us for debate this afternoon. As Mr Carlaw will know, that is not a point of order, but the point has been made, Mr Mackenzie. Noting that, Presiding Officer, I would urge patients when all will become clear. The Labour Party refused to commit to ring-fencing the health budget, and neither did they promise to increase it. The Labour Party amendment is therefore disingenuous. With regard to primary healthcare, there are very good arguments that can be made for increasing resources. There are also good arguments that can be made to increase funding for every other aspect of healthcare. However, what the Opposition members fail to do, as they always do, is to say where the cuts will fall to fund an increased allocation of resources to primary care. No, thank you. Against this background, perhaps later, but not just now, against this background, Presiding Officer, this background of austerity, this background of falling public budgets, this background of cuts to her block grant, I am pleased and I am proud that this Government has maintained health spending. I am pleased that it has been possible to increase primary care spending by almost £80 million. I am pleased that we have recently announced a further £60 million for the primary care development fund. I am pleased that the number of GPs in Scotland is at an all-time high. I am pleased that we are increasing training places for GPs from 300 to 400 a year from next year. I am pleased that we already have fewer patients per GP than either England or Wales. I think that Sandra White touched on that fact. I am pleased that the Scottish Government has announced that it will work with the BMA to dismantle the quality and outcomes framework system of GP payments, reducing that bureaucratic burden on all of our GPs. I am pleased that the Scottish Government has recognised the teamwork approach to the delivery of primary care. I am pleased that a vital role played by nurses and community pharmacists and physiotherapists is increasingly being recognised by the Scottish Government. No, thank you. Primary healthcare is important. Healthcare is important. However, as we increasingly move to patient-centred delivery of healthcare, it is important to realise that the patient too has a role to play in this, in playing their part in remaining healthy, in maintaining healthy, active lifestyles. We are fortunate in healthcare to be living in the 21st century. Looking back, many of the big improvements in public health outcomes have been made by improving lifestyles in the environment in which we live. Public water and sanitation systems have delivered, for instance, huge improvements in health. That is why we must maintain our momentum on drives to reduce smoking and improve our relationship with alcohol and to encourage active lifestyles. However, most of all, we must recognise that the biggest current threat to better public health outcomes is rising inequality. We must renew our fight against austerity, which inevitably, with cuts falling as always on the shoulders of those we are able to bear them, has the effect of increasing inequality and increasing all the health problems that go along with it. I am pleased that Mr Mackenzie's speech only lasted six minutes and we did not have to listen to another second of it. It is a pleasure to follow Mr Mackenzie, but I would be lying, so I will not. Appeals by some are not to make the NHS political. I have to say to some that people get real. The fact that we have a socialised healthcare system funded via taxation is hugely political in itself, and it always will be. For politicians to say that health should not be political is at best naive and at worst downright stupid. Try to tell that to the people in America who have been tearing each other apart over the future of their healthcare system, and it is a hugely political issue and always will be. However, the backbone of our healthcare system is the dedicated and committed staff on the front line. I think that we all recognise—many people have said it today—that we all recognise a tremendous debt to social care workers, community nurses, midwives, community psychiatric nurses, and our GPs. They are the folk who hold the system together and without them our hospitals would be even more full and more pressured than they are at present. However, those people do not want patronising warm words, they want action. However, the very same people are coming under pressure like never ever before. The ageing population, multiple complex needs of patients combined with a crisis in GP recruitment and cuts to student numbers have created the perfect storm. In my area, the clinical director of the West Llyddian health and social care partnership has said, and I quote, that there is a serious nationwide crisis in general practice. I wonder if the cabinet secretary agrees with that statement. Maybe, in her summing up, she can address whether she does believe that there is a crisis. That is the word that I would like her to address in her summing up if there is a crisis in general practice. A system that is working well should see sufficient numbers of GPs, nurses, home care staff, all working seamlessly, taking actions to ensure that people are treated appropriately and in the right place. If someone can be treated at home with the right care package put in to support them, that takes pressure off the GP surgery and allows the doctor to address more pressing and complex cases. That is part of the solution in the report by Dr Richie. I would like to see all of that go a step further. It matches the approach that we have taken in West Llyddian for many years, where different services come together in partnership centres. We have GP practices, dentists, pharmacy, sport and leisure facilities, Jobcentre Plus, library, all housing office, all coming together in new modern state-of-the-art buildings, providing services, services that cross-referent to each other to address the needs of local people. That is the vision that we should have for our public services. All of that working together will improve the health and wellbeing of people. Too often, staff shortages of one kind or another prevent that from happening. I spoke to one practice last year, which was operating in one of the poorest communities in Scotland. It had gone for a whole year without a health visitor. A whole year? That, to me, is almost criminal. I do not believe that it would have happened in another community with possibly a different socio-economic profile. Over the past few years, I spoke to doctor after doctor in my region, and they have either contacted me and requested to speak to me or I have contacted them because of problems experienced by patients who have contacted for assistance. Those doctors have been only two willing to speak, raising their concerns, and I thank them very much for their candour. Only this past year, we have seen 42 practices taken under control of NHS boards as practices buckle under pressure. Last year in Lothian, I think that the count was one in six practices having some sort of restriction on taking in new patients, some of them with lists completely closed. Local residents forced to go elsewhere to access the GP in areas where population is increasing significantly, and it is going to get worse, especially as more than a quarter of GPs are within five years or less of retiring. We see an increase in caseloads and GPs and, certainly, Dr Richard Simpson. Just to update you on the restricted practice element, figures that I have received today from Lothian are 32 out of 125 practices and are now operating restrictions. That is a quarter of all practices in Lothian. Thank you for that. That shows the extent of the problem. A decade ago, when a GP was retiring, practices would have a healthy list of people who want to take on that partnership. Many of them have zero applicants. If they are lucky enough to secure locum cover, they think that they have won the lottery and clung on to that locum-like olympic. Doctors tell me of them coming into work early, working late, working through lunch breaks, taking work home, working on their days off, just to stand still. I think that the reduction in bureaucracy will be warmly welcomed because many are at breaking point. For patients, it is getting worse too. All sorts of systems are operating in surgeries to try to address pressures. We have doctors operating like a supermarket butcher, where they take a ticket and sit as long as they have to until they are called. We have others who are now assessing people on the phone. That may be necessary in order to deal with a short-term problem, but what we could end up with is that situation being embedded in our system. I do not think that that would be acceptable. Sorry that the time is tight. I am almost certainly the third speaker in this debate, whose nesons predates the founding of the health service. It is always as well to, when you are talking about redesigning primary care, to think about the process of change that has been. Family tree research is one of my interests. I see death certificates very regularly from the 1880s and the 1890s, where it simply says that, on the cause of death, old age, senility, decline, decay, no medical attendant. Access to medical advice and to doctors is something that has come in relatively recently. Lloyd George, of course, in 1908, set in process the act that ended up as the 1911 national insurance act, which meant that there was a little contribution taken from each wage packet to pay for healthcare. Indeed, to this day, my records and many other people are still kept in these medical folders, which some of the older GPs still call Lloyd George's, because that is when they were introduced. The Highland Health Service in the 1930s set a pattern for much of the health service, but, of course, post-war, the Labour Government, probably the greatest achievement post-war, established universal healthcare free at the point of supply. My father was a GP in that service, retiring in his 70s in the 1970s. The world has changed dramatically since he was a doctor. That is the really interesting point. In those days, we only had doctors, hospitals, nurses, dentists, chemists and opticians. We did not have urgent care centres, primary care, emergency centres, community, unscheduled care, nurses and a whole plethora of definitions that, whenever the patient is exposed to them, are confused. The world would be rather better, I think, and care would be better if we simply had simple titles that we used with people. I think that I referred to page 64 in the report that we have before us that says knowledge of who to turn to, what to do in the event of feeling unwell when the doctor surgery is closed and which service to turn to first. There is considerable confusion because of the complexity that is presented to patients. Perhaps, while we need complexity under the surface to deliver the care service, we should look at a little simplicity in how we deliver it and talk to patients about our health service. When my father was a doctor, it was incredibly easy. He just needed to know one telephone number, which was Cooper 3182. As luck would have it, the cottage hospital was Cooper 3128, so if you got the numbers muddled up, you got one or the other, and that was just okay. The world was, of course, very different in all sorts of ways. My father used to write his prescriptions in Latin, so it was trezin DM rather than three times a day. Of course, the quantities were written in Greek in minims, so he had perhaps a deca minims of whatever it was. Fortunately, the pharmacist also spoke Greek. He was a rural doctor, and to this day rural issues remain a key problem for the health service. I am fortunate not to know the name of my GP because I have no contact with that person, but I know that in rural areas, often distant from their patients, often isolated from the kind of help that many doctors in urban areas have, we have got to look further out at that. Out-of-hours provision, which is something that has been referred to on a recurring basis throughout the debate here, is a more complex thing for the patient. I have actually only, in reading the material for this debate, discovered that NHS 24 is 111, I did not know that, I never had to do it, I never had to consider what the number was. I would have previously just looked up, I got this number in the phone book, but at least I now know that. Out-of-hours is, of course, the area of the health service with the lowest satisfaction rating. Perhaps that is not too surprising because, of course, when you want out-of-hours care, that is related to a crisis in your personal health, a point where you are less likely to be tolerant, more likely to be critical, you feel that sense of urgency. Now, technology is, of course, helping doctors and helping patients. Nowadays, the health service is asking us all to do some of the health checks. I have just completed one of the regular health checks for those of us of my age and all clear again, and that is good news. My watch can tell me what my heartbeat is, and I know that I did that just before this debate. It was sitting pretty well, it should be, and the data is already being stored in a server in California, so it could be available to others. Of course, one of the things that is said in the report is that information about people's health history is not broadly available. Perhaps we should do something very, very simple. Just take all the handwritten notes and scan them in. We are sort of focusing on those difficult things of translating them into words and interpreting them. There are things that we perhaps ought to do, but, Presiding Officer, in the last 10 seconds that you might grant me, I think that we are doing very well. The quality of care compared to 50 years ago and when I was born is incomparably better. We can always do better. As us old wrinklies get older, we will demand more. That is inescapable. It is just one of the challenges that we are going to have to rise to. I welcome this debate today. The second debate, in recent times, is outwith legislation. The more of it, the better. We had been described on a journey of health and social care integration and, of course, redesigning of how our primary care is part of that journey. As Bob Doris rightly says, there is a lot going on. The frustration might not be the carping from the sidelines that has been put mildly by Jackson in terms of the concerns about the lack of progress. We all are concerned about the lack of progress. Audit Scotland is concerned about the identified risk of the lack of progress in health and social care integration. It has identified risks in Government and accountability, budgets, strategic plans and, indeed, the workforce. While the Government can draw confidence from the fact that anybody who has been interested in the debate, in the committees and in this Parliament, the Government has the confidence that all the challenges that we face, the demographic challenge that we face, are complicated by long-standing health inequalities where people are living longer but with more complex conditions and ill health, not brought about by recent austerity, but our failure to deal with that over a period of time. Indeed, as Campbell Christie once said, we had lots of money during the term of this Parliament and we didn't deal with some of those issues, so it isn't simply money, of course it isn't. We are dealing with a workforce challenge. We face a significant challenge that is currently in terms of how we spend the money on locums and temporary workforce and all those things, which are not good use of the finances that we have and we are spent in preventative areas. I think that we are concerned that, at this stage, the health workforce of the future, that workforce that is going to work in the community, deliver health and care from home, has not even been visualised yet. There is no real discussion that this Parliament is aware of about what that workforce will look like in the future. Of course, the financial challenge and, of course, that would have been great. We could not have picked the worst time to be on this journey. There was a time when this Parliament had more money if only we had been wiser in its use. There is a cultural challenge. There are people who find change difficult, whether they are professional people or whether they are care workers. They find change work in the suggestion that they may have to work in a different area. The suggestion that they may have to avail themselves of new education and new experiences and new training is that they may have to work out of the building that they have been working in for 13 years. That is challenging for people, so nobody should underestimate that we are not aware of the challenges. In fact, it is quite interesting that we are celebrating at a no-brainer that people who work to provide their care and health services should work together, revolutionary stuff. They should work together using all of the skills to the maximum of their licence to ensure that our health service continues to provide the quality of our services. What is revolutionary about that? Underlying all that, there is difficult cultural changes. We should not do this easily, but it is. The Government has to have confidence that this Parliament supports them in this journey. Those who are expected to make those changes must have the confidence that they will be supported to make that change. The appropriate investment will be placed where it needs to be placed and will be supported in that service to make that change. Of course, GPs are central to that role, but they are not solely GPs. They need to be confident or will not reach the objective of emergency out-of-hours redesign. If GPs are not confident that we have highly skilled care workers, social workers who are delivering quality services in our community, they will not refer those patients who meet out-of-hours to the community. They all stand together, and unless we can give them the confidence that the decisions that they will make in terms of people's care will be satisfied within the community, they will not do it. We have a big problem in that, in recent years, although we have been protecting the health budget, we have not been protecting the local government budgets. They are inheriting a workforce that, in some cases, is demoralised, unchained and poorly paid, and that needs to change. I am pleased that we are debating this important issue this afternoon. It is so important that all people in Scotland have the means and services to enable them to enjoy optimal health and a properly resourced health service that is there for them when they need it. Without health and wellbeing, it is difficult to make the most of life's opportunities. We know only too well the impact of inequality on health, so it is essential that we do all that we can to ensure that everyone in Scotland has access to a GP when they need one. However, as we have heard, that access is becoming more of a challenge than ever before. This year, here in Lothian, practices in Rathol and Bangham have struggled to provide primary care to patients. At the time, a constituent who lives in Rathol village wrote and told of the extraordinary position that people living in Rathol village found themselves in, where we will have no doctor in the surgery for the next week, and they had only had a doctor for two days a week for the six weeks beforehand. My constituent advised that he had been offered an alternative surgery in Leith. That is a journey of around 10 miles, one way. In terms of cost and travel time, not to mention time of work or school, it is difficult to imagine a less convenient option. Like many people, he wants to understand the events and circumstances that led to the situation, and he asks that the local health board provide an explanation of where systems and planning have led to the situation. He asks why has this happened. He used the word extraordinary, and that is because the lack of access to a GP is unexpected, it is unusual, and clearly it is extremely worrying. However, there are many reasons why that has happened, and I am pleased to say that there are solutions. However, we have moved from a position where competition for GP positions was intense, with several applicants for each post, to the situation reported in MSP meetings with NHS Lothian, where interview dates have been cancelled due to lack of interest and due to lack of candidates for an advertised post. Of course, as GP vacancies increase, the burden on existing staff increases, adding to workloads that the BMA describes as already unsustainable. It tells us too that morale among GPs is at an all-time low, that more GPs than ever before are leaving mid-career and senior GPs are retiring early. I know one such GP who told me recently that the bureaucracy that he was dealing with meant that he simply could not do the job that he had been doing previously—the job that he wanted to do, needed to do—and, unfortunately, he felt that he could not carry on. He worked in a practice in an area with many social challenges, and the loss of his skill, passion and experience will have a negative impact. I am very pleased that the burden that is coff is being removed. Presiding Officer, we have heard too that there are practices with restrictions on their lists. For example, potential patients may only be able to register on certain days of the week. Lack of access to primary care can often result in patients seeking assistance in hospital, sometimes heading straight to accident or emergency, or having been unable to access primary care and initially non-serious illness has become more acute and requires that attention in hospital. I welcome the Government's commitment to address this issue and the on-going work to agree a new GP contract from 2017, because it is clear that action is required. It is really important that we listen to and work with the profession to ensure that we get the change right. The Royal College of General Practitioners, the BMA and the Royal College of Emergency Medicine have worked hard engaging with Government and Parliamentarians. Marta McKechnie, the vice-president of the Royal College of Emergency Medicine, asks us to invest in GP training and retention in order to see fewer patients heading to A and E for care. He does credit the Government with increasing consultant numbers and asks that even more is done so that every hospital in Scotland can provide a 365 days a year service. He highlights the loss of graduate emergency registrars, a lot of them to Australia, and the RCGP tells us that many qualified GPs, too, are leaving to practice abroad and that there are insufficient numbers undertaking GP specialty training. The Royal College of General Physicians has told us that GPs want to look after their patients and not the books. They want to see a more appropriate replacement evolving for quaff, one that works for patients and GPs. The BMA asks us to recruit, retain and value doctors and asks that all parties in this Parliament work with them to support Scottish general practice. We need to make being a GP in Scotland a really attractive career opportunity. That attracts people in the way that it did previously, one to which GPs taking a break will return. I really do hope that the current work on agreeing this new contract will take those factors and more into account. GP practices have worked on a small business model since the 60s. That might be the preference of many practices, but more and more GPs don't want to be partners and don't want to be full-time. They might prefer to be employed by the NHS or by the practice. New models and changing contracts can make a GP a more attractive career to a greater number of people. Working and listening to and with health professionals in this country gives us the real possibility of developing and delivering a healthcare model that will better support those working in the NHS, helping them to keep our growing and ageing population well. Sir Lewis Ritchie's out-of-hours model makes much sense fully involving a whole range of allied professionals in primary care in a way that we have not to date in a transformative way. That will have positive impacts in our care. Just as I finish, it is clearly very important that, at the forefront of all debates on health, we focus on the need for preventative ill health. I think that the BMA's suggestion of a portion of fruit or vegetables for all primary school children in Scotland is one that is well worth looking at, as is a living wage. Thank you, Presiding Officer. I would like to start by commending the good work of dedicated health and care professionals in Scotland who provide a vital service to ensure that people of Scotland are healthy and receive the best care possible. Effective front-line community healthcare is vital to helping people to enjoy life at home or in a homely setting for as long as possible. However, we face the challenge of recruiting and retaining general practitioners, GPs, and we need to address that problem to make sure that the people of Scotland receive all the care that they need. I support the current work to agree a new GP contract from Scotland for 2017, which we will see bureaucracy reduced for GPs, hopefully, to give them more time with their patients and present the opportunity to go even further to tackle health inequalities in communities. I would now like to talk about the integration of health and social care that is currently under way in North Lanarkshire. Integration is about local teams of professionals working together alongside partners, including unpaid carers, the third sector and independent sector, to deliver quality, sustainable care and services. The focus of integration is on ensuring that people get the right advice, support in the right place and at the right time. Yesterday, a new timeline was published with key plans for how integration will be delivered in local areas. North Lanarkshire Health and Social Care partnership is striving to ensure that the process is as understandable as possible. The aim of the timeline is to bring further clarity around the integration process. Janice Hewitt, chief accountable officer of North Lanarkshire health and social care partnership, said that the overall vision of integration is to make sure that the citizens of North Lanarkshire achieve their full potential through a living safe, healthy and independent lives in their communities. She adds that we also want people to receive the information, advice, support or care that they need at the right time, every time, efficiently and effectively. I hope that this example from North Lanarkshire said some light and how integrated health and social care at a community level can be achieved and I applaud the work of everyone in North Lanarkshire who has made this integration portable. Previously, as a councillor, I dealt with many patients who unfortunately could not get out of hospital on the day of their release due to the fact that nothing was in place at their home. I also dealt with the fact that both the hospital and the social work were blaming each other for the delay. I am sure that this new integration, with this new integration that these problems will be resolved finally. I now turn my comments to out of hours service. As many people may or may not know, from Monday to Thursday, an ordinary week out of hours comes into play at 6 p.m. to 8 p.m. the next day. Then comes into play on a Friday at 6 p.m. straight through the weekend to a Monday morning at 8 p.m. That work that out-of-hours staff, doctors and drivers often goes unnoticed. As I have previously stated in this chamber, I had the experience and the honour of working part-time as a driver for out-of-hours, for over two years prior to coming to this place. I saw for myself the hard work done by all staff who work for out-of-hours. All staff are well trained in customer services and dedicated to that service. Next week we will see our out-of-hours service put to the Christmas test once again. During the two years that I worked there, I for the first time in my working life ever worked the festive period. Christmas eve, Christmas day, inboxing day. It certainly wasn't as quiet as what a lot of people think. It was actually very busy. Driving, conveying patients to their appointment was certainly an eye-opener. I saw for myself what the staff in our NHS have to cope with. Even after four and a half years on, I am sure that I have got busier in the time that I have been away. When GP surgeries closed next week, any and out-of-hours will come more into play. During the one-year period, 1 May 2014 to 3 April 2015, almost 1 million contacts were made with primary care out-of-hours services. NHS 24 dealt with 1.3 million calls. I want to compliment NHS 24 on the work that it does in triaging and arranging appointments for patients. They are the front line. In that period, I also mentioned that A&E also cope with over 900,000 emergency department attendancies. Also, Scottish Ambulance Service dealt with 500,999 in general practice urgency calls. The annual cost of delivering primary out-of-hours care reported by Scotland's NHS boards in 2014-15 was £81.8 million. NHS 24 incurred costs of £40.4 million. That totals to £122.2 million. I also want to highlight that staff working both in hospitals and out-of-hours deal with many difficult pressures, particularly delivering care during unsocial hours and through the night. Some staff work in isolated areas. I have also been in areas of hospitals where the only people that were there were doctors from out-of-hours in the consulting room, myself in the waiting room, along with patients. I would suggest that this is why some doctors do not want to work out-of-hours due to safety concerns, but I know that those concerns are being addressed. Presiding Officer, I will finish my speech by thanking all who work in our health service. I wish them well over the coming festive period. Many Christmas and a happy new year to all. They look after Scotland's health, and they deserve all our support all year round. Many thanks. We now move the closing speeches, and I call on Jim Hume. Thank you, Deputy Presiding Officer. I think that we have had a good debate in most parts. There is agreement from across the chamber that we need to act and act urgently on primary care. That is encouraging. We will, of course, have different views on how and on what the progress is to date, but I think that we agree that change is needed. We need to see action from whatever Government, as Bob Doris said, we have. We heard from one SNP—I cannot remember his name exactly—who mentioned austerity and what they would be able to do if they had cuts. I would doubt that I would be able to dig a intervention from someone who would not take any intervention from herself. I failed to mention the £347 million reported by Audit Scotland that was unspent by the Scottish Government in the last year, so they cannot really use that old out-of-date excuse. GP numbers are already fewer than they should be. Just today, we saw newly released information that average GP practice list sizes have increased by 10 per cent since 2007. The Government has simply not done enough at this point to vert a crisis, so we are already seeing practices not accepting new patients on their lists. The cabinet secretary herself acknowledges that, and I quote from her that there is an increasing awareness of practices facing sustainability challenges across Scotland. With more than a third of GPs set to retire within the next decade, the midpoint for recruiting those exiting the profession is about 740. To further guarantee that general practice is sustainable, we are looking at an approximation of 915 GPs needed. The Government needs to plan for the changes in demographics in GPs and, of course, the population, a point that I think was made by many members today. The announcement of dismantling the quality outcomes framework for GP practices is a welcome step forward. That will allow GPs to spend more time with their patients. It is a step in the direction that we have wanted on those branches to move in for a long time, to allow doctors to do their jobs and put professionalism back in the profession. However, that still leaves unaddressed the role that general practice and primary healthcare professionals will play in the integration plans this coming April. With only a few months to go and the last I heard, only six of the 31 integration areas have their plans agreed, so that is worrying, but we all wish for that to be a success, of course. Professionals in the primary care services need to have reassurances and they need to have proof of those reassurances. The Royal College of Nursing provides helpful recommendations on how to better redesign primary care. Nurses are already a vital part of primary care teams delivering services in hours and out of hours settings. They will naturally be affected by the GP contact changes, but we can take this opportunity to bring out radical changes that empower nurses' roles and make the most of their vast knowledge and skills. There are advanced nurse practitioners whose role can be very beneficial to the whole community, working alongside other health professionals. It is also the great benefit that they offer of freeing up time for other medical professionals to focus more time on patients. District nurses in some remote areas are the only providers of face-to-face healthcare. While we are looking at using this resource, we must keep in mind the worrying trend of increasing nursing and medwifery vacancies. There are now over 2,400 vacancies for nurses and medwifers, and 500 of them have been unfilled for more than three months. That says and continues to warn about the unsustainable vacancy levels, and we must listen to that. Last week, the NHS staff survey showed that 75 per cent of nurses say that there is not enough staff for them to do their jobs properly. Overworked staff is clearly the last thing that we want to see, not just for patient safety but also for the wellbeing of the already hard-working NHS staff. However, Deputy Presiding Officer, almost 90 per cent of the staff in the survey are willing and happy to go that extra mile at work when required. Something that shows the first priority of health professionals is, of course, patient care. What the Scottish Government has to do is to recognise their importance and support them to do their jobs. The Richard report should offer the guidance on what steps should be followed. Deputy Presiding Officer, while it is welcome that the Scottish Government puts forth this debate, there is no point in having it if it refuses to face the facts and rejects realities on the ground. NHS staff left and right are warning us that the NHS is becoming unsustainable. Nurses, GPs and pharmacists note that embracing and utilising the skills and clinical expertise of staff can provide innovation. Making the NHS a good place to working and be treated at does not only take considerable financial investment for such investment as necessary but also smart and practical guidance. NHS staff is the most important asset in the NHS itself. As Liberal Democrats want to see that any recruitment problems are preempted and prevented. When the Scottish Government wants to talk about primary care for Scotland's communities, it should start with redesigning its approach as to how best to serve the needs of staff working in our communities. There is critical need to align spending on health services with clinical needs and the level of their capacity. That is what health and social integration requires, putting primary care in the centre of it. We need to do that by first recognising the risks to GP services, recognising that health inequalities are a national disgrace and we need to address recruitment across the board in the NHS and, in particular, announcing an extra 100gp training position is not enough. That means nothing when we can only fill 237 of the 300 positions at this moment. We need to recognise the importance of GPs, a key part of delivering healthcare in Scotland and the Liberal Democrats shall strive to ensure that Scotland has a robust NHS for generations to come. There was almost the first whiff of nostalgia this afternoon, as we came to the end of the year, with just 11 working weeks of this Parliament left. We heard from three of the self-appointed Cheerio Squad and the Labour Benches, from Drew Smith, from Duncan McNeill and from Richard Simpson, all of whom will be leaving us at the end of the term voluntarily. We heard from my colleague Nanette Milne, who is also retiring. We heard twice from Jim Hume, who, the electorate of the south of Scotland, will show good sense and retire. We had possibly the most bizarre contribution of the afternoon from Mr McKenzie. Mr McKenzie is not known to us in these health debates. I do not think that he is really a regular participator, as far as I can recall. Clearly High Command decided that a vital contribution from him was needed this afternoon. I was reminded of my old maths teacher, who used to look at my homework and say Bilge, Supreme Bilge, because that was the best that could be said of Mr McKenzie's contribution. Mr McKenzie ignored the fact that his former cabinet secretary for health, Alex Neil, in response to a written question confirmed that the health service in Scotland had received an additional £1.3 billion in consequentials arising from increased health spending at Westminster during the lifetime of this Parliament. No cut from Westminster, Mr McKenzie, and no austerity on health. During the course of the next five years, by the end of it, we should be seeing an additional £800 million annually for the health service in Scotland. That in itself is not the solution to the crisis. No, I am trying to help you, not to hinder you any further. Mr Stevenson interjected, and I was getting worried, Mr Stevenson, because I thought that you were reducing the reputation of your family somewhat when you concluded by saying that healthcare was incomparably better now than it was when your father was a GP. I am sure that that was meant to be a personal observation, but I will take it at face value. We came in the debate, broadly, to a consensus about the fact that primary care is the key area of health, the health service, that needs attention, investment and leadership. I think that it was Nigel Don who touched on the concept of leadership, because we discussed this last week in the integrated joint boards, that we talk about leadership as if it is something that grows on trees. It is actually a very difficult thing to nurture and to have within something as huge and complicated as the NHS, but so much of what we are looking to achieve will require political leadership, as well as leadership within the health boards. I think that we need to educate the public. I wonder whether, when young people come of age having been in the health service since birth, there should not perhaps even within the curriculum be a proper session that educates them as to what they can expect from the health service, but also of their own responsibilities to their own healthcare as they go through life. Should we not, as I said earlier, be ensuring that households have a proper annual statement that directs them correctly within their health board region as to where the services they need to access are? We assume that so many people understand and know, and very often they do not. We talk about multidisciplinary teams operating within potential GP hub facilities, but I wonder whether the public knows what we mean when we talk about multidisciplinary teams. We need to ensure that first responders are encouraged. Conservatives believe that we also need to look very carefully, and we make no apology for repeating again, at GP-attached health visiting teams on a universal service across Scotland, with additional concentration in areas such as Drew Smith and, I forgot his name now, the fellow at the back. Mr Findlay indicated with a concentration of that resource in areas of higher inequality. As well as providing a second to none GP healthcare service, we also need to use it to assist in the reduction in inequalities. However, the realities are within Lewis Ritchie's report that we are looking to a potential shortfall by 2020 in the number of GPs that we have. That is a real challenge to make that service one that attracts new recruits into it. We know that there are a considerable number set to retire in the next five years. We know—and I do not mean this in any sense—that there is a cut, but the increase in overall health spending has nonetheless masked a reduction of the percentage of that that has gone into primary care from 9.5 down to about 7.5 per cent. We need to see that reversed if what we are saying is going to be given effect and meaning. The health service funding issues, of course, would be resolved completely if we had £1,000 for every time. Mr Doris said that I want to put that on the record, because I know that that is his favourite phrase, and it is repeated so regularly that it could save the finances of the NHS. However, I believe that, as a result of the debate that has taken place this afternoon, there is an understanding from all parties that this is the principal challenge of the next Parliament. It is not that other areas of the health service do not need attention, too, but we need to get GP primary care services right for the future. We talked about 2020 in our vision for the health service, and for a while it always seemed that something like 2001, a space order is a way off in the future. It is four years away. We are very close to already being in 2020, and we still have a lot of work to do to have a health service and a primary care health service that will succeed in the face of the challenges ahead. I begin by paying tribute to the staff. Our people are the most valuable asset we have, those who work in the NHS and those who work in local government, providing health and social care. We need to tell them that they are valued, but we also need to go further and we need to show them that they are valued. If we do not give them the right support, if we ignore the needs of health and community care, we do not show them that value. We must stop creating boundaries between health care and community care. We must give them parity of respect and esteem. I think that we agree that people should live independently for as long as possible at home, and if that is not possible, they should be in a homely setting. Regardless of where they are, they should receive high-quality care. However, primary care and social care have been underfunded while we concentrate on the funding of acute care. Mental health and learning disabilities have also moved out of the hospital and into the community without adequate resource transfer. That is the unintended consequence of increasing pressure on acute care, as people reach crisis with no cheaper or easier intervention in the community. We need to redesign services to stop this happening. Margaret McCulloch said that 90 per cent of healthcare happens in primary care and only 10 per cent in acute care. We need to redesign our own culture of giving greater esteem to acute care to make this change. We called for a full-scale review back in 2011, a beverage 21, as Richard Simpson said, to create a health service fit for the 21st century. We were made aware of problems in the NHS by our constituents, some of them were patients, some of them were staff. All had concerns about the direction of travel and indeed the impending disaster. The Scottish Government rejected those calls saying they knew what was wrong, then they had to fix it and our review would have taken too long. Had it started in 2011, it would have been finished by now. Instead, it has come and belatedly to realise the scale of the problem and some four years later have called for a national conversation. In the meantime, we had already set up two commissions, one on health inequalities and one on social care. They have now reported. If Jackson Carlaw thinks that that is yad yad yad, I would have to say sadly it's the truth. We brought concerns in good faith, consensus politics works in both directions. We had genuine concerns and we wanted to instigate change and improvement, and yet it was being dismissed as carping from the sidelines. Respect works both ways and I see raising our constituents concerns, not just being partisan, I believe it is our duty. That is why I welcome the change of tone from the cabinet secretary today. I will join it in our fitting tribute to Richard Simpson. We are all going to miss his wise counsel and his knowledge of the health service. However, the fact that he also met with him to discuss his paper is detailed, it is thought through, it has positive solutions and ideas. I believe that that shows a change of heart and I hope that she will give it the attention that it requires and I think it will show a way forward certainly within general practice, which is in crisis, as other members have said Neil Findlay, Alison Johnstone and indeed others. We need to solve the crisis in general practice if we are going to deal with primary care. A number of speakers also spoke about health inequalities. Drew Smith talked about investment in preventative care, but also the imbalance of resources in the most deprived area where they were most required. We have heard deep-end GPs talk about the inverse care law before. The more the need in an area, the less of the funding that goes. There is more calls, more need for appointments but less funding. He also made the point and I think that it is something that we often miss when we talk about the inverse care law. In a way, it is those who shout the loudest get the service, but it is also about the low expectation of those people who live in deprived communities. They have been taught over a lifetime not to expect very much and because they have that low expectation they do not call out for services. We need to change not only the service that we give them, possibly throughout their lives to build that expectation, but we need to make sure that they get fair access to services, especially when they become unwell. Duncan McNeill talked about demographics and again that impact on health inequalities because we have an ageing population and that is good. People getting older, living longer, longer healthy lives is what we want. Unfortunately, in deprived areas, those lives are shorter, but the proportion of those lives spent in poor health is no longer in comparison and that is surely wrong. We need to do something about it. We need to invest in community care to relieve some of the pressure on GPs, as Neil Finlay said. I think that it is very important that community care fills is not only for GPs but also in acute care. Richard Lyle talked about bed blocking. Bed blocking happens because there is not the services in the community to either stop people going into hospital in the first place or to allow them to get home when they end up in hospital. A number of speakers talked about Sir Lewis Ritchie's report and the impact that it could make. He speaks about the things that we know are required, things such as resource hubs that keep people at home, joined working multidisciplinary teams. As Duncan McNeill said, revolutionary people working together. Surely this is almost a no-brainer and it is a bit sad that we need a report to tell us what is staring us in the face. Duncan McNeill also said that GPs need to have confidence in those solutions within the community, because if they do not, they will continue to refer people into acute care because they are afraid of the alternative about keeping them at home. We need to look at new models of care. A number of members spoke about models in their own constituencies. I will mention one in mind. In Sky, Macmillan and Boots the chemist have worked together looking at palliative care, working with care homes, working with GPs who are looking after patients at home, making sure that medications are right, that the right interventions are found in time and that there is really quick intervention. That has saved a huge amount of money, but more than that it has provided really good quality patient care. I think that that is what we should all be striving for. A number of people talked about training and staffing and indeed the decrease in training that has gone on over the past few years. Audit Scotland in their report about integration talked about the staffing profile for joint working and said that the staffing profile is set by past cuts rather than current need. That is something that needs to be addressed very quickly if integration is going to work. We welcome the debate. We really need a step change on how health is delivered. We know that we need to move to preventative and community care. We have known about that for some years, but we are still talking about it. There is consensus, we need a strategy and we need delivery. I welcome what has been a largely consensual debate this afternoon. I just wanted to take a moment to put on record my appreciation of the life of Dr Brian Keithley, who I attended the memorial service for him yesterday along with Richard Simpson and many others. In fact, it was a full house. As a previous chair of the BMA and an involvement in medical politics going back many, many years, he is certainly a big loss to Scotland, and I would want to pass on my condolences to his family. I want to come back on as many comments as possible, but my apologies if I do not manage to cover them all. Richard Simpson asked for some bits of information. First of all, just in general terms, Rhoda Grant mentioned Richard's paper and the fact that we had met it. I thought that it was a very productive meeting. I think that it is fair to say and I think that it would be worrying if this was not the case that, by and large, what was in Richard Simpson's paper is already either being done or planning to be done. If it was not the case, it would be a bit concerned, given Richard's knowledge and the expertise of the people that we have taken to build up the plan. There is synergy there, and that is to be welcomed. Richard asked a number of questions. He mentioned the issue of the risk registers. I am told that they all have one in place, but he can be assured being me. I will check that and make sure that that is the case. He also referred to the role of nurses. Although there has been an understandable focus on general practice, it is absolutely the case that this is about the wider workforce in primary care. Of course, the nursing workforce is critically important in that. Of course, he will be aware that, in the last year, we have seen an increase of more than 500 whole-time equivalents of all nursing and medwifery staff, and we are projecting an increase of more than 600 whole-time equivalents over the course of this financial year. Of course, if you also look at the investment in health visitors, there is a total of more than £41 million over four years to 2018, which will increase that workforce by 500. There is a lot of investment going on around that wider workforce, but, of course, as ever, there is more to be done, and we recognise that. Jim Hume talked about the level of investment. Of course, he mentioned the £40 million in one year becoming £60 million over three years. I think that £60 million is still greater than £40 million, but there is always more to be done. I am sure that he will recognise that as being a key priority for the Scottish Government as we look at the budget and beyond tomorrow. He also mentioned the issue that a few people have done around the percentage share of investment going into GPs. Jim Hume has asked me quite a lot of questions. I was happy to provide answers to him, but, of course, the answer that he cited was a figure that was net of dispensing and reimbursement of drugs, which, of course, is a figure that can go down sometimes due to more efficiencies in the system. Of course, he was also provided with an answer on the expenditure on GP services, both in cash terms and in real terms, since 2007-8 to 2013-14. Of course, he would recognise that, in 2007-8, the percentage, the amount of expenditure in percentage terms is 8 per cent and in 2013-14 it is 8.1 per cent. I merely make that point that there has been a continuity of level of investment in percentage terms, but the point has been made, which I accept, that if we are going to do more in primary care, if we are going to ensure that people can get more of their treatment in primary care, then we need to spend more in primary care. That is, hopefully, a point of agreement that we can all unite around. Jackson Carlaw. Before I couldn't allow Jackson Carlaw to get too carried away with the supposed largesse of the UK Government when it comes to health, I want to make this point, because it is important. Jackson Carlaw cited that the Scottish Government was due to receive £800 million over the next five years, because, presumably, he is referring to the £8 billion figure that has been widely understood in terms of UK Government investment. What he will fully understand, I am sure, is that, when you look at the budget, the UK Government spending review, a good chunk of that £8 billion is within health movement of resources, so what they have done is that they have removed a big chunk of investment in public health and nurse bursaries and have moved that to the NHS. They have redefined what they mean by the NHS, to quite a narrow view of the NHS. Of course, there are no consequentials flowing from that resource. We would envisage that, now, the consequentials would be, from around £4 billion, not £8 billion. I am happy to follow that up in writing with Jackson Carlaw, because it is important that we understand that there has been some of that in-year movement of resources that, obviously, affects what we would receive here. I think that Drew Smith made a comment that I want to come back on around the issue of Professor What's report, the deep end practices, the Scottish allocation formula, the need for us to ensure that, going forward, there is more of a reflection of the needs of communities in deprived communities in terms of the resources that go to them through the formula. All of those things are subject to negotiation around the contract, but, as I have said before, I recognise very much that we need to ensure that those practices operating in more deprived communities with all the challenges that they have are recognised in the resources that are provided in primary care. Just to correct him around the motion, I will, in a second. The motion actually very clearly says that the new contract presents the opportunity to go even further to tackle health inequalities in our communities, and I deliberately put that in to recognise that point. I'll give way to Duncan MacNeill. Duncan MacNeill has rightly said that more will be expected from primary care services and there will be an increased investment. How will we measure the outcomes, given that co-off is disappearing? How will people know that we are getting the outcomes for that increased investment and activity? Duncan MacNeill will appreciate that there will be an interim set of arrangements in terms of the transition year, because the new contract itself is still subject to negotiation. That is very important, and that would be a very important part of the negotiation. I think that, in the health service more generally, we need to move to more of an outcomes-based approach, not just for primary care but for acute services as well as we move forward. I can assure Duncan MacNeill that that work is on-going and I am very happy to keep him and other members appraised of progress as we move forward. In fact, Duncan MacNeill, in the same way that I said to Richard Simpson, experience that she has brought as a former GP to this panel, will also be missed in the same way that I said about Richard Simpson. Duncan MacNeill, although not a GP to trade, has, over the years, developed a real knowledge of health and care services. As convener of, the Health and Sport Committee has brought a great deal of experience, which again will be missed. Although I am sure that that will not be the last health debate that all of you, as retiring members, will be taking part in. I do not want it to sound like that, but I thought that it was appropriate to take the opportunity to pay tribute. Neil Findlay talked about the position in Lothian. It is fair to say that there are some parts of the country that have particular challenges and that that has a sharp focus in some parts of the country more than others. We would not be here debating the future of primary care if I did not think that we had the challenge that needed to be addressed, and I am absolutely determined to do that. We have already made progress with the investment of £60 million over the next three years, the rapid dismantling of the quaff. All of that is really to send a signal, which I think is very important. We want Scottish general practice to be a success story. I think that it was the net mill who said that we need to be promoting Scottish general practice as a good place to come and work and train. I think that it is really important that we send that message, despite some of the challenges of which we have heard of many this afternoon, that, with that plan and with the support and the right investment, we can make Scottish general practice a place that doctors want to come and work in, but, importantly, that young medical students make their choice of which specialty to go into will choose general practice and that we will see that coming through over the next few months and years. Thank you. That concludes the debate on redesigning primary care for Scotland community. Sarah Boyack has a point of order. Can I ask a point of order in relation to the stage 1 proceedings of the land reform bill tomorrow? Our debate on land reform is taking place at 4 p.m. and we have yet to receive the response to the committee's stage 1 report from the Scottish Government. I understand that this is not going to aid our scrutiny of this important bill. Will the Presiding Officer be able to ask the Scottish Government to ensure that we have this important report that will aid our scrutiny as soon as possible? It is now less than 24 hours before this really important debate. Thank you, Ms Boyack. I saw that the Minister for Parliamentary Business was listening very intently to your point of order. You are well aware that I have said on numerous occasions that I want as much information in the hands of members as possible to allow that debate to happen, so I would like the Minister for Parliamentary Business to consider Ms Boyack's request urgently. Thank you. The next item of business is consideration of business motion 15186, on behalf of the Parliamentary Bureau, setting out a revision to business programme for Wednesday 16 December 2015. Any member who wishes to speak against the motion should press the request-speak button now, and I call on Joe Fitzpatrick to move motion 15186. No member has asked to speak against the motion. Therefore, I now put the question of the chamber. The question is that motion 15186, in the name of Joe Fitzpatrick, be agreed to? Are we all agreed? The motion is therefore agreed to. There are three questions to be put as a result of today's business. The first question is amendment 15172.2, in the name of Richard Simpson, which seeks to amend motion 15172, in the name of Shona Robison, on redesigning primary care for Scotland's communities, be agreed to? Are we all agreed? The amendment is not agreed to. We move to a vote. Members should cancel the votes now. The result of the vote on amendment 15172.2, in the name of Richard Simpson, is as follows. Yes, 46. No, 63. There were no abstentions. The amendment is therefore not agreed to. The next question is amendment 15172.1, in the name of Jim Hume, which seeks to amend motion 15172, in the name of Shona Robison, on redesigning primary care for Scotland's communities, be agreed to? Are we all agreed? The Parliament is not agreed. We move to a vote. Members should cancel the votes now. The vote on amendment 15172.1, in the name of Jim Hume, is as follows. Yes, 36. No, 73. There were no abstentions. The amendment is therefore not agreed to. The next question is at motion number 15172, in the name of Shona Robison, on redesigning primary care for Scotland's communities, be agreed to? Are we all agreed? The Parliament is not agreed. We move to a vote. Members should cancel the votes now. The result of the vote on motion number 15172, in the name of Shona Robison, is as follows. Yes, 104. No, five. There were no abstentions. The motion is therefore agreed to. That concludes decision time. We are now moving to members' business. Members should leave the chamber, should do so quickly and quietly.