Plenary, 20 Sep 2001

Meeting date: Thursday, September 20, 2001

Official Report 731KB pdf

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Patient Care

The next item of business is a debate on Conservative motion S1M-2207, in the name of David McLetchie, on improving patient care, and on two amendments to the motion.

Let me begin with a paradox. Opinion surveys show increasing dissatisfaction with the performance of the health care system in the United Kingdom, compared with comparable European countries such as France and Germany. At the same time, surveys also show a high level of satisfaction when patients are asked about their own personal experience of the national health service. How do we reconcile those apparently conflicting public perceptions?

My own view is that the level of personal satisfaction is a great tribute to the dedicated staff who work in the health service. I refer not only to the nurses and doctors, but to the forgotten foot-soldiers: the porters, ambulance drivers, receptionists, cleaners and laboratory staff without whom our hospitals, our clinics and our surgeries would cease to function. That is why I am particularly sorry that the Minister for Health and Community Care recently chose to attack those who work in the NHS for what she called scaremongering. Frankly, that was a bit rich, coming as it did from a party that, for its own cynical advantage, elevated scaremongering about the health service to a fine art.

Most people recognise that NHS staff assessments of the current state of the service are the concerns of dedicated people who are struggling to cope with the increasing pressures that have been placed upon them. They cannot forever paper over the increasingly apparent cracks. That is why we owe it to those who work in the health service, and to the patients whom they serve, to ensure that we have a modern health care system of which we can all be proud.

In creating and building such a system, we have to take account of the changes that have taken place in society since 1948 when the NHS came into operation. Society today is more affluent and more demanding, and people have a longer life expectancy and are more vulnerable to chronic diseases than our forebears of 50 years ago. Technological advances in medicine—such as those in the fields of surgery, pharmaceuticals, biotechnology and genomics—have transformed the scope of health care since the inception of the NHS. Those advances have, in fact, undermined one of the assumptions upon which the original NHS was based. In 1948, it was seriously believed that, once the backlog of ill health had been treated, demand on, and the costs of, the health service would be stabilised. Today, however, we know that the demands on the health service are huge, because health is the key to financial and physical independence, whether people are of working age or in retirement. Moreover, the pressures on the NHS have increased, because the extended family, which cared for elderly and frail members at home back in the early days of the NHS, is no longer the norm for a whole variety of social and financial reasons—although I would not wish to diminish in any way the important role that family carers still play in the care of many people in our society. However, we have to acknowledge that trend.

Despite those difficulties, the principles underpinning the NHS still command widespread public support. The NHS aims to provide a comprehensive service while ensuring equality of access. However, it is failing to meet those objectives. The NHS is far from comprehensive. For much of the life of the NHS, most people believed that comprehensive meant that everything that medically could be done, should be done. In reality, of course, and despite the rhetoric, the impossibility of providing every service that medically could be made available was well recognised by those who worked in the service. However, that truth was concealed by allowing doctors a wide discretion to ration—and thus to present decisions to treat or not to treat patients as if those decisions were purely clinical judgments when, in fact, they were not. Doctors went along with that strategy for a long time, but in recent years there have been increasing complaints that budgets are too restricted. The new reluctance to pretend that rationing is carried out on purely clinical grounds has contributed as much as anything else to the atmosphere of dissatisfaction within the health service.

The NHS promises equality of access, but I feel that that confuses two ideas. For most people—including me and my party colleagues—it means that everyone, rich and poor alike, should have guaranteed access to high-quality health care. It is vital that everyone is guaranteed access to health care and the fact that a system such as that in the United States fails to do so for 44 million people—16 per cent of the country's population—is morally unacceptable. That would not be tolerated in this country, and rightly so.

However, just accepting and applying the principle of guaranteed access does not produce equality of provision for all. It is patently obvious that standards differ in different parts of the country. The question that we have to ask is this: do we then establish a policy that seeks to eradicate those differences by levelling down, or a policy that, through the promotion of choice and competition, encourages standards to rise for everyone?

The reality is that the NHS provides a standard that is considered acceptable by doctors within the budgets that are available to them and, because of that, in many areas it fails to match the standards of care that we see in other western European countries. Instead of trying to sweep the realities of rationing under the carpet, it is high time that we had an honest debate about the failings of our health service and a constructive debate about how we can create a system that meets the objectives that we wish it to meet.

For too long, the debate over the NHS has been sterile and dominated by party-political point scoring. I hold up my hand and admit that I have not been immune from that myself. Mea culpa. I will not pretend today that all the problems of the health service in Scotland began on 1 May 1997. Indeed, I acknowledge that more is being spent on the health service in Scotland today than was being spent in 1997. I also acknowledge that some of the problems that we are seeking to tackle have been endemic in the system for a number of years. However, it is about time that the Executive stopped trying to blame the failings of the NHS on the previous Conservative Government, as if all the problems of the health service could be solved by Labour alone. Such an attitude ignores the reality of our record in office and ignores the fact that, under Labour, far from things getting better, and far from the NHS supposedly being saved, in many areas things have actually got worse.

Two weeks ago at question time, Hugh Henry told the First Minister of a constituent who had to wait 89 weeks for a barium meal. Just the other day, a Fife Labour councillor—Mrs Joyce Smith—wrote to Henry McLeish and told him that health services in her area were better under the Tories, with higher standards and shorter waiting times. She told Mr McLeish—and I quote from that fine paper, The Fife Free Press—that:

"Under the Tories patients were seen in less than 15 weeks.

Patients are now receiving appointments for June 2002.

Is that acceptable? I don't think so."

She is right. All I can ask Labour ministers is, although you may not listen to me or my colleagues, why will you not listen to your own people—people on the ground who can reflect the experiences of the people that the health service is meant to treat?

The previous Conservative Government, along with its predecessors, devoted an enormous amount of time and money to improving the health service. That is why we have a liver transplant service at Edinburgh royal infirmary; that is why we have had a massive increase in the number of whole-body scanners; and that is why we became the first country in Europe to introduce a nationwide breast and cervical cancer screening programme and to establish three brain injury rehabilitation centres in Scotland. On top of all that, we were also able to initiate seven of the eight new hospital developments, many of which were built as a result of private finance initiatives, which Labour opposed at the time and now seeks to steal the credit for.

Instead of Labour refusing to admit that real improvements took place during that period, and instead of Labour pretending that it has a monopoly of virtue and wisdom with regard to the health service, it is about time that Labour was a bit more honest about the fundamental flaws affecting the service as a whole.

Mr McLetchie's speech is very interesting and quite well balanced. However, in the interests of balance, will he talk about the vast increase in the number of administrators, and the reduction by 8,500 in the number of nurses, in the last 10 years of the Conservative Administration? The Conservatives' failure to increase the number of medical students landed us with an inadequate number of consultants, whom it takes a long time to create. If Mr McLetchie is really being honest, he must be balanced and talk about the problems that his party created for our party in 1997. Those problems were very severe.

I try to be honest about those matters. Problems with nurse recruitment and nurse numbers have not diminished; in fact, I think that they have become rather worse in the past few years.

A lot of nonsense is talked about bureaucrats and administrators. Good managers and administrators are needed to run the budget of a health service that costs more than £5 billion. It does no service to diminish the contribution that those people make to the running of that service. We have to know what the service costs and how resources can be allocated most efficiently. To do that, we need high-quality administrative staff. I really feel that Labour hits the wrong mark when it attacks those people. For an organisation of its size, the NHS is not overburdened with bureaucrats.

There is a problem of underfunding. Despite the money that has been put into the health service by Governments of all political persuasions, when compared with countries of comparable wealth such as France and Germany, we consistently spend a lower percentage of our gross domestic product on health. Although we spend less public money on health from taxation than is spent in those countries, the disparity is greatest in relation to private spending on health, which is far higher in those countries than in the United Kingdom. That means that we compare badly with western European countries in terms of the number of doctors, nurses and beds in our health service. There are twice as many doctors and hospital beds per 1,000 people in Germany as there are in the United Kingdom, and almost twice as many nurses. That lack of capacity has led to the most obvious failing of our system—long waiting lists and waiting times.

I will not rehearse all the numbers—we have been through them many times. However, even using the new measure—waiting times—that the Minister for Health and Community Care has introduced, nearly 60,000 people have had to wait more than three months for an operation and patients now have to wait, on average, an extra three days when compared with the situation in 1997. We have reached a deplorable situation, where, as the result of the recent European Court of Justice ruling, we now have to consider the export of our patients because our health service is unable to treat them within a reasonable time. That is damning evidence of our failure and should be a spur to action on all our parts.

The health service suffers from lack of competition, which many people wrongly assume has no place in health care. Competition and diversity of provision should be encouraged to raise standards. We should remember that the private commercial sector is not the only alternative to the state. Development of health care can come from the voluntary sector, as exemplified by the hospice movement. Hospices are perfect examples of modern care, combining innovative developments in palliative care with compassion for those facing terminal illnesses and support for their families. Does anyone seriously believe that our world-renowned hospices would be better off being run by a state monopoly? I think not.

In any case, as has been stated, we know that the Executive is happy to take the credit for all the Tory-initiated new hospital developments. All that we are asking is that the Executive extend its pragmatic attitude, so that the principle of partnership with the independent sector is extended to the delivery of health care to raise standards and improve access.

Tony Blair and Alan Milburn have signed a concordat with the independent sector to utilise spare capacity for the benefit of NHS patients in England. That concordat is described as not just a short-term fix to reduce waiting lists and waiting times, but something that is intended to turn partnership between the two sectors into a matter of routine. Such a concordat should be signed in Scotland to give our patients the same benefit. Only this morning, we read that 40 heart patients from Liverpool who have waited six months for bypass surgery are to be operated on at Health Care International in Clydebank, but in Scotland patients would have to wait for 12 months before that would be done or even considered. Just how stupid and blinkered can we get? We have a wonderful facility on our doorstep, but we will not use it properly.

The potential to use the independent sector for the benefit of NHS patients is undoubted. Mr Chapel, the Scottish director of the Independent Healthcare Association has stated that the independent sector in Scotland has the capability to perform an extra 100,000 operations a year. Co-operation could significantly reduce waiting lists and waiting times for hundreds, if not thousands, of NHS patients.

Many of the reforms that have been introduced by the Labour party have been going in the wrong direction. Labour has diminished choice, increased centralisation and refused to use the spur that competition can bring to improve services. We need to reconsider some of the areas that I have mentioned today.

We know that we cannot start again from scratch and nor would we wish to do so. We must find ways in which the current system might be modified so that we build on where we are succeeding and what is best in the system and we improve standards where we are failing. That requires a debate that is open and influenced by developments in other countries and which is not inhibited by outdated political dogma. We need to guarantee everyone access to medical care, but that objective does not require a public sector monopoly or putting our whole system into an ideological straitjacket.

There is no single solution to the problems of the NHS. All systems of health care are imperfect. Neither social insurance, nor total tax funding, nor private health insurance alone can provide all the answers. One size no longer fits all, if indeed it ever did. The complexity of modern society demands a pluralistic approach that is flexible enough to change as circumstances alter. We need a less doctrinaire and more flexible approach involving different forms of funding and greater choice, as well as the adaptation of some of the more successful features of international experience and practice to British conditions and preferences.

I do not often agree with the First Minister, but in relation to health I certainly share his view that "what matters is what works". I hope that he and the Executive are willing to practise what he preaches and initiate the open-minded debate that is so badly needed to improve health services in Scotland.

I move,

That the Parliament welcomes the opening of the new hospitals built thanks to the PFI programme initiated by the last Conservative governments but notes with grave concern that the delivery of health care in Scotland has fallen far short of the standards people expect, with local hospital services under threat and patients waiting longer for treatment and facing the prospect of being forced to go abroad to get the treatment they need in a reasonable time; calls upon the Scottish Executive to extend the principle of partnership with the independent sector to the delivery of health care and begin discussions with the independent sector with a view to signing a "concordat" in similar terms to that already established in England, and further calls upon the Executive to initiate a debate in Scotland about how to improve standards of health care to the levels of the best European countries without raising taxes to unacceptable levels and whilst ensuring that access to high quality care is guaranteed for all.

I welcome this morning's debate and I have listened with interest to David McLetchie's opening remarks. I welcome his acknowledgement of the complexity and scale of the task of modernising and developing the NHS. I also welcome his desire for a balanced and measured debate about the NHS, which is something that I have been calling for for some time. Indeed, I have come under attack from David McLetchie for saying just that, but I will give him the benefit of the doubt and will remain pleased to engage in such a debate.

I am sure that I am not alone in finding it difficult to take the Tories too seriously on this issue. The Tories feign sincerity, but I find it unconvincing. Their record in Government speaks louder than any amount of warm or weasel words from their leader. I will use my time to focus on the facts of what ministers in the coalition Scottish Executive are saying and doing, and on what is going on in our NHS.

Let us remind ourselves that the NHS is our nation's biggest and most important public service. It is our country's largest employer and accounts for one third of the budget of this Parliament. It serves our entire population and it is a service of which we can and should be proud. The service is facing enormous challenges, but it is responding to those challenges day in, day out.

We have made clear our determination to work for and with the NHS in Scotland to address the challenges through investment and reform and to do so in partnership with staff and with patients. We are under no illusions about the scale of that task, but that makes us all the more determined to take forward the programme of work that we have set out. We will build on success as well as tackling failure.

Last December, we published "Our National Health: A plan for action, a plan for change". The plan set out a radical and ambitious, but achievable, programme for our NHS. It made clear our determination to rebuild our NHS as a truly national service: replacing competition with collaboration, combining investment with reform, setting national standards to be met locally and working to deliver services built around the needs of users, not the convenience of providers. Crucially, the plan was clear in its determination to improve health, not just to improve the treatment of ill health.

Since then, a massive programme of work has been under way to implement that plan. It has commanded widespread support throughout the country. I am delighted that a wide range of individuals and organisations are working with us and the NHS to ensure that the plan is translated into practical action and that it delivers real results for patients across Scotland.

In just over a week's time, new unified NHS boards will come into being across the country. The first of those boards is already in place in Tayside. That part of the NHS has a troubled history—blighted by fragmentation and poor leadership. However, we are starting to see a much-needed sea change in the way that the NHS in Tayside does business. There is meaningful teamwork, proper local dialogue and better performance. That is the way forward for the NHS in Scotland.

Across the country, the bureaucratic, over-layered machinery of the Tory internal market is being replaced with proper integration and improved accountability. Staff and local authorities are being given a meaningful voice around the NHS board table. That reflects our commitment to ensuring that partnership working, within the NHS and between the NHS and other organisations, is the norm in the future.

The minister mentioned improved accountability. What does she say to those members of the public in Perthshire who feel that there has been no accountability to the health board in the review of the provision of paediatric care? Does the minister believe that accountability has improved for those people?

I believe that accountability has improved in that area as in others. There is still some way to go, which is why we continue to make changes and improvements in the accountability of the service. Compared with what was happening two or five years ago, the extent of the dialogue and consultation that is taking place on that issue, in that area, is fundamentally different. That must be the direction for the future.

Let me be clear: the creation of unified NHS boards is a means to an end, not an end in itself. The test will be the results that those boards deliver. That is why, alongside the creation of unified boards, we are introducing new performance standards for the service, better financial systems, clear national priorities, and a renewed emphasis on the things that matter to patients, such as reducing waiting, improving communication, and working to ensure that people get the right care in the right place at the right time. That can be achieved only by the NHS working together as a whole.

At the heart of our approach is a clear focus on the clinical priorities of the NHS: cancer, heart disease and mental health. What is radical and different about our approach is the degree of ownership and control that is being given to staff and patients to take forward the work. National leadership is required, and we are giving it, but we recognise that change is achieved not by issuing diktats from the centre, but by harnessing the skills, expertise and enthusiasm of staff and patients.

There is little that I disagree with in the minister's speech so far, but will she clarify how far she is prepared to see private finance being used in the national health service?

I am glad that Shona Robison welcomes what I have said. Of course, the difference between our policies and the SNP's policies is that we have some, and we have translated our commitments and aspirations into practice. In a moment I will address private sector involvement, because it has featured prominently in the debate, but for now I will concentrate on investment, which rightly often features in debates on the NHS.

We recognise that delivering results requires investment. That is why the health budget in Scotland will rise from just less than £5 billion in 2000 to almost £7 billion by 2003—a substantial increase by any measure. Yesterday, Angus MacKay and I announced the release of a further £90 million to the NHS in Scotland to give our new boards a fresh start, to wipe the slates clean, to clear the accumulated deficits of the past, to enable the NHS to prepare for winter, and to continue to build for the future.

We are determined to ensure that that investment delivers results, that it reaches the areas of greatest need, and that it gets to front-line patient care. We have resisted the temptation to indulge in quick fixes, gimmicks or cosmetic changes, all of which have blighted the NHS in the past. We are investing in a way that is meaningful and sustainable.

The implementation of the Arbuthnott review is resulting in resources being allocated more fairly across the NHS in Scotland. Much-needed investment in infrastructure is now taking place. We are seeing the biggest-ever hospital-building programme; replacement and refurbishment of health centres across the country; redevelopment of accident and emergency departments to provide better and more responsive patient care; and investment in information technology to support telemedicine, the transfer of patient records, better appointments systems, test results and discharge information. That much-needed equipment has been long neglected but, together, those developments are beginning to transform the patient experience. Common sense tells us that new buildings and major IT projects are not developed overnight, but no one should be in any doubt about the correctness of investing in those areas or of the results that are being, and will be, achieved.

Of course, we continue to invest in staff: 10,000 nurses will qualify in the coming five years, 1,500 more than was originally planned; 475 more junior doctor posts have been funded; additional consultant posts have been created; and there has been major investment in the development of family health services. Alongside that, we continue to work with the Scottish Partnership Forum, which brings together all NHS staff groups in Scotland, to develop a better, safer workplace through improved health and safety measures, more flexible working, better child care, and better education and training. All those measures will ensure that we have the work force that we need now and for the future. But we are not complacent. This week, I will be writing to all those with an interest in the future of nursing in Scotland to invite them to attend a nursing summit, so that together we can continue to take action to recruit and retain the nurses that we need in the NHS in Scotland.

I have said quite a bit about investment, but let me be clear that money alone will not deliver a modern, patient-centred NHS; new ways of working, better communications and a change to culture are also required. That is why I am delighted that we now have more than 300 one-stop clinics in Scotland. We are slashing waiting times and delays, giving people more personal specialised care, and transforming the patient experience. That is the solid foundation upon which we are determined to build.

Much has been said here today, and elsewhere, about the role of the private sector. Much of what is said is confused, some of it is misleading, and some of it is just plain wrong. The fact is that the private health care sector has co-existed with the NHS since its inception. The fact is that the NHS in Scotland, from time to time, uses the private health care sector for the treatment of NHS patients where the capacity exists and where it is right for patients. There is nothing new in that, but the fact is that here in Scotland, capacity problems do not exist on the scale or in the concentration that they exist in some parts of the UK. The fact is, also, that the private health care sector in Scotland is significantly smaller than in other parts of the UK. The Tories' suggestion that concordats and the like between the NHS and private health care providers are the way forward for the NHS in Scotland simply ignores the reality.

Will the minister give way?

The minister is winding up.

There has always been, and there will continue to be, a role for partnerships between the NHS and various parts of the private sector, where that can add value to the work of the NHS.

Today, the SNP asks for less private involvement and the Tories ask for more. Our guiding principle is simple: what matters is what works for patients. We reject the tired old Tory dogma of private good, public bad. Our emphasis is on the quality of service, not just the cheapest price. What came through in David McLetchie's speech was the true subtext of the Tory agenda—to have a two-tier health care system and to build up the private sector in Scotland. I know what our priority is: to build up the NHS in Scotland. We are committed to that task. We are working with the NHS to achieve it, and we will stick to it, because it is the right priority for the people of Scotland and our health service.

I move amendment S1M-2207.2, to leave out from "built" to end and insert:

"; notes the progress that has already been made across Scotland in improving services for patients and believes that continued implementation of Our National Health: a plan for action, a plan for change will deliver increasing benefits for patients, with the objective of high quality care for all."

I agreed with one thing in David McLetchie's speech, which was that not everything started to go wrong in the health service from 1997 onward, which is why the Tories have no credibility when it comes to the health service. When they open their mouths, it reminds everyone of 18 years of butchery of the health service, from which it has not recovered.

Will Shona Robison take an intervention?

No thank you.

It reminds people of the madness of the internal market, which David McLetchie seems to want to re-establish, unless I misunderstood, and the privatisation of public assets. The really irritating thing about all this is that it gives new Labour the excuse time after time to say, "What do you expect after 18 years of Tory rule?" That is beginning to wear a bit thin. Everyone accepts that there are major problems to be resolved in the NHS, except perhaps the Minister for Health and Community Care, who tells us that everything is rosy and condemns staff for daring to complain, which reminds me of a rather famous Tory lady and her "moaning minnies" speech some years ago.

Successive Tory and new Labour Governments have failed the NHS in Scotland. Under the Tories, waiting lists stood at around 80,000. Between 1992 and 1996, the number of nurses in the NHS fell every year, while the number of health service managers quadrupled. New Labour has admitted defeat on waiting lists and scrapped the pledge to bring them down, yet at the same time the median waiting time for out-patients has risen to 51 days. There are 1,000 fewer nurses under Labour than there were under the Tories and nearly 2,000 fewer ancillary staff. In addition, there are almost 3,000 patients awaiting discharge from hospital, and they are occupying more than one in 10 NHS beds.

The NHS has its problems, but privatisation is not the answer. The Tories are in danger of never learning the lesson that ideological dogma is not the solution for public services. However, with the election of Iain Duncan Smith I suspect that we have not seen anything yet. Today's debate shows the direction that the Tories are heading in—the mass privatisation of the NHS, as I am sure that Ben Wallace is about to confirm.

I wonder whether Shona Robison agrees with her principal spokesman, Nicola Sturgeon, who in an interview with The Economist on 14 July mentioned that perhaps we should move to the European system of a partly social-insurance based system instead of a taxation-based system for the provision of health care. Health care in Europe is private and public, and in many countries it is private.

Ben Wallace has misunderstood the concept of the privatisation of the health service, which his party wants to happen.

I find myself in the somewhat strange position of facing a pro-privatisation alliance among the unionist parties in the chamber. The question is just how far each of them will go. The Tories are right about one point in their motion—PFI was their idea, but the Labour party has well and truly stolen the Tories' clothes, making Scotland the PFI capital of Europe.

The question is how much further Labour will go. Tony Blair wants to go all the way. He still has the scars on his back from the previous big ideological fight, but he won that one and I think that he will win this one too. Henry McLeish was not keen at first but, in true Henry style, he changed his tune and started to talk about how traditional public services had lost sight of their main goal—to serve the public. Does that mean that he believes that the private sector could do better? Does the Minister for Health and Community Care agree with him? The assumption of private sector good, public sector bad has no foundation other than the fact that Tory politicians, and an increasing number of Labour politicians, tell us that that is the case.

Let us consider the reality of Scotland's experience of privatisation. The Tory motion extols the virtues of using PFI to build Hairmyres hospital, yet it fails to mention the problems that have been experienced there. The records of 200,000 patients have gone missing; raw sewage has been seeping through the floor; staff have been receiving electric shocks—I am sure that the people sitting in the gallery will find it strange that some members find that so funny—because of faulty work; meals are being prepared by contractors 200 miles away and the air conditioning is faulty and is causing the building to overheat. Is that success on a plate, minister?

I wonder whether the SNP's deputy health spokesperson has ever visited Hairmyres hospital. Will she tell us whether she has ever spoken to the staff there or whether she has ever investigated any of the allegations, printed in tabloid newspapers, that she has just repeated? I have done all those things; I have heard directly from patients and staff about what is and what is not working. I have heard from them the effect that such false allegations have had on their morale. Will the SNP tell the truth on those issues?

I will do better than that; I will quote one hospital worker who said:

"Morale couldn't be any lower. We are no longer working as a team because half the staff is employed by a private firm, while the rest are NHS. One team has patient welfare as a priority, the other has profit as a priority."

That came from a hospital worker.

The true cost of the Edinburgh royal infirmary—with the loss of 500 staff, including consultants—has emerged. That is another example of how the price of PFI has to be paid.

The great privatisation itself—of the hospital cleaning services—started under the Tories and continued under new Labour. It is no coincidence that in recent years the incidence of hospital-acquired infections has risen dramatically. That is no surprise, given the fivefold decrease in the number of domestics in the NHS since services were contracted out. While the Government estimates that hospital-acquired infections cost the NHS £21 million a year, a recent report suggests that they could cost it as much as £186 million. We are supposed to believe that privatisation is cost-effective and efficient. I do not think that it is.

I turn to HCI in Clydebank. The Tories are trying to turn logic on its head with that. Instead of highlighting the solution for the NHS, the Tories are highlighting the problem—there is a lack of capacity in the NHS. That shows the absolute absurdity of the NHS being reliant in any way on the private sector. Instead of pouring more and more money into the private sector we should be building up the capacity of the NHS. The Tories appear to be happy to play the tune of the private sector. However, spending extra money on the private sector would not provide one extra nurse or doctor for the NHS.

Will the member give way?

No. I am just winding up.

The Scottish National Party would spend Scotland's money more wisely. An SNP administration would never allow £718 million—money that could have been used for public services—to be underspent. We would make Scotland's wealth work for Scotland's health. Seven hundred million pounds a year could be freed up through spending resources that are raised in Scotland. That £700 million could be spent on Scotland's public services and health service. We would use Scotland's wealth to build up the family silver, not sell it off to the private sector to be lost for ever to future generations. I am happy to move the amendment in my name.

I move amendment S1M-2207.1, to leave out from "welcomes" to end and insert:

"notes that, as a result of successive government policies, Scotland has become the PFI capital of Europe and that PFI is the most expensive method of financing hospital building; further notes that the privatisation of domestic services in hospitals presided over by the last Conservative government has resulted in a deterioration of standards of cleanliness in hospitals and record levels of hospital-acquired infections; believes that further private involvement in the delivery of health services is not in the interests of patients, and is committed to rebuilding a public health service in Scotland that is capable of delivering the highest quality of care for all our citizens."

I found myself in the unusual position of welcoming much of what David McLetchie said, until he got further into his contribution and then, unfortunately, it all fell apart. I welcome his comments about the contribution made by national health service staff and his statement that no party in this chamber or elsewhere will have all the answers to health service problems, of which there are, undoubtedly, many.

His motion opens up a thorny debate about the involvement of the private sector in Scotland's health service and in Scotland's wider health. The Liberal Democrats view with concern any plans for the privatisation of the national health service by the back or front door and any attempts to build a two-tier health service that is based on the ability to pay. However, we must also acknowledge the crucial role that private companies play in the health sector, whether they be pharmaceutical companies that are advancing new drugs and funding research, private companies such as Agilent Technologies in my constituency or those in other members' constituencies that are investing in effective employee health programmes that assist the public health of Scotland.

Scotland has made it clear to the First Minister that Mr Milburn's concordat approach is not being followed here, but it is also clear that there is a role for the private sector. Indeed, the minister said in her speech that the national health service occasionally uses the private sector when it is necessary and when there is capacity, and when it is the right thing to do for a patient. I believe that to be the right thing to do.

We will have this discussion time and again between now and the next Scottish parliamentary elections, not least because Mr McLetchie and his party will be intent on building a new, free-market, two-tier health service now that the rest of us have managed to dismantle their last one. The internal market is a recipe for division and for a massive increase in the number of NHS managers instead of—as Shona Robison, the minister and others said—an increase in the number of nurses. The Tories' agenda is driven by ideology and cheered on by their new London master.

I make it clear that I believe that there are two dogmas that we should adhere to for health services in Scotland. The first and fundamental one is to put quality patient care at the top of our agenda. The second is to preserve, protect and improve our NHS and to give real support to the 130,000 staff who work within it. It is essential that those staff are motivated, nurtured and supported to continue to deliver quality services in what are often difficult circumstances. My colleague George Lyon will talk about that at some length in a few moments.

Shona Robison's amendment is right in highlighting some of the difficulties that have arisen because of the privatisation of cleaning services in hospitals. That circumstance plays a small part only in the problem of hospital-acquired infection, but an important point is that sometimes the private sector does not get things right and sometimes people can see a difference in the quality of service. We should be saying that our No 1 dogma and ideology should be driven by what is going to deliver best-quality patient care. That is our approach.

Will the member give way?

Yes.

Would the member accept that the introduction of competitive tendering exposed many of the problems in catering and cleaning in the health service? Those companies who took on contracts no longer enjoyed Crown immunity, so that when there were problems there was also the ability to solve them. Would the member accept that that was not possible previously?

I accept that anecdotal evidence and other evidence such as the report that Andrew Walker produced, which Shona Robison mentioned and which was published a couple of weeks ago, say that hospital-acquired infection is a problem. All our constituents say that the cleaning levels in some hospitals are unacceptable. I do not care too much who does the cleaning. I just want to ensure that we have good value for money and good-quality patient care. The people who work in those services should be treated with respect, accorded dignity and given a decent wage for a job well done that will retain them in those hospitals to do that quality work. That is what I am bothered about.

Sometimes we need to find the pragmatic approach to private involvement and ensure that we make that work, whether that be through support for new PFI projects, such as the new Edinburgh royal infirmary. I assure Shona Robison that I support that through gritted teeth. Members should not get me started on the new royal infirmary from a parochial position. However, having toured the new hospital and talked to people there, I know that we will have a state-of-the-art hospital that will deliver good-quality patient care. I would prefer hospitals and schools to be paid for from the public purse, because they are fundamental to public services, but the pragmatic view that we have had to accept is that in order to deliver those hospitals, that is the only game in town. The Parliament has been able to improve matters in connection with PFI, such as contracts. We must make the fundamental acceptance of that fact.

About a year ago, Audit Scotland produced a report that covered the hiring of agency nurses. Sometimes that gives the service flexibility. If a nurse is required at short notice, it may be easier to get one from a bank or agency. However, a price tag is attached to that in the phenomenal amount of money that that costs the NHS in Scotland, in the continuity of care and in the limited access to protocols that those nurses can maintain on the wards. We must weigh up whether using the private sector will deliver better-quality care.

The jury is still out on the effectiveness of PFI in the long term. I look forward to the Audit Committee's examining PFI. A recent Treasury task force review of PFI suggested that it represented excellent value for money, whereas a report by the Office of Health Economics, which focused on PFI in the NHS, claimed that net benefits appeared to be small and might involve higher costs of borrowing, after accounting properly for risk. That office said that PFI would probably yield better-maintained hospitals over the 30-year period, but concluded that public sector managers should not be forced to adopt a PFI solution. That leads to the suggestion that PFI sometimes may be the right way forward, given further work, and sometimes may not be, as with the Western general theatre extension in my constituency.

The Health and Community Care Committee has not been able to gain information about the cost involved in current PFI projects. We have a problem in the clash of cultures between an increasingly open and accountable Parliament and a secretive, competitive business sector. That breeds suspicion, whether correct or not.

The Tory motion attacks the state of the NHS. We can applaud the barefaced cheek of this discredited right-wing party, but no members should take lessons from the Conservative party on how to run the health service. The Conservatives tried to privatise the health service and turn it into a business. Although we have seen the repentant, acceptable face of the Conservative party in Mr McLetchie, we must never forget that behind him lies Ann Widdecombe. In January 1999, she said:

"I think if someone wants to pay to see their GP they should be encouraged to do so … The problem with the NHS is that we do not charge for much of what we do."

Miss Widdecombe missed the point. The NHS does not charge for what it does because we believe in a service that is free at the point of need and at the point of delivery. We do not charge for it.

Liam Fox has said:

"Philosophically we have moved on, insurance companies could cover conditions that are not high tech or expensive, like hip replacements and cataract operations … we would then leave expensive treatment like cancer therapy to the NHS".

Members can imagine the bureaucracy that that would involve and the difficulties that those who could not afford to pay for health insurance would face.

The Scottish Liberal Democrats are committed to increasing spending in the NHS.

Will the member give way?

No interventions. Margaret Smith is winding up.

The Liberal Democrats are committed in the Executive to record investment across the board, as the minister said. Everyone will receive a 5.5 per cent increase this year. A record number of operations is being carried out. New measures are being taken to tackle waiting times. A new emphasis is being placed on investment in our housing stock, free personal care, healthy living centres, one-stop clinics, NHS 24 and cancer plans, to name but a few of the initiatives in which we are investing.

We want to ensure that all the people of Scotland have the best-quality public services and NHS. Ensuring that will involve an element of working with the private sector, but not to the extent that the Conservative party would go in taking that road.

We now move to the open part of the debate. Several members wish to speak. In the time that is available, I will be unable to call all those members. I ask the members who participate to keep their speeches brief, to allow me to try to accommodate as many members as possible.

It is unfortunate that Shona Robison did not deal with improving patient care, but concentrated on the outdated assumption that only state monopolies work. SNP members would be better spending their time in Dundee today, because their contribution to the debate has been zero.

I say to Margaret Smith, my colleague on the Health and Community Care Committee, that she can continue to quote Ann Widdecombe, Liam Fox and whoever, but she does not realise that in the Conservative party, Scottish health policy is devolved to members of the Scottish Parliament. Perhaps policy is not devolved in Margaret Smith's party or the Labour party. If she wishes to quote members of the health team in the Scottish Conservative party, we will take responsibility for those comments.

Will the member give way?

No.

We all agree that health care has moved to new ground. I will start by briefly considering the European Court of Justice ruling that patients can challenge their health authorities to obtain treatment abroad if that cannot be provided domestically in an acceptable time scale. In Germany, any wait for treatment of more than four weeks is considered too long, and in France, any wait of more than two months is unacceptable, yet in the UK, six months is the norm. Many patients in Scotland would be delighted to see a consultant within six months, let alone to wait six months for treatment.

The idea of patients going abroad is not new. I would like to claim that it was a Tory idea, but in 1951, the Labour Scottish Office minister Peggy Herbison organised a scheme for patients with pulmonary tuberculosis to be treated in Switzerland. Seventy patients from Edinburgh—more appropriately known as Auld Reekie at the time—were flown out to Switzerland and joined later by patients from Glasgow. In 1951, Labour recognised that what mattered was what worked.

I would like to correct what Margaret Smith said about the Department of Health's concordat, by Alan Milburn, with the private and voluntary health care sector, which sets out a partnership approach that enables NHS patients in England to be treated free in the private and voluntary health care sector. The concordat says:

"The key test"

for this relationship

"is that it must represent good value for money for the tax payer and assure high standards of care for the patient."

In Scotland, are we saying that we do not endorse those key tests? Is politics in the Scottish Parliament overwhelmed by ideology?

I must correct Mary Scanlon's comparison of the 1951 TB epidemic to patients possibly going abroad today. I have written quite a bit about that epidemic, which was of massive proportions. People were dying in this country and the authorities were only too happy to shift patients out to Switzerland, Germany and anywhere that they could send them. It was the national health service that beat TB in the long run, so that TB hospitals had closed by the late 1960s.

I thank Dorothy-Grace Elder for her contribution. The national health service also found the best care for patients by sending them abroad.

Can we be absolutely clear about the new definition of waiting time? The British Medical Association suggested that the definition of waiting time should be the time from referral by the general practitioner until treatment. Will the minister confirm whether the new definition of waiting time is the time taken from being put on a list following the patient's appointment with the consultant or the time taken to wait to see a consultant? If we are to have an honest debate about waiting times and waiting lists, we need to be clear about the definition.

Some waiting lists are closed, including the list for the communications clinic at Raigmore hospital in Inverness. That clinic is where the diagnosis of autism and other disorders—

Will the member please come to a close.

What matters is what works. The SNP misleads members when it talks about hospital-acquired infections. Can Shona Robison prove that hospitals that are run by private contractors have lower, or higher, hospital-acquired infections than those in the public sector? We all need to hear that information.

The member must now come to a close.

My mother was in a hospital in Dundee that is run by an in-house contractor. That hospital was far from clean.

I will wind up with a final point—

The member must do so very quickly.

I want to mention the case of Alec Grant, a patient who has spent three years being assessed and diagnosed inappropriately. He saw a doctor again yesterday, but he has to wait until December to get on a waiting list—

The member must close.

He will have to wait a year. If the Executive does not reduce waiting times, clean up hospitals, unblock beds and give patients appropriate care, the money will follow the patient to Germany, France and other countries.

For the Conservatives to have initiated this debate is breathtaking, given the years of underinvestment that we suffered while that party was in power.

In Glasgow, the rate of new hospital building and of lack of equipment is worse than in other parts of Scotland. That situation is only recently being put right through the application of the Arbuthnott formula. It is also being put right through the recently initiated £300 million per year programme of hospital building—double that which was spent in 1997.

It is also important to recognise, as did Susan Deacon, the £400 million increase that has been put this year into patient care. There is more money, but there is also an increased need for patient care. We need to address that increased need in different ways.

I have recently begun to follow up the incidence of oesophageal cancer in north Glasgow. Over the past decade, oesophageal cancer has increased significantly in Scotland; we now have the highest incidence of oesophageal cancer in the world. Projections indicate that for the next 10 years, the incidence is likely to increase. Oesophageal cancer is a dreadful form of cancer because of where it is found in the body and because the survival rates are so low.

In recent years, major advances in the management of oesophageal cancer have taken place. These include better staging of the disease, improved endoscopic techniques for curative treatment in its early stages to reduce the need for major surgery and better palliation of the more advanced stages of the disease. We can do more for patients who suffer from oesophageal cancer. We have to look critically and imaginatively at what can be done to assist this group, and other groups, of patients. If patient care is to be our focus, we need to look at patient care from the patient's point of view.

Many of our debates on health are pretty sterile. People can often seem to be chucking figures at each other from one end of the chamber to the other. What is important are patients and what happens to patients. I am angry about what happens to patients in some of our hospitals. I am angry about the time that they have to wait and about the misapplication of invasive techniques because diagnostic techniques are not in place. That is not the responsibility of one political party, but it is for all political parties to do something to put right the situation.

We can prevent much of the distress that patients suffer by engaging in better co-ordination and management. In Glasgow, oesophageal cancer is dealt with in three different places. Every surgeon says that the best people, equipment, research and resources should be concentrated in one place so that people get the best form of treatment. If we engage in a process of better management and co-ordination, we can assist people to make better use of the additional resources that are in the system. We need to focus our attention on the patient's needs and requirements throughout the patient's journey.

I disagree with one point that was made by Susan Deacon—there is a capacity problem in the health service. That is especially true in the area of diagnostic testing. We need more machines, equipment and organisation. That would speed up diagnosis. However, the additional resources will begin to make a difference to diagnostic testing and to improving elective surgery.

I agree that we have to focus our attention on the priorities of cancer care and cardiac care. If we do that, we can achieve better outcomes for patients.

Will the member please wind up.

We have, and can, achieve better outcomes for patients within the integrity of the NHS. Everybody in the Scottish Parliament would subscribe to that. We should not move outside the NHS, but we must work—

The member must now close.

We must work imaginatively to ensure that people get a better service.

The Tories really are one of the wonders of the ancient world.

That is you.

You are older than me, sunshine.

Along with the hanging gardens of Babylon and the Colossus of Rhodes, the Tories are talked about, but defunct. However, a fresh breath of stale air seems to have wafted through their ranks since the election of their new leader—the well-known Mr what's-his-name.

In the Scottish Parliament, Tory members, led by Mary Scanlon, have served on the Health and Community Care Committee with distinction and without bias and they have produced some ethical work. However, when grouped together as they are today, only one collective noun can be applied to them—Thatcherism.

A direct attack was made, once again, on the national health service, but the health service is something that every member of the Scottish Parliament must be committed to defending. It is amazing to see the Conservatives continuing to promote zealously the principles of PFI and the private-public partnership. A Treasury committee regards PFI as outdated and attacked those principles in a report. The principles were also attacked in the Office of Health Economics report, which Margaret Smith, convener of the Health and Community Care Committee, mentioned.

Those distinguished bodies could find no PFI deal in Britain that could be proven to be worth more than a public deal. That would have to be the case as, for starters, thousands of millions of pounds are lost in the VAT shelter that is applicable to public, but not to private, deals. Before the first brick is laid, one finds a large open drain and starts to chuck public money down it. At the end of the day, in a PFI hospital deal, the public do not own one brick. Who would call that a good deal? Only the private market and the financiers would call that a good deal.

Will whoever-it-is give way?

I say to the Conservatives that it is natural for the markets and the private financiers to call that a good deal. Do the Conservatives think that those institutions are into building hospitals because of their love for humanity? Oh, no. They are in it because of their love of lucre. That is the raison d'être for many in the Conservative party.

Will the member give way?

To Phil Gallie, of course.

Dorothy-Grace Elder is always generous.

The member attacks the Conservatives for their longings and desires for PFI. Surely we are no longer the party of government. Surely she should be looking at the Labour benches, as Labour members seem to have embraced the principles of PFI hook, line and sinker.

It has embraced it like something from "The Kama Sutra".

Which page?

It has indeed gone further than Phil Gallie's party. As my colleague Shona Robison said, it has stolen the Conservative party's clothes—after it had been stripped naked of all credibility—and run off with them and now it zealously pursues PFI, to no end whatever. The Minister for Health and Community Care says that there is no quick fix. I am terribly sorry, but I do not even see a slow fix emerging—not in Glasgow, where I operate.

The health minister must know from her constituency work the number of people who are trying desperately to have a simple operation done. Her statistics claim that, in Glasgow, for instance, the wait for a hip replacement operation is eight months. The reality is that people have a year's wait to get on the queue to wait for an operation—people in Glasgow, queueing for operations at the Glasgow royal infirmary, have to wait almost a year to see a consultant. Here is a letter from someone in the east end of Glasgow. The man says that his lifespan is limited, that he is in agonising pain and that he can wait no longer for the operation. Patients are deteriorating because they have to take so many painkillers.

I submit that the shambles that is the NHS in Scotland—under new Labour and inherited from the Tories—is cruelty to the Scottish public. I ask members to support the SNP amendment.

Following that speech, I will try to restore some decorum and decency to the debate.

We should not doubt the commitment of every member to improving health care and services for patients. That is a priority of the Liberal Democrat-Labour partnership Government and has already resulted in record investment in the health service in Scotland and improvements to the way in which the NHS operates, such as streamlining and getting rid of the disastrous Conservative internal market.

However, no one pretends that all is well in the NHS in Scotland. We all recognise that it will take time to reverse decades of neglect, particularly under the Conservative Government. The NHS cannot be changed overnight. As David McLetchie said, the NHS was formed in 1948. For 35 of its 53 years, the Conservatives were in charge. No wonder it is in such a mess.

I agree with some of Des McNulty's points about diagnostic issues. Money alone is not enough. Huge capital investment in the NHS has been made, but that is not sufficient. We have to get more nurses, doctors and radiographers in place, which takes time. Nurses, doctors and radiographers cannot be conjured out of thin air; they have to be trained. One big area of neglect during the Conservative Government and the first two years of the Westminster Labour Government was the underinvestment in training for the various health professionals whom we need to improve the health service.

The SNP's amendment is typical of the SNP, as it fails to address any of the key issues.

Will the member give way?

I am sorry, but I have only four minutes.

Cleanliness is important with regard to hospital-acquired infection, but it is not the be-all and end-all. The public are being led to believe that, once our wards are sparkling clean, the problem of hospital-acquired infection will disappear. That is not the case. The issue is about control. The Liberal Democrats were the first to highlight the matter, during the general election. We called for a national strategy and, in particular, for the introduction of infection-control nurses and teams in every hospital. We believe that that is the right way forward. It will result in significant savings to the health service—money that can be reinvested in patient care.

I am confused by the SNP's amendment. It says that

"further private involvement in the delivery of health services is not in the interests of patients".

However, today's The Scotsman reports Nicola Sturgeon on the HCI project. She is quoted as saying that

"the deal would mean patients in Scotland will wait twice as long as their English counterparts before being referred by their NHS trust to private hospitals for treatment."

She says:

"This will further disadvantage Scottish patients who have been waiting too long for operations."

Does the SNP believe in private involvement or not?

Will the member give way on that point?

The member did not give way to me, so I will not give way to her.

The SNP contradicts itself. It wants one thing for some people and another thing for others. It either believes that people have to be admitted to private hospitals or it does not. It cannot say that it thinks the involvement of the private sector is bad for patients and then say that it is bad that that sector is not being given an opportunity in Scotland. That is a typical SNP contradiction.

As for the Conservatives, David McLetchie was right to address issues such as the backlog of ill health. The Liberal Democrats have long said that the problem with the national health service is that it is actually a national illness service. That was why health promotion has been an important part of the Liberal Democrats' commitments in government—£26 million a year will go into the health promotion fund.

David McLetchie referred to Joyce Smith's comments on the situation in Fife. I know Joyce well—we were councillors together in Fife for many years—but she has got this totally wrong. Under the Conservatives, Fife had the worst waiting lists and the longest waiting times in Scotland. We did not have a good health service under the Conservatives and no one should pretend otherwise.

The problem with the Conservatives is that they want a health service paid for by an acceptable level of taxation, but they do not tell us what that acceptable level of taxation would be or how much money they would spend. In particular, they do not tell us whether that acceptable level of taxation will comprise direct taxes such as income tax or whether it will comprise the charges that it will impose on people, such as prescription, eye and dental charges. The Conservatives are dishonest on taxation and dishonest about the health service.

David McLetchie's interesting analysis, which I listened to carefully, contains many truths. I welcome his acknowledgement of his own part in the sterile inter-party debate that has gone on. I would not call it a debate, however; I would call it scrapping. To call Susan Deacon the worst health minister that we have ever had is pretty rich coming from the party that spawned Michael Forsyth, a total zealot who gerrymandered the health service.

The Conservatives' solution, which was outlined in the second part of Mr McLetchie's speech, is not about pragmatism—which we embrace—but about the creation of a much more substantial private sector. One of my constituents recently had a heart operation in HCI. He was given a deadline by which he would either receive the operation in the public sector or at HCI. When that deadline approached and it was clear that he was not going to have the operation in the public sector because of winter pressures, for example, he had it at HCI. That certainty was important to him and his family. That sort of pragmatism—using the extra capacity of the private sector—is not a problem. The Scottish health service is using the private sector for about 5 per cent of services.

Our pragmatism and the creation of the one-stop clinics—as Susan Deacon said, there are now 300 of them—have meant that another of my constituents was seen in 48 hours at the pain clinic. That was followed up by NHS cardiac laboratory results inside a week and a triple bypass inside three weeks. That is faster than anything I could have achieved for my private patients when I was in practice. That is pragmatism and prioritisation and it is partly what this issue is about.

On privatisation and coming to an arrangement with the private sector to use spare capacity as the need arises, does the member agree that it is perhaps better to do that on a nationwide basis—as has been done in England—so that we get best value for money?

No, I do not. If we set specific waiting times and invite the now unified health boards to spell out those waiting times to their local populations, those should be guarantees, beyond which we use the private sector. Alternatively, we should use other health boards, if that is appropriate and if they have no waiting times, as can happen. That is a totally pragmatic approach. We do not need a national concordat in Scotland.

Although pragmatism is important, so is the building of capacity. I referred in my intervention on David McLetchie to the fact that the number of nurses in Scotland fell by 4,500. We have increased the number to previous levels and are just about to go beyond that. We will have a 15 per cent increase on the planned levels over the next few years. We are improving retention and reducing drop-out rates, although that is still a significant problem and we are not pretending that it has been completely solved.

Doctors are also important. The consultants that Susan Deacon talked about employing do not just drop out of thin air. We have decided, on a UK basis, to increase the number of medical students from 5,000 to 7,500, but that increase will take time to come through. We are building capacity for the long term. As Susan Deacon said, we are not going for a quick fix.

Des McNulty gave the best example of the problems that are created by the internal market—the three oesophageal cancer centres in Glasgow. In my constituency in the Forth valley, competition between Falkirk and Stirling meant that, every time Stirling appointed a consultant, Falkirk had to appoint a consultant, too. That is totally inappropriate for the size of population in the area.

The immediate task of restoring the structure that will create the public sector ethos is now almost complete, and I welcome that. We now have the beginnings of a truly patient-focused, accountable service, whose modernisation is important. In modernising, we must have an open debate with the professions about their undoubted territoriality. As with some politicians, there are medical politicians who need to be told that shouting from the rooftops is inappropriate. I am not talking about the generality of health service staff, who are excellent, get their job done and are a caring set of professionals. However, there is no doubt that some professionals simply shout "Rubbish!" from the rooftops.

What Shona Robison said about Hairmyres sounded reasonable until she said that profit was unacceptable. Some profit is always involved in a private contract, so that is not a problem. I have not had enough time to speak at length about the SNP, but I think that it should look carefully at the Finance Committee's PFI investigation, which I believe will show that the transfer of risks is important in the PPP.

On Monday evening, Tayside Health Board and the Tayside NHS trusts held a public meeting in Forfar to present their annual report and accounts. No members of the public turned up. In light of the fact that the NHS in Tayside accrued a cumulative deficit of £16.7 million over the past two years, it is perhaps not surprising that members of the public show no interest in hearing the presentations of health service managers. That is regrettable, because a lot of time and effort must have gone into preparing those presentations.

It is clear that the focus of interest of health service users in Tayside is on patient care, not on reports and not on well-publicised overspends. There is a perception locally that patient care and the interests of health service users have been ignored in recent years. At a time when the future of Stracathro hospital in Brechin, which has served Angus and the Mearns well over many years, is still uncertain, and as Perth royal infirmary will maintain maternity and children's services only because of the tireless efforts of local campaigners who took on the bureaucrats and won, it is hardly surprising that the public are somewhat disenchanted with the local health board.

Across Tayside, patient groups have spent the past two years fighting to ensure the provision of the best possible locally provided health care, whether at Stracathro, at Perth royal infirmary or more locally, and I applaud their efforts. We should remember that the reason given by Tayside Health Board for the removal of acute services from Stracathro was the budget deficit. Now that the minister has announced that the deficit is to be written off, will she tell Tayside Health Board that the acute services have to go back to Stracathro? That decision has to be reviewed.

Murdo Fraser should be aware of the fact that the overwhelming majority of community hospitals in Scotland were closed by his party. It was the Conservatives who removed local care instead of adapting it, and it was only in the last few years of their Administration that they suddenly realised that that might be a big mistake and conducted a review that concluded that it was a big mistake.

Richard Simpson will appreciate that Stracathro is not a community hospital. It was an acute hospital.

Murdo Fraser referred to local services.

Stracathro was an acute hospital, and it is the removal of the acute services from Stracathro that concerns me.

I welcome the introduction of schemes such as care together in Perth and Kinross, and I am delighted that PRI will be a demonstration model for the delivery of maternity services in Scotland through the introduction of midwife-consultant partnerships. However, I am concerned that there is still uncertainty about the long-term future of paediatric services at PRI. I have met many parents from across highland Perthshire, some of whom have to cover great distances to get access to maternity services. It is for them that we must ensure 24-hour cover. Mothers must be given the choice of giving birth at their local hospital and we must ensure that, wherever possible, first-class local services are available.

Will Murdo Fraser give way?

I am running out of time.

I welcome moves to improve health care provision in Angus, another area where patients often have to make long journeys to receive care. It is vital that the new hospital that we are promised for Angus is constructed on the Stracathro site and not at Arbroath or elsewhere in the county. The necessary infrastructure is already in place at Stracathro and the site is readily accessible from most parts of Angus. Most important, an excellent, dedicated work force is already available. The economy of north Angus, which has suffered a great deal in recent years and months, needs the jobs at Stracathro. Just as there was a cross-party campaign to fight for services at Stracathro, I hope that there will be a cross-party campaign to fight for the new Angus hospital to go to the Stracathro site. It should not be elsewhere in the county and, in particular, it should not be split between different sites.

It is essential that any future changes to health care in Tayside take into consideration the need to ensure that the patient's experience is a satisfactory one. Transportation of patients to and from hospital, and arrangements for visitors, are issues that directly affect an elderly patient's experience of hospital.

Communication systems between those who deliver health care and those who receive it must be improved. In its report on the consultation on the acute services review, Tayside Health Board concluded:

"It is no longer sensible to plan services in any one part of the system in isolation."

I am sure that none of us would argue with that sentiment. It is for the Parliament to ensure that every person in Scotland receives the highest possible standards of health care.

We are running out of time, so there will be only one more speech in the open debate. I call Stewart Stevenson.

I remind members of the voluntary declarations that I have made in the register of members' interests with regard to my pension from the Bank of Scotland and my shareholdings there. I do that because I have been one of the happy beneficiaries of PFI. Bankers everywhere love PFI and, when we come to the nub of the matter, this Tory debate is about money. In fact, I am holding a bank note that depicts one of the most famous Tories of the 19th century, Sir Walter Scott, who is immortalised on our money even today.

Will the member give way?

We are very short of time. Perhaps Brian Monteith and I can discuss his point privately.

Let me give credit to the Tories. In their 160-word motion—quite the longest sentence that I have seen for a long time—the 15th word is "PFI". At least they are honest about PFI being their policy. In a 10-minute speech, the minister got to 10 minutes and 38 seconds before she mentioned PFI, and yet that is at the core of the policy that the Government is pursuing.

It has been said that there are three kinds of bankers: those who can count and those who cannot. Well, even a former banker like me—[Laughter.] They got it. Good. The Tories are awake. Well done. Even a banker who cannot count can see that this debate is about money. The Tory motion is about money, not health.

Richard Simpson made some interesting remarks about community hospitals, building on what Murdo Fraser said. The minister referred to the Arbuthnott formula. In Grampian, 10 per cent of Scotland's population now receives 9 per cent of health funding, and community hospitals are under threat as a result. In my constituency, the Chalmers hospital in Banff, which has been promised redevelopment for 10 years, is now under serious threat. Community hospitals are a cost-effective way of delivering health care.

Competition has been mentioned, but I have to ask whether it really drives up standards. Supermarkets, which are at the forefront of competition in this country, deliver cheap food rather than quality food by and large, and the Labour party is the McDonald's party rather than the new party. However, what concerns me most about PFI is much more long term. PFI locks us into long-term commitments—typically for 30 years—and that is a big threat to community health care. We cannot get out of paying for those large facilities that are being developed in many places through PFI.

Will Stewart Stevenson give way?

I am sorry, but I am in my final minute.

If we are going to have to focus the expenditure when it is reduced by the Arbuthnott formula, as it has been in Grampian, we will be at serious risk of not delivering the health service that people want.

I shall conclude with a personal recollection of how patients feel. In the 1970s, when I was doing some parachuting, I came out of a plane, looked up and saw that my parachute had not opened.

Had the member packed it himself?

Yes, I had packed it myself. I plummeted towards the ground, but the reserve parachute saved me.

Aw.

Well, that is why I am here today.

These days, many of the people who are on NHS waiting lists feel exactly as I felt 25 years ago as I plummeted towards the ground. PFI is taking money out of the health service that we should be spending on health, not on bankers' profits.

We now come to wind-up speeches. As we are over time, it would be helpful if members could take less than their allotted time.

I shall try to be brief.

I welcome yesterday's statement by the Minister for Health and Community Care to the effect that all NHS trust debts will be written off. That demonstrates to the Scottish public the fact that the coalition is committed to improving health care and the fact that that we are making substantial increases in investment in our health services. I shall raise some points specifically on rural health services.

Since the Lib-Lab coalition came to power, investment in the NHS has risen dramatically, which is to be welcomed. That investment is beginning to pay dividends on the ground. In my constituency, there is the prospect of a new hospital. Improvements are being made to medical centres and there has been a general improvement in services. Nevertheless, there is still a fundamental problem in delivering better services in rural areas.

During the summer, Margaret Smith and I spent three days touring my constituency, visiting hospitals, meeting general practitioners and finding out from the front-line troops what specific problems they face daily. The simple message was delivered to us time after time that the fundamental problem that faces general practitioners, nursing staff and practice nurses in the delivery of better services is the recruitment and retention of staff.

The provision of decent housing for medical staff in rural areas is often an issue. GPs also told me that a big issue is partners' jobs. If the partner of a GP working in an urban area wants a career, there is no problem, because the partner would be guaranteed a job. However, in rural Scotland—in small villages and towns such as Campbeltown—that possibility does not exist, which puts a lot of people off applying for jobs. If their partners cannot secure a job that has career prospects, medical staff are not willing to move to those areas.

Probably the biggest issue, however, is out-of-hours work for GPs in community hospitals. In Campbeltown, some GPs are on call for three or four days a week, which is a huge commitment. They are not on call only as GPs, but as hospital doctors. That can mean up to four or five hours' work a night if there is an emergency in the area. I hope that that issue will be tackled.

A document has been produced by our lead GP, Eric Jesperson, on behalf of the local health care co-operative in my constituency, entitled "Integrating primary and community emergency care services within Argyll and the Islands". That document was commissioned and paid for by the Scottish Executive and contains many good suggestions for ways in which we might tackle the problems. The issues that arise in my constituency arise throughout rural Scotland, so I hope that the minister will look closely at the recommendations in the document, and that the coalition Government will implement some of them.

The Tories' motion calls for the Executive to

"improve standards of health care to the levels of the best European countries without raising taxes to unacceptable levels".

None of the Tory speakers has defined what on earth an unacceptable level of taxation might be. Of course, we all know what the Tories think—Oliver Letwin, the new shadow Home Secretary, certainly has a view on public spending and taxation, which is of cuts worth £20 billion. Iain Duncan Smith is on record as saying that public spending should be reduced to 35 per cent of gross domestic product. The only way in which the Tories can square the circle of making those cuts while bringing health care up to the levels of the best European countries is to abandon the principle of free health care at the point of delivery. The Liberal Democrats and the other parties will oppose that tooth and nail.

I will deal with the Swiss issue first. When my late father was first lectured to in Edinburgh University on the subject of tuberculosis, he was told that sending people to sanatoria did no good and that they might as well be quietly put down. Fortunately, the situation moved on a bit during his career as a chest specialist and he saw tuberculosis off. However, the notion that sending people to Switzerland was a ringing endorsement of privatisation, rather than something pragmatic, is naive to say the least.

I should point out that I did not connect tuberculosis patients with privatisation. I was speaking in the context of the European Court of Justice ruling.

Thank you. I will crack on.

All of us have been in hospitals and have sat with people in the casualty department. We will have been aware that the staff were harassed, overworked and thin on the ground. Indeed, we know that throughout the UK, the health service is trying to recruit people from abroad to make up the numbers. We all recognise the problems and I am confident that we would all try to address them if we were in power.

Susan Deacon got a little bit tetchy about one specific visit to one particular hospital. However, on three occasions recently, I have spoken to various representatives—senior and not so senior—on health boards and it is clear to me, even from the coded language that officials use, that they are a bit short of dough and resources.

I find it incredibly crass that the Tories lodged the motion. Their doctrines produced the experience of PFI—I suppose that they are proud of that. When PFI was introduced, the SNP objected to it on principle, as did the Labour party. The SNP objects to it on the ground that it duplicates the negative aspects of hire purchase: the product can be had sooner, but the eventual price will be greater. That has been known to people for a long time. Paying for hospital construction from Government resources is the cheapest and most sensible option. We agree with Margaret Smith on that point.

In Iain Smith's slight assault on Nicola Sturgeon, he missed out the last part of the quotation—which of course is good politics. Nicola Sturgeon was quoted as saying that the deal

"shows the absolute absurdity of the NHS being reliant on the private sector".

I wonder what the purpose of the motion is. Is it a self-congratulatory memorial to a Tory initiative? Is it designed to test Labour's support for PFI, which it took on board from the Tories? Is it supposed to find whether there are chinks in Labour's commitment to PFI? If it is, I must point out that I have not seen any so far—I have heard none of the Labour members railing against PFI. Is it a doctrinaire attempt to give succour to the independent sector in health and to aid and abet those whose motives, however pure, are underpinned by the profit motive? The Tories seemed to object when Shona Robison suggested that that might be the case. Methinks they did protest too much.

My bottom line on health is that when I require health care—non-urgent or urgent—it should be provided timeously, efficiently, compassionately and to the highest professional standards. I believe—as, I am sure, all members do—that that applies to every citizen of Scotland. Health care should be free at the point of delivery. We all agree on the objectives: we want the very best—a world's best standard—for all our citizens. That will not come cheap.

It is interesting that, as George Lyon pointed out, the Tories did not address the part of their motion that talks about improving services

"without raising taxes to unacceptable levels".

I wondered what they meant by "unacceptable levels", but they did not tell us. Do they mean unacceptable levels of income tax or indirect taxation, which has gone up by the equivalent of 8p in the pound since Labour came to power in 1997. Is that little phrase an admission that Mrs Thatcher's policy of slashing direct taxation was a mistake or that that policy—and Labour's subsequent commitment to it—is a major reason for the resource shortcomings in the NHS?

The Tories' choice of motion raises more questions than they can hope to answer. It highlights the party that led the nation to starvation of resources in health and local government, reduced employment and depressed large sections of the population—probably some of them clinically. The motion reminds us of a party that increased the number of hospital managers from 523 in 1991 to 2,392 in 1996 and reduced ancillary staff from 15,000 to 11,000. I cannot believe that the Tories have been naive enough to embrace the motion and thus draw attention to their appalling record. I exhort all MSPs of intelligence, perception and sense to vote for the Scottish National Party's amendment.

The debate has been good. On a day on which there is good news for the health service in Tayside, I welcome the pupils from Lochee Primary School, which is in Kate MacLean's constituency.

We all appreciated the first half of David McLetchie's speech. He made an interesting point at the beginning: the majority of people are satisfied with the treatment that they get from the health service, but still have serious concerns about the health service as a whole. We need to remember such facts and perspectives in any health debate.

Clearly, for many people, treatment is good. In fact, it is getting better in many cases. For example, Richard Simpson reminded us of the one-stop clinics that are fast-tracking treatment for so many people. In the context of the references that many members made to heart surgery we should remember, for example, that the median wait for coronary artery bypass grafts is down from 120 days in March 2000 to 73 days in March this year.

There is progress, but we acknowledge the problems that remain. The 89 weeks' wait to which David McLetchie referred is totally unacceptable. Indeed, I used those words in letters to Wendy Alexander and Hugh Henry who wrote to me on that subject.

Mary Scanlon emphasised the importance of waiting for the first out-patient appointment. We are certainly focusing on that now, although I say to Dorothy-Grace Elder that the median wait for the first orthopaedic appointment in north Glasgow is three months not, as she said, a year.

More controversially, in the second part of his speech, David McLetchie turned his attention to the independent sector. We have nothing against the independent sector: I met the Independent Healthcare Association recently. We are supportive of the voluntary health sector and have several new initiatives for it. Many health boards also use private hospitals. The fact is that the independent health care sector has a role to play, but the size of that sector in Scotland is not remotely comparable to its size in England. There are already local links between the NHS and independent providers and we can see no reason to change that to a national relationship, because it would add no value.

Is the minister aware that his department, in an answer from the Minister for Health and Community Care over a year ago, told me that it collated centrally no information about links between health boards, health trusts and the independent sector in Scotland?

Such links are a matter for local determination. The lack of information does not mean that such links do not happen.

In the second half of his speech, David McLetchie veered towards the traditional Tory dogma—private sector good, public sector bad. Shona Robison, however, appeared to turn that on its head. We are quite happy to use both sectors. We are proud to be supporting the largest building programme in Scotland since the NHS was established. That means funding some new hospitals by PPP, but it also means using traditional funding. Traditional capital expenditure has increased from £136 million when Labour came to power in 1997 to £295 million this year.

Is the minister equally happy that 500 staff have had to be lost from the Edinburgh royal infirmary due to the costs of PPP or PFI?

There has been a lot of activity to protect the rights of staff under PPP contracts. That is one of the main changes that we have made to the arrangements that we inherited. Margaret Smith was absolutely right when she said that we should be driven by what delivers best quality patient care.

Shona Robison talked a lot about cleaning services. Earlier in the year, we said that contracting out of cleaning services should no longer be the norm. We are therefore now following the principle that I quoted from Margaret Smith. For the first time, there are national standards for decontamination, cleaning services and infection control. Those standards will be closely monitored. The new Clinical Standards Board for Scotland will establish and oversee those new standards.

David McLetchie pointed out that standards differ in different parts of the country and he proposed competition as the answer to that problem. That has been tried and it has failed. We are rebuilding the NHS as a national service—partly through new bodies such as the Clinical Standards Board for Scotland and partly through the new performance assessment framework, which is starting this year. That framework will examine standards and will also consider issues such as public involvement and other issues across the board.

Will the minister give way?

I might give way in a minute, but I am running out of time so I had better press on.

Des McNulty and Richard Simpson referred to capacity problems. Those problems exist and Susan Deacon acknowledged that. However, they do not exist on the same scale as they do in the rest of the UK. Shona Robison used the figure of 1,000 fewer nurses—a figure that has been thrown around recently by the SNP. The fact is that there are 450 more qualified nurses now than there were when Labour came to power. We must also remember the closing of learning disability hospitals, which meant a reduction in the numbers of nurses, although they might still be working in the community.

Des McNulty also referred to cancer and to oesophageal cancer in particular. Recently, I was pleased to visit Gartnavel hospital to talk to the gastrointestinal surgeons. We clearly acknowledged, in the recently published cancer strategy, the capacity issues in relation to cancer. I am pleased to see that there have been two new radiotherapy machines installed at Gartnavel. I was also pleased to see new endoscopy equipment.

The cancer strategy and many other initiatives that were announced over the summer all have extra sums of money attached to them. We all know that results matter, but results cannot be achieved without money. Members should remember that there has been an increase in funding of more than £0.5 billion from last year to this year and that there will be an increase of more than £0.5 billion from this year to next year. There have not been such sustained funding increases under any Government in recent times. Everybody should welcome that important development.

The new distribution formula takes account of deprivation and rurality. I hope that that meets with the approval of George Lyon, who majored on that topic. The Executive has already established an expert group—the remote and rural areas resource initiative—to develop responses on the delivery of health care in remote and rural areas. RARARI has established a short-life working group to examine specific recruitment and retention issues that affect staff in the full range of national health service work.

My time is up. I thank members for their contributions to an interesting debate. I hope that everybody will acknowledge the progress that has been made and accept that we know that there is a long way to go.

I thank the Minister for Health and Community Care and I welcome the new money that was paid yesterday to Tayside Health Board to cover up its deficit. As identified by Professor Clark, many of the problems in that health board were management problems. It was right to prevent patients in that region from being punished for those failings.

Alan Milburn, the Labour Secretary of State for Health, said:

"I honestly couldn't sit here and say that for some bizarre ideological reason I was not prepared to contemplate the use of spare private sector capacity in private sector hospitals for the benefit of NHS patients if they are waiting in pain and discomfort."

Closer to home, Iain Smith was right to highlight Nicola Sturgeon's remarks about how the use of HCI by English patients from Merseyside would disadvantage Scottish patients, who would end up waiting longer—far too long.

Will Ben Wallace give way?

I will come to Shona Robison in a minute, so there is no need to give way to her. After four and a half years under the present Government, I am afraid that Susan Deacon's record does count. Patients are waiting longer, and more of them are waiting. They are experiencing services that are much worse than when we left office. Some of the Government's targets are only just on course to match in about two years' time the targets that we left it with.

I believe that Labour has forgotten about patients. Contrary to Johann Lamont's comments last week—to the effect that no one will trust the Tories with the NHS—people are quickly seeing that we were getting it right and that some of Labour's major policy objectives are failing and failing badly.

The fact that Susan Deacon did not even recognise that there was not spare capacity in the NHS is worrying and Des McNulty pointed that out. One reason why waiting times are increasing is that lack of capacity. Who are we not to use the spare capacity that might be on offer today or tomorrow to prevent patients from having to wait in pain and suffering?

Will Ben Wallace kindly acknowledge that the NHS uses the private sector in Scotland to deal with capacity issues? Those capacity issues exist in the NHS in Scotland, but the scale and concentration of those capacity issues is not on a par with certain other parts of the UK.

I acknowledge the minister's point, but why are waiting times still growing larger in many sectors if there is spare capacity? Why are people not being sent to use the spare capacity in HCI? I rang Liverpool Health Authority this morning. People waiting for cardiological treatment wait less time in Merseyside than any normal NHS patient in Scotland, yet it was still felt best to cut their waiting time by using HCI's capacity. If the Executive cannot explore such options, it is doing a disservice to patients.

Will the member give way?

I must push on.

Much of the root of the problems lies in the differences between our Minister for Health and Community Care and the Secretary of State for Health for England and Wales. His reform and action plan is called "The NHS Plan: A plan for Investment. A plan for Reform". He builds on our reforms, going back to 1979, and at the same time strives to achieve best value for patients in England and Wales. Our action plan, "Our National Health: A plan for action, a plan for change", however, wants to change us back to how we were in the 1970s—pre-Griffiths report—to vandalise the empowerment that general practitioners got through fundholding and to remove any element of private partnership or contracting out.

This is the point at which to turn to Shona Robison's amendment. She obviously did not read the Audit Scotland report of a year or two ago, which clearly identified the fact that the main reason for hospital-acquired infections is lack of controls, lack of strategic plans on infections and lack of personal hygiene. Until recently, the only in-house cleaning contract—in Tayside Health Board—had the worst record in Scotland. That does not show that public is best, nor that private is bad.

Is Ben Wallace really trying to tell me that a fivefold decrease in the number of domestic staff working in hospitals could in some way have helped maintain clean hospitals?

If Shona Robison had read Audit Scotland's study, she would have seen that it was predominantly about control teams. The Executive has rightly introduced infection control and staff to make sure that the problems in that area are put right. It is not about numbers of people. Shona Robison claimed that 500 people are losing their jobs because of the opening of the new Edinburgh royal infirmary. There is something called efficiency—sometimes it works better.

I turn now to the points that were made by Richard Simpson—the pragmatist in an ideological party. He talked about publishing waiting times for health boards and commissioning from one board to another. That sounds a bit like league tables and a form of internal market to me.

I agree with Des McNulty that there were problems with fundholding and that there was fragmentation, but Labour did not have to throw the baby out with the bath water, something that I have heard previously from the Labour benches in relation to the Conservatives. When fundholding was introduced—when 25 per cent of the United Kingdom was covered by fundholding—£65 million was saved by GPs. GPs were allowed to reinvest that money in their practices for treatment on the front line; it was not skimmed off for tax cuts. There were a many very good things about fundholding, and we will not apologise for that.

George Lyon talked about acceptable taxation. We do not want to put in a penny this year, two pennies next year and so on. Where would the Liberal Democrats stop? Drug inflation is running at 10 per cent a year. Do the Liberal Democrats intend to keep raising the rate of income tax by 1p in the pound? To give it its due, the Labour party has matched the Liberal Democrats' spending commitments and doubled them, without raising taxes by the 1p that the Liberal Democrats continually boast about. We do not want an open-ended commitment. We want to tackle the problems of the NHS for the future. We want to give the NHS a future. To do that, we must start a debate on rationing and on ideology—on what is best done by the private sector and what is best done by the public sector.

Dorothy-Grace Elder talked about sending people abroad. We should remember that in the SNP's Scotland, Carlisle and Newcastle are abroad. As for her reference to the "Kama Sutra", on policy the SNP has had more positions than the "Kama Sutra". Funnily enough, I noticed that the SNP spokesman on defence was present in the chamber this morning. He was obviously trying to avoid the debate on NATO that is taking place in Dundee. However, we do not want to talk about that.

The Scottish Conservatives can live with the compliment that many of the hospital building programmes that have been commissioned were started by us. We can live with the compliment that PFI is an acceptable way of funding some projects, although not all projects. However, we will not stand by while patient care is put to one side for ideological reasons. We want to build an NHS for the future. We will be brave enough to discuss the future funding of the NHS. We will be brave enough to discuss rationing and what we can and cannot do. I urge members to support the Conservative motion.