Meeting of the Parliament

Meeting date: Thursday, May 10, 2012

Official Report 1109KB pdf

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Dewar Report (Centenary)

The final item of business is a members’ business debate on motion S4M-02016, in the name of Dave Thompson, on the centenary of the Dewar report. The debate will be concluded without any question being put.

Motion debated,

That the Parliament congratulates the Dewar 2012 Committee on organising a programme of events and a touring exhibition to commemorate and raise awareness of the centenary of the publication of the Report of the Highlands and Islands Medical Service Committee, the Dewar Report, by Inverness MP, Sir John Dewar; notes that the report shocked contemporary politicians with its portrayal of the inadequate provision of health services in the Highlands and Islands; recognises that the report resulted in the establishment of the Highlands and Islands Medical Service (HIMS), which it considers transformed the medical service in the Highlands with its commitment to high quality health care, its bottom-up structure and its careful consideration of the needs of rural health care, and considers that HIMS was the first model of state-funded healthcare in the world and provided the blueprint for the NHS in Scotland.

17:08

In the first few decades of the previous century, a Welsh MP and Chancellor of the Exchequer introduced a string of reforms that tackled social inequality and delivered welfare provision to men and women across the country. David Lloyd George’s welfare reforms should be compulsory history reading for every school pupil, followed by a chapter on William Beveridge’s proposal for the welfare state and a chapter on Aneurin Bevan’s establishment of the national health service. I applaud those men for not being so obsessed with power as to be oblivious to injustice, or so concerned with Parliament as to forget the needs of the people.

However, there is one important chapter in the history books of welfare and social injustice that also needs to be read, and it is entitled “Sir John Dewar and the Highlands and Islands Medical Service”. This year, we celebrate the centenary of state-funded medical care because—contrary to popular belief—it was neither Beveridge nor Bevan who spearheaded the free, local and accessible healthcare system that we call the NHS. In fact, more than 30 years before that, the blueprint was drawn in the Highlands and Islands by the MP for Inverness-shire, Sir John Dewar.

At the turn of the 20th century, the Highlands and Islands were extremely impoverished; their inhabitants lived in poor conditions without access to transport, to medical services or even to adequate food. During his committee’s tour of the Highlands and Islands, Sir John Dewar conducted a series of meetings with local residents to ascertain the needs and requirements of the people—a bottom-up approach that we should emulate today. Sir John documented his findings in a report that became known as the Dewar report, and proposed the creation of the Highlands and Islands medical service.

The Highlands and Islands medical service enshrined three inspirational principles, which we still commend today: the right of every individual in society to local and accessible healthcare, the responsibility of the state to provide healthcare to every individual, regardless of their ability to pay, and the importance of delivering good-quality, well-organised and satisfactory medical services. Sir John’s recommendations were accepted in their entirety by the Government and they revolutionised medical care in remote and rural areas.

Historians accept that the Highlands and Islands medical service was well ahead of its time. By 1929, there were 175 nurses, 160 doctors and 150 practices in the Highlands and Islands, and in 1935, the first air ambulance service was established. In 1948, the national health service brought together services that had previously been provided by a combination of the Highlands and Islands medical service, charities and private organisations.

The NHS in Scotland has been very successful. I believe that that is because it has not deviated from the basic principles and values that were enshrined in the Dewar report. As NHS Scotland watches its southern sister suffer at the hands of a United Kingdom Government that does not seem to value the principles that were enshrined in the Dewar report, or to remember the history that gave birth to the NHS, we in Scotland can be relieved that the Scottish Government has a very different attitude.

The most appropriate way to celebrate Sir John Dewar, the Dewar report and the Highlands and Islands medical service is to continue the good work that was begun 100 years ago. As we consider how to protect and improve medical services throughout Scotland, we already have the foundation of having an exceptionally good model on which to build; as we update the NHS to meet the demands and needs of the 21st century, we must not discard the building blocks of the Dewar report. The NHS in Scotland must still be accessible to every individual in society, irrespective of geographical location, ability to pay or medical needs.

It is because of my firm belief in free and accessible local healthcare that I lodged a parliamentary motion on the centenary of the Dewar report. In my constituency of Skye, Lochaber and Badenoch, there are many remote and rural communities that bring challenges to delivery of healthcare, just as they did in Sir John Dewar’s day.

Last year, I spoke to Dr Stephen McCabe, who is a doctor based in Portree—I think that he is in the gallery today. He has been active in promoting the centenary, as have Dr Miles Mack of Dingwall and Dr Jim Douglas of Fort William, who are also constituents of mine. Indeed, the Dewar committee is holding a reception after the debate, to which all members are cordially invited. Dr McCabe told me that many of the issues that Sir John Dewar highlighted in 1912 were still evident when he came to Skye in 1996 and are still evident. The challenges include lack of employment opportunities, poor public transport, poor housing and rural poverty. Although many of the issues are masked by a stunningly beautiful landscape and hard-working people, Dr McCabe comes face to face with the challenges of healthcare provision in remote and rural communities every single day.

Many communities in my constituency have the same problems as Skye has. Just this week, I have raised with NHS Highland the difficulty of retaining medical staff in Ardnamurchan, following the resignation of the two general practitioners and the practice manager at Acharacle, partly because of the problems of providing a GP service in such a remote and sparsely populated area.

In Scotland in the 21st century, we need to ensure that we stay true to the foundations of the national health service. We must be careful not to overlook rural medical needs in favour of urban environments, in the rush to make savings. We need to ensure that medical care is easily accessible, while taking into account the longer and more expensive travel that is required in remote areas. We must work hard to deliver health services that are fit for purpose with adequate resources and professional staff.

Protecting, improving and providing medical care in Scotland requires a collaborative relationship between healthcare professionals and politicians. I value that relationship with doctors and healthcare professionals in my constituency and I hope that, together, we can build up our health services to a standard that would surprise even Sir John Dewar with their accessibility, efficiency and quality.

17:15

I thank Dave Thompson for bringing the debate to Parliament. I was born and brought up in rural Inverness-shire, blissfully unaware of the Dewar report. The education authority was fixated on the Roman and Norman invasions, so the teaching concentrated on those issues. That was a lost opportunity, because Sir John Dewar would have been an excellent role model for us all, so I am grateful to Dave Thompson for highlighting the issue. Lloyd George is to be commended for setting up the Dewar committee. The terms of reference clearly indicate the humanity that underpinned the process.

I am grateful to the British Medical Association for the briefing that it has provided, and which makes terrible reading in that it describes appalling squalid conditions, malnourished children and high infant mortality. Those aspects, and the fact that one in five deaths went uncertificated by a doctor, is what concerns me. Certification is not a cold administrative process—we value life by determining issues about death.

It would not have been called a road show or focus groups, but the Dewar committee went on a tour and took evidence. It would have been fascinating to listen to that. We cannot change the geography of the Highlands and nor would we seek to do so; people have a right to live and prosper in challenging environments. The Highlands and Islands are full of vibrant communities. As the Dewar report indicated, the Government has a duty to provide and, as Dave Thompson eloquently said, parties across Parliament support the work of the NHS in Scotland.

I am proud that the report introduced the first public healthcare system in the world and that it formed the basis of the start of the NHS in 1948. I wonder what Sir John Dewar would think of the service today. We had a temporary blip yesterday, with the air ambulances being out of service and cover being provided by the military and the coastguard. He would have felt that such provision goes a long way towards dealing with the transport problems to which Dave Thompson alluded.

We still have poor housing and poverty, and rural deprivation is not always recognised. As has been said with reference to west Ardnamurchan, the delivery of healthcare remains challenging, and that is also the case in Wester Ross. Clearly, we cannot have a specialist in every town or township, so people’s expectations must be realistic. However, there are creative ways of meeting the challenges, and the Cabinet Secretary for Health, Wellbeing and Cities Strategy has addressed the issues in those locations.

The equal top measures in Oxfam’s humankind index are “Affordable, decent and safe home” and “Physical and mental health”. Dave Thompson talked about free and accessible healthcare, which we should strive to ensure remains a foundation stone of Scottish society. Sir John Dewar served as the member of Parliament for Inverness-shire from 1900 to 1917; what parliamentarian would not wish for the legacy that he left through the report that was produced.

17:19

I congratulate Dave Thompson on securing the debate. I confess that, despite being a doctor, I was not aware of the Dewar legacy until last year, when David Stewart lodged a similar motion. At that time I took the trouble to look up the issue.

When, in 1851, the Royal College of Physicians of Edinburgh carried out an early investigation into the deficiencies of medical provision in the Highlands and Islands, it found that only 62 of 170 parishes had a resident doctor and that 41 parishes could be

“regarded as destitute of medical aid”.

Sir John Dewar’s report in 1912 was the world’s first analysis of health provision in rural communities, and the analysis and recommendations in that Edwardian study remain just as pertinent in current debates about providing healthcare to Scotland’s rural communities. Dewar’s principal recommendations included better training for rural doctors, better use of transport and technology, and guaranteed minimum levels of service provision for rural populations, despite geography. However, the Highlands and Islands medical service was not established until 1923 and Sir John must have been as concerned as some of us are today about the rate of progress that can be made on such matters. It is not easy for Governments to make changes, although I have to say that 11 years seems to be a rather long time to take to introduce such a service.

I agree with Dave Thompson that the HIMS provided the template for the future NHS. Interestingly, Ernest Beveridge, who was a Liberal, was the research assistant for Sidney and Beatrice Webb at around the time the Dewar report was being formulated and might well have picked up from that some of the material he subsequently translated into the reforms that Aneurin Bevan took forward and which resulted in one of the world’s greatest social creations.

Current healthcare provision problems in remote and rural Scotland include recruitment, retention and, as John Finnie pointed out, increasing specialisation across the professions. I know that general practice is a recognised specialty, but it is difficult to take the approach to generalism in rural general hospitals.

Through the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians, Australian and Canadian general practitioners have led the world in defining modern rural practice and the training that is required. WONCA’s working party on rural practice has gone a long way in that direction and has given us some suggestions about what should be happening.

In Norway and Sweden, rural healthcare is underpinned by telemedicine and a well-organised transport infrastructure, including fast boats. I know that we are endeavouring to increase the use of telemedicine in our own setting. The centre for rural health, which was set up by Labour, has been continued by the current Government and important managed clinical networks have been developed in the Highlands. Medical and communications technology have been improved, emergency response times have been maintained by community first responders, defibrillation teams and rural GPs attending road accidents and—as far as coronary disease is concerned—emergency call-to-needle times are being reduced by paramedics giving pre-hospital thrombolysis supported by telelinks to coronary care.

However, it should be pointed out that rural general hospitals in Shetland, Orkney, Stornoway, Fort William, Oban and Elgin are having problems in maintaining consultant-led services because of the increasing specialisation that I mentioned, the European working time directive and the reduced training time for consultants, which means that consultants who come through now are less experienced than those in the previous generations. Although all those elements raise challenges, they also provide hope for the future provision of healthcare in remote and rural Scotland.

The Government’s 2008 report set out what I thought were very challenging implementation plans and tight timescales, and I wonder whether the cabinet secretary will tell us whether all the dates, none of which went beyond December 2009, were met, and whether she will place in the Scottish Parliament information centre details about the plans’ implementation.

Presiding Officer, I apologise for going on a little longer than usual. In conclusion, I believe that remote and rural healthcare will continue to be a challenge and that the integration of services for health and social care will be as important in those settings as it will be in more urban settings. Although we owe a debt to Dewar, we also owe it to today’s communities to strive for better services now.

17:24

I congratulate Dave Thompson on securing the debate on the centenary of the Dewar report. It has been an educational experience for me, as it has been for the other members who have mentioned researching their speeches. I was unfamiliar with the Dewar report until fairly recently.

I have not just learned more about the Highlands and Islands medical service and its role as a model for our NHS; I have also learned something about Scottish film history, because one of the best sources of information about the Dewar report is the 1943 film “Highland Doctor”, which was filmed on the islands of Lewis, Harris and North Uist, and on the mainland at Ullapool, Inverness and Dingwall. It was directed by Kay Mander, who settled in Castle Douglas in Dumfries and Galloway, which is one of the areas of South Scotland that I represent. She was one of the first female film-makers and helped to shape British documentary film-making in the 1930s and 1940s with the dramatised documentary format.

The film “Highland Doctor” was used for overtly political reasons—to make the case for the NHS, which was obviously very successful a few years later. It opens with an old Highland doctor, played by Alexander Mackenzie, describing practice in the Highlands before the Dewar report transformed the service. He describes vividly his patients being scattered around the country like threepenny bits in a Christmas pudding. There is footage of doctors travelling along dirt roads in pony traps, signalling to patients on islands using semaphore, and hiring rowing boats to attend emergencies.

We can see that the film-makers paid close attention to the evidence that was led in the Dewar report, because the report is now available online. Some of it makes for quite startling reading, as John Finnie said. I will take the liberty of reading out a little bit. Dr Bremner of Sutherland said:

“When I go to the west (of Sutherland) the people flock round me. It is difficult to get away.”

Dr Leach of Beauly said:

“Honest people, if they cannot pay for his services, won’t send for a doctor until it is too late.”

Dr Maclennan of Thurso said

“I might mention that one finds generally that a large proportion of non-attendance exists among children.”

The Highlands and Islands medical service put an end to all that and we should constantly remind ourselves of that.

I also congratulate the committee that is organising the Dewar centenary. It is worth drawing attention to the fact that many of the members of the committee are rural doctors who are committed to rural healthcare, and many of them are members of the remote and rural health education alliance.

As other members have mentioned, although the healthcare landscape in remote areas has improved beyond measure in the past 100 years, some familiar problems remain—for example, recruitment and retention of staff.

Some members will have had time to look at the 2010 final report of the remote and rural implementation group that was formed to oversee implementation of the recommendations of the Scottish Government’s “Delivering for Remote and Rural Healthcare” report. It highlights some achievements, including the development of an education and performance management framework to ensure that services in remote community hospitals can be delivered, the establishment of the aerial medical emergency retrieval service, and the establishment of new specialist training programmes in remote and rural general surgery, anaesthesia and general medicine. It concludes that many of the targets that were set by the implementation group have been met, but highlights the work that still needs to be done.

There is always work to be done, particularly when budgets are under considerable pressure. However, I have every confidence that today’s rural medical professionals, like those of the Highlands and Islands medical service, will continue to do their utmost to deliver for patients, and that the NHS in Scotland will stay true to the universal principle that was first laid down in the Dewar report.

17:29

I have to be honest and say that I have rarely found an opportunity to thank Dave Thompson for anything, as he knows, but today is different. It is worthy for a member’s business debate to commemorate the centenary of the Dewar report, and I thank Dave Thompson most kindly.

I welcome visitors to the gallery—there are one or two familiar faces there, including Miles Mack.

I also acknowledge today’s challenges, particularly, as the health secretary knows, in relation to Ardnamurchan.

The motion is fairly polite and diplomatic in stating that

“the report shocked contemporary politicians with its portrayal of the inadequate provision of health services in the Highlands and Islands”.

It certainly was inadequate. Many crofters and their families could not afford medical care and treatment, and general medical practice rested largely on minimal subsidies from the poor law authorities and other public authorities. The Dewar report states that

“the remuneration from these various authorities bears no proper relation to the work done or to the degree of responsibility involved.”

As a result, as Joan McAlpine outlined, individual practitioners were discouraged and medical services as a whole suffered.

I found the Dewar report interesting. I did not expect to read as much of it as I did. One of the most harrowing parts of the report is part 4, on evidence of the inadequacy of medical attendance relating to uncertified deaths. Figures provided by Dr Macdonald, medical officer of health for the county of Inverness, confirmed that, out of a total of 3,825 persons who died, 1,821 had not received medical attendance for some time prior to their death. That means that 47 per cent of those who died had received little or no medical attendance. At a time when, in the whole of Scotland, the average percentage of deaths that were uncertified was 2 per cent, in Uig it was 69 per cent, in Shieldaig and Applecross it was 78 per cent and in Coigach and Lochbroom it was 81 per cent. In the parish of Kilchoan, in Ardnamurchan, between 1907 and 1909 the total number of deaths was 33 of which 30 were uncertified and only three were certified by a doctor. Dr Macdonald of Inverness also stated that the deaths were among very young people—children—or very old people and were due, to a large extent, to poverty and inaccessibility.

Another part of the Dewar report that I found interesting was under the heading “Qualifications of Nurses”. Under the subheading “Maternity Nurses”, the report states:

“These are women—generally widows—who have attended a course of lectures and have conducted a certain number of confinements under the supervision of a medical man or midwife attached to a teaching institution ... The duration of the courses, both theoretical and practical, is three months.”

“Cottage Nurses” trained

“for a period varying from six to twelve months”

and “Fully Trained Nurses”

“had three years’ hospital training in a recognised hospital of not less than 100 beds”.

The Dewar report highlighted the inadequate number of nurses and the need for efficient nursing for

“(a) The birth and infancy of children.

(b) The “following up” and treatment of diseases and defects in children as disclosed by school medical inspection.

(c) Promoting among the people a knowledge of personal and household hygiene, dietary, etc.

(d) The earlier detection of illness.”

The outcome of the chapter was a recommendation that

“all existing voluntary nursing agencies,”—

many of them were charitable—

“where practicable, be organised under a county or district scheme”

and that nursing be an integral part of the medical service. We cannot imagine otherwise today. It was also recommended that suitable houses be provided for the nurses and that telegraphs/telephones be made available to them and to Scottish hospitals.

Those recommendations and many others more than justified the committee of seven men and one woman going out on foot, on horseback and by boat to 17 remote locations from Argyll to Shetland and from the east Highlands and highland Perthshire to the Western Isles. With doctors guaranteed a minimum salary and reimbursement of travel, and with a guarantee of involvement in public health, school work and attendance at childbirth, the service was formed in 1913 with a grant of £42,000.

Without any shadow of doubt, the Highlands and Islands medical service revolutionised healthcare for more than 300,000 people on half the landmass of Scotland. Unlike other local medical schemes, it was directly funded by the state and administered centrally by the Scottish Office in Edinburgh. By 1948, it had already been providing comprehensive healthcare for 35 years when the rest of Britain was about to experience a national health service for the first time.

17:35

I congratulate Dave Thompson on enlightening me and others about the Dewar report. I have lived in the Highlands for only the past 40 years rather than for 100 years, and those 100 years have been fascinating and the history is quite different in many respects from that of other parts of Scotland.

Many reports and books have been written, some of which are told from a crofter’s point of view. I think that I am right in saying that there are a couple of books from that period and earlier by the Highland doctor, most of which are fairly amusing. The doctor may have had a hard time, but there were often great stories to be told, and those books probably reflect life in the Highlands better than anything.

I remember reading that, at the time, if money had to be paid for a fee, it was more likely to go to the vet than to the doctor, but the vet was known to treat ringworm in children as well as in cattle. We have—thank god—moved on from those times, and much of what was in the Dewar report has come to pass. However, we still face difficulties in creating and delivering a universal health service in remote and rural Highland.

We can be optimistic about two things, one of which is the future of telemedicine. Although people groan and say, “We don’t like change,” and, “Change comes hard,” we can, by enabling self-empowerment in health, face the challenge of becoming a healthy nation. Many of the health issues across the Highlands are to do with conditions that we can challenge as communities and as individuals. That is not to say that we do not need doctors, but it is possible to achieve general health in the Highlands, and there are many opportunities for us to live healthy lifestyles.

In the 100 years since the Dewar report, depopulation has taken place, with occasional blips when there has been growth in large industry. For example, the oil industry in Shetland, the post-war developments in Dounreay and Caithness and the smelter in Invergordon created populations who moved there for the work. The second cause for optimism is that, in the past few years, there has been, for the first time, a genuine increase not only in the population, which has been increasing for the past 12 years, but in the birth rate. For me, that is a real signal that the Highlands have become an attractive place in which to live and work, and health and living in rural communities that are not unused to having to make things work for themselves are part of that image.

There are many other services that we might consider to be universal that are not delivered to every corner. We would not expect them to be, nor should we pretend that we can do that. However, we can inspire healthy communities, and Highlands and Islands communities will generally respond positively when they are offered such opportunities.

I will cite—as I have done previously in the chamber—some of the research carried out by Dr Jane Farmer at the University of the Highlands and Islands. I know that the research did not work everywhere, but where it did work we found that, where 20 people had been upset at the withdrawal of a social service—whether that was in the form of a lunch club or whatever—suddenly 60 people were doing things for themselves and increasing and looking after their own health. We know that the existence of certain regulations can be a barrier to that. I know a couple of old crofters who have been crofting all their lives and are nervous of regulation and other things with which they feel they can no longer cope. Their sheep and lifestyle are probably what keep them healthy.

For the next 100 years, I would like those of us in the Highlands and Islands to consider what we, as communities, can do and how we respond to one another. That is what brings many people to live and work in the Highlands and keeps many people there. We do it really well when we get it. When the community grasps that we can be in charge of 50 per cent of our health ourselves, another report—perhaps in 50 years’ time—may provide a different reflection on the health service that we need to deliver.

17:40

I am delighted to have the opportunity to participate in the debate. Like other members before me, I congratulate Dave Thompson on bringing the topic to the Parliament and giving the Dewar report the profile and recognition that it deserves. I also thank all members who have participated in the debate.

I also welcome the doctors who have joined us in the public gallery. I know, not least from the fact that I follow some of them on Twitter, that they have been doing a fantastic job of promoting the centenary of the Dewar report. I thank them sincerely for the work that they, like Dave Thompson, have done and continue to do to raise awareness of the report, the significance that it had 100 years ago and the significance that it has today.

The debate has been very good. There is a real sense of history about it. Each of us—not only people from the Highlands and Islands, but everybody in Scotland—should take pride in the place that the Dewar report and the Highlands and Islands medical service have in the history of our national health service. Given the defining impact that the report had, it is right that we celebrate its centenary and give it the recognition that it deserves.

Like others who have spoken in the debate, I managed to get through my primary, secondary and tertiary education, as well as nine years in the Parliament, without knowing about either the content or even the existence of the Dewar report. It was not until, as Cabinet Secretary for Health and Wellbeing, I was preparing for the NHS’s 60th anniversary celebrations that I became aware of the report and the Highlands and Islands medical service. I was completely fascinated and blown away by what I learned at that time.

If we can and should do one thing to celebrate the report’s centenary, it is to resolve and pledge individually and collectively that future generations of Scots will know about the report and the Highlands and Islands medical service and will know about and be proud of the way in which they paved the way for our national health service. That would be an important legacy of the centenary celebration.

As others have said, the report was, in many ways, shocking. It gave politicians of the day a real jolt. It also—I say this not only because doctors are listening in the public gallery—demonstrated the leading role that doctors have played, and continue to play, in the drive for social justice.

For all those reasons, we should celebrate the centenary with pride, but I will isolate two overriding and overarching reasons why the celebration is so necessary and appropriate. First, without a shadow of a doubt, the Dewar report set down solid foundations for the provision of healthcare for people who live in remote and rural areas. Let us never forget that, today, that means one in five of all of us who live in Scotland. Those foundations continue to have resonance today. Secondly, as others have said, the Dewar report paved the way for the NHS that we know today. For that reason, it is no exaggeration to say that Sir John Dewar should be seen alongside Nye Bevan as one of the founding fathers of our modern national health service.

The debate is partly about history, but it is also about the present and the future. The principles and recommendations of the Dewar report still inform our approach to rural healthcare today. They underpin the principles in “Delivering for Remote and Rural Healthcare”, the strategy that we published back in 2007. As John Finnie and others said, delivering healthcare in remote and rural areas was challenging, remains challenging and will probably always be challenging, but there is no doubt that the Dewar report can claim to be the philosophical driving force behind so many of the changes that have been made in the past five years.

Some of those changes have been mentioned in the debate; for example, telemedicine was mentioned by a number of members. However, the two changes that I want to highlight today, because I believe that they have been transformational in the way in which we deliver services, are the emergency medical retrieval service and the embedding in our national health service of six rural general hospitals. They provide sustainable models of care so that people can be clear about the conditions that can and will be treated locally.

The emergency medical retrieval service was piloted and then rolled out across all of remote and rural Scotland in 2010. I guess that Sir John Dewar would have thoroughly approved of the service, but he would probably have been astounded by our ability to deliver such a service. It is something of which we should be extremely proud.

There is no doubt that remote and rural healthcare has come a long way since the Dewar report was published 100 years ago but, equally, there is no doubt that without that early and, at the time, shocking report, we would not have seen many of the changes and developments or much of the progress that we have seen—we would not be where we are today.

The second reason why we should celebrate the Dewar report is that it paved the way for the institution that we all love so dearly—the national health service. The Highlands and Islands medical service was not just the first model of state-funded health care in the United Kingdom but the first model of its kind anywhere in the world. It was the blueprint for the modern national health service.

Our model of publicly funded and delivered healthcare is not perfect. No system of delivering healthcare is perfect. However, I can say without any doubt that I believe that our model of healthcare is the best in the world, and I am extremely proud of it. It is called into question in other parts of the United Kingdom, but I believe that the commitment to that model of healthcare on the part of this Government, this Parliament and this nation is unshakeable. Let the final thing that we do in this debate to celebrate this important anniversary be to reaffirm as a Government, a Parliament and a society the precious principle of a universal health service that is free at the point of need and publicly delivered. On behalf of the Scottish Government, I reaffirm that loudly and clearly.

Many thanks. I now close this meeting of Parliament.

Meeting closed at 17:48.