The next item of business is a debate on motion S5M-01677, in the name of Anas Sarwar, on protecting local national health services.
14:40
In my first speech in this Parliament, I spoke about my belief that the Parliament has been at its best when it has found common ground and when members across the chamber have come together to do what is right by their constituents and the country—when, whether on land reform or the smoking ban, parties have united in common cause.
This afternoon, members from all parties once again have the opportunity to put aside their party allegiance and political partisanship for the sake of their constituents. We all have the opportunity to stand shoulder to shoulder with patient groups across Scotland who are fighting to save valued local NHS services. When we speak as individuals, none of us does so as powerfully as the collective voice of this Parliament. That is why I strongly believe that we can and should speak with one voice when it comes to protecting and defending the services that our constituents rely on.
Would the member say that we should never close any hospital or facility? Surely we should put more effort into preventative spend that will help people in the community before they have to go to hospital.
Of course we should put more money into preventative spend, but John Mason’s intervention is interesting. He had an opportunity to intervene to say that he believes that we should protect the hospital that protects his constituents, but instead he chose to make a different point. It is important to stand up and represent the individuals, families and communities who sent us to this place to represent them.
I want to talk briefly about what constitutes a major service change, because it is certainly not clear or consistent. Given that, rightly, the removal of a children’s ward is deemed to be a major service change, how can the closure of a whole hospital be deemed minor?
The Scottish Government’s amendment references the role of the Scottish Health Council in what constitutes a major service change, but its guidance is clear. It states:
“The decision on whether a service change should be regarded as major ultimately rests with Scottish Ministers.”
Furthermore, the Scottish Government’s own guidance states that health boards should
“seek advice from the Scottish Government Health Directorate ... on whether a service change is considered to be major”.
It continues:
“for those that are, Ministerial approval on the Board’s decision will be required.”
That is an important point. In our system, the Cabinet Secretary for Health and Sport is responsible for the health service. The buck stops with Shona Robison, and she is accountable to this Parliament. That is why it is vital that the cabinet secretary calls in the proposals, so that all members of this Parliament, representing their different communities and constituencies, can ensure that all the various voices are heard.
That is what was reflected in the proposed Liberal Democrat amendment, which was not selected. I support its sentiment. It set out the importance of democratic accountability and responsibility in our health service, which the Government seeks to avoid in its amendment. Indeed, I would go further and say that it would be a democratic outrage if we allowed health boards to proceed with these decisions without individual members, this Parliament or indeed the cabinet secretary having a say.
Ministers should be free to say whether they do or do not support the proposed changes. What is particularly frustrating for campaigners is that the cabinet secretary is saying nothing at all. Her position is spectacularly unclear. If the cabinet secretary opposes any of the proposed changes, she should say so and thereby remove the concerns of local families and campaigners.
Is the member saying that for those service change proposals that are major and that will come to me, I should say at the moment whether I support them or not, although I will have to make a decision on them? Is that not a bit silly?
What is silly is the cabinet secretary’s intervention. If the cabinet secretary opposes, as she said she did prior to the election, any of these service changes, she should be brave enough to say so. Conversely, if the cabinet secretary supports any of the proposed changes, she should be brave enough to come to the chamber and openly say so and to make the case for why the changes will not impact on patient care. There are members of the campaign groups in the public gallery, watching this debate. Perhaps the cabinet secretary should reflect on that when she makes any further interventions.
I do not believe that voters would ever forgive any minister or, indeed, any member who sidestepped their responsibility to step in and show their support for their local services. [Interruption.]
It seems that the cabinet secretary wants to intervene again. I will happily take another intervention in which she can say that she will protect local services and which ones she will keep.
I will make the difficult decisions on proposals for major service changes that come to me, but what I will not do is prejudge them. I have not seen the clinical evidence on proposals that might come to me. When they come to me, I will make the decision. That is the process that we have. It is long established in this place and is one that I will follow.
I thank the cabinet secretary for that intervention because it is actually very helpful. She is saying that she might support proposals to close services and that the promises that were made before the election were not true. She has the ability to designate the proposed changes as major service changes and call them in, because ultimate responsibility lies with the cabinet secretary. However, instead of doing that, she is hiding behind faceless health boards. She should use the powers that she has and not duck and dive, and hide and say “It wisnae me.”
All of us, whatever our party allegiances, owe our place in this chamber to the public. Every one of us was elected as their voice to speak up and stand up for them. That is why we are urging support for Labour’s motion to ensure that all the proposals from the respective health boards are deemed major service changes and are called in by the cabinet secretary for decision. We seek the support of Parliament to ensure that the Cabinet Secretary for Health and Sport has the final decision on what are clearly major service changes and to ensure today that our constituents have their voice heard in the Parliament.
We now have it in black and white from the health boards that the proposed downgrades or closures involve maternity services at the Vale of Leven hospital; the children’s ward at the Royal Alexandra hospital; maternity services at Inverclyde hospital; orthopaedics at Monklands hospital, in Airdrie; the Lightburn hospital, in the east end of Glasgow; in-patient beds at the centre for integrative care at Gartnavel hospital; and the centralisation of cleft palate services away from Edinburgh.
I am sure that other members will want to cover each proposal in more detail. However, before moving on, I welcome to the public gallery representatives of several of the local campaign groups, including Gerry McCann of the save Lightburn hospital campaign; Catherine Hughes of the centre for integrative care campaign; Evonne McLatchie of the cleft services campaign; Susan Archibald of the Vale of Leven save our services campaign; and Carole-Anne Davidson from the kids need our ward—KNOW—campaign for the Royal Alexandra hospital.
Those people are not interested in day-to-day political squabbles or partisan politics. [Interruption.] I am sorry that the cabinet secretary is tutting at that comment about people who are her constituents. She should show some respect for her own constituents. I know that she does not respect the chamber, but she should at least show respect for the constituents whom she seeks to represent, because they do not want us to squabble in the Parliament; they want their politicians to work together to protect their local services.
I will turn briefly to each service. Lightburn hospital is a specialist unit that provides rehabilitative care for older patients. It includes specialist units for stroke and post-trauma patients plus a day hospital and out-patient clinics. For some reason, the plan to close it is not significant enough to merit being a major change—[Interruption.] If the cabinet secretary wants to say that it does, that will be good.
Anas Sarwar has just made a factually incorrect statement. No decision has been made yet on whether what will happen at Lightburn will constitute major service change. He is factually incorrect, and he should be accurate in the things that he says in the chamber.
I am happy to pass to the cabinet secretary the board paper, if she has not read it, that makes it clear that the board regards the change as a minor service change. If she disagrees with the health board, perhaps she should tell it and call in the proposal. She can do that today.
The centre for integrative care, which is currently an in-patient service that delivers holistic care to patients, was said to be a national resource by the Minister for Mental Health, Maureen Watt, and the former Cabinet Secretary for Health and Wellbeing, Alex Neil. I had the pleasure of visiting the centre last Friday, and I heard at first hand from clinicians, nurses and patients about the difference that the in-patient service makes to them and the impacts if it closed. Again, that is not deemed to be a major service change.
At Monklands hospital, the plans are to remove not just trauma orthopaedics, but all in-patient orthopaedics. A little under two weeks ago, I attended a public meeting in Coatbridge at which not a single Scottish National Party or health board representative turned up. If they had done so, they would have felt the unanimous strength of feeling in support of their local services.
Let us be clear about what the changes would mean to Monklands. They are major service changes. In the words of Lanarkshire NHS Board:
“This will be a major change in the configuration of several key acute specialties (including critical care, general surgery, orthopaedics and rehabilitation).”
Will the member give way?
I am happy to give way to the cabinet secretary. I hope that he will use the opportunity to say that he will support the motion.
I am not the cabinet secretary. The member needs to get his facts right. I am the ex-cabinet secretary.
On Monklands, the member said earlier that everybody should speak with one voice, but the Labour Party does not speak with one voice. The Labour leader of North Lanarkshire Council has publicly given unqualified and total support to the health board’s proposals. How is it that he is in favour of them, but the Labour Party is supposed to be speaking with one voice? People cannot speak with one voice inside the Labour Party, never mind everybody else.
The SNP is not speaking with one voice. It tells communities that their hospitals are safe and says in the chamber that it has not made a decision yet. That is not speaking with one voice; it is speaking with a forked tongue.
We and the motion are very clear. We expect a major service change at Monklands hospital, and we want that proposal to be called in and rejected. Again, the final decision will lie with the cabinet secretary.
On Inverclyde hospital, the Presiding Officer has seen before the front page of the Greenock Telegraph. Shortly before the election, no less a person than the First Minister guaranteed that the maternity services at Inverclyde hospital were safe. The cabinet secretary might want to say again that the decision on that has not been made yet, but the First Minister’s comments are pretty clear. Again, that was a proposal for closure that was not regarded as a major change.
The Royal Alexandra hospital has already been mentioned, and there can hardly be a more important issue than the future of children’s services at the RAH, which treats 8,000 children every year. Given that those changes are already recognised as major changes, nothing stands in the way of members joining colleagues and supporting our motion. That again demonstrates the Government’s inconsistency of approach when it comes to NHS cuts.
I am sure that at least one constituency MSP, irrespective of party allegiance, will put aside party loyalty, stand on the side of their constituents and be a true champion of their local NHS. I hope that others will follow Jackie Baillie’s example. Today, she will put her constituents first and vote to protect maternity services at the Vale of Leven hospital. Again, despite previous promises, that change has not been designated as a major service change.
In conclusion, I reach out across the chamber to other constituency MSPs who are affected by the proposals. We have an opportunity to put aside our party allegiances and work together to protect our local NHS services. I reach out to Ivan McKee—I am not sure whether he is even in the chamber—
Members: He is.
I am sorry; I did not see him. I reach out to Ivan McKee, who has made commitments to fight to save Lightburn hospital. If he is sincere in that commitment, I hope that he votes with us today.
I hold out the hand of friendship to Stuart McMillan and ask him to work with us to protect maternity services at Inverclyde Royal hospital. I say to George Adam and Tom Arthur: do not vote for an amendment that takes out all mention of the RAH. Instead, join with us today to save RAH paediatric services.
I appeal to Bill Kidd. I know that he is a whip—the chief whip, no less—but his first responsibility is surely to his constituents, so I urge him to support his constituents by supporting our motion to save the CIC in-patient services in his constituency.
I know that in Alex Neil’s heart, he would like to support the motion. He is a rebel at heart, and I ask him to let that inner rebel come out today and work with us to save orthopaedic services at Monklands hospital.
Our motion is clear; Labour is clear: we want the services to be designated as major service changes, called in by the cabinet secretary and rejected. Many MSPs in this chamber stood on the banner “Standing up for Scotland”. Today they have an opportunity. Will they stand up for their communities and for our NHS?
I move,
That the Parliament notes the widespread public concern over proposals to downgrade valued local services, including maternity services at the Vale of Leven Hospital, paediatric services at the Royal Alexandra Hospital, maternity services at Inverclyde Hospital, trauma orthopaedics at Monklands Hospital, inpatient services at the Centre for Integrative Care, cleft palate services at the Royal Hospital for Sick Children and the closure of the Lightburn Hospital; believes that all these proposals constitute major changes in service provision, and therefore calls on the Scottish Government to call in these proposals, as set out by NHS Greater Glasgow and Clyde, NHS Lanarkshire and NHS Lothian, for ministerial decision.
14:56
The debate provides a timely opportunity to acknowledge the commitment and dedication of health and social care staff across the whole of Scotland; to reflect on our record of protecting and enhancing local services; and to comment on the actions being taken to ensure that Scotland’s NHS continues to be world class. I welcome local people to the gallery.
Turning to the Labour motion, I think that it would be helpful to state the facts as initially set out in response to Jackie Baillie’s members’ business debate on the same issues on 13 September. First, no final decisions have been made about the service change proposals mentioned. NHS Greater Glasgow and Clyde formalised its proposals at its board meeting in August and, as we would expect, is now in the process of engaging with the affected local communities, staff and other stakeholders in order to carefully consider their views.
I encourage local people and their representatives to play a full part in the process. The proposals may well change in the light of the results of that process, which will take the form of three months of public engagement, running from September until November, on the proposals relating to the CIC, community maternity units and Lightburn hospital. It will help to inform the health board’s on-going work with the independent Scottish Health Council, which includes coming to a view on which of the service changes should be considered major. The board will reconvene following that work, probably at its meeting planned for December, and will then agree the next steps.
Will the cabinet secretary give way?
In a minute; I know that Anas Sarwar is keen.
Should any of the final proposals be designated as major, the board must undertake formal public consultation of at least three months, and its final service change proposals will be subject to ministerial approval.
The cabinet secretary is right. I am keen.
I beg your pardon, Mr Sarwar—just a minute.
I am keen to protect NHS services. The independent SHC’s guidance clearly states that ultimate responsibility lies with ministers. If the cabinet secretary can instruct it that the proposals are major service changes and call them in, why will she not do so?
The process is established and robust, and is informed by the work of the SHC. When I come to make the decisions, I want to know what the SHC thinks. When the board comes to make its decisions, it wants to know what the SHC thinks.
The SHC was set up by statute in 2005 in this Parliament to provide independent oversight in the key area of patient focus and public engagement. The Labour motion quite inappropriately asks Parliament to cut across the vital work of the SHC, which should be allowed to get on with its job and with fulfilling the duties that this Parliament ascribed to it. What is the point of having the SHC if we do not allow it to get on with its work?
Thank you very much for taking an intervention, cabinet secretary.
NHS Greater Glasgow and Clyde, in its consultation proposals for the IRH birthing unit, thus far has not suggested a public meeting. I have asked for a public meeting in Inverclyde so that the birthing unit issues can be fully addressed. Does the cabinet secretary agree that we should do that?
I look forward to having as much public engagement as is possible, including public meetings and other ways of engaging. I think that that is important.
I return to the service change proposals. In the case of the plans to transfer paediatric in-patient and day cases from the Royal Alexandra hospital in Paisley to the new Royal hospital for children, NHS Greater Glasgow and Clyde will discuss the next steps at its meeting in October. The board has already been clear that, should it move to proceed with those paediatric proposals, that would represent major service change and therefore it would come to me for decision.
With regard to the trauma orthopaedic services at Monklands hospital, NHS Lanarkshire—supported by the Academy of Medical Royal Colleges and Faculties in Scotland—has been clear that the interim changes are necessary to ensure the safety, quality and resilience of local services. I have been assured that the interim plans will not materially impact on the provision of accident and emergency services at any of the three main hospitals in Lanarkshire. The health board has repeatedly given assurances that it is committed to retaining three district general hospitals with full A and E departments as part of its longer-term plans. Those longer-term plans will constitute major change and, as such, are now subject to formal public consultation; they will come to me for decision. I encourage all local stakeholders to play a full part in the consultation in order to help shape the future of those local services.
Will the cabinet secretary take an intervention?
Briefly.
Having just said what she did about public consultation, will the cabinet secretary comment on the fact that trauma orthopaedics is being removed? I consider that a major service change, with the decision having been taken during the recess with no public consultation.
I have just explained that that is an interim solution based on patient safety, but the longer-term plans are a major service change that has to come to me. It is very clear and straightforward.
If any politician would stand by in the face of being told that a service is not safe, we would all have to take responsibility for a decision to ignore clinical advice. It is very clear that the interim proposals are based on patient safety advice, and we have to listen very seriously to that.
The Labour motion refers to cleft palate services at the Royal hospital for sick children in Edinburgh. Ministers are fully aware of the strength of feeling from those who oppose the recommendation to consolidate cleft surgery in Glasgow. There are very strong views on both sides.
Will the cabinet secretary take an intervention?
Not just now.
I want to be clear that the Government has been given an assurance that the proposed changes relate only to cleft surgery. Nonetheless, they remain proposals and no decision has been made. As the Minister for Public Health and Sport made clear in the members’ business debate on that subject on 7 September—
Will the cabinet secretary take an intervention?
Not just now.
Mr Johnson, please take your seat.
Ministers will have the final say, and our decision will be informed by planned visits that I am undertaking to both Edinburgh and Glasgow to visit the cleft surgery teams and hear their views first hand.
Has the cabinet secretary seen the same figures that I have seen? They would indicate that the surgical outcomes in the Edinburgh unit are better than those that are achieved in the Glasgow unit.
I will take into account all the information; that is why I am making the visits. I will take into account all the information that is presented to me before I make a decision. That is the right way to make decisions that are important to a lot of people. That is the right way to make decisions.
The possibility that some or all of those service change proposals may change as a result of the public engagement that is under way, and that some—or indeed all—of them may ultimately be subject to ministerial approval, means that it would be inappropriate for me to discuss the specifics in any detail today and to say whether or not I support them. If I am making the final decision on them, of course I will wait for the information and the evidence to be brought to me.
I want to be clear that this Government remains committed to robust, evidence-based policy making, as set out in our national clinical strategy. [Interruption.]
Mr Sarwar, I am not keen on props.
The member should raise his game and respect the people in the public gallery, as he said earlier.
Mr Sarwar, I have already indicated.
Underpinning that is our long-term commitment to secure local services and develop specialised services when necessary. I am prepared to take difficult decisions where the evidence supports it. However, where change is advocated, we must ensure that the local boards work with all stakeholders to make the case. We will not countenance change being dictated to local communities, as happened in the past under Mr Sarwar’s Administration.
I reiterate that local people can be assured that this Government will always focus its approach on providing as many services as locally as possible. Our record in government stands in stark contrast to that of the previous Administration. That can be seen in Nicola Sturgeon coming to Parliament to save the A and E departments at Monklands and Ayr hospitals, or in our protecting the damaging uncertainty of the previous Labour-led Administration that Jackie Baillie served in when the Vale of Leven hospital was under serious threat of closure.
Will the member give way?
The cabinet secretary is in her last minute. Please sit down, Ms Baillie.
The vision for the Vale has saved that local hospital. We will make sure that those services that would have been lost under the previous proposals are improved. Of course, the local hospital has seen a big improvement and increase in the number of patients using its facilities.
I note that Opposition parties constantly call for increased investment in primary and community care and say that they support shifting the balance of care—the Tories said that only last week. At the same time, they come and seek to oppose each and every proposed change—even where changes are not proposed—in acute services.
Collectively, we will have to come to some decisions about whether politicians in this Parliament will argue against any change, anywhere, ever happening in our NHS now or in the future. If that were to be the case, the shift in the balance of care and the increased investment in primary care—as called for by the Tories only last week—will be made all the more difficult to achieve.
I reiterate this Government’s commitment to the delivery of high-quality, sustainable health and social care services. Where there are proposals for major service change in the NHS, they must be subject to formal public consultation and, ultimately, ministerial approval. I do not shirk my responsibility in doing that whatsoever. Local people can be assured that, in all such cases, ministers take into account all the available information and representations before coming to a final decision. That is a proper and responsible way to run our health service.
I move amendment S5M-01677.1, to leave out from “the widespread public concern” to end and insert:
“that no decisions have been made in respect of current service change proposals from NHS boards; welcomes the Scottish Government’s record of protecting local services, including saving the A and E departments in Monklands and Ayr, ending a decade of damaging uncertainty in 2009 by approving the Vision for the Vale of Leven Hospital, and securing inpatient paediatric services at St John’s Hospital in line with the independent report from the Royal College of Paediatrics and Child Health; recognises that there is an established process around service change in the NHS, and that the decision about whether a particular service change is deemed major is one that is taken in consultation with the independent Scottish Health Council, which was established in statute in 2005 to support and advise NHS boards and to quality-assure the public involvement process; endorses the National Clinical Strategy, which was published in February 2016, with its aim to provide more care where people need it and with as much care as possible delivered locally, and remains committed to maintaining and improving safe and effective local services across Scotland.”
15:07
I am delighted to be here discussing health again on a Wednesday afternoon, and hope that it becomes a regular occurrence. I do not say that flippantly. Following my party’s debate on health in the chamber last week, it is right that we subject this Government’s record on health to frequent and effective scrutiny; it is right that the NHS is a running theme.
We will support the Labour motion. I accept that, technically, it is somewhat premature because, as it stands, the proposals have not reached the point at which the Government requires to take a decision about whether the proposals would be major service changes. However, clearly there is a wider public interest at stake here that transcends that point on process, so we are happy to lend our support to the motion and call for the procedure to be expedited and for the specific proposals to be called in now.
The wider public interest is manifested in the widespread concern over the various proposed service changes.
Will the member give way?
Not yet.
That concern is obvious in the levels of support that public campaigns against the closures have reached. To name but a couple, nearly 2,000 people have signed a petition against the proposed changes to Vale of Leven and more than 6,000 have done the same against the proposed closure of Edinburgh’s cleft palate unit.
It is our fundamental belief that, given the public concern and the controversy surrounding the proposals, they should all be classified as major service changes, so that the SNP Government takes responsibility for the decisions and can be held to account.
I hope that we would all agree that blanket opposition to any change in the NHS would be impossible and, indeed, irresponsible. The NHS can never be static. The British Medical Association warns today that the NHS is
“not sustainable in its current form and action needs to be taken now.”
Will the member give way?
No, hold on.
We accept that tough decisions have to be taken, even when they are not popular; a strong, responsible Opposition recognises that. What is difficult to fathom is the approach of a Government that is content merely to do nothing.
The Government continually reinforces the point that the NHS needs to be more community orientated. We hear that, among its priorities for the coming year, is
“to empower a truly community health service”
and to
“deliver the reforms needed for successful community health services.”—[Official Report, 21 September 2016; c 31,32.]
With those aims in mind, it is understandable why so many people will be puzzled that the Scottish Government’s idea of delivering more community health services is to sit on its hands in the midst of controversial proposals that, if they are enacted, will see communities lose services, not gain them.
Just as we did in the debate last week, we urge the Government to take responsibility or, at the very least, to take a view. It is only right that, in all cases in which important services are at risk of closure, the SNP Government should step forward and make its position clear.
Having dealt with correspondence on some of the issues, I know that people—many of whom are here today—want to know simply where the Government stands. The proposals are so controversial and serious that it is not good enough for the Government to float indifferently above the fray. Let me give one example. We have asked countless questions about the centre for integrative care and its future in general. Where does the Government stand? What consideration has been given to central funding? What discussions have been had? What is the Government’s position? The only answer that has been forthcoming is that those are matters for the health board—the Government has again washed its hands.
I argue that the proposals could be classified as major service changes, using the Scottish Health Council’s own guidelines. We know from those guidelines what major service change is and that the decision ultimately rests with ministers. Not only that, but there is ample evidence on the ground to support that classification. For example, as I said during the debate about the Vale of Leven maternity unit, closure of that service would force women in labour to travel an extra hour from Dunbartonshire and Argyll and Bute to facilities in Glasgow and Paisley. That could constitute a change in the accessibility of services and thus qualify as a major service change.
Plans to close the Lightburn hospital would mean that elderly patients and stroke patients would have to travel to the Queen Elizabeth university hospital, putting pressure on that hospital; that could constitute “Consequences for other services” and thus qualify as a major service change.
There is a historical precedent for ministerial intervention in the proposals for the Vale of Leven and Lightburn hospitals. Both were the subject of proposed changes in 2008 and 2010, respectively, which were similar to the changes that are proposed now. Those proposals were deemed to be major service changes then, so why are they not now? I could go on. The facts support the proposals being major service changes.
In any event, the Government can intervene further down the track—again, there is historical precedent, which the Government’s amendment mentions. The SNP Government was more than happy to intervene 10 years ago when there was a proposal to close the Ayr and Monklands accident and emergency units. As soon as the SNP took office in 2007, the current First Minister, as health secretary, immediately stepped in, overturned the decision and set up an independent review of the processes that had been carried out by the health boards. If the Government could intervene then, it can intervene in the future.
Does the member recall that those proposals, which I did not agree with and spoke out against, were based on what the health board said were safety reasons?
I cannot recall that, as I was not a member of the Parliament at the time. The point that I am making is that Nicola Sturgeon intervened in that decision and did so again in 2010 in the face of the health board’s recommendation to close Lightburn hospital. She said:
“The government has a policy of maintaining local access to healthcare services where it is appropriate to do so, and where it is in patients’ best interests. It is my view ... that local people’s interests are best served by maintaining Lightburn Hospital and its healthcare services.”—[Written Answers, 19 December 2011; S4W-04640.]
If the Government could intervene then to save local services, it can intervene in the future.
Last week, we highlighted the major staffing crisis that exists in our NHS and social care services. We told the Scottish Government that there are still major gaps in general practice, nursing and midwifery. We revealed the spiralling locum costs in our NHS and spoke out for Scotland’s social care sector. We also suggested solutions such as investing 10 per cent of NHS spending in general practice by 2020.
Will the member give way?
I am in my last minute.
Yes, thank you, Mr Cameron. You are in your last minute.
There is a clear link to be drawn between this debate and last week’s debate. One of the reasons that was given by NHS Greater Glasgow and Clyde for removing the facilities is the lack of staffing, and we know that in other hospitals throughout Scotland the shortage of staff directly affects the provision of services. I repeat the example that I gave in my maiden speech of my local hospital in the Highlands, where there have been no scanning facilities for pregnant mothers since 2013 because there has been no ultrasonographer. Short staffing has huge implications for local services, and I have no hesitation in laying the responsibility for that at the door of the SNP Government, as I did last week.
It is clear to me that the Scottish Government must be held to account for the proposals. We believe that they represent major changes in service provision and should be called in for review, with their final approval resting with the cabinet secretary. For that reason, we will support the motion.
We move to the open debate. I will not embarrass the members concerned, but three of you have not pressed your request-to-speak buttons. You cannot be called if your button has not been pressed.
15:15
I declare an interest in that I am a pharmacist, registered with the General Pharmaceutical Council, and until my election in May I was employed by NHS Highland.
In its briefing for today’s debate, the Royal College of Nursing Scotland said that, to ensure the longer-term sustainability of services and meet the needs of an ageing population in the future, health boards need to do things differently. RCN Scotland has been saying over the past year that urgent transformational change is needed. Its briefing went on to say:
“To achieve this vision, politicians, professionals and the public must be prepared for transformational change and all stakeholders involved with the changes will need to put vested interests to one side and work together to deliver the changes which are so urgently needed.”
I hope that we can achieve that in this debate.
As I understand it, no decisions have been made about the service change proposals that are mentioned in Anas Sarwar’s motion. Rather than address proposals that are still at an early consultation stage, I will take the opportunity to look more generally at why we need to transform hospital care.
The Scottish Government is committed to evidence-based policy making, as set out in the national clinical strategy. There is an overwhelming amount of evidence that complex operations are best performed in more specialist settings. There is increasing evidence that teams that specialise in doing complex operations frequently get better outcomes for patients, who tend to have fewer side effects and spend less time in hospital.
We understand that we need to adapt to meet future demand. In doing so, we can make the best use of the skilled staff and technology that we have. We have much more complete evidence about the connection between volumes and outcomes—we know that the more often a team does a procedure, the better are the results that it gets. That evidence is pushing a need to plan for some procedures on a population level rather than at a health board level.
Some procedures are becoming exceedingly high-tech, such as robotic surgery, and need to be concentrated in relatively few sites to make the best use of skilled staff and specialist equipment.
By using telemedicine for virtual consultations, as we often do in the Highlands and Islands, we can reduce the burden of travel and ensure that high-quality care is given in remote and rural locations. A couple of weeks ago, I spoke to a surgeon at Raigmore hospital who regularly holds out-patient consultations by telephone, which saves his patients several days of travel in from the islands.
There are always pressures to stick with the status quo, but it is wise for us at least to consider whether the current service configuration offers the best possible service provision.
Is the member aware that much of what she is saying in her well-delivered speech was in the Kerr report of 2005, which was a precursor to health boards making the wrong decisions to downgrade A and E services at Monklands and Ayr hospitals?
Wisdom’s being long held does not make it any less relevant.
There are plenty of examples from history. Years ago, general practitioners performed emergency surgery in small community hospitals. No one would advocate such an approach now.
In the summer, members of the Health and Sport Committee visited the Golden Jubilee national hospital—I did not personally visit. The Golden Jubilee foundation is an example of a new model of service provision that has been extremely successful. The hospital has expanded year on year to meet the health demands of Scotland’s population. It is responsible for delivering more than 25 per cent of Scottish hip and knee replacements and up to 18 per cent of cataract operations for the whole country. That is in addition to the thousands of patients with acute and long-term conditions who are treated through the heart and lung unit, which is one of the largest in the United Kingdom. The Golden Jubilee is the only hospital in Scotland to carry out heart transplants.
Innovation and participation in active research are core to the hospital’s success. Some of the programmes that have been developed there, such as the enhanced recovery service in orthopaedics, have been adopted all over Scotland and across much of Europe.
The hospital’s outcomes are excellent. It has some of the lowest complications rates in the country and boasts the UK’s fastest door-to-balloon time for patients who require primary percutaneous coronary intervention.
As someone who represents a rural constituency from which people often have to travel long distances for hospital care, I appreciate the provision of a hotel on site. That may seem trivial but, if people have to travel for healthcare, as we in the Highlands often do, making it easy for our nearest and dearest to travel too is helpful.
I will reiterate why so many health professionals and policy makers are prompting us to consider a change in acute hospital services. Such a change has the potential to significantly improve outcomes—that is the main driver. The new technology that we use nowadays in modern medicine dictates the need to have centres of excellence for more complex interventions. We have said many times that, as our population ages, there will be increasing volumes of elective procedures for cataracts and joint replacements, and there are pressures in recruiting highly skilled staff.
If we can find a way to deliver hospital care more efficiently, we can focus our attention on locally delivered primary and community health services to better meet the needs of our ageing population, who will have multiple long-term conditions, and to tackle health inequality. That is why the Royal College of Nursing says that Scotland must look at different ways of delivering services.
Let us hear what the health boards have to say about service redesign, let us consult and listen to both the staff and the local population and let us follow due process.
I call Jackie Baillie, who has a tight six minutes.
15:21
No one in the chamber can be in any doubt about the importance of the Vale of Leven hospital to me and all my constituents. It will therefore come as no surprise that I will focus on the Vale of Leven community maternity unit.
Maternity services are the beating heart of any hospital. Nothing quite surpasses the cry of a newborn baby and the joy of a new life and a new family. The majority of women give birth without a great deal of intervention, other than perhaps pain relief. Of course specialist services are needed but, as ever, the issue is where the balance is struck.
I say to the cabinet secretary that I will take on any Government of any political hue that threatens the Vale of Leven hospital—she knows that. She also knows that I supported the Scottish Government when it brought forward the “Vision for the Vale of Leven Hospital”, which contained commitments to deliver a wide range of services at the local hospital. The cabinet secretary knows that, despite the vision being in place, staff numbers have dropped dramatically and a substantial number of clinics have been cancelled. Nevertheless, the vision remains an important commitment for people in my community and I support it.
The community midwifery unit was so important for the Vale vision that it was pictured on the document’s front page. The exact wording of the commitment was:
“The Community Maternity Unit will be sustained and promoted”.
That is the very same maternity unit as is up for closure today.
The health board says that the unit is up for closure because the numbers have dropped, and indeed they have. However, I ask members to please look a little closer. Between 2009 and now, the overall number of women from my area giving birth has dropped by 8 per cent, but the number giving birth at the maternity unit has fallen by nearly 70 per cent, which is a shocking difference. That tells me that the health board has not been serious about marketing the CMU.
When I consulted GP practices, I found out that some did not even know about posters or leaflets. Key to the problem is the fact that bookings had been taken out of GPs’ hands and centralised in a telephone line by the health board. Since that happened, numbers have declined. The health board is closing the unit by stealth. The problem has been entirely manufactured by the health board in order to close the unit, and the cabinet secretary must not be fooled by that.
The health board has not committed to a full and formal public consultation with my community. Instead, we are to have an engagement strategy that is based on a consultation that was undertaken a decade ago. The health board cannot be serious. We need a full community consultation so that everybody has an opportunity to make their voice heard.
In advance of the election, the cabinet secretary popped through every door in my constituency on a leaflet that said:
“I will not approve any move away from the Vision for the Vale commitment”.
I say three cheers to that. I want to believe her, and my community wants to believe her; indeed, we all want to believe that she will keep her promises.
The proposed cut, like the other cuts that have been described today—to the maternity unit at Inverclyde, to Lightburn hospital, to the centre for integrative care and to the Royal Alexandra hospital—is so important that it must be designated as a major service change.
Will the member give way?
Let me explain why that designation is so important, and then I will be happy to bring in the cabinet secretary.
If the changes are designated as major service changes, they will end up on the cabinet secretary’s desk. That is important to me and my community because it would mean that the health board did not have the final say. It is important for accountability and democracy. I want the health board to be accountable to the cabinet secretary and in turn for her to be accountable to the Parliament. I hope that she agrees that that is a fundamental matter of democracy.
As I said earlier, that might well end up being the case, because no decision has been made about whether the proposal constitutes a major change. However, will Jackie Baillie acknowledge that I have asked the chief medical officer to undertake work on why there is such a low midwife-led birthing rate across NHS Greater Glasgow and Clyde?
I will. I invite the chief medical officer to look at what has happened as a result of centralising the booking service, because that is key to the issue. I welcome the cabinet secretary’s intervention on that point.
I know that cabinet secretaries have in the past operated on the basis that, if something did not cross their desk and they did not need to see it, they could turn round and blame the health board because somebody else had made the decision. I am afraid that that is no longer good enough. The decision on whether a service change should be regarded as major is ultimately a matter for the Scottish ministers. Of course, there should be discussions with the Scottish health council and the health board but, please, cabinet secretary, do not hide behind them.
The cabinet secretary has had discussions with NHS Greater Glasgow and Clyde and agreed with its arrangements for consultation. A health board paper says:
“In our view the changes to the CMUs do not meet the criteria for major service change.”
Does the cabinet secretary agree with that statement? I am happy to take a yes/no intervention on that point.
You cannot, because you have only 30 seconds left.
That genuinely is a shame, but I hope that the cabinet secretary will pick up on that in her closing speech.
I beg your pardon, Ms Baillie. If the cabinet secretary wants to intervene, I will give time.
I am happy to intervene. I will be guided by what the Scottish health council and the health board say but, ultimately, I will decide whether the matter is to be subject to ministerial decision.
I thank the cabinet secretary for that response. I hope that she will decide that a major service change is involved. I say as gently as I can that it would be simply unacceptable if the matter was left to the health board because, as night follows day, that will be the death knell for the Vale of Leven’s maternity unit, and she knows that. Cabinet secretary—
I am sorry, but you must conclude.
I call Fulton MacGregor, to be followed by Brian Whittle, who I see is not in his place, but I have no doubt that he will sprint here in time or that somebody will tell him to be here.
15:28
I take the opportunity to declare that I have been appointed as the parliamentary liaison officer for the Cabinet Secretary for Health and Sport.
I am sure that I am not the only one who finds it ironic that, almost 10 years to the day since Labour voted to close the Monklands hospital accident and emergency department and downgrade the hospital to a grade 2 hospital, it has now lodged a motion that claims that the Government is downgrading services there. As has been said, it was the SNP Government that reversed that appalling decision by Labour—a reversal that has saved countless lives in my constituency and beyond.
Every SNP health secretary—Nicola Sturgeon, Alex Neil and Shona Robison—has unequivocally guaranteed that Monklands hospital will retain A and E services and that its grade 1 status is safe. The guarantee was again given in the chamber only a few weeks ago when I asked the health secretary whether the Monklands accident and emergency unit was safe from closure and she of course confirmed that.
The Labour Party seems to have decided that the Monklands should be used as a political tool in its almost desperate attempts to keep control of North Lanarkshire Council next year. As my colleague Alex Neil pointed out, that is the view only of Labour Party members here at Holyrood, because the Labour leader of North Lanarkshire Council, Jim Logue, has given the plans his full backing. I am sure that he would have appreciated some discussion of that.
Why is the Monklands mentioned in the motion and why are we talking about the services there? NHS Lanarkshire recently proposed to move orthopaedic and trauma services temporarily from Monklands while a consultation takes place on the permanent future of those services. As we have heard, there may be an argument in hindsight that it would have been better for NHS Lanarkshire to have consulted on the move. However, the simple fact remains that the services are being moved because Healthcare Improvement Scotland and the General Medical Council, among many others, have identified significant risks and demanded that changes be made to improve patient safety.
Will the member take an intervention?
Not just now, Mr Leonard.
Those changes are being made temporarily with concern for patients’ lives and wellbeing as the priority. I welcome the long-term plan to have all specialist orthopaedic services in one centre of excellence in Lanarkshire. I fully support amendment S5M-01510.1, lodged by Alex Neil, which calls for Monklands to be that centre. I will fight for that.
It is important to note that, while there is to be a temporary transfer of orthopaedic services to Hairmyres, the patients who require that service will, from a service delivery point of view, still attend Monklands in the first instance. The reality for the people of Coatbridge and surrounding areas is that, despite the temporary changes, if Monklands is their A and E hospital, that is where they will go.
Only 2 per cent of all those who attend the Monklands accident and emergency unit will need to visit another hospital under the temporary arrangements. The vast majority of orthopaedic patients will still have their initial treatment and follow-up care managed locally. What the people to whom I have spoken really care about is how they will be affected, so I will make it crystal clear. If they live in Coatbridge or Airdrie and they need to go to A and E, it is Monklands A and E that they will go to.
The changes are welcomed by a number of professionals, including Dr Iain Wallace, who is the medical director at NHS Lanarkshire. He highlights that, following a number of independent reviews, a temporary transfer—
Will the member take an intervention?
I am struggling for time as it is.
What about a short intervention?
Please sit down, Mr Leonard.
Dr Iain Wallace highlights that a temporary transfer of 2 per cent of the most complex trauma cases is the only viable option to ensure that services remain safe and sustainable in the interim period.
Dr Jane Burns, who is the medical director for NHS Lanarkshire’s acute division, has acknowledged that trauma and orthopaedic services in Lanarkshire have been under pressure for some time and that changes need to be made to services now. There has been an on-going risk to patient safety, which the NHS board is keen to address before the coming winter period.
If we look to the future, the news of a £400 million investment in a new hospital in the Monklands area by 2023 is welcome. The investment will mean that we can provide strong and appropriate local health services that meet the high standard that is required to treat the area’s changing demographic. The new hospital will ensure that the people who are served by Monklands hospital receive the high standard of care that they not only expect but deserve. That is investment in local services.
Furthermore, in the past five years, £65 million has been invested in Monklands, including funding for the new critical care unit, the new pathology unit, the Lanarkshire Beatson centre and a refurbishment of the mental health unit and operating theatres. There has also been £1.5 million of investment in the provision of a consultant-led rapid assessment and treatment area in the emergency department and in extending the same-day surgery unit. That is investment in local services for local people.
The SNP is committed to making Monklands hospital the best that it can be. We think big for our local area and services and are not content to score cheap political points. The two towns that are mainly affected by the Monklands issue now have four SNP representatives in Westminster and Holyrood. There is a reason why the people of Monklands now back the SNP: they know that their hospital is safe with us.
By the end of the current session of Parliament, the people of Coatbridge and beyond will be able to see for themselves that the construction of a new hospital is under way, which will fulfil my aim and the aim of the SNP for my constituency to be the best that it can be and to realise its full potential.
I will always fight for the Monklands. Over the past few months, I have been working with my colleagues in the area to ensure that we get a hospital that is capable of delivering the best services for the people it serves. I have engaged with the NHS board and with other elected representatives, including Elaine Smith—
You must conclude.
I have secured an additional NHS-led public meeting on 10 October specifically on this matter. I urge everyone with an interest to come together, get involved in the consultation and attend the meeting.
Now—
Can I just finish—
No—you are stopping. I am sorry—I might have missed it, but did you declare at the beginning of your speech that you are a parliamentary liaison officer, as it was your first opportunity to do so?
Yes.
You did—my apologies to members in the chamber.
15:34
I am pleased to speak in the debate and I thank Labour for putting health on the agenda again after the Scottish Conservatives’ health debate last week, because the pressures on our NHS and its staff are many and ever present: the pressure to continue to deliver a world-class service while being squeezed from both sides with ever more complex procedures and treatments, within ever more closely scrutinised budgets; the pressure of an increasingly unhealthy nation, which is an issue that we cannot and should not shy away from; the pressure of staff shortages and continuing recruitment issues; and the pressure of an ageing population—I am rather pleased that I may get a few more years in my dotage to annoy the children.
We should discuss the motion on the protection of local services in the context of an overall health strategy and the services that are provided at local, area and national levels. As the service that the NHS provides continues to develop, it is important that the long-term strategy at least keeps pace.
There is no doubt an advantage in having centres of excellence for once-in-a-lifetime procedures such as transplants or hip and knee replacements. It makes sense to fully utilise the best surgeons and healthcare professionals in their fields. However, more acute services, such as A and E, paediatrics, trauma orthopaedics, and some day care services and maternity units, should be much more readily accessible and it is right and proper that local MSPs and we as an Opposition question the Government and its reluctance to take a position on the cases that have been raised today, which involve significant material change in services, and to take responsibility and be held accountable for its actions and decisions, which affect these communities so fundamentally. It is not good enough to hide behind, “It’s not me, guv.”
This speaks to the motion—protecting local services. It does not mean looking at secondary care in isolation. These proposals must be considered in the context of the overall medical services on offer at the local level.
Perhaps it is time to start thinking much more strategically and creatively. Perhaps it is time to introduce budgetary terms of longer than a year to allow proper consideration for the implementation of longer-term strategies. Longer budgetary terms would certainly be conducive to a more cohesive preventable disease strategy. It would also help with staff planning and recruitment. Procurement then becomes a more manageable process.
If we want efficiency, longer-term budgets give more options. We have discussed creating GP community hubs as a good way of allowing GPs to engage and interact with their communities more effectively, with a multidisciplinary offer. Specialists in areas such as mental health, physiotherapy, nutrition, pharmacy and even exercise prescription could all be on site—I very much like the last one I mentioned. However, how about the creation of community hubs around pharmacies as an idea worth exploring? Pharmacies are often better positioned in communities, especially in the more deprived areas.
Even more fundamental, if we are to improve the health of our nation and release some of the burden on our NHS, we should be focusing on pre-school intervention. Intervention at that age is often mooted and understood as crucial, yet little is done. With the proposed 30 hours of free childcare for three and four-year-olds—although the Scottish Conservatives would like that age group to be younger for the most significant interventions—it should be possible, with a bit of will power, to engage with the childcare professionals to deliver a national, structured active play programme that tackles the foundation of health inequality and the attainment gap. After all, some children are already two years behind by the time they reach school age.
I guess that what I am saying in my own convoluted and inimitable fashion is that protecting local NHS services does not necessarily mean preserving them as they are now. Local services are multifaceted and specific changes to those services impact on each service, and any decision must reflect that.
NHS boards must have the autonomy to make their decisions within Government policy guidelines. Having said that, we must be aware that boards risk fixating on implementing cost cuts in the short term and ignoring the potential long-term costs. That is exactly why those specific decisions that will fundamentally change their local NHS service provisions deserve to be examined at ministerial level. The buck stops with the Government, even if the SNP tries to wriggle out of that responsibility.
The success of the NHS does not lie just with the people who work in it directly; everyone in Scotland contributes to the survival of our NHS. We see that today, both with Labour’s motion and with the reasons behind it. When the public hear that their local NHS services are in jeopardy, they rally round and fight to protect them, and that is why the Scottish Conservatives will support the motion.
Again, I repeat, please could members not talk across the chamber. It is a tight six minutes for all speakers and some of the later ones may have their time cut a little—I am sorry.
15:39
We are in very challenging times. The Scottish block grant is 5 per cent lower in real terms than it was five years ago. The Fraser of Allander institute recently predicted that the budget could be cut by up to 6 per cent. That is a staggering £1.5 billion over the next five years. The institute stated:
“The Scottish budget has faced unprecedented cuts since 2010.”
That represents a full decade of significant cuts to the Scottish budget and, if that was not bad enough, due to the impact of inflation any financial commitments that the Government has made, such as the commitment to increase the NHS revenue budget by £500 million in real terms, will be even more expensive. It will be the same story with repayments associated with revenue finance capital investment programmes such as the private finance initiative, which already represent a significant proportion of health spending.
That is the backdrop against which the achievement of the Government must be considered.
Perhaps the member could explain why the SNP Government has not passed on the money in the block grant that is specifically designated for the NHS.
Perhaps the member may wish to concern himself more with the “pockets of meltdown” that are predicted to affect the Conservative-run NHS in England.
We have seen achievements such as an increase in the overall NHS budget to a record high of £13 billion this year, and record numbers of staff across the board, from nurses to GPs, consultants and paramedics. Unlike in England, there are no compulsory redundancies in NHS Scotland. Band 5 nurses are on higher pay, and there is retained bursary support for nursing and midwifery students. I could go on, but I fear that I would run out of time. The NHS is demonstrably safe in our hands, so I urge Labour members to consider that the real reason for cuts to the Scottish budget is Tory austerity, and I ask them to unite with those on the SNP benches against the real cause and to stand up for Scotland’s public services instead of disparaging them.
The motion today concerns proposed changes to services, and in the list of hospitals that Labour has put forward, one affects my constituents. [Interruption.]
Excuse me, Ms Denham. I must point out to certain members that their sedentary interventions are annoying me. If they want to make an intervention, they should get on their feet.
I am talking about the proposal to change the provision of cleft lip and palate surgery. My interest in this is due to many constituents contacting me about the possible loss of service in Edinburgh. Furthermore, the service is currently provided from the Royal hospital for sick children. That hospital has now reached the end of its life and is being replaced with a state-of-the-art, brand-new hospital, which is due for completion in early 2018 and will be sited next to the Royal infirmary of Edinburgh in my constituency.
I am keen to ensure that my constituents continue to receive the very best in care. At the moment, the provision in Edinburgh at the Royal hospital for sick children is of the highest standard. It is led by Dr Felicity Mehendale, a world-class surgeon who is a leader in her field. Next year, she takes up a four-year presidency of the International Confederation for Cleft Lip and Palate and Related Craniofacial Anomalies—she is the first woman to hold the post—and in 2021 Edinburgh will host the 14th cleft congress, having beaten off stiff completion from Kyoto and Brisbane.
The proposal by the national specialist services committee, recently approved by NHS board chief executives, is to move away from a single surgical service over two surgical sites, to a single surgical service on one site. The new service is proposed to be run from Glasgow.
One of the surgical goals for cleft palate is that the patient must reach speech standards, which are assessed at age five according to UK protocols. The Edinburgh team scores highly on those standards, consistently scoring in speech standard 1 over the pass standard of 50 per cent, and in 2016 scoring an impressive 90 per cent. In contrast, the other team has on two occasions in the past four years failed to meet the pass standard, and in 2015 it scored as low as 36 per cent. Speech standard 2a, which is distinct in that it cannot be affected by speech therapy, shows a similar story over the past four years. The Edinburgh results for the past year were 95 per cent, and Glasgow’s were only 68 per cent, which fails the pass mark of 70 per cent. The Glasgow service, unfortunately, has not met the pass mark at all in the past four years.
Therefore, the clinical evidence supports the retention of services in Edinburgh. The Edinburgh service with its multidisciplinary team is one of the best in the UK and is recognised as being of international standard. The proposed change would mean an impact on families from the east of Scotland, who would lose the best care outcomes, and it would also create a deficit in the eastern part of the country. I have much sympathy for the fact that patients and their families will have longer travel times by car from Aberdeen and Inverness in the north and right down to Melrose in the south. However, by public transport, the journey times from Fife, the Borders, East Lothian and Edinburgh are significantly longer—in many cases, they are double what they would have been to Edinburgh.
I already have a meeting scheduled with the cabinet secretary to discuss this issue, and I hope that she will listen to the concerns of my constituents and retain the Edinburgh cleft palate service.
15:45
I welcome the opportunity once again to speak up for the many NHS patients and staff I represent, who are rightly concerned about plans to cut key local health services in the west of Scotland, including the RAH children’s ward in Paisley and maternity services at the Inverclyde Royal hospital.
I have lost count of the number of times that I have spoken in the chamber about the need to protect the children’s ward at the RAH. There has been a cloud of uncertainty over its future for far too long, and we know that the health board plans to transfer 8,000 paediatric cases from the RAH to Glasgow, which would represent the closure of the children’s ward as we know it.
I have said before and I will say again that the cabinet secretary should be under no illusions about the importance of the RAH children’s ward to local families, such as the ones I met at a public meeting that was organised by the kids need our ward campaign last week. As the health secretary has repeatedly refused invitations to visit Paisley and speak to those families, I want to relay directly to her some of what has been said by my constituents.
One Paisley mum said:
“My daughter was in Ward 15 for two weeks when she was six, the ward is very family focused and the staff are brilliant. Being close to home meant I could receive support from family which meant I was able to go home for a short time each evening. This could not have happened if she had been in hospital in Glasgow. Paisley desperately needs this ward to stay open.”
Another grateful parent said:
“Ward 15 saved our little boy when he was admitted at 11 weeks old ... being able to stay with him throughout the week and also having the support of family who live close to the hospital was invaluable. Without Ward 15, we may not have our energetic 4 year old now.”
Sandra Webster, a founding member of the KNOW campaign, described how her son has had to use the ward once a month for minor operations. She said:
“I cannot describe the upheaval, both financially and personally if we had to travel to the Queen Elizabeth University Hospital. Having the ward in the RAH makes our lives so much easier.”
The health secretary needs to listen to the children, the staff, the parents and the grandparents who want the RAH children’s ward to be protected. She should listen to common sense and also to the communities in Renfrewshire and beyond who use the ward. Shona Robison has said that she will listen to representations. She will be aware that she has already received thousands of petition signatures calling for her to stop these plans, and I can tell her that I have with me thousands more that will be arriving with her shortly.
Virtually no one in the local area believes that the cuts to the RAH children’s ward should go ahead, and they should not go ahead.
As I said in a speech in the chamber two weeks ago, concerns over the centralisation of NHS services are not just about children’s services but about maternity services. Closing the birthing unit at Inverclyde Royal hospital would mean that women are no longer able to give birth at their local hospital, close to their home, family and friends. I think that most people would consider that type of closure to be a major service change, and one that would be a major blow to people in Inverclyde. That is why it should be designated as such, so that the final decision on birthing facilities at the IRH is taken by the health secretary. It would be good to know when she will take the decision on whether the designation of the proposal will change.
People in Inverclyde will, rightly, expect the SNP Government to take responsibility. Let us not forget that, as Anas Sarwar said, the First Minister was on the front page of the Greenock Telegraph last year promising that
“There are no plans to centralise services out of Inverclyde”.
The reality is that the future of our local hospitals depends on keeping such key services. These decisions do not only have short-term consequences and consequences only for the people who are directly affected. The centralisation of services is leaving people across the west of Scotland concerned that questions will inevitably arise over the long-term sustainability of their local hospitals.
The SNP denied that these proposals existed before the election and said that it would protect local NHS services. The Government’s amendment today mentions the St John’s children’s ward but fails to even mention the RAH children’s ward or the IRH birthing unit. It cannot possibly be reassuring to worried local families that they are not even mentioned in the amendment. If local SNP politicians support the SNP amendment over the motion, they will be putting their own party interest ahead of their community’s.
Our motion today makes clear that all these cuts should be designated as major service changes and we believe that they should be rejected by the health secretary. We know that the health secretary has the power to act. The Scottish Health Council’s guidance is clear:
“The decision on whether a service change should be regarded as major ultimately rests with Scottish Ministers.”
It is time for the SNP Government and the health secretary to listen. It is time for them to stop hiding behind the health boards that are facing financial black holes because of underfunding from her Government. It is time for them to stop hiding behind the Scottish Health Council and get off the fence. It is time for them to stop sitting back and watching while the cuts happen and vital local services are axed.
The SNP said that it would protect local NHS services. The question now is simple: is it going to or not? I hope that members from across the chamber will do the right thing, stand up for the services that their constituents rely on, and support the motion at 5 o’clock.
15:51
I am pleased to have the opportunity to speak in this afternoon’s debate. I draw members’ attention to my entry in the register of members’ interests: I am a registered nurse and a member of the Royal College of Nursing.
It is because of my 30 years of experience as a nurse in the perioperative department—the operating room—and as a nurse educator that I wanted to speak in today’s debate. I think that everyone in the chamber can find common agreement in recognising that people absolutely value the NHS services that are local and convenient to them as well as valuing the contributions of all NHS staff who work round the clock to provide the safest patient care in the world-class health system that is NHS Scotland.
As a former Stranraer lass, I am familiar with the concerns of family and friends, as well as those of constituents I have spoken to, who make round trips of 150 miles and more for routine appointments in Dumfries. As Maree Todd mentioned, some of the challenges are already being addressed through the use of modern videoconferencing technology for diabetes, urological and respiratory clinics. Equally important, my professional experience is that multidisciplinary teams working across many specialties are vital to getting the best evidence-based outcomes for patients.
The RCN states that ensuring long-term sustainability of services means health boards needing to do things differently. I agree with the RCN that it should be consulted as an active participant in any service redesign. That means delivering services locally while putting the right teams together.
For example, providing orthopaedic trauma care, is not simply a question of having in place competent nurses and orthopaedic surgeons and the other team members—physiotherapists, occupational therapists, radiographers and radiologists. There is more to it. Orthotrauma requires specialised equipment and tools such as the nuts and bolts, plates and screws and power tools of all sizes and gauges that are needed to realign or rebuild fractured bones.
Service redesign—not downgrading—is about addressing shifting medical needs to address the health of our aging population. It is not easy to facilitate and provide all the advanced knowledge and technical requirements to assure optimal safe care.
Given all those considerations, any health board has to consider all the available options to put together the sort of teams that I have described in the most effective way. However, they must do so having regard to the national clinical strategy, which provides a long-term commitment to delivering local services wherever possible but which also recognises that there will be a need for complex treatments to be delivered in specialist centres where the right teams—as I have outlined—can be brought together with the volume of patients to ensure good clinical practice that meets our demanding national patient safety programme.
The point that I wish to make very clearly is that the practical experience of delivering modern healthcare involves constant effort to get that balance right, and reviewing service provision is part of that effort. Having said that, I would not wish colleagues to take that point—critical though it is—as a defence of what the motion describes as the downgrading of “valued local services”. It is anything but. Instead, it is an attempt to relate my front-line experience of NHS service provision to this debate and to explain why health boards review how they provide services.
The fact that boards consider service changes does not mean that those changes will be implemented or, should they be designated as major service changes, accepted by ministers. Boards have previously made recommendations that SNP ministers have not accepted, such as those on the closure of the Monklands A and E department and Lightburn hospital, both of which ministers rejected.
My practical experience of service delivery is that we engage in the best evidence-based practice to obtain the best outcomes that focus on safe, effective, person-centred, timely and cost-effective care, and that experience leads me to expect such issues to be fully considered in any health board service review. The service review is being undertaken and it has not finished yet. The Government cannot interfere while the process is on-going; it cannot interfere until the review process is complete.
I encourage colleagues to remember that the SNP has made massive commitments to resourcing our NHS, which will see funding rise to a record high of nearly £13 billion this year, with primary care receiving an increasing share of the NHS budget in each year of the current session of Parliament. That is a commitment that my Labour colleagues would not match in their manifesto. Indeed, their NHS spending plans were actually lower than those of the Tories.
I encourage everyone with an interest in the services that are being reviewed in the three health board areas to participate in the consultations. Where any of them result in proposals for major service change, those will be subject to ministerial scrutiny. I am confident that the Government will then weigh up the arguments very carefully in reaching a decision. I support the amendment in the cabinet secretary’s name.
15:57
I declare an interest as a councillor on the City of Edinburgh Council. I also have family members who are employed in the health service.
It was my privilege to take part in the health debate last week and to raise the important issue of GP numbers and the effect that the reduction is having on patients in the Lothians and across Scotland. If we were to get the numbers right, the pressure on hospitals would be reduced. It would be easy for me to talk again about doctor numbers and morale, but I want to move the debate on and look at something that is as important to patient care: the high-level decisions that are made by the Scottish Government and health boards.
The relationship between the Scottish Government and health boards is vital, yet too often they seek to blame each other for decisions that are made. There needs to be a close working relationship.
Here in the Lothians, we are in the first few months of an integrated health and social care board and the model that has been chosen is that of joint working between the City of Edinburgh Council and NHS Lothian. Most people believe that that is the right way forward and that it can work well, but we discovered this week that no budget has been set for the new board: neither the council nor NHS Lothian has been able to set a budget.
The issue was raised on Monday afternoon at the council’s governance, risk and best value committee, and it was made clear that the council has not set its budget because the Scottish Government is not clear on what funding it will get. That seems to me to be unacceptable. I ask the cabinet secretary to intervene to ensure that the council and NHS Lothian set a budget, given that we are now a third of the way through the financial year.
We are all aware that the health service has to change because our population is changing. The number of elderly people is increasing—a trend that will continue, as the BMA pointed out in its briefing paper for us, for the next 10, 15 or 20 years. However, as the health service changes, we need to keep its core foundation: helping people in need.
I will give members an example of a service that has been changed. It is a service in the Lothians but the example is illustrative of what is happening in other parts of Scotland. The Lanfine service is a specialist service that helps those affected by neurodisabling conditions, who have severe conditions and need help and respite care. The service offered individuals help with their conditions by taking them to hospital maybe once or twice a year to give them extra treatment and care, and to give respite to those who looked after them. The redesign of the service started in 2010 and was based on taking the number of beds down from 33 to 10. Many of my constituents who have contacted me about the service feel that the redesign is financially driven, despite assurances at the start that it would not be, and that people are being forgotten about in the process.
The service started its redesign six years ago, and a full outreach team was meant to be in place and up and running by now. However, as of today, nobody has been employed to help in the redesigned service. Beds have been cut, the redesigned service is not complete and people are wondering where they should go. The service is meant to move to the new Royal Edinburgh hospital, which is due to open in 2020. However, many of the services that people rely on are based at the Astley Ainslie: the smart centre is there, as is other professional help. What will happen when the service moves? Where will those services go? How will people access what they require? Those questions remain unanswered and are leaving many vulnerable people concerned and scared that they will not get what they require.
As a Parliament and a nation, we need to make difficult choices for our health service in the years and decades ahead, but those choices must be informed and must be about what is best for patients and the vulnerable in our society. I fear that, too often, decisions are made in boardrooms, driven not by patient need but by other factors. That needs to change.
16:03
In the short time that I have available today, I want to raise a few principal concerns about the proposed service changes: that there has been a lack of robust, meaningful public consultation; that the pace of change is too fast; and that our community services may not be ready to handle the impact of service closures. I appreciate that there can be long-term benefits when we shift the balance of care away from the acute sector. Like others across the chamber, I am not opposed to developing more specialised services if they deliver clinical benefits for patients. In that regard, I could agree with much of what Maree Todd said. However, there are fundamental questions about access to be answered, and I am not sure that we are ready for changes to local services on the scale that we are seeing.
We need to ensure that we have solid, well-supported community services that are flexible enough to handle the impact of any hospital closures. However, that is not to say that I support those closures. We need to know that clinical benefits for patients are proven, not just assumed, before pressing ahead with service changes. That requires robust discussion around future service delivery.
To be fair, the Government’s amendment points out the strong efforts that have been made to keep in-patient paediatric services at St John’s, just as the Royal College of Paediatrics and Child Health recommended. I am glad that NHS Lothian is acting on that expert advice and protecting local services for young people and their families, but we need to have far more discussion about the wide range of service changes that are proposed across the west coast. As Anas Sarwar’s motion makes clear, there is widespread public concern about those proposals. Too many patients, families and staff members feel that they have not been listened to. For too many, that has gone on for far too long.
Just a few weeks ago, we had a debate on the centralisation of cleft lip and palate surgery. My colleague Alison Johnstone pointed out that one of the national specialist service committee’s own papers on the proposals acknowledged that there were “lessons to be learned” from the consultation process. The involvement of service users, staff and the wider public has to be real and meaningful, and it has to help shape the outcomes. Have we really seen that level of public engagement around the proposed service changes? I do not believe that we have, and I am sick of many issues that affect my constituents going back to problems that relate to poor levels of consultation.
I am concerned that NHS Greater Glasgow and Clyde discussed significant changes to maternity services in August, when, as we know, the national review of maternity and neonatal care was in its final stages—the concluding report had not yet been submitted to ministers. Whatever the outcome of the review, it would have been reasonable to delay the plans to change maternity services until the review had been completed, its findings had been published and an informed public discussion had begun.
We know that supporting patient choice is incredibly important in maternity care. I am sure that we all want a full range of options to be locally available. If women can no longer choose to give birth in community maternity units in the Vale of Leven and Inverclyde, more will be booked into hospitals in Glasgow. We risk pushing women into giving birth in environments that they have not chosen to be in. Some may be able to have a midwife-led birth at the Royal Alexandra hospital’s community midwife unit, but that is certainly not a local service for my constituents in the Vale of Leven. Jackie Baillie has covered that point very well already.
NHS Greater Glasgow and Clyde’s board papers state:
“the main compelling arguments for change are based on staffing issues”.
Surely we should respond by providing better support to our local services. The same paper suggests that the dedicated home birth team, which currently covers Glasgow, can simply extend its services to the whole of greater Glasgow and Clyde. If staffing issues are the principal concern, how can we be confident that the home birth team is well resourced enough for such a rapid expansion?
As Neil Bibby mentioned, ending paediatric in-patient services at the Royal Alexandra hospital is estimated to affect more than 8,000 episodes of care. The board’s papers indicate that access to the Royal hospital for children in Glasgow will be a “significant concern” for patients in the Royal Alexandra hospital’s current catchment area. I know from the level of correspondence that I have received from constituents—some of those constituents are in the public gallery—that that is a huge concern.
On the centre for integrative care proposals, it cannot be taken for granted that out-patient treatment is feasible. Many people who use that centre experience chronic pain, chronic fatigue or other conditions that make everyday travel difficult. NHS Greater Glasgow and Clyde has stated that overnight accommodation will be available in “exceptional circumstances”, but we do not know what that means.
We all value our NHS. I hope that the Government can understand the concerns that have been raised and why many members across the chamber will support the Labour motion.
16:08
Lightburn hospital, which is in my constituency, is a key part of the local community. It provides in-patient, out-patient and day hospital services and is the base for the local Parkinson’s group. In August, Greater Glasgow and Clyde NHS Board presented proposals to close it.
As members will no doubt be aware, this is not the first time that Lightburn hospital has been threatened. In 2010, the health board made similar proposals. Those proposals were discussed at a meeting of Glasgow City Council in November 2010 and the Labour councillors supported the closure plan in order to save the sum of £500,000. As we all know, the health board failed to make the case, and those plans were overruled in 2011 by the then Cabinet Secretary for Health and Wellbeing, Nicola Sturgeon.
The health board had a meeting on 16 August this year, which I attended. At that meeting, it presented a paper that made the case for the closure of Lightburn hospital. I attended that meeting with the save Lightburn hospital campaign—Gerry McCann from that campaign is in the gallery. I have also met, separately and along with the save Lightburn hospital campaign and representatives of Parkinson’s UK, the directors of the health board to examine its case for closure in more detail.
In my opinion, the board fails to make a case for the closure of Lightburn hospital, based on what it has presented. The data that it presents is misleading and incomplete, and no data has been presented to back up its key claims around improved outcomes, which are a key part of the board’s argument for closure.
Out-patient services are to move from Lightburn to a proposed new health hub in the east end, but there is no timescale for its construction. The health board directs questions about the hub to the integration joint board—a case of integration being used as a vehicle to shift rather than share responsibility. There is no clarity as to what measures will be put in place to cover the period between the proposed closure of Lightburn and the hoped-for construction of the new facility.
In the meantime, the Lightburn site has suffered significant underinvestment. Recently, parts were boarded up, signalling that the site and the patients it serves are not valued. Lightburn serves a community with a high proportion of elderly residents and with low car ownership. Recovery rates are better when patients are closer to family and friends and can have frequent visits. The plan to relocate rehabilitation in-patient services to the other end of the city presents visitors with many transport challenges.
This Government aims to tackle health inequalities partly through shifting resources to the most deprived communities. The health board’s plan does precisely the opposite. It would move resources from an area that contains three of the four most deprived areas in Scotland.
I made all those points in the debate in the chamber two weeks ago. Today, I want to examine further the plans for continuing community health services in the east end of Glasgow. The Scottish Government has rightly put the integration of health and social care at the heart of its programme to improve health outcomes. It has transferred the lion’s share of funds from health boards to IJBs.
The Glasgow IJB has taken over responsibility for the provision of community health services across the city. Unlike the health board, where only seven of the 27 members are elected representatives, fully half of the members of the IJB are Glasgow city councillors. The IJB will have to consider how community health services should be provided in the city and, in August, it considered that very subject. The answer was to invest £32 million in a new community health hub in the east end.
Now, I can help the IJB by offering it some free advice. It could use its new-found powers and the funds it has been allocated to invest in and develop an existing site that already provides community health services to the people of the east end. In short, the IJB could site the new community health hub at Lightburn, alongside the existing services there.
Ivan McKee will be aware that IJBs are complaining about being underfunded by health boards. Has he just shifted responsibility away from the Scottish Government and on to IJBs, instead of defending Lightburn?
Jackie Baillie should have listened to the first three minutes of my speech in which I talked precisely about defending Lightburn. I am working with the save Lightburn hospital campaign, I have written to local organisations and I am committed to working to save Lightburn. In the IJB’s paper, the IJB itself has talked about investing £32 million in a new community health hub. The IJBs have the lion’s share of funding to the health service across Scotland. Jackie Baillie should read that document.
Who is on the IJB to make the decision? It is chaired by Councillor Archie Graham, and there are four other Labour councillors, including Bailie Elaine McDougall, who represents the east centre ward, which is adjacent to Lightburn hospital. [Interruption.] The money is there. It is in the IJB’s paper.
The public engagement on Lightburn’s future has started, and I have written to local community groups and community councils to urge them to take part in that process.
Will Ivan McKee give way?
No, I am in the last minute of my speech.
The health board’s proposals for Lightburn are flawed. The answer to shifting the focus of service delivery from acute care to the community is not to close a community hospital and move patients to a large acute hospital some distance away. The answer to tackling health inequalities is not to shift resources from the most deprived communities to the centre. The answer to improving outcomes for patients is not to move them away from friends and family, reducing rather than improving their outcomes.
The answer to improving health service provision for the people of the east end of Glasgow is not the health board’s proposal. I call on the IJB to step up to the plate and to choose to invest in the Lightburn site the money that it plans to invest in a new hub—as stated in its own paper—so that it can continue to provide services locally in the community in line with the Government’s national clinical strategy.
I call Elaine Smith, to be followed by Graham Simpson.
16:14
Labour’s motion reflects the number of major service changes proposed across the NHS in Scotland. I have expressed concern to the Public Petitions Committee about the proposals for the centre for integrative care. I have written to ministers with a particular focus on the closure of the CIC clinic in Coatbridge. However, due to time limits, today I will focus on the cuts to orthopaedics and trauma at Monklands.
A decade ago, NHS Lanarkshire carried out a review of acute service delivery under the banner, “A Picture of Health”, based on the Kerr report. Several options in that review involved downgrading Monklands hospital. I remind the cabinet secretary that the review was based on the alleged lack of safety of services 10 years ago.
None of those options proposed completely closing the hospital, or indeed the A and E. Nonetheless, that attack on our local health services in Monklands was completely unacceptable to local people, as evidenced in extensive consultations, and it was unacceptable to local politicians, including me.
The decision was devolved to the health board, but the Government has a duty and a responsibility to sign off major service changes, so the Labour-Liberal coalition signed off that change—wrongly, in my opinion—and, frankly, suffered the electoral consequences.
I spoke out against my own party on that issue. I lodged a motion on the future of Monklands hospital as my last motion before the 2007 election and lodged another as my first motion after I was sworn in following the election. I have no doubt that the SNP’s election campaign to save Monklands helped it to victory in 2007; indeed, “Save Monklands” was printed on the ballot papers beside SNP candidates’ names.
One of the downgrading options at that time—option D—specifically proposed removing orthopaedics and trauma. That option was meant to have been rejected when the newly elected SNP Government demanded a rethink by NHS Lanarkshire, which resulted in the status quo for Monklands. Those proposals were rejected 10 years ago.
Only, it has not really been the status quo. The loss of paediatrics has been added to over the past decade by the loss of gynaecology and dermatology. Heart attack patients are now treated at Hairmyres hospital. What we see now is a return to the downgrading of a decade ago, with the removal of orthopaedics and trauma, again based on alleged problems with the safety of services, as the cabinet secretary pointed out in her opening remarks.
That all looks very much like death by a thousand cuts to me. There is an opportunity, right now, to call in the current cuts proposals, to consult properly and to think again.
As for the proposal to build a new Monklands hospital in 7 years’ time, of course that investment would be welcome, but perhaps the cabinet secretary can clear up some questions. Where in her Government’s budget planning is the £400 million? What does she say to the health professionals who say that a new acute hospital would cost at least double that amount? Where will it be built? If a cost has been identified, the detail on that must surely be known. In fact, Fulton MacGregor seems to know it in today’s Airdrie & Coatbridge Advertiser—perhaps it could be shared with the rest of us.
The promise of a new hospital cannot be used as a smokescreen to cover up the current threat of the downgrading of orthopaedics and trauma. Let us have a look at the facts about the current threat.
Orthopaedic in-patient and trauma services are being taken away from Monklands hospital, to be delivered instead at Wishaw and Hairmyres hospitals, which are at least an hour away by public transport, with no new transport arrangements being proposed for, for example, patients with limited mobility. That will be for at least 7 years, apparently. That decision was taken during summer recess with no prior public consultation and the staff were issued with redundancy notices.
Due to that, Richard Leonard and I organised a public meeting to try to get public engagement with the health board. I would expect health board members to come to a meeting that was organised by MSPs, but they chose not to attend. They cited a lack of consultants at short notice. I did not ask for a consultant—I asked for one of the board members and/or a senior official.
However, it is important to hear the views of medical professionals, particularly those who have experience of working in Monklands. Orthopaedic surgeon Sathar Thajam, who has worked at Monklands hospital for 30 years, calls the plan
“ill-advised, ill thought out, badly planned and totally unnecessary”.
He goes on to say:
“The argument that Mr Calum Campbell and the Lanarkshire Health Board put out continually, saying that there will be no disruption to the care of the elderly and the young following the closure of the Orthopaedic and Trauma unit at Monklands Hospital, is in my opinion, frankly ludicrous.”
Having spoken to other staff privately, I know that we could hear similar things from more of them were they not worried about speaking out. Some consultants have spoken out. Six at Wishaw say that it is impractical to shunt patients about Lanarkshire in ambulances, and seven orthopaedic surgeons at Monklands have made the case for the service to stay at Monklands.
The SNP can and should step in to stop this major service change, and I believe they have a duty to do so. At the very least, the plans must be halted until a full consultation on this specific issue is carried out. A meeting is a start. The people of Monklands deserve to know the full facts.
Presiding Officer, at what point does the downgrading of Monklands hospital end? Does the Government really think that people will accept promises of jam tomorrow that, frankly, are designed to try to disguise cuts today? At what point do SNP constituency members put the people whom they serve first, and demand that the Government step in to stop those cuts? I did that a decade ago. I stood by my principles; SNP members should do that now.
We know that the issue featured heavily in the recent Coatbridge North and Glenboig by-election, with Labour’s Alex McVey elected on a promise to oppose cuts at Monklands. That sends a clear message that people care about their vital local services and increasing numbers are joining the campaign to save Monklands hospital. The least that they can expect—and some campaign members are in the gallery today—is for the Government to call in the matter.
I have no doubt that people power can and will win the battle to save services and we on the Labour benches will be standing firmly with the campaigners to stop the cuts. I hope that other elected representatives will do so, too.
16:20
This important debate—I thank Labour for bringing it to the chamber—follows on from our debate on health last week. We all use the NHS. Most of us have great experiences of it and we are grateful to the staff who provide such fantastic service. It is easy for those in Government to say, “What a great job we’re doing,” or for other politicians to say that the governing party is letting the public down. The truth is usually somewhere in between.
Some good things are happening in the NHS. Next week, I am attending the opening of a new health centre in East Kilbride—the one that my family uses—and there will be a new Monklands hospital in the region that I represent. However, there are problems and we need to be honest about them.
I will start with some general figures. The Royal College of General Practitioners says that Scotland is 830 GPs short of the number needed, following a 2.4 per cent fall in their number between 2013 and 2015. That is serious. This week, I was contacted by a local GP, who told me:
“Secondary care problems snowball back to primary care. Waiting times are increasing. I was informed 2 weeks ago that the routine waiting time for out patient Gastroenterology at the new Victoria is now 30 weeks. Waiting time for a Community Physiotherapy appt. in my area is now 12 weeks ... After a busy day (often 10 hours+), I like many other GPs, couldn’t face a shift in out of hours. There are shortages & closures as a result.”
That does not paint a rosy picture. Staff shortages mean that costs increase and add to stress levels among those who are left; they are changing the way that we deliver our health service.
I mentioned Monklands, which is the subject of part of Labour’s motion and has been heavily mentioned today. Let me be clear: a new hospital is to be welcomed. However, there have been big concerns locally over the changes to trauma and orthopaedics.
A Lanarkshire NHS Board briefing says that the most complex trauma cases that require surgery are being moved from Monklands to Hairmyres and Wishaw general hospitals. As Shona Robison said, that is an interim move, but proposals are under way to take the services solely to one site, probably Wishaw. My own sense, as someone who lives at the other side of Lanarkshire, is that Monklands is probably the best place to have the services; it is the easiest place to get to.
I welcome the member’s tone so far. I want it to be clear that the health board is saying that the trauma centre should be in Wishaw, because the paediatric services are there, but that the elective orthopaedic centre would not be in Wishaw. My preference—and I think that this is what will happen—is for that to be in the new Monklands hospital when it is built in 2023.
I agree. As I have stated, that would be a more practical option; there will also be a brand new hospital.
The health board has stated that risks have been identified within NHS Lanarkshire’s trauma and orthopaedic services that could affect patient safety:
“We have an immediate pressure to make interim changes now so that the service is safe and sustainable for patients in Lanarkshire.”
Those are serious words:
“so that the service is safe”.
How has it been allowed to get to this stage? [Interruption.] I want to make progress. There have been 10 years of SNP Government. Staffing issues have been in the pipeline for some time, but sufficient action has not been taken.
Let me be clear. I understand and agree with the move towards having specialisms delivered more centrally. That makes sense for the professional and the patient. Changing the way in which we deliver GP services so that people do not always have to see the family doctor also makes sense. However, the proposals in Lanarkshire are perceived as a downgrading of Monklands hospital even though we will retain three fully functioning A and E departments. Irrespective of what is planned, we need to know how we got here, because, after a decade of having the SNP in charge of Scotland’s health service, we still have staff shortages.
Here is what consultant orthopaedic surgeon Alberto Gregori has to say:
“There’s a shortage out there. We can’t recruit. Part of that is people don’t want to work in small units and part of it is there is a national shortage. ... The present status quo is not sustainable, it’s not safe.”
So far, Shona Robison has hidden behind the health board, but she has to take some responsibility. She is in charge. I do not want her to step in on every decision that is made locally, but these are big ones and she must step up to the plate. After 10 years of the SNP being in charge, the time for blaming others has to end.
16:26
As one of three healthcare professionals recently elected to the Parliament and one of the two nurses in the chamber today, I feel that it is particularly important for me to speak in this debate on the future of healthcare services. The Government’s vision is that, by 2020, everyone will be able to live longer, healthier lives at home or in a similar setting. To ensure quality and consistent care, the health service must be smart and efficient in order to meet the increasingly complex health needs of an ageing population. The national care strategy, which is the blueprint for health and social care in Scotland, takes that population change into account. Its emphasis on the shift to multidisciplinary working and the use of advances in research and technology is designed to support the needs of this generation and of the generations to come.
I am no stranger to periods of transformational change. I have been a mental health nurse for over 30 years and, in that time, there have been huge changes not only in the way that we view mental illness but in how we care for and treat people who are suffering from mental illness. I would go as far as to say that we have witnessed a revolution in mental health care. When I began my nursing training, the majority of patients with mental illness were cared for in large institutions. Those asylums, many of which were built in the late 1800s or the early 20th century, were frankly no longer fit for purpose. Often physically disconnected from modern life and society, patients were isolated from their communities, their families and their existing networks of support. In many cases, that isolation was for years at a time. It was not unheard of for someone who had been admitted to hospital for an illness that would now be treated in primary care by GPs to never return home. Often, wards were home to in excess of 40 or 50 patients, with little personal space or privacy. Long-term patients spent years of their lives in those institutions. I personally cared for many men and women who had been in hospital for over 30 years, forgotten about by society and estranged from their families and friends. The staff and other patients were their only social contact.
The hospitals became communities of their own where work activities were supported and encouraged, where social events were organised and held and where shops provided not just sweets and drinks but clothing and shoes. There was little reason to leave the hospital grounds, and for many patients there was little prospect of returning to a life outside hospital. However, in the 1980s and early 1990s we began to see a change in how mental health services were delivered, and multidisciplinary community mental health teams were formed. No longer would community psychiatric nurses, of whom there were only a few, work in isolation. Psychiatrists, psychologists, occupational therapists and pharmacists all adapted to new ways of working in new settings.
Ideas of where mental health care should be delivered began to change, and in most cases that was in a community setting, where most people wanted to receive care and treatment. The majority of large institutions were closed and newer, smaller, more modern facilities were built to provide care for the most acutely unwell patients. Long-term care was no longer the norm. If someone needed to be admitted to a mental health facility, it was for as short a period of time as possible rather than being committed to care for the rest of their life.
The public came to expect to be able to access mental health services while remaining at home. As well as community mental health teams, support services were delivered by third sector partners, thus addressing the social as well as the mental health needs of people who required additional support to live their lives.
Out-of-hours mental health services began to develop, with telephone triage and access to mental health assessment and care outside normal working hours. Again, those services helped people to stay at home rather than be admitted to hospital.
In the early 2000s, crisis services began to be developed across the country. Seven days a week, teams provide crisis management and support to some of the most unwell and vulnerable people in our society. They provide intensive home treatment, often visiting several times a day to ensure that a patient is safe and can remain at home.
Specialist community teams have also been developed, to provide expert care and treatment in areas such as eating disorders and perinatal mental health, and to ensure early intervention in psychosis.
All the service changes that I have described are now accepted as the norm in mental health care. Throughout my career, there has been a profound change in how we care for patients and their carers and families, which has helped to reduce the stigma around mental illness and has encouraged people to access care and treatment at an earlier stage. We talk about mental illness, instead of shying away from it. That is to be welcomed.
None of that would have happened without service redesign.
Will the member take an intervention?
No, sorry.
At the time, the changes were difficult. Service users, carers, staff and the public were worried and concerned about bed and hospital closures. People worried that services would not meet their expectations. They worried about safety. However, no one would argue for a return to old ways of working. We accept that the model of mental health service delivery is much more modern, evidence based and rights respecting than it was in the past.
If we are to change the focus of healthcare away from the existing models and hospital settings to community settings, as we did in mental health, we have to review services. We have to be open to discussion about what can be done differently, what can be done more efficiently and what is best for patients.
Service redesign should not be automatically viewed as negative. Changes to services can be challenging, but with the challenges come opportunities to make positive changes to people’s lives.
16:32
I congratulate the Scottish Labour Party on bringing the motion to the Parliament. In particular, I thank Anas Sarwar for his kind remarks about the amendment that the Liberal Democrats lodged. We will embrace the spirit of cross-party consensus to which he referred.
This debate is not about exercising top-heavy parliamentary control—far from it. As a Liberal, and as a passionate exponent of subsidiarity, I would not rise to speak in support of a motion that sought to give ministers or the Parliament the whip hand so that they could ride roughshod over the careful plans of clinicians and managers and oppose rationalisation or redesign on a whim. However, on decisions of this magnitude, on proposals that threaten much-loved and well-used local facilities—proposals that have induced dozens of constituents to seek appointments in our constituency surgeries—we have a duty to raise the issue in the Parliament and in the corridors of Government, to give stakeholders their day in court and to test the reasoning of the clinicians and managers who proposed the changes.
Parliamentarians are asked, on doorsteps, in our surgeries and through our mailbags, to account for the day-to-day decisions that health boards take, but I am not content to hide behind the health board when I reply. I want answers that go beyond the vague, opaque language of funding pressures and optimisation. Every day, decisions are made to rationalise and optimise. Well-paid people, who are experts in their fields, take decisions, as is absolutely right. In the vast majority of cases, what is decided is the right thing to do. However, sometimes the bottom line or what appears to make sense does not elicit the expected public response. For example, a huge amount of research went into the designing and commissioning of the Royal hospital for children, on the site of the old Southern general hospital. Colourful, state-of-the-art, single-occupancy rooms were constructed, to much fanfare—until the kids arrived. As a youth worker of 19 years’ experience, I could have told the commissioners that vulnerable children do not like to be left alone. There has now been a row back on some of what was provided.
My point is that what looks good on paper and is backed up by research sometimes requires the end user’s direct input before it is signed off. If parliamentarians cannot voice Scottish patients’ concerns and enable them to have that input, I do not know where the interface can take place.
We have heard compelling evidence of specifics at the children’s ward at the Royal Alexandra hospital and the Vale of Leven maternity ward. In my constituency, the constituents and patients who come to my surgeries overwhelmingly voice concerns on the issue of cleft palate and craniofacial services in Edinburgh. The surgeon Felicity Mehendale leads a world-beating team there and, as we heard from Ash Denham, she is set to play host to the field’s international congress in 2021. We know how good she is—we have heard about that in the debate—but that is only because 6,000 campaigners raised freedom of information requests as part of the consultation process to prove who good she is. That speaks volumes about how opaque and untransparent the process is. To move her to Glasgow on the ground that not to do so would be sub-optimal would run the risk of losing her from the Scottish profession altogether, and that would be not only sub-optimal but a criminal waste of talent. I find it astonishing that the only time the Parliament has had the opportunity to debate the planned closures has been Miles Briggs’s members’ business debate two weeks ago and this Opposition debate day. That is not how Parliament should scrutinise such decisions.
We still have challenging decisions before us. Health boards will make decisions down the line that we cannot even conceive of. We have heard how the paediatric ward at St John’s has been saved—the Government referenced that in its amendment. However, recent closures and staffing pressures paint a worrying picture of the future viability of that service. I want to know—because St John’s is the hospital of choice of many of my constituents—that if the issue of viability raises its head again, the chamber will have the opportunity to question the cabinet secretary and scrutinise the arguments for the service’s retention or closure.
This debate is not about rejecting all organisational redesign but is an opportunity for the cabinet secretary to enlist us as champions of that redesign or for her to think again, if the weight of argument and intervention from the chamber compels her to. I welcome the opportunity that the Labour Party has given us, and the Liberal Democrats will support the motion.
We move to closing speeches.
16:37
I am pleased to close today’s debate for the Scottish Conservatives. It has been useful in that it has allowed members from all sides of the chamber to voice constituents’ genuine concerns about service changes or downgrades in their areas.
I grew up in rural Perthshire. Any time that I or anyone in my family needed care, we could rely on the highly valued Perth royal infirmary. I am pleased to say that I did not need to call on its services very often when I was growing up, but the same cannot be said for my sister, who fared much worse, with broken arms and other fractures over the years—the life experience of growing up in the countryside.
When thinking about today’s debate, I considered just how valued Perth royal infirmary was to our family and how grateful the whole community across Perthshire and Kinross-shire has always been to NHS staff, the vast majority of whom live locally, for the services that they provide. I was therefore saddened to learn of how many of Perth royal infirmary’s key services have been lost to the local community in recent years. In fact, since the SNP Government came to power, Perth royal infirmary, which serves one of Scotland’s fastest-growing population areas, has seen the continuous removal of services such as the maternity ward, paediatrics, pathology, weekend surgery, emergency surgery, and, most recently, the GP out-of-hours service, which have all been centralised at Ninewells hospital in Dundee. SNP ministers and health board officials stated that each proposal did not constitute major changes to services. However, it is pretty clear to anyone looking at Perth royal infirmary that the staged removal and closure of services that has taken place over a number of years has ultimately led to the end of PRI as an acute district general hospital.
As it has with all the key hospital services that are mentioned in the Labour motion today, too often the Scottish Government has been satisfied to hide behind health boards’ decisions and to support the downgrading and closure of services. The unintended or perhaps intended consequence has been the highly centralised health service that we are seeing being developed in Scotland today.
On services that are currently under threat in Lothian, I welcome the positive case that Alex Cole-Hamilton and Ash Denham made for retaining the cleft palate surgery unit in Edinburgh. I am pleased that, on that issue, SNP members have started to speak out against the proposals. I again call on the Scottish Government not to approve the centralisation of the surgery unit, which we debated in my recent members’ business debate on the subject. I welcome the fact that the cabinet secretary has announced that she is due to visit the Edinburgh and Glasgow teams over the next few weeks and I hope that those visits will help to persuade her that the two-site model, which works well in Scotland and in many locations across the United Kingdom, is in the best interests of cleft patients across Scotland.
Does the member agree that, although we can talk about the facts and figures of such cases, the reality, especially for children’s surgical services, is disrupted families? Husbands and wives are having to live in separate places and children are not seeing one of their parents for perhaps weeks at a time because they are getting treatment tens or hundreds of miles away from where they live.
I very much agree with those points. A key point in the debate is that our NHS belongs to the people whom we serve in Scotland, and the Scottish Government needs to start working with that in mind as well.
The Government amendment mentions St John’s hospital in Livingston, which currently provides cleft palate surgery. However, as I have highlighted in the chamber previously, the cleft services that are located at St John’s are delivered by the Edinburgh cleft surgery unit. I am sorry to say that, to date, I am not sure that ministers have grasped the facts around the proposed centralisation of cleft lip and palate surgery in Scotland. Although I do not have time to raise specific concerns, I have today written to the cabinet secretary to further highlight them.
We need a continued focus by the Scottish Government on recruiting the consultants who are needed to keep key paediatric services at hospitals such as St John’s and the Royal Alexandra, rather than a decision simply to centralise those services.
One theme that has emerged during the debate is the lack of confidence that many of our constituents have in the consultation processes that are organised on health board service changes. Jackie Baillie made a passionate speech highlighting the fact that constituents often fear that consultations do not take into account their views or are skewed towards approving decisions that have already been made. I have to say to the Scottish ministers that the idea of a consultation is to listen to the people who are responding.
Ministers talk about patient-focused healthcare and services being as close to patients as possible, but the reality that we see is the constant centralisation of services, which once lost are never returned. As Ross Greer and Donald Cameron said, it is starting to feel as if the centralisation or consolidation of our health services is increasingly being driven by staff shortages in the NHS. The Scottish Government’s failure to deliver an NHS workforce plan should not be a reason for the closure of vital local services.
Patients and communities want to know what services will be provided locally and they want to have confidence that those services will be properly maintained and made sustainable. Increasingly, communities feel that they are facing the constant threat that the valued services that they hold so dear will be removed. The SNP Government was elected on a manifesto commitment
“to keep services local and improve the availability of these services”.
However, it is clear from today’s debate that the SNP is increasingly failing to keep that pledge to communities across Scotland.
16:43
What is not in question today is the priority that the people of Scotland afford to the safe stewardship of the NHS. No public services are valued more highly, and I put on record again the Government’s sincere appreciation of the unstinting professionalism and commitment that are shown by those who work so tirelessly in our health and social care services.
On that note, it is appropriate to remind ourselves, as Maree Todd and Clare Haughey did, of what one staff body—the RCN—said in its briefing for the debate. It said that, to ensure the longer-term sustainability of services and to meet the needs of an ageing population in the future, health boards need to do things differently. It also said:
“politicians, professionals and the public must be prepared for transformational change and all stakeholders involved with the changes will need to put vested interests to one side and work together to deliver the changes which are so urgently needed.”
I genuinely think that we should unite behind that rallying call from the RCN, regardless of political party, as opposed to the approach of Anas Sarwar, who implored us to unite on an irresponsible narrative that is big on grandstanding but short on detail and facts.
As the cabinet secretary pointed out, there is a clear and robust process that should be followed that gives an opportunity for engagement, and no decisions have been made about service changes. The process was set up by statute in 2005 to provide independent oversight in the key area of patient focus and engagement.
Donald Cameron’s comments seek to cut across that process. On the one hand, he seemed to accept that it was premature to prejudge the process, but on the other hand, he asked the cabinet secretary to expedite the process. He simply cannot have it both ways. He went on to say that blanket opposition to any change is impossible and that tough decisions need to be taken.
I accept that such discussions are emotive and of huge importance and that it is absolutely right for Opposition parties to hold the Government to account, but the Opposition needs to realise that it needs coherent arguments and that it must be responsible in marshalling the facts. The Government and the cabinet secretary have made clear our responsibilities in taking decisions and in using the clinical and local evidence.
The minister accuses me of grandstanding, but I am here standing up for and representing my constituents. Members such as Bill Kidd, John Mason, Alex Neil, Tom Arthur, Stuart McMillan and George Adam have chosen to stay in their seats and not speak while we are discussing their constituents’ services today.
I have heard many members—
On a point of order, Presiding Officer. For the record, the debate was well oversubscribed, which is why many of us were not selected to speak.
That is not a point of order, Mr Neil.
I have heard a number of speeches today from back-bench SNP members, who made huge contributions and articulated incredibly well their constituents’ needs and desires. What has been said follows on from my point about Anas Sarwar’s grandstanding when he rose to his feet earlier.
I want to talk about Elaine Smith—
Will the member take an intervention?
I am sorry, but Mr Findlay was not in the debate, and I am sure that other members will want to interject later in response to my comments.
On Elaine Smith’s point, I have no doubt about her commitment to Monklands hospital, unlike the rest of her party nearly 10 years ago. However, she failed to recognise the £65 million that has been spent on Monklands over the past five years—on a new critical care unit, upgrading operating theatres, a new Lanarkshire Beatson satellite radiotherapy centre, a new pathology unit and extensive refurbishment of the mental health unit. That is a clear commitment to the hospital from the SNP Government.
Will the minister give way?
I will make this point for clarity and then I will let Elaine Smith in. I understand that, although NHS Lanarkshire could not make the meeting that it was asked to attend at incredibly short notice, it has offered to work with her on an alternative date.
Many thanks—NHS Lanarkshire has indeed made that offer but, unfortunately, I have just found out that the meeting will be a drop-in session and not a public meeting, which I do not think is acceptable.
Will the minister recognise that Karen Whitefield and I, in arguing against the proposals, got commitments on things such as the Beatson? I therefore recognise that those services are now at Monklands hospital.
The member failed to make her point in any way at all. She failed to recognise entirely the Government’s commitment in saving Monklands A and E and in further enhancing the services that are provided at the hospital.
Ross Greer made a number of valid points that will need to be addressed in the engagement process that is under way. He made a good point regarding the clarity of communication, which holds true for all our public bodies and not just for the NHS.
Ivan McKee raised the issue of deprivation and highlighted the inequalities in the constituency that he represents and the additional barriers that they create for access to services. That must be borne in mind in designing those services.
I know that Neil Bibby and I will disagree on a number of issues in the debate. However, on the theme of listening and engagement, I do not think that anyone could fail to have been moved by the accounts that he read out from the families who have incredibly strong views about the future of the hospital in their area. Of course those views must shape and hone the decision-making process. Likewise, Clare Haughey excellently articulated, with a great deal of authority, the wider changes that we need in healthcare and especially in mental health, on which work will be taken forward by my colleague Maureen Watt.
There has been mention of the need to ensure that the NHS has enough resources. Ash Denham set out the challenging backdrop against which the debate is taking place.
I remind the Opposition that the Government has ensured that health spending in Scotland during 2016-17 has risen to a record level of close to £13 billion, despite Westminster cutting Scotland’s fiscal budget by 10.6 per cent in real terms between 2010-11 and 2019-20. We have increased the front-line health budget by 8.2 per cent in real terms between 2010-11 and 2016-17 and we will continue to provide real-terms protection.
In 2016-17, territorial health boards have seen a 5.5 per cent increase in budget levels. The funding includes investment of an additional £250 million to support the integration of health and social care.
Brian Whittle made some inaccurate claims, so I will clear up the position for him—every penny of health resource consequentials has been passed on in full since 2010-11, plus an extra £54 million last year. That will increase the NHS revenue budget by £500 million more than inflation—that is nearly £2 billion over the lifetime of the parliamentary session.
You must close, please, minister.
With the record of increased numbers of staff, including front-line staff, and increased investment, we have a clear plan for the NHS and we will continue to engage with the population. Opposition members must understand that they need to have their facts right before they come and grandstand in the chamber.
16:51
I refer members to my entry in the register of members’ interests, which shows that I was employed by Parkinson’s UK when I was elected in May, although that employment has ceased.
In today’s debate, we have heard the voices of thousands of concerned families from across Scotland. Member after member has stood up for their constituents and sent the clear message to the Scottish Government that it is time to listen.
We heard the voices of people in West Dunbartonshire when Jackie Baillie spoke passionately on their behalf to expose the attempt to cut by stealth maternity services at the Vale of Leven hospital. We heard the voices of people in Renfrewshire and in Inverclyde when Neil Bibby spoke up for his constituents and continued his fight to save the children’s ward at the Royal Alexandra hospital and maternity services at Inverclyde hospital. We heard the voices of people in Lanarkshire when Elaine Smith again championed Monklands hospital and highlighted community concerns over plans to axe in-patient orthopaedics at Monklands. We heard the voices of people in Glasgow when Anas Sarwar spoke about the impact on the availability of care for some of our older, most vulnerable residents if the closure of Lightburn hospital goes ahead.
What we also heard is that those concerns cut across party lines. It was not just Labour members who spoke passionately about their communities—Donald Cameron, Brian Whittle and Alex Cole-Hamilton rightly asked why the cabinet secretary does not seem even to have a view yet on whether the plans that are before us are major service changes.
Daniel Johnson, Ash Denham and Miles Briggs raised concerns on their constituents’ behalf about plans to centralise cleft palate services away from Edinburgh. Ross Greer rightly highlighted the concerns of his west of Scotland constituents about the lack of public engagement in the planned changes in his area.
It is clear that the concerns that have been raised today unite members across party lines, which is what Anas Sarwar called for. More important, it is clear that those concerns represent the views of a growing number of people in the communities that we are here to represent.
Earlier today, along with a number of members, I had the pleasure of meeting representatives from the KNOW campaign from the Royal Alexandra hospital, the save our services campaign at the Vale of Leven hospital, the campaign against the downgrading of the centre for integrative care at Gartnavel, the cleft services campaign, the save the Lightburn hospital campaign and those campaigning to protect services at Monklands.
Gerry McCann, who is the chair of the east Glasgow Parkinson’s support group, told me how the closure of Lightburn would impact on people with Parkinson’s—a condition that I know is debilitating for those who live with it every day. He also told me how that closure will impact on those with heart failure and dementia and those who have suffered strokes—some of the frailest people in an area with some of the poorest health in Scotland.
Gerry McCann told me about the campaign that he led against the closure of Lightburn hospital in 2011. He cannot understand why the proposed closure of the last in-patient facility in the east end of Glasgow was deemed a major service change in 2011 but not now—not so far—even though the evidence that it is a major change is already clear.
Those campaigners took the time to come to Parliament today to share their stories with us. It is therefore a disgrace that the SNP amendment pretends that those communities and those concerns do not exist. As if in a scene from George Orwell’s “Nineteen Eighty-Four”, the cabinet secretary’s Newspeak amendment would airbrush out any reference whatsoever to the word “concerns”. It does not even mention the services that we are here to debate. Well, I can tell the cabinet secretary that those communities have concerns and that they want the Government to face up to its responsibilities.
As several members have highlighted, and as the Scottish health council’s guidance states clearly,
“The decision on whether a service change should be regarded as major ... rests with Scottish Ministers.”
I know that the proposals that we are debating are major service changes. The patients groups that are here today know that they are major service changes. As Neil Bibby said, it would be good to know when the cabinet secretary will decide whether she will take the decision on those services. That is the least that the Scottish Government needs to do because, ultimately, the reason why many of the plans are being considered is, as Jeremy Balfour highlighted, a direct result of the funding challenges that health boards face.
When I made my first speech on health in the chamber in June, I said that we needed to have an honest debate about the future funding of the NHS. We all accept that we have an ageing population and more people with complex care needs. However, despite a growing demand for services, local health boards are still being hit by significant health savings targets that cannot be achieved without impacting on services.
This year, my local health board, NHS Dumfries and Galloway, has to make so-called savings of £13 million. NHS Greater Glasgow and Clyde must make savings of £69 million, and NHS Lanarkshire must save £45 million. It is those cuts that are driving many of the changes that we are debating. They come at a time when the NHS has a struggle to recruit and retain staff, which is exacerbated by the number of unfilled trainee and specialist posts.
One in four of our GP practices reports a vacancy, and we have a ticking time bomb of GPs queueing up to retire. In my health board area—NHS Dumfries and Galloway—the number of GPs has fallen from 134 in 2012 to 118 in 2016. Just today, I received a letter from NHS Dumfries and Galloway that highlights the fact that it cannot recruit two out of the three GPs that are needed to maintain the GP practice on Moffat High Street. Those vacancies will be covered by locums in the short term, and then the NHS plans to merge practices and close the outreach surgeries that are held in the villages of Wanlockhead and Crawford to manage that crisis in GP recruitment.
The letter says that
“there are an increasing number of GP practices that are unable to continue to provide services”.
The Royal College of General Practitioners has predicted that, by 2020, Scotland will have a shortfall of 830 GPs, which would be needed just to return to 2009 levels. I say to the cabinet secretary that, if that is not a GP crisis, I certainly do not know what is.
It is not just in GP numbers that we have that crisis. There are more than 350 consultant vacancies, nearly half of which have been vacant for more than six months. There are 2,500 nursing and midwifery vacancies, including more than 300 unfilled mental health nurse posts. The consequence of high vacancy rates and training posts going unfilled across the NHS is an increase in the burdens on existing medical staff, which are adding to an already unsustainable workload and, as we have heard today, the closure of facilities across Scotland.
Despite that, the SNP has after 10 years in power lodged an amendment that simply says, “There is no problem. Nothing to see here. Simply move on.” The amendment treats communities with contempt by failing even to acknowledge that there are local concerns across Scotland. It fails to mention the very services that we are debating; many of the SNP members who represent the affected areas have been posted missing, and SNP members from as far away as possible have been drafted in to talk about anything other than the motion that is before us.
I say to members in the chamber that it is the motion that we will be voting on and that it is the communities and areas that the motion mentions that they must make a decision on.
The member mentioned that already.
I also mentioned the areas that the motion covers, unlike the Government’s amendment. I urge members across the chamber to stand up for the communities that they represent, to recognise those communities’ concerns and to support the motion that is before us.
That concludes our debate on protecting local NHS services.
On a point of order, Presiding Officer. How many members requested to speak in the debate but were not called?
That is not a point of order, Ms Grant, but I will find out and return to you after decision time.
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