Hansard

I am grateful for the opportunity to praise the fantastic work that general practitioners and their staff do all over Scotland. I thank the members who signed the motion in my name and who have remained to speak in the debate.

Throughout Scotland, from single-handed rural one-person GP surgeries to busy multipartner practices, which are mainly in our cities, the whole range of practices provides an excellent service to us. I make no apology for approaching the debate from a rather biased perspective as, in a former life, I was a GP for 30 years. I declare that I am a member of the British Medical Association, which promotes general practice week, and of the Royal College of General Practitioners.

Many MSPs have had the opportunity to visit GP practices in their constituencies in conjunction with the BMA and have found that useful. General practice week aims to build on the positive feedback that was received about those visits.

Last year was busy for general practice, not only because of the recent prolonged cold weather, but most notably because of the increased pressures from the swine flu vaccination and pandemic. That is just the most recent demonstration that GP primary care has proved over the years to be the part of the national health service that is most capable of a rapid and flexible response.

The BMA's document "General Practice in Scotland: The Way Ahead—Final Report", of which members should have a copy, spells out a clear vision for the future of general practice. From about 120 responses to the association's consultation, the BMA felt that six key areas needed to be addressed to ensure that general practice meets the aspirations of patients in the community. Those are access, out-of-hours care, health inequalities, workforce planning—the right workforce as it is called—the balance of care, and infrastructure in terms of premises and information technology. I will try to touch on some of those issues.

Don Berwick, the noted American academic, has called general practice

"the jewel in the crown of the NHS",

and, in a recent paper in the British Medical Journal, has said that, if we were to lose the core values of general practice, we would all live to regret that loss. It is hard to disagree with the sentiment.

An effective GP service not only provides rapid diagnosis in an emergency but, by providing continuity in a trusting relationship between the patient and primary care team, is the bedrock for prevention, supported lifestyle changes, self-management of long-term chronic conditions and family support.

Access is a matter for discussion. When I became a consultant psychiatrist, I found that too many practices had used the Scottish flexible approach of the 48-hour target for the time within which a patient has to be seen by a health professional to introduce unacceptable appointment systems. Patients had to phone at 08:00 to get an appointment and sometimes then spent an hour on the phone only to be told that, unless it was an emergency, they had to call again the next day.

It is very important that the Government works with the BMA and the Royal College of General Practitioners to reward continuity and good access systems that suit individual localities. We must tackle the injustices that will arise from responses to poorly validated access questions in the current quality and outcomes framework survey. The QOF survey has done us a disservice in that regard; it has created—reasonably and appropriately—a lot of resentment among general practitioners.

In the main, health mostly does not happen in hospital; it happens at home and in the workplace, school and community. Health is not just about the absence of disease. It is not even just about fitness. It is about the mental and physical wellbeing that gives us the energy, hope and self-esteem to achieve what we want to achieve. Looking after the health of the whole community is the job of general practice, primary and community health services and social services, working together to provide genuinely holistic health services close to home. Health professionals need to be well connected to the other services that are provided in their area, particularly local council services.

There is too much division between health and social services sectors. Indeed, divisions between GPs, hospital consultants, social care workers, public health officials and allied health workers have all deepened. Those divisions have shifted the focus of the professional from the patient as an individual to the part of the patient that the professional is servicing. That does not make it easy for the professional to consider the whole health and wellbeing of the person. I wish the Government success in its integrated resource approach, which is the latest Government effort to achieve integration. I hope that it is more successful than the joint future programme with which the previous Government wrestled over a number of years.

I read this recently:

"Hospitals, as most GPs will tell you, are foreign countries; they do things differently there … Hospital specialists still routinely refer patients to one another without any reference to the patients' GPs, whilst the tendency of hospitals to call patients back for further outpatient consultations repeatedly, even though there is no obvious medical benefit for doing so, is still too prevalent. Encouraging hospitals to do less will require more than just a review of their funding arrangements therefore; it will require a re-examination of the fundamental ethos that governs the working practices of hospitals."

Sadly, we still have a situation in Scotland where the poorer someone is, the less healthy they are. Scotland has pockets of real poverty. Poorer people tend to fall sick more often and have long-term illnesses and long-term poor health. As Professor Graham Watt has urged, if we want everyone to be healthy and if we want to improve the quality of care in our hospitals, we need to ensure that GPs in poor areas are given extra resources with which to do their job well.

Primary care needs modern premises. With capital budgets being restrained, there are serious concerns about the future premises replacement programme. Primary care needs modern IT systems. The demise of the general practice administration system for Scotland—it was almost a national system for Scotland—reflects very badly on our ability to make public sector IT software work. I am concerned that the replacement system may prove as inadequate to the task as GPASS proved to be.

In England, Labour has chosen a combination of approaches, based on patient choice, underpinned by commissioning or purchasing—initially by primary care trusts and then by GPs—and linked to foundation hospitals, which have achieved a level of service and governance, both clinical and financial, that allows them freedom that is not afforded to ordinary NHS hospitals. In Scotland, we have chosen a quite different approach. The challenge will be, with that approach, to match the progress that the NHS in England is undoubtedly making. The intention must be that, eventually, people will expect rarely to see the inside of a hospital. Hospitals will be seen no longer as the centre of the health service but as an essential high-quality—and, no doubt, high-cost—but increasingly smaller backstop for things that cannot be accommodated in the service that is provided in local communities, which is the front line for the new NHS. Everyone will understand that the local services that the primary care team provides bind together—or should bind together—the whole NHS around the individual's personal needs.

It is disappointing that Audit Scotland has been unable to identify much in the way of a shift in the balance of resources to match the intended shift in care. In England, primary care trusts are required to define and finance such a shift in their annual plans. I ask the minister whether there is anything comparable in Scotland.

I commend to members the BMA's final report on general practice in Scotland and look forward to the report by the Royal College of General Practitioners in the autumn. I hope that all of us can work together to resolve issues relating to access, out-of-hours services and the workforce and to create systems that support what all of us seek—a continuing rise in the quality of primary care, so that it remains the jewel in the crown and a world leader.