 The next item of business is a debate on motion 9218 in the name of Miles Briggs on general practice. Can I ask those who wish to speak in the debate to press the request to speak buttons? I call on Miles Briggs to speak to and move the motion. Absolutely no more than eight minutes, please, Mr Briggs. Thank you, Deputy Presiding Officer. I'm pleased to open this debate and again to bring a focus on general practice to our Parliament. Members from across the chamber will be acutely aware of the shortage of GPs in their own communities. The number of practices unable to take on new patients and patients struggling to secure an appointment with their family doctor due to ever-increasing demands. The fact is, the number of GPs has remained around the same since 2008, but the number of patients has increased by more than 5 per cent in Scotland, with the number of patients aged over 65 or over rising by around a fifth. At the same time, the number of GP practices in Scotland has fallen by some 6 per cent, while average list sizes have increased by 12 per cent. All the time, the demand for consultations is continuing to grow significantly. The RCGP Scotland has correctly described the long-standing underfunding of general practice over the last decade. For everyone taking part in this debate today, it is worth noting that general practice in Scotland received 7.24 per cent of the health budget compared to 8.24 per cent in Northern Ireland and 8.79 per cent in England. Another stark indication of the huge pressures on GP services will be demonstrated in my own Lothian region tomorrow. The GP partners at the East Cragues practice here in the capital, which serves almost 8,000 patients, will become the latest in a growing number to hand back their practice to the local health board, having previously closed their list to new patients. A notice to current patients from GP partners states, due to the on-going nationwide recruitment crisis in general practice, we are unable to provide the level of services that we would like. Local patients and local people in this part of West Edinburgh are understandably anxious and uncertain about the future of their practice, and angry that their valued family doctors feel that things are now so bad that they can no longer both manage the practice and provide local healthcare. The fact that even GP practices in dynamic, attractive and growing cities like here in Edinburgh are finding it impossible to recruit new GPs speaks volumes, I think. Two decades ago, many GPs would have jumped at the chance to secure any position within an Edinburgh practice. What frustrates our hardworking GPs who have been having to deal with such pressures and demands as our population grows is that SNP ministers were consistently and repeatedly warned that a GP shortage was likely and coming in given the demographics of our doctors and increasing demands on general practice. Tom Arthur. Given Richard Votre, chair of the GPs and BMA, he said that 8 out of 10 of England's GPs have said that their field of workload is unmanageable. That was a record number of closures of GP practices in England last week and last year. The point that I want to make to Miles Briggs is that he raised issues. He referenced Northern Ireland, Wales and England. That is a global phenomenon. His pressures have felt right across the UK. Would he recognise that that is a far broader phenomenon? If he is going to come and make accusations against SNP ministers, would he not see Jeremy Hunter's responsibility as well? I will give you an extra half minute. I think that I might need three yet. I will remind the member, and like we have to do with all SNP members, this is the Scottish Parliament, this is Scottish Health. Would you stop shouting, please, Mr Arthur? He said that a workforce crisis was imminent and too few GPs were being trained to replace those retiring or leaving early. The then health secretary now, the First Minister, insisted that there wasn't any problem and the SNP had a robust GP workforce plan in place to retain and recruit doctors. The reality is that those plans don't appear to have ever existed, perhaps except in Nicola Sturgeon's imagination. We are still waiting all these years later for a national GP workforce plan, which is yet to be published by this Government. Meanwhile, we are nearing a severe crisis that could affect primary care in every community of our country as we see a shortfall of 856 GPs predicted by 2021. The situation is critical. The truth is that when general practice works well, our NHS works well. The new GP contract contains some welcome elements, but many of those have come too late. Rural GPs in particular have serious concerns about aspects of the proposal, as voiced in the last few days by the Rural GP Association of Scotland. Those will need to be addressed as GPs begin to vote on whether to accept the new contract in the next few days. The new contract needs to contain flexibility, as one-size-fits-all approach will clearly not suit the needs of all GPs in different parts of our country. As Margaret Watt, the chair of the Scottish Patients Association said just at the weekend, we need fresh blood in our government who have new ideas and a new way to take forward GPs, the NHS and collectively take our NHS forward into the future. As an opposition, we are working hard to provide some of the new thinking and fresh ideas to make general practice as attractive a career choice as possible. That means investing in front-line technologies to make long-term savings and a redesign of service to help modernise health systems. It means more, more Scottish medical places for Scottish students from all backgrounds and then being encouraged to stay in Scotland, work in Scotland and give back to our NHS here in Scotland. It is worth reflecting that if the SNP Government had maintained the percentage of Scots domicile students studying medicine at 1999 levels and not allowed that to plummet, we would be training hundreds of more young Scots to become GPs every year. Today, we see a recruitment and retention crisis in general practice in Scotland and an SNP Scottish Government which has almost had as many GP recruitment campaigns as it has managed to recruit GPs. Presiding Officer, just like this SNP Government has dragged down Scotland's world-class education system, it has presided over a crisis in our GP surgeries. To use the First Minister's favourite saying in this chamber, SNP MSPs should hang their heads in shame. Presiding Officer, it is now perceivable that Scotland could face a shortage in the number of GPs of over 1,000 by 2021. It is little wonder then that we will likely hear excuses that we already have from SNP members and backbenchers, but it is time that SNP ministers took responsibility for the crisis they have presided over in general practice. Our NHS desperately needs effective and strategic leadership from Government. Instead, most people I speak to who work in our NHS and even the Government's own advisers are simply waiting for the SNP health front bench to be sacked or redistributed. Let me tell ministers that we make no apologies for bringing this debate to Parliament today. We on these benches care about our NHS and like GPs and patients across Scotland, we want change. Presiding Officer, I would call on the other Opposition parties in this Parliament to support my motion today, as this Parliament can send a clear and united message that the SNP Scottish Government needs to take urgent action on general practice to do far more than it is currently doing to prevent a meltdown in local GP services. Until this Government fundamentally addresses the crisis-facing general practice in Scotland, I believe that it will fail to realise the other health and social care opportunities and policy agendas that have cross-party support, shifting the balance of care from acute to community, can only truly be achieved, Cabinet Secretary, by a well-resourced and funded GP service in Scotland. But above all, when this SNP Government is rejected by the people of Scotland in 2021, I believe that it will be because of their mismanagement of our NHS by Nicola Sturgeon and this Government over the last decade. Deputy Presiding Officer, I move the motion in my name. I call Shona Robison to speak to and move amendment 9218.4. No more than six minutes please, Cabinet Secretary. Thank you, Deputy Presiding Officer. This is a landmark month for general practice and I welcome the chance to talk today about what we and the Scottish Government are working hand in hand with the BMA, integration authorities, health boards and the wider health professionals who hope to achieve together for primary care over the next few years. It's ambitious and it's exciting and it's an opportunity to talk up general practice in Scotland, something that we've heard very little of in the last few minutes. Before I get to that, let me stress as I have on many occasions that I fully understand the issues facing GPs and patients right now and we are absolutely far from complacent and that's why we're taking action we are, which I'll come on to in a minute. In particular, I'm very aware of the specific challenges of recruitment and retention for GPs in some areas. The same issue is affecting GPs elsewhere in these islands. Although there have been increases in the number of GPs under this Government up 6.9 per cent since 2006, on its own it's not enough. We need more GPs and more members of the wider multidisciplinary team and healthcare has to adapt to meet Scotland's changing needs. In March, I announced that funding in direct support of general practice would increase by £250 million by the end of this Parliament as part of our commitment to increase primary and community care funding by £500 million to 11 per cent of the front-line budget investment that was described as a positive step in the right direction by the BMA. Of course, in September, we announced plans to lift the pay cap in Scotland for NHS staff in our next budget. What we've announced is a game-changing new GP contract offer. The offer was prepared jointly between the BMA and the Scottish Government, something never done before, and a marked contrast to the contract imposed on GPs in England in 2013. I understand that many of those GPs are considering with great interest our offer on the new GP contract that was published by 13 November. In fact, Alan McDevitt of the BMA has been invited to many meetings in England as that interest grows. GPs told us that they were overworked and spending too much time on matters that would be better led by other professionals such as nurses or pharmacists, so the contract offer will mean that the core role for GPs is the one that they've trained to do, caring for people who don't know why they are unwell or who have complex needs and improving the quality of care in their leadership role. At a local level over the next three years, new services will be developed and staffed, based in general practices, to take work off our busy GPs where it is safe and appropriate to do so. They will be run by multidisciplinary teams of pharmacists, nurses, allied health professionals, community links workers and many others. We can't mandate a one-size-fits-all approach. Neil Findlay. I'm listening very carefully. I wonder what the cabinet secretary would say to the practice managers and GPs who I met over the summer, who told me that they are a resignation away from closure. I would say that I hope they support the new GP contract and vote for it, because it will usher in a new era for general practice and primary care in Scotland. In Scotland, some of our practices have a lot of older patients, some are in remote rural and island communities and others in areas of socioeconomic deprivation. We've published a draft memorandum of understanding, setting out how we expect services to be developed and delivered locally, led by the health and social care partnerships and with national and local oversight involving our GPs. We're not starting from scratch. Through our primary care transformation fund, we've already funded tests of change in every corner of the country. The learning from which will support development of these new services locally. In some areas, such as in our test of change in Inverclyde, GPs are already seeing the benefit of having embedded pharmacy support. In fact, across the country, 198 pharmacists and 47 pharmacy technicians have already been recruited and are providing support to over a third of practices across Scotland. Under that contract, every practice will receive pharmacy support by April 2021. At a national level, the third part of the national workforce plan, focused on primary care, will be published early next year, following on, obviously, from the contract negotiations. It will help to identify and address the key issues for every part of the workforce. We're also dealing with premises problems that are faced by GPs. We've published a new premises code backed by £30 billion of new investment. We're addressing the day-to-day challenges that GPs tell us they face. We've increased funding fivefold for GP recruitment and retention this year to £5 million, part of an overall £71.6 million package of investment this year in direct support of general practice. The number of GP specialty training posts in Scotland was increased from £300,000 to £400,000 in 2016. Bursaries of £20,000 were available for some of them. More GP training posts have been filled this year in Scotland than at any other time since the beginning of the decade. The cabinet secretary speaks of the importance of recruitment and retention, but does she not agree that, while recruitment lies at the heart of this, we simply don't train enough doctors and we need a significant number of new training places available beyond those already created by the new graduate school of medicine? That brings a new meaning to very quickly. Alison Johnstone will be pleased to know that we've increased the supply and widening access within medical education and, of course, we've increased the training places. We will look to do more, but we're investing £23 million into our wider medical education package, including an increase of 50 medical undergraduate places from 2016-17 to pre-medical entry programmes that commenced this autumn. The establishment of Scotland's first graduate entry medical programme commenced in 2018 and focussing on rural medicine and general practice in particular. Bursaries are available to students on that SCOTGEM course in return for service to the NHS in Scotland. Above and beyond, we've committed to investing in a further 50 to 100 undergraduate medical places over the course of this parliamentary term. To conclude, we are investing in the here and now and we're planning ahead for the challenges to come. That means more investment, more staff, more GPs and it means locally driven change. We want everybody involved to get behind our vision of the future for primary care and help to make it a reality. I have pleasure in moving the amendment in my name. I now call Colin Smith to speak to and move amendment 9218.2. No more than five minutes please. General practice is at the heart of our NHS. Almost 90 per cent of patient interactions are with primary care. For many, GPs are that first vital point of contact with our healthcare system. GPs in their practice is also of a vital ongoing relationship with patients, whether through managing long-term conditions such as diabetes or care with the acute setting of a hospital. However, a decade of cuts to the share of NHS spending for GP services and to training places has left that point of contact at breaking point. Like the NHS as a whole, GPs are facing an ever-increasing demand. In the decade up to 2016, the average GP practice list size increased by 12 per cent but surgeries are simply not being equipped with the staff and the resources that they need to meet that demand. In fact, GP practices are closing at an alarming rate with 70 fewer practices in Scotland since 2006. A record number of practices have had to be taken over by health boards with one in 20 now being operated by boards. Put simply, the number of patients is growing but the number of GPs is not. My home region of Dumfries and Galloway, the number of GP practices in the region has decreased from 160 in 2008 to 130 in 2016. Over the same period, the average practice list size has increased by 228. Crucially, research by the British Medical Association found that almost half of practices in Dumfries and Galloway have a vacancy. Nationally, one in four GP practices has at least one vacancy and three quarters of those vacancies have been open for more than six months. That problem is set to get worse. A BMA survey found that a third of GPs in Scotland plan to retire within five years while only 15 per cent of medical students indicate an interest in entering general practice. The estimates from the Royal College of GPs predict a shortfall of 856 GPs by 2021. It is, frankly, a ticking time bomb, a crisis that is not just happening on the watch of this Government. It is a crisis that has been caused by many of the decisions made by this Government. As Miles Briggs highlighted, it is also a crisis that the Government was warned about time and time again. In 2008 Audit Scotland called on the Scottish Government to collect comprehensive data on GP and GP practice staff numbers to support workforce planning and to avoid a crisis. Almost a decade on, that crisis is upon us and the Government's response so far has been woeful. A GP recruitment and retention programme set up in 2015 with the aim of securing more GPs in rural and deprived areas has recruited a total of 18 doctors since it was launched across only five health boards. Those tokenistic attempts to improve recruitment failed to recognise the deep-seated issues that underpin the workforce crisis our health service faces. Increasing workloads but resources simply not keeping up with demand. In general practice we have seen the share of NHS funding fall by more than a fifth to just 7.3 per cent, even lower than in England. Like all staff across the NHS, GPs' wages are also falling in real terms. Yet the Scottish Government has continued to impose a pay policy that means that someone entering a nursing today is £3,400 worse off in real terms than someone who entered nursing seven years ago. A pay cap that every single SNP MSP voted with the Tories to keep when this Parliament voted on the issue in May failing to recognise the link between a pay cap on NHS staff and the recruitment crisis in the NHS. Staff shortages and surges. I'll give way, yes. Shona Robison. Maybe Colin Smyth could explain why on 1 November Labour voted against the SNP amendment that the Parliament believes that the Scottish Government should work with the unions to lift a pay cap. Colin Smyth. Labour voted with the motion that we had put forward. If it's a debate about who's going to vote to lift a pay cap today, Shona Robison might get to her feet and tell us whether she's going to support Labour's amendment today, which calls for a real-terms increase in staff wages in the NHS. I didn't think so. Staff shortages and surges are compounding the pressure on GPs and it's not surprising that this is put in patient care at risk. A BMA survey found that 9 out of 10 GPs believe that the quality of care that their patients receive has been negatively affected as a result of their growing workload. 9 out of 10 cabinet secretary saying that patient care has been negatively affected. This is the reality behind all the figures and reports quoted today. Patient care is being compromised by decisions that this Government has taken, but it's not just in relation to GPs where the Government has failed to listen to warnings about its inadequate crusade in workforce planning. There are three and a half thousand nursing and midwifery vacancies, more than 950 of which have been vacant for three months or more, 476 consultant vacancies, 543 vacancies among allied healthcare professionals and 159 pharmacy vacancies. The consequence of those high vacancy rates is an increase in the burden on existing staff, which adds to their already unsustainable workload. From GPs to nurses, we have an NHS workforce that is overworked, under pressure, under resource and underpaid. It is a workforce that this Government has failed. I move the amendment in my name. We now move to the open debate and we are extremely pushed for time, so no more than four minute speeches please. Jamie Greene followed by Fulton MacGregor. I am extremely grateful to Miles Briggs for bringing forward this debate in Opposition business today. Some members will recall back in 2008 that the BMA said that a workforce crisis was imminent, with too few GPs being trained to replace those retiring or leaving. They gave this warning to the then health secretary, Nicola Sturgeon. The now First Minister said at that time that the SNP had, and I quote, robust GP workforce plans in place to retain and recruit doctors. So here we are, nine years later, and where are we? One in four surgeries in Scotland has a vacancy. One in eleven are turning away new patients. One surgery closes every month. A record number has been taken over by health boards, and we are looking at being over 800 GPs short by 2021 at the current rate. If the First Minister had such robust GP workforce plans in place, the question remains to be asked. What went wrong? Perhaps I can offer some insight, because promises and policies are one thing, but they must be backed up by sufficient funding. Investment in GP services in Scotland has fallen from 9.8 per cent of NHS spend in 2005-2006 to just 7.2 in 2015-16, and this is at a time when demand for health services is increasing due to an increasing and ageing population. In my own region, NHS Ayrshire and Arran was running a £5 million healthcare deficit built up over many years. In Scotland, spending has been stagnant at £800 million a year, despite more than 125,000 extra patients since 2012. Do not just take my words for it. What do the experts say? The RCGP Scotland chairman said recently that the state of the general practice service in Scotland is the worst that has been for at least a generation. Last year, the BMA said that the lack of GPs in Scotland was extremely concerning. This year, the BMA accused the SNP of simply ignoring a critical shortage of doctors. Jamie Greene has mentioned the BMA three times. Will the SNP join the BMA and encourage GPs to vote for the new contract? I would like doctors to make that decision for themselves. As it stands, there are 52 Scottish GP practices, which are now classed as 2C practices. That is to say that they are run by the local health board, mostly due to the lack of GP staff. The number of patients being treated by 2C practices in Scotland has almost doubled from 83,000 in 2007 to 160,000 in 2016. In our eyes, that is wholly unacceptable. Anyone who took part in my recent member's debate on GP shortages in West Kilbride learned that that particular practice was handed back to the health board by its long-standing GPs. If you were in the chamber today for portfolio questions just before this debate, you will have heard the health secretary claim that I am simply complaining about the state of affairs in GP practices in Scotland. Apparently, we are talking down GP practices in Scotland. In fact, the local Airshire MSP Kenneth Gibson said that we are skirmongering in the local community by highlighting the situation. The SNP full outrage that the Conservatives dare to come here and raise these issues on behalf of our constituents is as laughable as it is telling. I make absolutely no apologies for coming here to be the voice of the many people who fill up our inboxes or attend our surgeries asking us to raise these issues. The knock-on effect of this is not surprising. When people can't access their GP, they turn to acute hospital treatment and this causes massive additional strain on A&E services, of which are already under intolerable pressures. This is about much more than a GP recruitment crisis, this is a crisis of governance and I urge all members in the chamber to support Miles Briggs in his motion today. Thank you. Fulton MacGregor to be followed by Neil Findlay. Thank you, Presiding Officer. As members already know, I am the PLO to the cabinet secretary. Leaving aside the outright brass neck of the Conservatives to criticise spending on health or any public service at all, it is important that we recognise that general practice is a highly valued part of our healthcare system in Scotland. I agree that we should be taking measures to ensure that general practice is an attractive path for doctors to pursue and this, I believe, can be achieved through the new GP contract. This reform, as has been said, has been reached through discussion between the BMA and the Scottish Government and I support the view that it is best support Scotland's health needs at this present time. I was pleased to read only today in the Cope Ridge advertiser, my local paper, that the Scottish Government's proposals are being welcomed, particularly by Dr Chris McIntosh of the Lancashire Health and Social Care Partnership, and he stated that it is his view that it has the potential to ease the current pressures on GPs by cutting bureaucracy. There is somebody in the field, a professional, who does not have the same doom and gloom approach as we have heard from the Conservatives today. Through the new contracts, GPs will be able to achieve a much needed balance that will allow patients to have access to GPs when they really need them. There are many reforms that are needed in general practice. The discussion around who we see when we attend our local surgery is an important one. Is it always necessary for us to see a doctor when we need a health advice? The answer is almost certainly no. One of the local practices in my constituency, Waverly and Cope Ridge health centre, has been operating with nurse practitioners for some time, and I would suggest that there is a model worth looking at. They also operate a system that sees GPs answering the triage line. It is often possible for a doctor to give advice over the phone, reducing the number of sick people sitting in the waiting room. I recently visited another GP practice in my constituency, the Jameson in Creson, and I had a very useful and frank discussion with the doctors, nurses and support staff about the challenges that they face as a village practice. I should also say that it is a sister practice to another one in Moody'sburn, where there are other issues as well that I am taking up with the health board. It was made clear to me at that particular visit that one of the major stumbling blocks to get more GPs into practice was the requirement to take a share of the financial risks involved with the building itself. I am glad to see, as part of the proposed reforms, that there will be a fund created to ensure that health boards are taking on the ownership and associated financial burden that comes from those buildings. That simple step will undoubtedly bring more young doctors into general practice. Despite all the good work that has been done by the Scottish Government to drive up the standards in our NHS, there can be no doubt that the Brexit shambles, presided over by the Tory Prime Minister in London, is doing more damage to our health service than it could ever be mitigated. No, I am running out of time. Shamefully, the Tory UK Government is refusing to guarantee the rights of EU nationals prospects that they do not like this at all. That is one of the biggest threats to our current NHS workforce. As we know, EU nationals currently account for 3 per cent of the workforce in the health and social care sector, around 5.8 per cent of doctors are non-UK qualified. I would like to make it clear yet again how much we value those workers and we will continue to fight for their rightful place in our diverse workforce. Our NHS will undoubtedly be damaged if our EU medics and their jobs are not secured after Brexit and our Tory members need to start providing assurances and answers rather than attacks on this SNP Government. I will conclude with that. Neil Findlay to be full by Richard Lochhead. The searching speeches of a liaison officer, every one of them. Over the summer, I held a drop-in session for GPs and practice managers. What they told me was truly shocking. Things are at a very critical stage in many, many practices. Here are the facts. NHS Lothian has spent nine times as much on locum doctors to staff practices as it did just two years ago. NHS Lothian has been forced to take over the running of nine practices in recent years. That is more than any other area in Scotland. Many practices are reliant on locums to keep the doors open. Several long-standing and well-established practices have told me that they are a resignation away from closure. Locums are commanding a fee of anywhere upwards of £450 a day, and they are able to dictate what they will and won't do for that money. The simple principle of supply and demand sees costs soar at a time of shortages. In short, it is a locums market. 51 of the 122 practices in Lothian are restricting new registrations, and a number of those are informally closed to new patients entirely. It deans aniliburne medical practice in Livingston. All five GPs resigned back in March, and that practice had been taken over by the health authority. It is now run by a company called Barclay Partnership, which has been invited in to take over failed practices. It has a growing portfolio of them, and I think that it is the one that has taken over East Craigs as well. I hear regularly of practices reporting that they are unable to secure any cover. Others say that they have advertised for new GPs or new partners, and whereas in the past they would have had a dozen applicants, today many are lucky if they get one. Lots of them receive no applications at all, and all the time patients wait longer and longer for appointments. An existing staff drown under the pressure of trying to keep things afloat. The medical practice in Bonnyrig recently had to tell patients that it could only offer emergency appointments due to shortages. It is just another example of how the crisis is impacting on patient care. Once a patient's ability to see a doctor is blocked or delayed, the more someone is likely to present at A and E, where, according to yesterday's figures, we have the longest waiting times on record. Is it any wonder when we have the GP situation as we have? Alternatively, people start putting off getting things checked and bigger health issues emerge down the line. All of that causes further delay in the system and ultimately more cost. Overwhelming number of patients do not have the option to go private, do not have the option to go anywhere else, and neither should they have to. That is their only option, and this Government is failing them. I will take the intervention. Can you explain why he is so concerned about spending, why he stood in a manifesto last year for Labour, which committed less to the NHS than the SNP, and does in fact less to the NHS than any other party in this Parliament? Ms McAlpine, as usual, likes to mislead Parliament and she has done it again. The Government may have increased funding, but the problem is recruitment and retention of GPs with high workloads and a lack of support. Many junior doctors are not looking at general practice as an option. The Scottish Government has to be called to account for this crisis. It cannot come as a surprise to it that a large cohort of GPs were coming to retirement age or that potential recruits to a profession wanted more of a work-life balance. Where was workforce planning? What did previous health secretaries do to plan for this? What did the First Minister do to avoid this crisis when she spent years as health secretary? A combination of Tory austerity and the SNP's shambolic incompetence in this issue has brought one of her most vital elements of community healthcare to the brink. We have to stop cutting, start investing, do things better than smarter, but we also have to train more GPs, but my fear is that things will get much worse before they get any better. For many of the same reasons that other members have mentioned in terms of the situation in their constituencies, I have had more reason to speak to local GPs and medical staff in Murray over the past year than I have in the past 12 years. I have to say that what they are telling me does not exactly chime with what we heard from Miles Briggs. We do not hear vitriol from them or simplistic solutions. What I hear from my GPs in Murray is that this is a very, very complex situation. Indeed, it is a situation that is facing not just the rest of the UK, as we have heard from other members, but many Western societies because of some of the demographic trends that countries are experiencing and other issues that we experience in this country and, again, Western societies where people want a better work-life balance. In this country, we have had budget difficulties over the past few years, particularly because of the Conservative Party's austerity agenda. I hear from Miles Briggs briefly at this time. Miles Briggs has taken the intervention. I have a response from the cabinet secretary about the finance that the health service will receive. She says that the budget for 2017-18 will be £304 million in additional Barnett consequentials. Is that not new money for our health service? I think that one thing that we have not heard is that the NHS is facing a humanitarian crisis, as we have heard, where the Conservatives are charged south of the border in recent years. The SNP Government has got good track records stewarding the NHS in this country. Action that has been taken, I think that the GP contract is going to make a positive difference. GPs, their early feedback to me and Murray, of course, will pay close attention as it moves forward. The fact is that they will not have to own their own buildings, and the fact that more staff will be employed in the practices to help to free up GPs, to focus on some of their specialities. A number of other issues, such as a minimum income guarantee, are very popular measures. I hope that that will make GP practices a much more attractive choice for our young people going forward. Facilities, of course, is very, very important. I had the pleasure of welcoming the Cabinet Secretary to Murray and to Dr Gray's and also Keith Health Centre and Turner Memorial Hospital just this Monday, where she met local GPs and lead consultants at the hospital and discussed some of the fantastic opportunities. We have to change things there to attract more doctors to go and work in Murray, as well as discussing some of the challenges that they face. Facilities, of course, is an important issue. If you have a modern state-of-the-art health centre, that is more attractive in terms of recruiting more GPs to come and work in rural areas in particular. That is why Keith Health Centre, for instance, along with the local community are campaigning for new facilities there. Another issue that has been raised with me, which I am thankful that the Government is addressing, is the need to ensure that we give more incentives to medical graduates to stay and work within the Scottish RHS when they graduate. That is why I very much welcome the first graduate entry medicine programme that is going to commence in autumn 2018, which, of course, includes that return of service bursary of £4,000 per year and an optional grant worth £16,000 over the four-year course that will be payable to students in exchange for a year of service in the NHS in Scotland. One issue is that many doctors now choose to go and work elsewhere for a few years, and we have to attract them back to the Scottish NHS. In Scotland, we have to attract them back to work in rural locations as well. I spoke to a doctor at Dr Gray's who is a trainee doctor. Of course, they have to serve some of their training at local hospitals. She is called Caitlyn Collins. She said that she will praise Dr Gray's to the sky to other trainee doctors across Scotland to try to get them to go to that hospital and train. She said, I have just finished the foundation year 2 and have therefore completed my basic training that all UK junior doctors must complete. Usually at this point in our career we apply for specialty training or other training jobs. I am sure that you are aware, however, that there is an increasing trend for junior doctors at my stage to move out of training, out of the NHS and even out of the country to places like New Zealand and Australia. That has become popular for a number of reasons, mainly a better work-life balance, further experiencing specialities that they are interested in before applying for a training post, hopefully back in Scotland, and experiencing at a different hospital an area and opportunities to improve their CV. The demands of trainee doctors in the 21st century and age is much more different to past times. We have to take that on board and recognise that as we move forward. I welcome all the effort that has been taken by the cabinet secretary and the Scottish Government. I ask the Conservatives to try to bring some common sense to this debate so that we can move forward with a much more rational debate. Alison Johnstone is followed by Michelle Ballantyne. General practice is clearly a vital front-line service of the NHS. None of us can do without access to family doctor, and current vacancy rates are unacceptable. We cannot support early health interventions without well-resourced GPs. In this chamber and beyond, I have made the case that investing more in general practice is key to tackling health inequality. It is unacceptable that GPs in the most deprived areas received very little additional funding per patient when they typically managed longer patient lists and more patients with complex long-term health conditions. The Conservative motion calls on the Scottish Government to take urgent action to prevent a crisis in general practice. I agree that action has been urgently needed. I do not want to pre-judge the proposed GP contract. It was published only a few weeks ago, and we have not yet heard all the representations that GPs and other health professionals will wish to make. However, whatever your opinion on the new contract, it clearly represents a significant intervention on the Government's part to address GPs' workloads and conditions. For that reason, I will not support the Conservative motion today. The contract does outline a new way of working. I note that Dr Petra Sumballia, a deep-end GP, says that she is surprised and proud that the Scottish NHS is trying a different way of supporting GPs. Importantly, a revised allocation formula for the first phase of the contract will give greater weight to deprivation, a change that I have called for and welcome. Ultimately, recruitment and retention challenges lie at the heart of pressures on general practice. I agree with the Labour amendment. Years of pay restraint have affected staff retention across the NHS. Staff shortages elsewhere create pressures on general practice. My party has been very clear that the NHS pay cap must end. Staff should have the real terms pay rise that they deserve. We also have to tackle the shortage of GPs at its root. We simply do not train enough doctors and must seriously increase the number of medical school training places. We have to make careers in medicine much more accessible to students from working-class backgrounds. Last year, researchers at Dundee University found that the vast majority of students at Scotland's medical schools come from the most privileged backgrounds. In fact, 86 per cent of Scottish medical students have parents in the very highest earning professions. Between 2009 and 2012, less than 5 per cent of medical students in Scotland came from the least affluent 20 per cent of postcodes in the country. We understand that access to other publicly important professions—the judiciary, our media, our Parliament—should reflect the population that we serve, and the medical profession is no different. The fact is that competition for medical school places is less intense than generally believed. When NHS chief executives presented evidence to the public audit and post-legislative scrutiny committee, they noted that last year 830 students leaving school in Scotland applied for a total of 834 available medical school places. We must increase the number of places and take strategic action to contextualise admission to medicine at university and radically change their intake. Those steps are necessary to ensure that, in years to come, we are not struggling to recruit and retain talented, enthusiastic junior doctors who are keen to build their careers in the NHS in Scotland. Making general practice an even more attractive profession is vitally important, too. I have seen the difference. A little bit of protected time makes to GPs and patients in the governship project, encouraging young GPs to commit to working with patients with complex health needs. This involves providing some additional funding so that GPs can lead extended consultations with patients, making a difference to the most vulnerable families and reducing demand on acute services. I believe that all practices should have access to expert money advice workers because embedding financial support in general practice is a really effective way of boosting low family incomes and protecting health. That focus on the family is vital. We often talk about person-centred care, but GPs get to know families across generations. We cannot allow that unique perspective to be lost. I call Michelle Ballantine to be followed by Alex Cole-Hamilton. Over 10 years in government, the SNP has systematically driven general practice to the brink. One Scottish surgery closes or is handed back to the local authority every month. One quarter of GP training places go unfilled. Thousands of GPs trained right here in Scotland are leaving the country to live and work abroad. We have a crisis of recruitment, a crisis of resources and a crisis of confidence in this SNP government. This did not emerge overnight. The cabinet secretary was warned last year by the BMA that a lack of GPs in Scotland was extremely concerning. As Miles Briggs and others have indicated, the First Minister was warned in 2008, while she was health secretary, again by the BMA, that a workforce crisis was imminent, with too few GPs being trained to replace those who leave or retire. The First Minister did not listen, instead declaring the SNP's GP workforce plans were robust. I wonder now whether she would like to reconsider that declaration. Presiding Officer, we must not look at this issue in a vacuum. As the SNP has systematically weakened general practice over the last decade, we have seen A&E services out of hours and acute hospital admissions put under extreme pressure. Credit where credit is due, Presiding Officer. I believe that the new contract for GPs is a step in the right direction. A new funding formula to better reflect workload demands and demographics in the local area, service redesign to permit longer consultations for patients with complex health needs and proposals to reflip focus and refine the role of the GP and to expand multidisciplinary teams, factoring in and expanding the skills of other health professionals, including nurses and pharmacists. Those are laudable and necessary actions. They should go some ways towards relieving the unsustainable workload force facing general practice, allowing our incredible GPs to do what they do best, provide expert and patient-centric generalist medical care. For many who lived and loved the profession, the damage is already done. This is particularly stark in my south Scotland region. I have spoken with constituents on the doors. I have heard their concerns at my surgeries and their opinion does not diverge. The GPs are brilliant, their expertise and compassion is unquestionable, but getting an appointment feels like an insurmountable task. In fact, seven out of 13 GP surgeries in Midlothian now operate a restricted list. One of them, the fantastic new buyers medical group in Gorebridge, wrote to me in September to explain their decision to restrict their list. They said, and I quote, We did not take the decision to restrict our list lightly. We came to the decision in order to provide safe, quality and accessible care to our existing patients. Over the last 18 months, our list size has grown by over 12 per cent, with no increase in central funding. Whilst we have had to increase the number of GPs, along with an increase in nursing and phobotomy hours, Midlothian is the fastest growing local authority area in Scotland. The influx of new housing and new families all needing a GP will exert further pressure on local surgeries like new buyers. I submitted written questions to the Cabinet Secretary in the hope of clarifying for my constituents exactly what the Government is doing to support these surgeries. One question was on action to improve GP recruitment in Midlothian. The other was on what discussions the Government has had with Midlothian GPs around the impact of increased house building. It will come to no surprise to many in this chamber that the answers that I received were almost identical, a cut and paste response that did nothing to address the concerns of GPs and patients. This is simply not good enough. In closing, Presiding Officer, this is not an isolated issue. From Gorebridge to Garthdy, West Linton to West Kilbride, GPs on the front line have been crying out for help, and yet they are consistently let down and underfunded. A cut and paste solution will not work. I hope that the new contract will be a catalyst for the fundamental change, but, after years of empty rhetoric from the SNP, it is no surprise that many GPs are not holding their breath. I hope that members will support the motion today. The last of the open debate, Presiding Officer, is Alex Cole-Hamilton. Thank you, Presiding Officer. I am very grateful to the Conservatives for securing time for this debate this afternoon, and while I believe their motion to be incomplete, I am happy to assure them of our support for it tonight. Just days after I was elected, something strange began to happen in my constituency. I had a small but steady stream of people walking into my office with letters stapled to their prescriptions from doctors at the East Craig's medical practice. The letters were short but amounted to something akin to a distress call. Help us, they said. Contact your MSP, we cannot go on like this. Members may find that story familiar, and they should do, because I have told it nearly every debate about this GP crisis since I took my oath. I have told that story and I have backed it up with representation to the cabinet secretary and to NHS Lothian. Nevertheless, irrespective of my work and the work of the partners at East Craig's, it emerged last week that they had to hand back their contract to NHS Lothian and will be taken over by Barclays medical group. There will now be an element of disruption, a loss of local knowledge in relationships and possibly even a reduction in out-of-surgery services. I want to put on record my thanks to the partners, doctors and staff at East Craig's for soldiering on so valiantly in the teeth of the worst crisis facing our surgery since the formation of the NHS. Factors, the pressures on East Craig's represent a microcosm of a story that is being played out in every constituency in this country. Increased demands on lists, compounded by the needs of an ageing population and worsened still by an inability to fill partner vacancies. I welcome the motion today, put forward by the Conservatives and stand with them in their condemnation of a Government that seems wholly unequal to this crisis. In its reluctance to put local medical services at the heart of planning reform through workforce planning cycles of five years which failed to recognise that it takes seven years to train a GP and in a failure to answer the issue of mental health in our constituencies which still accounts for one quarter of all GP appointments. As I said at the top of my remarks, it is incomplete. It conveniently fails to address the £600 gorilla in the wings that is the headlong rush of the Conservative Party into a hard Brexit. Brexit has the potential to turbocharge our GP's staffing crisis. Indeed, the Royal College of General Practitioners in this country said that if the 226 GPs from other EU countries working here were forced to leave, it would have grave consequences for patient safety. The uncertainty is already having a material impact on staffing levels. Doctors who might have come here are now put off. Those who are already working here are returning to other EU countries and, frustratingly, this uncertainty is far from necessary. The UK Government could and should immediately guarantee the rights of all EU citizens who are already working here, recognising how important free movement is to our NHS. I am quite certain, Deputy Presiding Officer, that nobody who voted leave in June last year did so on the basis that their local GP could well be deported. What makes this all the more pressing, Deputy Presiding Officer, is the irrespective of Brexit. By 2021 Scotland will need an additional 856 GPs. The Scottish Government has been staring this crisis in the face for years and still found wanting. The UK Government is now threatening to compound that with uncertainty for our European workforce. My party will not back down from calling either of them out in this regard. We owe a great deal to our primary care staff at all levels in our NHS. They are there when we need them, and the least they can expect is to have our support when they need us. We move to the closing speeches. I call Colin Smyth up to four minutes, please. Today, we have a chance to show our support to Scotland's healthcare workforce, not just with warm words but with meaningful action. SNP and Conservatives, after speaking, have highlighted that our GPs are the bedrock in which our NHS is built, as are our nurses and our allied healthcare staff who deliver care and compassion every day. It is just a pity that none of those same speakers said that staff should be properly rewarded for the job that they do. Praising good will only goes so far. It will not end the record number of nursing vacancies in Scotland's NHS, with 3,500 nursing and midwifery staff missing from our hospitals. It will not magic up the 856 GPs that we will need by 2021 just to return to the levels of 2009. Today's debate has exposed the failure of the Scottish Government to listen to warnings 10 years ago from Audit Scotland, the Royal College of GPs and the British Medical Association on workforce planning. A failure that has left us with a workforce crisis, a workforce under pressure, under resource and underpaid. The Government's amendment fails to recognise the fact that decisions made by this Government, such as the decision by Nicola Sturgeon to cut nursing midwife training places by almost 300 in 2012, has helped to create the workforce crisis that we face today. In responding to the crisis, the cabinet secretary talked a lot about the new GPs contract. There is a great deal here that I support, such as reductions in bureaucracy mentioned by Fulton McGregor under removal of the burden of premises off the GPs shoulders. I support the position of the Labour Party in Wales that, no matter what, it will not lift the pay cap and not properly renew my NHS or anyone else for that matter. I will let you tell Mr Mackay a wee bit about Wales. Wales does not have tax varying powers, unlike the Scottish Parliament. The difference is, of course, that Mr Mackay will not use those tax varying powers to stop the cuts in social care and our local councils. Hopefully, when it comes to the budget, we will force them to wake up to the crisis that is facing our health service, our local councils and social care across Scotland. As I said, there is much within the GPs contract that I support, the removal of the burden of premises off the GPs. I don't know if Mr Mackay has another intervention that he keeps shouting, does he? I have never had so much time in the chamber. I am quite enjoying it. In terms of resources to local services, why eight Labour authorities did not raise the council tax to invest this in local services? Let me tell Mr Mackay a wee bit about the hated council tax, as he used to call it. Council tax rose in every single local authority in Scotland because this Parliament voted to increase council tax. I thought that Mr Mackay might have remembered that because it was his proposal. If he wants a solution to the council tax, he has one. Scrap the council tax and replace it with a progressive taxation that does not impact on the poorest most. Back to the GPs contract. If that is Mr Mackay finished with his speech today, there is much that I support, as I said a few minutes ago, but there are issues with the contract that needs to be resolved. The rural GPs Association of Scotland has raised significant concerns about the impact that will have on practices in rural areas. I quote, "...certain key features in the proposal intended to address the challenges faced by the profession will instead destabilise rural practices. It is therefore vital to the Scottish Government to engage constructively with these concerns in order to ensure that the new contract works for rural areas with the impact of the SNP's workforce planning failures are particularly acute." Fiona Robinson and Alex Cole-Hamilton also talked about the possible impact of Brexit. Again, I share many of those concerns. Scotland's health and social care sector employs around 12,000 EU nationals, and we know that parts of the sector would simply not function without their contributions. I support the call by Alex Cole-Hamilton that the UK Government should guarantee the rights of those EU workers to remain within the UK. However, the Government amendment fails to recognise that, although 3 per cent of Scotland's NHS workforce is made up of EU nationals, 12 per cent is made up of workers from another part of the UK. A staffing crisis that our NHS faces is with us right here and now, even before the hard Brexiteers have their way. Presiding Officer, the contributions from the SNP today have failed to address the issue at the heart of the workforce crisis, the forcing down of the value of wages, the wages year on year. If anyone believes that a pay rise isn't affordable, they should listen to what Neil Findlay said about NHS Lothian, where they now have to spend nine times more on outcomes than he did two years ago. I urge members to support our amendment so that we can tackle our crisis. Shona Robison, up to five minutes please. I will try to respond to as many points that have been made in this debate as possible. I start with the issue of the rural GP Association of Scotland. I thank them for their positive and thoughtful response on the approach and intention behind the contract. Of course, we will listen to the issues that they have raised and I will be offering to meet them at the earliest opportunity. Can I also mention the issues that Miles Briggs raised? He said that the solution to general practice was to improve IT and increase medical places. Of course, we have just put out a new contract for a new GP system. Of course, we have been expanding undergraduate medical places by 50 to 100 over the course of this Parliament, so it is already happening. If that is it, I am afraid that it does not amount to much. I will let you in in a minute. Miles Briggs could have shown leadership in this debate by backing the BMA and backing the new contract. Isn't it interesting how prevaricating and equivocating Miles Briggs and some of the other Tory members with one exception were about the new contract? I think that perhaps that tells us all that we need to know. I will let Miles Briggs in at this point. Miles Briggs. In terms of retention and recruitment, the Scottish Government has a cap on the number of Scottish students able to study medicine in this country. They have put that in place. Does the cabinet secretary, if she wants to show some leadership, want to announce that that will be lifted today so that we can train more Scots to study medicine? I have set out very clearly how we are expanding medical undergraduate places and not just undergraduate places. We are expanding graduate medical places with a brand new medical school where bursaries will be offered in response to a commitment given to the NHS. Those are solid proposals that will make a difference. We have heard no ideas from Miles Briggs or the Tories other than what is already happening by the Scottish Government. We will take no lessons. I will let Neil Findlay in earlier on and I need to make progress. On pay policy, I have already said that we will negotiate a pay deal with the unions in partnership, as the unions expect us to do. On 1 November, we put forward a very clear proposition that believed that the Scottish Government should work with the unions to lift the pay cap. Fulton MacGregor quite rightly highlighted the premises fund, £30 million over three years to support that, because there is a real problem with GPs being concerned about being the last person standing with premises that may have negative equity, so it is quite right that we make progress on that. Richard Lochhead was quite right to also refer to the issues within his constituency, not least the Keith health centre that I had the pleasure of visiting on Monday. What I saw there was a group of very dedicated not just GPs but health professionals running a very high quality service. It is important that it is part of our modernisation of the primary care estate that we have, a modern estate that is able to meet the needs of patients, not just in the here and now but into the future as well. I welcome Alison Johnstone's comment about the GP contract as being a significant intervention. It is a significant intervention. She, of course, has had a commitment on this issue for some time with the wanting the Scottish allocation formula to better reflect deprivation. I am pleased that she recognises that the new contract does that. She also said about more training places— She is in her last minute. We do have more training places. We are, through our medical education access programmes, opening up medical training to those from a more deprived background. I believe that we will see more doctors coming through from our more deprived communities through those access programmes. I am happy to write to Alison Johnstone with more detail on that. I thank Michelle Ballantyne for welcoming the GP contract. She was the only person on the Tory benches who did that. Well done to Michelle Ballantyne. I might not agree so much just to make sure that she is aware that it is not local authorities that take over GP practices as health boards. Our salaried GPs do a fantastic job. They do as much as a fantastic job as those who are GP partners. We should remember that when we talk about 2C practices. Just finally, Alex Cole-Hamilton made an important point about Brexit. It is going to compound some of the challenges that we all already had. The Tories do not like to hear it, of course they do, but it will compound the issues that we have. Thank you to all the contributors of the debate, and I will write to those who have not managed to mention it. I call Brian Whitter to close this debate. I say that we have already entertained the next debate, so less than six minutes would benefit you all. As always, health debates tend to be rather feisty, and today has been no exception. I was quite interested to hear the cabinet secretary earlier on suggest that the NHS has to adapt to the changes in healthcare without having to mention the fact that the Scottish Government has failed to do exactly that. Although the Scottish Government may very well argue that there are record numbers of healthcare professionals working in our health service, it should conveniently ignore that there are a record number of vacancies. However, as the Royal College of Nurses said to me recently, it is fed up hearing the SNP boasting about the numbers working on the front line when there is a serious shortage of staff across all disciplines required to enable them to do the job that they are trained for, just another example of the poor workforce planning that is becoming the hallmark of this Government. There is also a worrying sign that GPs are no longer seen as a career path that it once was in 2010. 99.7 per cent of GPs' training places were filled and, by 2016, that had fallen to just 68 per cent. The cabinet secretary and her predecessor must shoulder some of the blame for that and the responsibility. That is compounded by a steady decline in the number of homegrown students that has already been mentioned studying clinical medicine at Scottish universities, dropping from 63 per cent in 99,000 to 51 per cent in 2016. The strain in our GPs and our GP practices that we see today has been a long time in the making and has been mentioned by numerous contributors today. The surgeries are closing across Scotland. I am aware of at least two cases of surgeries closing or being taken over by a health board in Kilmarnock alone. That might be the first, but I fear that it might not be the last. I recently visited a surgery and heard from practice partners faced with three GPs nearing retirement and being unable to find anyone to come in as a replacement. Increasingly, locums are being used as a serious financial cost to the health board. There is a real social cost. Losing that continuity of care that long-serving community GPs can give, knowing and understanding their patients' needs and knowing things that are not in the notes. The reality is, as Miles Briggs highlighted, is that GP numbers have stagnated since 2008, as a number of patients have risen by 5 per cent, with the BMA accusing the SNP of ignoring a critical shortage of doctors. In 2015-16, around 7 per cent of the health budget was invested in general practice against over 9 per cent in England. That is the crux of the matter. In government, you have choices to make. In this case, the SNP Government has consistently chosen not to invest enough in our GPs and GP practices. Felly, to invest in our GPs in the SNP Government, I have failed to shift the balance of care from acute to primary care, despite pledges made to the contrary. It is not too late to act, and we have made it clear that if that is the direction of travel that the Scottish Government goes and chooses to act, we will support it, but we will not support it if the only action is to promise action and not deliver. That is not us, and the Cabinet Secretary for Health is not Dorothy. Clicking her heels together and saying that there is no staffing crisis three times will not get the job done. In action, in decision and denial have left general practice without the resources required to deliver the service that they are trained to do and the service that we are asking them for. If the status quo remains, the mental health strategy, the diet and obesity consultation, shifting care to more community-led initiatives, especially around palliative care, will end up gathering dust on a shelf because the very people that we need to lead on delivering those strategies, our GPs, either will not be there or will be under so much pressure firefighting, they will be unable to commit the time or resource to the preventable agenda. Primary care is called up for a reason. It is the first port of call, the first step into care, and we need to get it right. Others today have been less precipitous in their interjections. It seems to me that the SNP is content to descend down to blame anyone else here. The Scottish Government health team needs to spend more time thinking about how to address those problems and less time finding and comparison from elsewhere to an attempt to make Scotland's situation look that much better. It is time for less spin and more doctors. For nearly two decades, the last decade with the SNP in charge, health has been devolved matter and it is time for finger stop pointing elsewhere. It is most recently the case of hiding behind Brexit, as was tried early on by Fulton MacGregor, to cover up an increasingly difficult problem. Yes, I recognise the difficulty in delivering the solutions here. I recognise that health is a major issue way beyond Scottish borders, but you cannot use that as an excuse for not making tough decisions, as Richard Lockhart tried to do. Tough decisions have to be made because the current situation of making no decision at all for fear of making a tough decision is not an option anymore. There is no getting away from it. Our GPs and GP practices are suffering from a chronic lack of investment and support. If this Government is serious about shifting the balance of care into the community to relieve pressure on acute services, it is time to stop talking about it and get on with the job. The place to start has to be with our GPs. They lead our healthcare front line, they are the trusted professionals in our communities and that is the first point of contact into the health service. We need to listen to what has been said on the ground and let the GPs help us to develop a profession that offers a desirable long-term career path once again. The thing that the GPs tell me that they require the most of all is time. Time for proper consultation, time for CPD, which is a luxury item these days, and time to do the job that they are trained for. That is the significant reason that they are quoted for leaving. The GPs may not be able to give the service that they want to because of the lack of time. It is time to support our general practice, give our GPs the tools to do the job that they are trained for, give general practice back the status that it deserves and give them the chance to lead the drive towards primary care, preventative health-led service and relieve the pressures on our hospitals. That concludes the debate on general practice and it is time to move on to the next item of business. If I could ask members to speedily get to the correct seats.