Chamber and committees

Thank you so much, convener. I thank you all for being so accommodating of my time; I am grateful to the committee for shifting this meeting to a slightly later time in order to help me with childcare issues. I am also grateful for the opportunity to be here today to respond to the committee on questions relating to the public petitions that the deputy convener mentioned.

Let me begin, as I did last week, by reiterating the fact that we are currently experiencing extreme pressures in our health services. This is, by any estimation, the most challenging winter that the national health service in Scotland and the United Kingdom has ever faced. Our NHS and its committed workforce face a perfect storm of intense pressures that are leading to difficulty, disruption and delay across the service—including in remote and rural communities, which too often face their own significant challenges. I suspect that we will touch on many of those issues during today’s discussion.

As I outlined last week, we have advised health boards to exercise their own judgment in relation to their locality and what action is necessary to overcome or, at least, to mitigate some of the challenges that they are experiencing. I am aware of the challenges that rural Scotland faces in healthcare, having visited all our health boards and spent a significant amount of time in boards that cover remote, rural and island communities. I am determined to ensure that our remote and rural areas are not left behind as we continue to invest in and reform our health and social care systems.

I expect NHS boards that service remote and rural areas to take account of the particular needs of their communities, to ensure that services are delivered flexibly and innovatively, to recognise the concerns of local populations and to take account of the significant geographical challenges. A blanket approach for a country that is as geographically diverse as ours is simply not appropriate.

Front-line workers are the foundation of our health and social care services. We have committed to growing that foundation and overall staffing levels have increased by almost 3,000 permanent whole-time-equivalent roles during the past year. That builds on our strong track record of delivering 10 years of consecutive growth, with almost 30,000 more whole-time equivalent staff working in the NHS now than there were in 2006; the actual figure is around about 28,900.

We are making nearly £8 million of funding available to NHS boards to support recruitment of up to 750 nurses, midwives and allied health professionals from overseas this winter. That will, of course, include boards that include remote and rural localities.

We are creating opportunities for an initial 250 band 4 assistant practitioners across acute services, primary care and mental health. We continue to expand the number of trainee doctor posts in line with medical workforce modelling. Since 2014, 725 additional training posts have been created, including 152 that I recently agreed would be recruited in 2023. I am sure that the committee will discuss this, but we know the importance of training posts being available in remote and rural health boards.

I recognise that general practitioners in remote and rural areas also have distinct challenges. That is why we have invested £7 million of funding since 2019 to take forward a range of initiatives to support rural general practice. Those include support for recruitment and retention: a “golden hello” scheme to attract new rural GPs; a £20,000 bursary to recruit and retain GP trainees in hard-to-fill locations; Scotland’s first graduate entry medical programme—ScotGEM—which provides a graduate entry medical degree that has a real focus; and a pilot scheme to recruit experienced GPs to provide support for rural practices. So far, 52 students have graduated from the ScotGEM programme—in fact, I think that the CMO was at that graduation—which has allowed them to progress to foundation year 1 posts.

We are also supporting a recruitment campaign called “Rediscover the joy of general practice”—many committee members will have heard of it—which aims to recruit experienced GPs to provide support for remote and rural practices. I will be happy, as we get into the meeting, to give some detail on how that programme has assisted. NHS Education for Scotland has also developed for doctors a credential in remote and rural healthcare that recognises the unique skills that are required to work in those challenging regions and provides a route for upskilling in those environments.

We are working closely with NHS Education for Scotland on scoping a national centre for excellence for remote and rural health and social care. That is another piece of work that Sir Lewis Ritchie was not just involved in but led. I am grateful for all the work that has been done in that regard. That centre will have an initial focus on primary care, although I imagine that it will be of interest to people from right across health and social care. It will be a resource that boards and health and social care partnerships will be able to use in support of their responsibilities in providing rural health and social care. Our aim is that the centre will identify, celebrate and—importantly—pull together the many examples of innovative work that are already going on, and promote excellence to address the long-standing issues, particularly recruitment and retention, in remote and rural areas.

We remain committed to growing our nursing workforce in remote and rural areas and we look forward to welcoming new pre-registration nurses to the University of the Highlands and Islands in the 2023-24 academic year. Since the programme was established in 2017, we have seen a fantastic increase of 34 per cent in intake.

Although we are committed to investing in reforming the NHS and social care systems nationally, we are fully aware of the challenges of rural healthcare and are responding to them.

Women’s health is a key priority for the Government, which is why Scotland was the first country in the UK to publish a women’s health plan in August 2021. Our ambition is to have a Scotland where health outcomes are equitable across the population, so that all women, regardless of where they live, enjoy the best possible health throughout their lives. There has been substantial progress since publication of the plan. There is now a specialist menopause service in every mainland health board and a buddy support system in place for island health boards. We have initiated new research on endometriosis, launched a new women’s health platform on NHS Inform and increased access to bridging contraception in community pharmacies. However, of course, there is still much to do. I hope that those are important and welcome first steps.

Although a formal review of NHS Highland’s gynaecology services is under way, the board has set up additional capacity for outpatient and theatre treatment. That will provide much-needed capacity across Caithness general hospital, Belford general hospital, Lawson memorial hospital and Raigmore hospital.

I thank our exceptional health and social care staff, who make an incredible contribution to keeping us safe, especially under the current challenging conditions and especially where challenges can be exacerbated by remote and rural geography. I am also grateful to the petitioners for taking the time to bring the petitions to our Parliament.

I am happy to take questions on those matters and any others that members wish to ask.

I will bring in Sir Lewis Ritchie shortly. It is a good question. We know that multiple good innovations are taking place across a number of health boards in remote and rural Scotland. Doing that work more collaboratively might bring a better return for those health boards. Essentially, it could be really helpful for the centre for excellence to multiply those innovative practices across remote and rural Scotland. Sir Lewis might be able to talk more about that, as he was deeply involved in the genesis of the idea for a centre for excellence, which is about sharing effective practice, data and evidence, and supporting boards to deliver a stronger collaborative response to concerns.

The biggest concern by far that I have heard from health boards in remote and rural locations is around recruitment and retention of the workforce. That tends to be the biggest challenge, and the centre for excellence can help in that regard. NES has agreed to host the centre, which makes sense, given its education and training remit. It is a natural fit.

Understandably, the big question is about funding. As you know, convener, we are in discussions about the 2023-24 budget. I will not pre-empt the conclusion of that budget process, but I have asked for a proposal on how much the centre would require in 2023-24 to make progress. I am still waiting for that information to come back from NES; I expect it shortly and will consider the proposal with an open mind.

I will pass over to Sir Lewis, who has been deeply involved in work on the centre.

Let me try to give a few solutions, if I can. Dr Gulhane is right, workforce recruitment, plus the retention of that workforce is exceptionally important. There are a few things that we are trying to do. First and foremost, we have a good record in recruitment and staffing. I referenced some of that in my opening statement. However, I do not disagree with Sandesh Gulhane that the vacancies are far too high. I look at the vacancy rates around nursing and midwifery in particular and they are clearly far too high. We have to try to resolve that.

I have often said in the chamber that we must consider recruitment and retention as separate workstreams, although they are interlinked. There is no point filling the leaky bucket; our recruitment record is good, we must ensure that our retention record is just as good. We start from a strong position, with that increase of staffing of almost 28,900 since 2006 and our having more GPs per head than anywhere else in the UK and more nurses per head than other parts of the UK.

Dr Gulhane talked about solutions. What are we trying to do about it? I will come to retention shortly, but I think about there being a three-pronged approach to recruitment. The first prong is the pipeline: we are ensuring that our pipeline of graduates coming through the system will match our demand for the future. For example, we have made commitments for the medical workforce and fulfilling the commitments to increase them by 100 per annum over the course of the parliamentary session—so, 500 by the end of the session. So far, we are not just meeting, but are exceeding that target—there have been 10 consecutive years of growth, as I mentioned.

The second prong is domestic recruitment, and by domestic I mean right across the UK. We have a very proactive campaign under way to recruit GPs, which has a focus on recruiting to remote and rural Scotland from other parts of the UK. I make no apologies for that, because remote and rural parts of Scotland are very attractive places to work.

The third prong is the international recruitment piece. You ask about solutions; there is £8 million to try to recruit 750 nurses, midwives and AHPs, but that is not a panacea. I will not suggest to you that international recruitment will resolve all the challenges that we face around the workforce, but it can make a difference as part of that three-pronged strategy. I engage with remote and rural health boards, and they believe that we can get more advantage than we currently get from international recruitment, particularly in remote and rural areas.

We are doing a lot on retention. I attended a nursing round table with the Royal College of Nursing, and a couple of members who are at this table were there. Gillian Mackay was certainly there, and she will remember a nurse’s comments about retiring and being rehired. The inflexibility that existed there meant that she was going to leave the health service altogether. That is a huge loss, because she had well over three decades of experience. That was fed back to the chief nursing officer who, I am glad, working with the RCN and others, has in place an updated retire-and-return policy that has been welcomed by much of the workforce.

The BMA, which is another trade union or professional body, has called for a direct pension scheme. It has called for an employer pension contribution recycling scheme to be developed to deal with some of the pensions disincentives that exist in the system. A direct scheme was very much in our gift, so we have devolved that to health boards, and direct schemes have been live in health boards across the country since the end of December. More can be done on pensions, and I welcome what the UK Government has done thus far, but the BMA is calling for it to go even further, and we support that call.

I have taken up a fair bit of time on that answer, but I could speak to more that we are doing on recruitment and retention. Much of it is geared towards helping our remote and rural health boards.

I will get you the latest position. Of course, choice is good only if people are offered it.

We do not create new agencies, organisations and institutions lightly. That is partly because we do not want to clutter a landscape that you could argue already has a fair bit of bureaucracy around it, but also because there are financial resource implications to which we have to be alive and alert, which we all are, particularly given the current pressures.

I am invested in and committed to the centre for excellence, which we have already spoken about. That can help us with some of the challenges in remote and rural Scotland. I do not think that it would have an advocacy role. I do not intend to create an agency that advocates for patients, although we have committed to a variety of commissioners already in this parliamentary session. Carol Mochan will know the work that we are doing on patient safety and patient safety commissioners.

I know that it will be a disappointment to the petitioners but, at this stage, I am not looking to create a new agency that works on advocacy. However, the centre for excellence can play a critical role in helping us with remote and rural healthcare.

Yes. It is given to me by some of the financial experts and analysts we have in the Scottish Government. They look at what the inflation level was when the budget was first set and what it was at the time we made that statement. Obviously, inflation fluctuates, but those figures were arrived at when inflation was at its peak. I am happy to provide more detail to Dr Gulhane if he wishes and to give him the full analysis and breakdown of that £650 million less that our budget is worth. I am confident in the figure.

I can provide a written update to Emma Harper on that specific issue.

We are very alive and alert to the issue of midwives in remote and rural Scotland. Emma Harper will know about the distance learning course that we are now running, which came on the back of engagement and discussions with rural and remote health boards.

The course for nurses to qualify as midwives is running for a second year at Edinburgh Napier University. My understanding is that the short midwifery programme allows students to fully qualify as midwives in just 20 months, so it is a really good course.

The percentage of nurses from remote and rural health boards who were enrolled on the distance learning course was 47 per cent, so almost half of the entire intake was from remote and rural health boards. That figure has now increased to almost two thirds—65 per cent of the students on the shortened midwifery course come from remote and rural health boards. Distance learning is an advantage for them because they can remain within their board.

We are doing a lot—that is just one example in relation to the nursing midwifery side of things. On Emma Harper’s specific point, I will send a written update to the convener.

That is a great question, and it is why so much of our focus has been on growing multidisciplinary team staffing in general practice and beyond, in primary care and other parts of the health service. Our ultimate goal is to ensure that people get treatment at home, if possible, or as close to home as possible. I would argue that that is just as important, if not more important, in remote and rural settings, given the challenges to access to secondary care. The focus on primary and community care is exceptionally important in that regard. A lot of our focus has therefore been on growing multidisciplinary teams, and the number of people in those teams has grown to more than 3,220 in the past number of years.

On the preventative side, we can focus on investment in allied health professionals. Clearly, if someone gets access to an allied health professional before their condition becomes a lot worse, there might be a lot of benefit in that from a preventative perspective. I have always been incredibly impressed by how much our advanced nurse practitioners can do, so embedding them in community facilities, particularly in primary care, can really help us.

I just want to make a final point, which Gillian Mackay made in her question. In the health service, we often have to deal with the immediate, so let us deal with the immediate winter pressures that are in front of us. However, I am keen that we, as a Government, never lose sight of the importance of the preventative agenda. I focus on that regularly, as I am sure members can imagine. Although we have had to deal with and prioritise the difficult challenges of the pandemic, we do not want to lose any focus on the excellent preventative work that we are doing on obesity, mental health, smoking cessation, alcohol and drugs, healthy living and so on. Maree Todd, as the minister with responsibility for public health, is leading on that, and—as members may imagine—she is driving that work forward at pace.

Sir Lewis Ritchie wants to comment on that, so I will let him come in next.

It is fair to say that, in my session with the committee last week, there was rightly quite an intense focus on capital infrastructure. I can point to investments that we have made. Dr Gregor Smith mentioned a couple of new hospitals that we built and opened last year—I was very pleased to be a part of that. There is absolutely a role for what we might colloquially call shiny new buildings that are built to the best standards to accommodate the equipment and the technology, and meet best access standards, net zero ambitions and so on. Communities will always welcome such buildings. However, there is also a significant need for refurbishment of our NHS estate.

I think that, last week, Tess White referred to the significant refurbishment backlog. The Government is committed to significant investment in that refurbishment, and that investment has to be not only at our large acute sites—although many of them need refurbishment—but at some of the local community facilities.

I will answer the two questions and, again, I will be happy for my colleagues to come in. The pandemic necessitated not just the use but, frankly, the explosion in the use of digital technology, and we want to retain that where possible. Members often speak to me about some of the challenges that their constituents articulate to them about access to local GP services. I have always maintained that GP access should continue to be a hybrid model. Where people need to be seen face to face, that should absolutely happen. However, it is no bad thing to embed the use of technology such as video and telephone consultations.

The member knows about the growth in the Near Me system, and he will know that we have a digital healthcare strategy, which I am sure he has seen. I have often referenced the strategy in committee appearances, and I commend it to everybody. It talks about some of the forward thinking that we are doing on the use of digital tech. A recent example—it is small scale, but it is important—is the launch of the NHS 24 app during this winter. It is a minimum viable product, but it will grow and evolve as time goes on, and it could be another tool in the toolbox to try to ensure that people get the right care in the right place at the right time.

I could go on for ages about the importance of digital tech, which clearly can make a big difference in remote and rural healthcare. I could give numerous examples of how we are deploying digital technology in remote and rural health settings. A number of campaign groups that I have spoken to have told me that that is significant and important to them. Clearly, however, the expectation is that anybody who needs to be seen face to face will be seen face to face. If that is not happening, I would be concerned.

On reliance on technology, we are cognisant of digital exclusion, and we clearly reference that in our strategy. We have to ensure that alternatives are available for those who are unable to connect digitally. The Government’s number 1 priority is to ensure that everybody right across the country has appropriate connectivity. While that investment is being made, it is about making sure that we have alternatives to digital available.

I think that both my colleagues want to come in, with the convener’s permission.