We now move to members' business. Members who leave the chamber should do so quickly and quietly. The final item of business today is a members' business debate on motion number 13973, in the name of Jim Hume, on promoting sustainable GP recruitment. This debate will be concluded with any questions being put. I invite those members who wish to speak in the debate to please press the request to speak button now or as soon as possible, and those members who are leaving the chamber again to do so quickly and quietly. I now call on Jim Hume to open the debate. Mr Hume, seven minutes please. Thank you very much, Presiding Officer. I welcome fellow members, of course, back for the first members' debate after the summer recess. Unfortunately, I have to bring to the attention of the chamber, as many are aware. There are many issues surrounding the state of our general practices, as we have not seen progress in either the numbers of GPs or their working conditions. Scottish Lib Dems have taken a strong stance and have raised the issue many times. Of course, my colleague Willie Rennie conducted a survey earlier this summer, which uncovered some truly disturbing facts about the moods of GPs and the state of affairs in GP practices across South Scotland and the rest of our country. The issue of GP recruitment and the future of GP surgeries that are faced with a crisis is one that affects the health of nearly everyone. As general practices deliver, 90 per cent of patient care in the NHS receives less than 8 per cent of the NHS funding. Naturally, that has hard-hitting consequences on GPs and the increasing demands that they are facing with increasingly shrinking budgets. Their funding has been facing a near-constant reduction since 2007, from 9.2 per cent to 7.8 per cent in 2013. That has, of course, been further reduced by the inflation of 1.2 per cent. The preventative amounts that the Government is spending, while evidence suggests that investing in GP practices can save the NHS in Scotland around £200 million. In line with its 2020 vision, the Government first pledged in November £40 million for primary care in 2015-16, then said that £50 million will be spent through the primary care fund over three years. That is a reduction of £24 million per year from the amount that was originally announced. One of those elements of the scheme, the pharmacist independent prescribers, promises to recruit 140 new pharmacists. That is 10 pharmacists per health board. I do not deny that that is a welcome start, but it is the first step of a very long journey that will need to ensure sustainability. When we are already seeing health boards taking over GP practices, we need to face the real numbers and see what the real issues are. If the Government does not reverse its spending cuts from where spending cuts are the most hazardous, we will face a 2020 crisis rather than a 2020 vision. The Royal College of General Practitioners has called on the Government to provide urgently a clear strategy for sustainably investing in Scottish general practices. We backed that call today. We also backed the call from the British Medical Association, which has raised a warning flag over recruitment. One-third of GPs are currently considering retirement, while more than one in 10 are planning to move to part-time work. That will leave a number of practices unable to operate. Will the member accept that one of the factors impacting on retirement dates for general practitioners is the change in the lifetime allowance for pensions? That has been encouraging a lot of senior GPs to consider retirement, making problems worse. As far as I recall, the Lib Dems were in government when that was proposed. I can assure you that the replies that we had from GPs focus on far different issues rather than their pensions. We need to look far into the future to see that that is a real problem that is already facing us. 463 practices have at least one GP vacancy, while some have not been able to secure locum GPs for 15 days or more within a one-month period. Practices that are unable to see as many patients as need to be seen, appointments are being slashed, waiting lists for registration are getting longer and people are being sent elsewhere due to the reaching maximum capacity. I want to stress the importance of the issue. The Government risks turning GP services from an accessible first point of contact service for every Scot into an exclusive service that many will not have access to. I want to point out how important it is for the Scottish Government to work constructively with GPs and listen to what they are saying as we are at risk of losing the right to health for all Scots. My colleague Willie Rennie spoke volumes of almost four in 10 GP practices to find their workload unmanagable. Those are the real reasons, Mr Campbell. They also say that this is their greatest challenge. They say that. What is most telling, however, is that 92 per cent of respondents want the Scottish Government's quality and outcomes framework for primary care to be reduced or abolished, which is 92 per cent. Perhaps one of the most worrisome and discomforting facts was that one-third of GPs answered the question of whether they would choose to become GPs again with an unfortunate answer of no. That raises many questions about the future of our GP services. Why is the Scottish Government not ensuring that the right amount of resources is being put where GPs think that it is important? Why are we seeing less GP trainees, less retention of GPs across Scotland? Why are current GPs under so much stress and work pressures that many see their own health deteriorate? When the Scottish Government enables GPs to put professionalism back to the profession, then many of those questions will surely have found their answer. If the Scottish Government wants to listen and implement some substantial solutions, there are a number of recommendations given both by the Royal College of GPs as well as the BMA. Seeing an investment in the tools that GPs have in their disposal to lead the development of new models of care would enable them and empower them to provide better services to their patients. Whether it is the newly announced investment of £500,000, which I did welcome into the programme for improving outpatient services with better technology or enabling GPs to work alongside advanced nurse practitioners in their practices, it is important to recognise the leading role that GPs are playing and must continue to play in communities and urge the Government to improve support and resources to ease the workloads and pressures of general practice. That includes, of course, reducing the administrative burdens. We know that GPs currently work not only more hours than they should during a typical work day, but they are also responsible for the administrative work when the practice closes up for the day. Instead of being forced to do tasks that are not related to medical practice, GPs should instead be able to spend more time with their patients, have closer work and relationships with other professions and be able to face a good interface with other experts who are involved with their patients' care. With the advent of social care and health integration, we can and should prioritise that. I want to close by expressing once more my concern for the future of our general practices in south Scotland and the rest of the country, and also my respect and gratitude to all our hard work at NHS staff and the hope that, by listening to the facts today, the Scottish Government will decide to act to prevent the cornerstone of our healthcare from reaching a crisis. Thank you very much. Now I call on Hans Allan Malik to be followed by Chick Brody, four minute speeches. Thank you very much and good evening, Presiding Officer. I would first of all like to thank Jim Hoog for bringing the debate today here because I think it's a very important debate and I also want to thank the national health service for the service that they currently provide in the danger of me forgetting at the end of my speech. I have to say that the general practitioners survey is a linchpin of the national health service. Therefore, when the British Medical Association stated that the shortfall on our general practitioners would impinge on patient care back in March, I'm surprised that the government didn't respond to that earlier. I think it's important to try and encapsulate the actual difficulties not only our GPs are facing but the public are facing. My colleagues have highlighted the number of issues facing our doctors today, the fact that vacancies are not being filled. I know of a practice in Glasgow where they're looking for somebody to fill a vacancy and they fail to do so up until now and the fact that the morale is very low amongst our doctors I think is quite shocking because we depend upon them to boost our morale. We depend on our doctors to be there for us to ensure that we are not suffering from all sorts of ailments and if they themselves are feeling under pressure, if they are feeling that they have inadequate resources at their hands to treat their patients, then that sends a very, I think, a very poor signal to our citizens. Inequalities in Glasgow are probably the greatest. We talk about services to communities which are sparsely populated, long journeys to travel, people have either patients have to travel long distances or the doctors have to travel the distances and then not to be able to get the service that they are hoping to get at the end of that journey is pretty detrimental. I would have thought for it for any community but also in densely populated areas such as Glasgow. I see more and more people now who are complaining about either not being able to get appointments or when they get appointments they feel that they are rushed in and out of surgeries because of pressures on doctors time and I think sometimes what is really important is that not only do we need to ensure that the doctors feel that they are valued, that they have the resources at their fingertips but also the patients when they go and see the doctors feel that they are being listened to and they are getting a good proper hearing. No patient feels comfortable if they go in, doctors say, what's wrong with you, start struggling, here's your medication out the door, that's not what a lot of people think they're going to see the doctor for, sometimes just good advice is very valuable for them and sometimes they don't actually need medication but it depends on what the doctor has at their resource. A lot of the things which are now happening for example when doctors say that they would rather not be in this job or in this career if they had another opportunity, I remember people used to want to give the right arm to become a doctor. This was a profession that people actually tried very hard to get into because they wanted to serve the communities, they wanted to make a difference where they lived and if that's not happening then it's a bad day. Therefore a proper policy developed which looks at all these various issues that the pressures are now being put upon needs to be done. The Scottish Government really needs to take up this conflict, really needs to take up this challenge and has to work with the doctors more closely than they have done so far. Talking to doctors is not a bad idea, let's please do that and let's hope that we can improve upon the service and the pressures that other people have that can stop. Thank you very much, Presiding Officer. Thank you very much. I now call on Tric Brody to be followed by Malcolm Chisholm. Thank you Presiding Officer, may I firstly thank Jim Hewn for bringing his debate forward this evening. Presiding Officer, as always general practice is central to the future of the national health service in Scotland. It is of course the front line for many people yet the recent BMA Scotland conference for Scottish local medical committees discussed the issue that many general practices are certainly not just to recruit doctors but also to get locum cover. General practice is or can also be a very cost effective part of the Scottish healthcare system. Recent calculations by the Royal College of General Practitioners has shown that even investing another £72 million in GP consultations in the UK would lead to a saving of £375 million arising to £708 million by the end of 2019, which translates into a possible saving of £70 million in Scotland. That is done by looking at a creative way of freeing up time for general practitioners. The Scottish Government recognised that when it announced in June this year increased funding into primary care of some of £50 million over three years. That increased investment provides an initial impetus to encourage GPs to try new ways of working over the next three years, helping to address the problems of recruitment and retention that are so common to primary care services. Alan McDevitt, the chair of the BMA's Scottish GP committee, also raised another important opportunity in increasing primary care funding, which is the evolving health and social care integration plan. Mr McDevitt states that, quote, investment in leadership training will provide GPs with additional skills to influence the design and delivery of efficient community services for their patients. He further went on to state that the recruitment of additional pharmacists working with GPs will provide much-needed support. I hope that, in the long term, investment could be extended so that every practice in Scotland would be able to have a practice-based pharmacist. Both practice-based and community pharmacists are uniquely placed to work with GPs to improve patient care and safety and to play an important role in the long-term management of patients with chronic diseases. I wrote to the Cabinet Secretary for Health suggesting that we should have triage nurses in pharmacies in this world of instant society so that lesser illnesses could be treated in the pharmacies and freeing up time for GPs. In March this year, the RCGP and the Royal Pharmaceutical Society issued a joint statement on GP practices. It highlighted the important role that practice-based pharmacists can have in creating efficient general practice services. There should be investment in recruitment and training of pharmacists based in general practice that would be of considerable value in reviewing patients' medication, managing polypharmacy, managing medication issues for the housebound within the newly integrated healthcare system, linking effectively with community pharmacists and medicines reconciliation across the interface all with significant benefit to patients' health and safety. This could improve care, save the NHS a significant amount of money and alleviate pressure on GPs. Thereby creating a free-time investment opportunity. The RCGP and RPS also work together on how community pharmacists and GPs can work together to improve patient care. They set out recommendations for benefits to patients in improving liaison between community pharmacists and GPs. Finally, there are already a number of initiatives across Scotland that promote collaborative working with community pharmacists. In the Highland Community Pharmacy, health care improvement Scotland also has a national patient safety programme. Much has been done to improve GP recruitment and retention, which I commend. We would like us to look at much wider vehicles to provide a more extensive landscape as to how we can create the retention and recruitment of GPs. Thank you so much. I now call on Malcolm Tism to be followed by Alex Rowlands. As the motion states, 90 per cent of patient interactions with the health service are with primary care services. Since the whole direction of health policy for over a decade has been towards more services being delivered in community settings, that percentage can only be set to increase. That is really the background to the very serious concerns that I am sure everybody has about the current situation. I found that in my constituency. Recently, the most stark example being the leaf-link medical practice, where three GPs left and they could not replace one of them. The result of that was 2,000 patients being told that they had to leave that practice and being sent somewhere else and the health board taking over the running of the practice. Of course, that is not unique in Edinburgh in terms of the health board's intervention. More nationally, of course, we know some of the alarming figures. I suppose that part of the background is the percentage of the budget on GPs being 9.8 per cent, for example, 10 years ago, and the latest figure that we have, or the 2012-13 figure anyway, being 7.8 per cent. That in itself is grounds for serious concern. The overall number of whole-time equivalent GPs is flattening, and the applications for the GPs training posts last year fell by 10 per cent. Clearly, something must be done, and I am sure that the Government accepts that as well. We probably need a whole range of measures, for example, just to pick out one incentive for graduates to enter GPs training. However, the big issue that has to be addressed is workload. Jim Hume referred to his survey, which overwhelmingly put workload as the number one issue. Of course, that is partly related to the overall number of GPs—that is fairly obvious—but it is also related to what GPs do and who they work with. In some ways, some people may be surprised that workload is such an issue, because, of course, after the new contract was introduced, which I was involved with at the time when I was a health minister, some people were saying that they have got it easy now and they are not having to do all that out of urge. That was the kind of mood music among a lot of people in the Parliament. However, we have to understand, as the years have passed, several things, including demographic change—more people in the population simply—including older people with complex medical conditions that have to be looked after by GPs and primary care more generally, and the shift towards primary care, which has not happened as much as we wanted, but has still been happening. To some extent, the Government has addressed the issue in the programme for government in general terms. It talked about developing clusters, and that is a good thing, so that the skills and expertise of GPs are shared across the practices. Of course, we need to embed general practice in the wider primary healthcare team and expand the wider primary care workforce, including practice-based pharmacists. Instead of the clusters, I should also have made the point that, in a way, it is fairly obvious that that needs to be aligned with the locality integration arrangements, and there is a good opportunity to do that. Of course, the co-off is much talked about as well. Some GPs, I note, want to abolish it, others want to disassociate it from practice income. I have to say that when the GP contract came in and I was getting a bit of a stick for those new contracts in those days, the consultant's contract and the GP contract, I was quite pleased that some of the extra money for GPs was related to doing specific things via the co-off. I notice that even GPs who are critical of it have said that it did transform the management of care, certainly for some practices who were perhaps lagging behind the best practices, no doubt the best practices such as Dr Simpson say that we are doing many of those things anyway. My own view would be that we need to keep the good bits of the co-off and still relate it to practice income, but clearly not all GPs agree with that. The final last point is that infrastructure is clearly very important, and one particular concern in my constituency is the development of the north-west partnership centre just on the edge of my constituency, which will have a new GP practice as well as many other services. That, of course, has been delayed because of the changes to the funding arrangements for the hub programme. I know that that is not totally within the control of the Scottish Government, but if the minister cannot say something about that, I really would expect the cabinet secretary to be making a statement about that to Parliament in the very near future. Presiding Officer, can I, like others, congratulate Jim Hume on securing this debate? It is a motion that should and I think obviously does concern each and every one of us. I would like to think that it is an issue that can be addressed by a genuinely cross-party approach as my party has been advocating over the last few years. The statistics that surround the subject really speak for themselves. If Scotland's predicted growth up to 2020 reaches its maximum, we will require 915 more GPs. If it reaches just its minimum, we will still require a further 560+. Let's take the average and assume, as the motion itself does, that we will require somewhere around 740 or 50 more GPs by 2020. That is quite a challenge, especially when you take into consideration that fewer medical students are opting to go into general practice every year, that two thirds of all GPs could retire within the next five years, and that 20% of GP training positions were not even taken up this year. If this isn't yet the crisis that the BMA claims, then it is certainly a major problem that demands urgent attention. I would suggest the first thing that needs to be done is that much more needs to be done to take action to improve recruitment and retention of GPs. Too many currently go abroad because of improved salaries and conditions, and they don't return. Too many GPs, 92% in the survey that's been spoken about, believe that consultation times are inadequate. 69% said their workload has a negative impact on the care received by their patients, so surely we need to review urgently aspects such as the box-ticking activities that GPs have to undertake that could just as easily be undertaken by nurse practitioners and others, especially as patients who need more specialist care are increasingly transferred from hospitals to their local communities. It seems to me that the current structure of primary care is not geared up to deal with the current policy of more and more people spending their latter years in their homes rather than in a hospital. That particularly impacts on rural constituencies such as my own of Galloway and West Dumfries. Across the local health board region of Dumfries and Galloway, there are currently around 12 GP vacancies out of a required establishment of 130. That's near enough 10%. Some of those vacancies are proving extraordinarily difficult to fill. The further west you go, or if I could put it another way, the more remote you become, the harder it becomes to fill those vacancies.  On top of that, the risks to both in-hours and out-of-hours services also increase and become very substantial under these circumstances. To the board's credit, advanced nurse practitioners are being appointed to try to plug some of the gaps, but the board accepts that if it is to manage age-related and chronic conditions outside acute hospital settings, a comprehensive primary care GP coverage is absolutely essential. If that coverage continues to decline at the current rate, the default position will simply be higher hospital admissions with the real possibility that there simply won't be enough hospital beds. Simultaneously, the planned integration with social care services will not be able to achieve its full potential without the required GP workforce. That doesn't paint a very pretty picture, Presiding Officer. What we must have, I think, is a clear strategic direction to try to reverse the decline in recruitment and retention. On that note, I was really interested in the First Minister's announcement this afternoon that 10 pilot schemes of new models of primary care to be introduced across Scotland would strongly recommend and suggest that one of them is located in the west of my constituency, where, if nothing else, it would be extremely well tested. I hope that that initiative works, Presiding Officer, because if it doesn't, then the crisis that the BMA is talking about will have become a very serious reality. Many thanks. I now call on Dr Elaine Murray to be followed by Mark McDonald. Thank you, Presiding Officer, and I start by thanking and congratulating Jim on bringing the issue to the chamber, because, as Alex Ferguson has said, a lack of GPs is a significant issue in Dumfries and Galloway, albeit a more significant issue in his constituency than in mine, but is sufficiently problematic to have been referenced in the BMA briefing specifically about Dumfries and Galloway in its briefing. One of the reasons that we have been told by the chief executive of NHS Dumfries and Galloway is that more graduates are interested in specialisms and that specialist medicine is more attractive than general practice for a whole host of reasons, and it is difficult to get people to go into general practice. The shortage of professionals is not confined to GPs in Dumfries and Galloway. We know that there are shortages, for example in recruiting teachers and there are shortages in recruiting social workers. Some of those shortages in professions are around the opportunities for the partners of professionals. That is an issue with a shortage of professional jobs, but within other professions there have been initiatives to try and grow more of those professionals. For example, Dumfries and Galloway Council paid for the training of social workers with the University of Glasgow, and we have recently had an initiative called Grow Your Own Teacher in Dumfries and Galloway, where people are being encouraged to come out of other professions within education and train as teachers. That is not as easy to do with GPs that you cannot really grow your own GPs, particularly in an area where there is not teaching hospitals and there is not medical courses on offer at the universities. We see things, for example, like attempts to recruit from other countries. That always makes me slightly anxious, though, because we are recruiting from countries where those GPs are needed in their own country and we are taking often from countries that are worse off medically than we are. I have to say that I, too, am concerned about recently trained GPs going off abroad, maybe into private practice, and I wonder whether there are some ways in which we can dissuade people who have been trained by the taxpayer here in Scotland or in the UK from taking those skills that they have recently acquired and taking them into private practice perhaps abroad. That is my idea, which comes from me. It is not Labour Party policy, so I hope that nobody is going to take it as that. I wonder whether there is a possibility of training other suitably qualified professionals to bring them into medicine. My daughter has degrees in psychology and she is training as a mental health nurse. I know a number of young people with degrees in history or in chemistry, even, who train to become lawyers after they have graduated. I wonder whether there is a possibility, for example, of well-qualified scientists managing to be retrained into medicine, perhaps with an indication that they go into general practice. I am not suggesting, for example, that lots of scientists leave science because we know that there is actually a shortage of scientists as well. However, people with that sort of training might be able to be retrained. We know that there is a loss of people from science. There is a loss particularly of women from science whether there is a possibility there. I did run the possibility of retraining other people past the chief executive of the NHS in Dumfries and Galloway. He was a bit concerned about it. He felt that people who were not adequately trained in medicine could be risk averse and could then just refer everybody on to consultants and create workload problems elsewhere. I do think, particularly in the sciences, that people who are trained to a high level in science have an expertise of assessing the evidence and making evidence-based decisions. On the table, I will probably completely horrify the entire medical establishment in Scotland by making the suggestion, but I wonder whether that is something that could be examined as to whether or not other professionals might be able to be trained. It would be shorter, it would be quicker and less expensive than training people from scratch and whether that might be a possible one of a number of possible solutions. I now call on Mark MacDonald to be followed by Dr Richard Simpson. Thank you very much, Presiding Officer. Having spoken a little bit about the issue around primary care and my contribution during the programme for government debate and, indeed, speaking about it during a health debate that we held prior to the summer recess, I thank Jim Hume for bringing the issue back to the chamber. I am interested in the comments around workload. One of the things that I have spoken about in the chamber in the past, and Malcolm Trism has alluded to it, is how we can perhaps better align primary care services to perhaps reduce GP workload by having people being appropriately triaged to other services, where that is the more appropriate place for their conditions to be dealt with. Some GP practices that I know from my constituency are speaking to people at the point that they request an appointment and are redirecting them to, for example, pharmacy, if that is the more appropriate place for them to be seen. Some GP services, I do not think, do that yet. That might be a contributing factor to some of the workload issue. Certainly, a percentage of the workload might be able to be redirected elsewhere and dealt with in a different environment. I think that the issue around how we utilise other primary care professionals is something that needs to be examined. I am confident that, through the work that the Scottish Government is undertaking, to look at redesigning how primary care is delivered, that will happen. There are good practice examples out there. The minister will be familiar with the middle field healthy hoose in Aberdeen. I think that an example of good practice and good use of nurse practitioner services could perhaps be remodelled in other areas, depending on circumstances. My colleague, Rod Campbell, raised in his intervention around pensions, is relevant to that. The conversations that I have been having locally with GPs, particularly those GPs in their mid to late 50s, suggest that that is a decision that they are now facing as to whether they continue to work in general practice and take the pension hit that will follow as a result, or retire early in order to benefit from their pension as a result of the changes that have been brought in by the UK Government. That is not a decision that one would want those GPs to have to be facing, but there is a financial element to the decisions that they now face in terms of retirement. We also have to look at the fact that the make-up of the GP workforce has changed over time. It used to be a predominantly male full-time workforce. It is now a predominantly female part-time workforce, and there are a number of reasons behind that, which probably do not have time to go into in detail. I acknowledge that you shake your head at that point, Presiding Officer. Do not worry, I was not going to go into detail. One of the things that needs to be looked at is how GP services are structured to deal with that change in the workforce, but also how we attract graduates in. That is a point that has been raised on a couple of sides of the chamber. Some of the discussion that I have had with medical students and medical student representatives has been the question of partnership, which has been a decisive factor for many in making their decision. I agree with the point that Dr Murray makes about being also about specialisms being perhaps more attractive, but I think that the view that there may be a requirement to take on the role of partnership and not feeling that that is something that graduates would want to do. That is why I think that looking at a confederated model where perhaps practices control a number of premises rather than one individual premise, so that you could have perhaps a smaller cohort of partners, but operating a number of practices where you could then employ those GPs is something that needs to be examined, and I know that it is being examined certainly by the health board in Grampian. I think that there are a number of things that can be done. I think that the programme for government makes some encouraging signs towards those reforms that are taking place, and I am sure that that will help in addressing some of the issues that we do face in our general practices at the moment. Thanks so much. Anna Cohn, Dr Richard Simpson. I am very glad that we are now debating general practice and I welcome Jim Hume's motion and the survey that he did. He knows that I did a survey this summer, as did the BBC. There has been a lot of work done on trying to collect the data. The first point that I would like to make is why on earth did we not have this data very clearly available before. The growing crisis has not just emerged out of nowhere. I warned in 2010 that we should be considering a separate GP contract because the NHS in Scotland is now so radically different from England, and yet we still have a UK contract. I am glad that we are now going to have a separate contract in Scotland. Let us look at the factors. I am not going to talk about the solutions. I am publishing a document tomorrow with a comprehensive list. It is not actually comprehensive, but it is a consultation document of all the suggestions that I have received over the summer. I received 400 replies from doctors representing 330 practices. Actually, when the survey closed, there were another 49 practices responded. The factors that are around are very clear. First of all, there has been an increase in the population, roughly 170,000 since the SNP came to power. If it is one for 1,500, that means that we needed about another 120 GPs just to provide a standstill situation in terms of population, but it is worse than that because the number, the demographic character of that population has also changed. There has been a 17 per cent increase in the number of over 75s, and it is the over 75s who have more complex conditions. That means that GPs have to spend more time with them. Why? Because the hospital services operate on a silo basis. They treat single disease entities not humans in holistic form. That is what general practices are good about. That is what GPs are excellent at. They are good at diagnosis, they are good at managing complex morbidity, but they do not have the time to do that. The reason is because the cof, which was useful initially, was a good part of the new contract. The first time general practice was paid for quality, the cof became an increasingly bureaucratic exercise. Two years ago, the document on cof ran to 226 pages. Even last year, with the cuts, it was 186 pages. Now, the other thing that has happened apart from the increase in morbidity, increase in population, increase in the number of over 75s, has been a shift in the balance of care, something that we have all wanted, but that has been completely and almost totally unresourced. Those are the factors in the background. What is the result? The result is today, trainee vacancies, 20 per cent as we stand here today this year, 20 per cent trainee vacancies, predominantly in the west of Scotland. Immigration is up. In my own practice, Bridge of Island, and the neighbouring practice of Dumblane, two of the nicest spots that you could want to practice in have lost one doctor each in the last 18 months to Australia. These are doctors in their 30s, and when I contacted them and asked them about it, they said, there's no way we're coming back. One of them said that he was going to just try it, but he phoned up and said, no, I'm definitely not coming back. This has been something that has been going on for some time. Malcolm Chisholm mentioned the reduction in the proportion of funding from 9.8 to 7.8 per cent, so it's not coincidental that, with a share of funding going down to general practice and the resources that they need to have to go up, there is a crisis. In 2011, the party said that we should have a national conversation. We called it the Beverage Commission for 21st century. This Government ignored that request and, indeed, so did the Conservatives. However, what the Welsh Government did was to establish the Beverage Commission. In 2013, it introduced clusters that are only now in the Government statement today that they're going to have clusters. The result of introducing clusters and a raft of other measures—which, in fact, I was discussing with the people in Wales—has resulted in the per capita population, GPs per population, rising in Wales in the last 18 months, whereas it's continued to sink in Scotland. I'm glad that the crisis that I've been recognised, the debate on BBC that I had indirectly with Maureen Watt earlier this summer, we were told, oh, there are more GPs in Scotland than ever. That's been the mantra for three years. However, the numbers of full-time equivalents have only gone up by 35 since 2008. I'm glad that the crisis is recognised. I'm glad that some funding is being applied. That funding, in my view, is wholly inadequate. We will need to do very much more. I will have my proposals published tomorrow. We are discussing that with general practitioners. Thank you so much. Maureen Watt closed the debate on behalf of the Government. Seven minutes are thereby, please, Minister. Thank you very much, Presiding Officer. We've heard much this evening about the difficulties which part of general practice finds themselves in. I will address those issues shortly. However, firstly, I want to make it clear that this Government attaches the highest value to Scotland's GPs and the work that they do. Scotland's population is increasing, as we've heard. We're living longer with multiple and often complex conditions, which will become increasingly the norm over the next years. I have every confidence that Scotland's general practice can deliver what is needed to meet the challenge of demographic change, but I also recognise that some significant changes need to be made to relieve the work pressures and to help with recruitment and retention, and we're working with GPs and have started to make those changes. Earlier today in the chamber, the First Minister set out the programme for government and highlighted the early success of the integration of health and social care, and that will ensure that as much care as possible is provided in community settings. The First Minister also outlined the importance of testing new models of care, building on innovation that is already being developed locally and integrating different types of care. We want to ensure that local community-based services are delivered by the appropriate range of health and social care professionals working together more effectively. That comes with a commitment to invest. In Scotland, we spend a record £12 billion each year on our health service, of which some £770 million is invested in general practice. We will be investing a recently announced £60 million primary care fund to transform primary care, building on great examples across the country of providing care for patients at or near home rather than in hospital. That funding will help to address immediate workload and recruitment issues through long-term sustainable change. Specifically, that fund will increase the number of medical students choosing to train as GPs and encourage those wanting to work in rural or deprived areas. We will continue the enhanced returners programme, supporting GPs who wish to return to the profession and develop a programme for local GP leadership and networking. One of the things that you have touched upon is students wanting to go on to become general practitioners. I was wondering whether there is a possibility of working with the education institutions to see if we could actually increase places as well for general practitioners to try and relieve the short pressure that we are facing in the real, near future. Hans Alamake, I am an important point. For every student place that we have, there are 11 young people wanting that place. We have people wanting to go in to the medical field, but we need to be sure that we are getting the right people in as students the ones who want to live and work in their own communities and to be GPs. That is what we are working with the BMA and others on. We are consulting with others to increase the output from medical schools, encouraging and improving training in general practice. By the end of 2015-16, we will already have invested in an additional 10 million in enhancing primary care. That will be further supported by total investment of 50 million over the following two years. However, there are challenges. The Government knows that GP workload is increasing as is the complexity of healthcare. Where more is being delivered outside hospital settings, resources have not always followed. We understand that GP services in some places are stretched and that, at the same time, communities rightly expect more of their health services. Our plan is to transform our approach to primary care to ensure that, in the future, people see the right professionals more quickly. That is why we will continue to work with Scotland's GPs to design that new future. That is why a review of primary care out of our service was commissioned. That is why we need to redesign primary care in a collaborative and inclusive way, transforming and invigorating the workforce, creating new roles and supporting communities to innovate so that services are available where people need them. Scotland's GPs have a vision for the future of general practice and it is a compelling vision which this Government shares. That is a future where care is provided by multidisciplinary professional teams, planned and delivered within the localities that need them. That is a future where GPs are the expert medical generalists, the doctors making the critical clinical decisions about their patients but not necessarily being the first point of contact. We have been working with the Scottish General Practitioners Committee to redesign the contract and will have the first version in place by 2017. That is the timescale GP union leaders tell us that it is realistic and that negotiations on the detail will take place in 2016. As others have mentioned, we have a separate agreement in Scotland and English GPs are very envious of that. By 2017, we will have made significant progress to change the way general practitioners work. We will remove the annual churn of contractual changes and introduce the next version of the GP contract three years later in 2020, when the transformation in the way GPs work will be near complete. Our approach will build on innovations already under way that reflect local priorities. For example, in reducing health inequalities in Craig Miller and Govan, improving mental health in Fife and helping people to age well in Tayside. Equipped with this flexibility, care will develop in ways that match the needs of different individuals and communities in cities, towns, villages and rural areas. The integration of different types of care is already the practice at Clarkmaninshire Community Healthcare Centre. It provides primary care through three GP practices while also providing wider services such as outpatient services to inpatient wards, a day therapy unit and local mental health resource centre. The centre is also a base for district nurses, health visitors, community rehabilitation teams, health improvement and a wide range of support services and classes. We know that one size does not fit all. That is why we wish to test and seek views of new models of care, including those that might be delivered by multidisciplinary teams in a community hub-type arrangement, whether that is physical hubs or virtual hubs, but where professionals collaborate across the boundaries of primary and secondary care. All of that, of course, is focused on high-quality care and improved health outcomes, which will provide more connected, streamlined working within healthcare and across healthcare and social care and voluntary support services. Professionals will be able to support patients who are facing wider social issues, which are having an impact on their health and wellbeing, and clearer signposting, information and support so that people know where to go for the most appropriate treatment or follow-on service. The times come to start talking up Scotland's general practice to encourage more doctors to stay within the profession and to ensure that medical students choose a career in general practice because it is one that deserves to be admired and respected. It is time to create some excitement for the future of general practice in Scotland, and I know on social media that that is already the case with some of our young students. For now, the Government will continue to work with Scotland's general practitioners to deliver a model of sustainable general practice that is right, both for the profession and, more importantly, for the health of the people of Scotland. That concludes this important debate. I now close this meeting of Parliament.


This week on the anxious truth, we're going to answer some anxiety recovery questions, including how do I face a scary exposure? Is it normal to have symptoms late in recovery? Which comes first the symptom or the scary thought and others all sent in by the Facebook community. So let's get to it Hello everybody, welcome back to the anxious truth. My name is Drew Lynn Salada. I am the creator and host of this podcast I'm a therapist in training in New York in the United States specializing in anxiety and anxiety disorders I am clearly a podcaster and author and an educator in this community and a former sufferer of anxiety disorders depression and OCD For many years of my life. Welcome to episode 286 of the anxious truth. Today. We're gonna do a good old-fashioned Q&A I asked my Facebook audience to send in some questions over the weekend because I kind of hate Facebook and Therefore I haven't really been paying my Facebook friends must attention or showing them much love in the last year Sorry guys. So this week we're gonna take some questions from the Facebook community And we're gonna do our best to answer them before we get started and germane to today's Q&A theme I have to ask you to take advantage of all of the content that's already out there There are 285 previous episodes of this particular podcast on your favorite podcast app or on YouTube or on my website There's the disordered podcast that I do with Josh Fletcher. We do that every week. We've been doing it for a year That's a disordered FM. There's all of my past social media posts and I have written three full books on anxiety and anxiety recovery So take advantage of those resources because many of the questions that were sent in this week in the Q&A episode were of the How do I overcome or why does this happen ilk and that? Content clearly and repetitively addresses those big sort of foundational questions So if you're kind of new to this and you wanted to ask me, how do I overcome? I urge you to take advantage of all the old podcast episodes Maybe buy one of my books check those out check out disordered watch the videos comb through all of my old social media posts Those questions get answered again and again and again, but even if you did ask that question, you didn't do anything wrong I appreciate you asking just go check out the other resources You'll find everything linked on my website at the anxious truth comm So let's get to our questions. The first question is how do I face a scary? Exposure and the answer to this is that I hate that there's actually no real answer to this I wish there were steps that I could give you but a good place that I think you can start bike because there are no steps I don't have particular step one step two step three for being brave or doing courageous things But I think one of the things that you can do when you feel like I'm going into the exposure Or I'm trying to face my fear and I just can't seem to do it. I can't take that step forward I can't take that leap of faith. I can't let go. I keep retreating. I run. I escape. I don't do it How can I take that next step? What I would urge you to do is Acknowledge that you are in fact scared to do what you want to or need to do in that situation Just acknowledging I'm afraid right now is a good first step and remember that you're supposed to be afraid Some people get a little bit stuck because they're like I need to find a way to be a little bit less afraid So I can take that step forward, but that's not really the way this works Always remember it's okay to acknowledge that you have been triggered into a state where you are afraid But that you are choosing to practice being afraid That's really important because it keeps you from falling into the trap of thinking Oh, I should be able to do this without being so upset or or afraid or uncomfortable No, you're doing it while you are afraid Upset and uncomfortable and you're doing that for a reason so that you can learn that you can handle that That's really important The other thing that I want to mention in terms of like I just can't seem to make myself face the scary exposure or face My fears. How do I do that? Everybody reaches the point where they are ready to take that leap of faith because it does feel like a leap of faith Everybody gets there in their own time and in their own way And ultimately I think it comes down to the point where Not taking the step forward is more painful than the retreat Right. So if you retreat in that moment of fear and uncertainty and you feel like you can't do it You get some instant relief. That is 100 true But then there's some pain that comes after that because all my life is still restricted. I'm not recovering I don't like this. I want my life back at some point For a multitude of reasons that I could never nail down for anybody on the internet because they don't actually know you And it would probably take us days to try and dig into all of those things in a podcast episode For a multitude of reasons everybody gets to the point where they hit sort of that tipping point Where the pain of not facing the fear is greater than the pain of facing it When you get there you may find that things change and again Everybody gets there in their own way for their own reasons and in their own time So I think it's always important to remember that as well Because I think we sometimes forget to mention that We're asking ourselves to do really scary difficult things that require that be we be courageous and brave And that's not normal or intuitive for a human being So there has to be something in there that says no no no I will choose to do this because choosing to not do it Is not acceptable to me anymore and you're going to get there when you get there So you're going to have to be a little bit patient and a little bit kind to yourself And understand that that's not a thing that has steps But it's a good question. It's one of the the basic questions that most people will ask when they say when they start Can you believe that I just got a notification come through? Anyway, when people hear initially like oh, well, I have a problem here because now I have to face my fear This is one of the first questions they will ask But how do you face the fear and that's the answer? I wish I could tell you there are steps for doing brave things But they were simply not So the second question I want to answer is Is it normal to still have symptoms or say scary thoughts even though I'm kind of far down the road in recovery And this was asked in various forms. Some people asked about symptoms specific symptoms some people asked about specific thoughts and What I want to say right away is it's okay sometimes to get some assurance Like assurance is needed assurance is education assurance lets us know that we are on the right path and we can keep going There's nothing wrong with that There's also nothing wrong with looking to the experiences of others Because some people let us this question We're asking about my particular personal experience because we can use the experience of others to help us get over the rough spots Or give us some encouragement or inspire us in some way So if there's never anything wrong with asking questions like this and the answer to the question is yes It is a hundred percent normal. In fact, it's not just normal to have recurring symptoms or scary thoughts Far into recovery. It's actually normal to have those things even after recovery now When you hear me say that do not freak out because what a lot of people will hear when I say that is Oh, no, Drew just told me that I just have to get used to being like this for the rest of my life That is not true. That's that's what you're gonna hear But but let's step back for a second and let's just comment down a little bit What we're saying here is that the primary lesson that we must learn in recovery Is that it's actually okay to have those symptoms and those scary thoughts we can handle it We can allow the triggered state that fear that uncertainty that this comfort to pee can come back down We can work through that. We do not have to change our entire lives. We don't have to avoid We don't have to escape. We don't have to make our lives tiny We can go forward even when we're feeling those things and when you can learn that lesson Which means that you're kind of saying if I had to experience these things for the rest of my life I could when you get to that point Then the happy sort of secondary outcome of recovery Is that they tend to lessen or even go away for long periods of time? Maybe forever it is possible, but it's not guaranteed because even recovered humans or humans that have never had an anxiety disorder Will be triggered into anxious states. They'll have disturbing thoughts. They'll have scary Sensations they'll they'll experience fear and uncertainty and all of those things So it's really important that you not judge the progress of your recovery based on how you feel You really want to look at the progress of your recovery as being based on how you handle how you feel That's important again really good question So let's do question number three and that is what do I do when I'm not anxious and I have no symptoms or thoughts to deal with Well, the first thing I would tell you is do your best to enjoy You've probably earned that because that means that you've been doing a lot of hard work and heavy lifting And you've been brave and you've been choosing to willfully tolerate and surrender to things that you thought you couldn't do So first is if you're experiencing that now as part of your recovery Congrats. Good job. It means you're doing a good thing for yourself. So do the best you can to enjoy it However, the best you can do there is just try to engage in your life as best you can Now a common response to that is well, I want to engage in my life when I'm starting to find little periods of relief But I keep having a thought but it's going to come back But I'll be anxious later the thoughts are going to come back the symptoms are going to come back And the answer is yeah, you may have those thoughts and yeah, especially when you first start to experience those little glimpses of recovery The odds are really high that the thoughts and the sensations are going to come back Maybe in an hour. Maybe in a day. Maybe in a week But remember look at the primary target that you're aiming at in recovery recovery is primarily about learning that virtually all states are permissible And handleable even when they're not desirable So I'm going to repeat that one of the primary lessons of recovery is that all states are permissible and handleable Even when not desirable So if you're not anxious now and you're getting a glimpse of like maybe life as a recovered person That's awesome live as best as you can while not anxious But also simultaneously may be worried that you will be anxious again And if you are in fact anxious later because the symptoms and thoughts kind of came back Then do the best you can to work with that Work on sort of abandoning or stepping away from the need to find meaning in every state or to somehow Manage it all the time. That's a big ask. That's really not fair of yourself You're learning that you can handle all the states that humans experience. So go experience them the best you can So next question which comes first scary sensations or scary thoughts and the answer to this honestly It's a little bit tongue-in-cheek. It's both Now this might be debated hotly if we took a bunch of anxious people and hooked them up to electrodes and slid them into functional MRI scanners We might have a big debate among neuroscientists and folks like that That say well, no, it looks like the sensation first No, it seems like in these people the thoughts come first We don't really know it's both of those things at the same time. That can be true, right? Some people in our community will say that they are triggered by physical sensations Others will insist that they are never triggered by physical sensations only by thoughts and guess what? Both of those things to those different people will feel special And like this is my special kind of trigger. Can you tell me more about that? But really they're the same trigger Both scenarios the thoughts come before the symptoms and the or the symptoms become Come before the thoughts are accurate and valid and for any individual person that might even shift from day to day Or maybe even hour to hour or week to week So that being said both of those things are sort of accurate and valid But does it actually matter because in the end the approach to facing a scary thought is the same as approaching a scary symptom Or a scary symptom triggered by a scary thought or a scary thought triggered by a scary symptom It doesn't matter like maybe just start from the from the statement. I am afraid And go from there. That's a good starting point And that's where you're going to work from anyway regardless of how that presents The sequence of the triggers be they thoughts first or symptoms first or sensations first Is largely irrelevant from kind of that general broad brush point of view that I can give you guys on the internet and a podcast So I hope you found that helpful Let's see. Let's do three more questions How can I be sure that this is just anxiety or could it be a gut feeling that I should follow or my intuition? Well, the answer is you can't no one can ever know that whether you are in a state of disordered anxiety Or a completely non-anxious person or recovered person no one can ever know for sure right you can't so that's Probably the most important part of this answer But when you are sort of in the the grips of a struggle with an anxiety disorder and trying to go through the process of recovery And this in this situation we're talking about anxiety triggered by your own thoughts and physical sensations that are indicative that there might be something wrong gut feeling air quotes and intuition are two things that in my opinion my approach to this Need to be set aside for a while Not forever if you're a big believer in intuition. Maybe it's just part of your culture. Maybe it's part of your faith There's nothing wrong with that but gut feeling and intuition While you're in a state of disordered anxiety is something that I think needs to be set aside because when your body and mind are in that constant cycle of of being triggered and sending out false danger alarms and then dragging you up and down the street against your will and Making you follow those false alarms as if they're not false Then every single alarm is going to give the appearance of Just a strong feeling of intuition my gut tells me that something is wrong here But it's always wrong Like the gut feeling or the intuition when it's driven by disordered anxiety is always wrong So if I lined up a thousand people struggling with anxiety disorders and said how many people here Have felt over and over that their anxiety was was a gut feeling or intuition that they should follow It feels like something is wrong. I really should pay attention to this And then you discovered that that was wrong and it was actually nothing But a false alarm of a thousand people 900 people would instantly raise their hands So if there is such a thing as gut feeling or intuition and I'm not passing judgment Whether there is or there isn't only you get to decide whether those concepts work in your life Disordered anxiety is a thing that's sort of like Just jams jams a monkey wrench in those works and renders them. I'm not going to say useless But far less reliable than you otherwise think they might be So For now you may have to abandon the idea of following gut feelings or intuition And by the way If you decide to turn your back on what you think are gut feelings or intuition that will feel risky reckless and dangerous So let me acknowledge that before you even go into that. That's true. It's difficult But that's what I think you have to do with gut feeling at least for now So let's see. Let's go to our second to last question This is a question about The selfish nature of anxiety and anxiety disorders Several people asked said, you know, my anxiety makes me appear mean or selfish or when I get anxious I take things out of my family and my family is not really understanding of me because I have so many restrictions And I cause problems in their lives because of all of the rituals. I have to do and all the avoidances My anxiety makes me appear very selfish What's up with that? How do I handle that and the answer to that is yes An anxiety disorder is very self-centered. Let me just repeat that the anxiety disorder is very Self-centered it will take all the attention it can possibly get from you It just wants what it wants and it does not care what that costs It is just not interested. So remember that we're talking about the part of your brain That's designed to keep you safe and alive. It has zero interest in your happiness It has zero interest in your romantic relationships. It has zero interest in the dysfunction or health of your family It does not care about your best friend It is only there to keep you safe and alive so that you can theoretically perpetuate the species procreate and do your job In that situation it will follow those instructions at all costs. It does not care about the damage it does So in this situation We can really look at this and say An anxiety disorder is a state that is in fact quite self-centered. It might appear selfish. It might appear mean Some people say my family thinks I'm being mean because I just let my anxiety run rough shot over them Like I don't care about them, but you do. I know you do In fact, if this is a thing that you're struggling with like clearly you do care about that You don't want to impact your family. You don't want to have a negative impact on your friendships or your relationships That's true. That's a hundred percent true The disorder itself can be quite selfish and self-centered and can look very mean Doesn't mean that you are That is critically important in my view of this and again just an opinion I'm just the guy with the microphone here. You can take it or leave it But I like to look at the disordered state or the irrational fear as incredibly self-centered and incredibly mean and Incredibly like all it has tunnel vision It only wants what it wants and it doesn't care what it with that cost But that doesn't mean that you are there's a difference between You and your morals and your values and your core values and who you really are as a person And the disordered part of your anxiety that is just triggering false alarms and demanding that you be safe all the time Those are not the same thing and just because your anxiety is presenting that way doesn't mean that you are mean or self-centered So I did a whole episode of this on this on the anxious truth. It's called it's episode 101 It was done a few years ago But if you check it out on my website or on youtube if you're watching on youtube or whatever podcast app Maybe go listen to that It's a whole episode dedicated to the selfish nature of anxiety and anxiety disorders And it might also be helpful to get some family members or friends or partners to listen to that with you because it kind of explains And maybe they can start to understand also. Oh, that's not my partner. That's not my best friend That's this this is the anxiety disorder speaking And it may help them understand a little bit what you're dealing with and how they can maybe maybe better support you And also can help you maybe open a discussion with them like listen. I know how this looks to you I know how it looks some of it and I talked about that in that episode Some of it is we do have to own that a little bit. Yes. The anxiety is making me things. I wish I wasn't doing Let me admit that I don't want it to be this way So that's a way to open the conversation and maybe check that out again It's episode 101 of the anxious truth speaks directly to this particular question And there's another notification. Sorry guys. I should have turned those off and I didn't Um Google is telling me I have to get out the door because of traffic And so let's wrap up the episode with one more question and this is kind of a big question It's a very overarching question and that is How can I stop doing the things that I do when I get anxious or triggered? Because those things are now causing me problems and I want to stop Excellent question. It's right in the core of the things we talk about in this podcast and I've written about in my books and all of those things We use the word and I want to answer it by framing it in the sort of exposure thing We use the word exposure around here all the time But really I should be using the term exposure and response prevention I should probably never use the word exposure by itself. Why? Because it's the response prevention part that is the most important part of the exposure A lot of people think well, I do exposure. Which means I just do things. I just I'll I'll do the things I still do the things But it's really the part where we Try to not engage in our usual response to a triggered state That's where the magic is and this question is actually somebody asked I get withdrawn I retreat I get in my own head and I just sit and I ruminate and I scan myself And I ignore my family and it's starting to cause problems. How do I stop doing that? Well in this situation If that as an example if that's the way you respond to maybe a panic attack or being triggered You get withdrawn and you isolate and you ignore your family and your friends And you just actively sit and keep tabs on yourself for the next two weeks after you're triggered That would be the response the exposure would be the triggered state And in that situation I have to turn that off. I'm sorry guys. That's that's that's not cool I should have turned it off now. I'm turning it off. Um, so that it stops reminding So in that situation the triggered state is the exposure However, the way it was triggered whether you did an exposure to trigger it or it just occurred naturally because that's the way your life is going Right now that would be the exposure the response prevention is Instinctually I want to retreat. I want to go and sit on the sofa for four days. I want to get inside my head I want to keep tabs on myself. I want to check how I'm feeling. I want to check my thoughts I want to check my body. I want to make sure everything's okay. That's what I want to do that would be my response But if I'm going to engage in exposure and response prevention It means I have to decide to do something different than that So in a situation like that you can't just say, oh, I'll just do something different I'm just going to never do that again. That would never work So you could try to take a different approach and change things just a little bit All I want to do right now is sit on the sofa for for two days And go inward and check on myself to make sure I'm okay But instead I'm going to go out and take a walk with my friend because that's what we had decided today For example And I'm going to do that while all I want to do is be back on the sofa just checking myself to make sure that I'm safe That's a scary thing to do that feels dangerous. That's going to require courage And while you begin to engage in response prevention, you will get sucked into the old responses. That's okay That's normal. We don't get to just turn off a switch and do things totally different overnight It doesn't work that way So recognize that what you're trying to engage in now if you want to stop doing all the things you do in response to anxiety You have to recognize what they are You have to understand that oh this is teaching my brain that it should just keep firing false alarms because every time It does that I follow along with it and I go along with it and I thank it So I had to start to do things different Which means I'm going to feel like I'm taking big risks and doing dangerous reckless things Which means I'm going to have to be sort of brave and and also remember why I'm doing that and what I'm trying to learn And I'm going to just try to change a little bit at a time Just a little bit so instead of sitting on the sofa for the next eight hours going inward I'm going to try and take a walk or I'm going to call a friend or I'm going to do my crossword puzzle I'm going to read my book while my brain is screaming at me But I'm going to start to break that response habit so that I can begin to prevent The response that is helping to perpetuate the cycle There's no fast answer as you could see I gave you a whole lot of words to to answer that question And there's a reason why there were a whole lot of words. It's complicated It's a simple concept, but the execution could be really complicated because it's going to depend on each individual I cannot give you the specific steps on how to stop withdrawing or how to stop scanning I've talked about that in different social media content broad brush general ideas that you can begin to apply But it's complicated But that's generally what you're trying to do to recognize that the things you do that when you are triggered Are your anxious responses and your job is to try to change those responses So that you can learn a new way to interact with and relate to that triggered state that teaches you Oh, this is okay. I don't like this. I don't want it, but I don't have to change my whole life around it Again, that was a whole lot of words. I hope you hung in there. Where are we about 23 minutes or so into the podcast at this point? That's more than enough We'll do this again from time to time from time to time. Maybe I'll ask youtube for questions I'll ask instagram for questions and we'll do these q&a episodes because they seem to be really popular I do like hearing what's on your mind. I will try my best to answer the questions I can't unfortunately answer all of them, but I will try to group them into categories like I did today I don't know if I answered anybody's specific question But I did try to answer Questions that were asked again and again and again and sort of represented them in the questions that I put Forward in this podcast episode. So that is episode 286 of the anxious truth in the books You know it's over because the music If you are listening to this podcast on apple podcast or on spotify or some platform that lets you rate a review Leave a five star rating if you really dig it Maybe take a second and write a review because that means you like the podcast And then it helps other people find the podcast who are looking for help with their anxiety and anxiety disorders And I really appreciate when you guys do that because it does help me help more people Of course, if you're watching on youtube and you're not subscribed to the channel hit the subscribe button Hit the notification bell so you know when I upload videos Like this video if you liked it and if you have a question ask it in the comment section I try to go back at least once or twice a week answer comments on youtube So i'm happy to hear from you guys and uh, yeah, thanks for hanging out today Thanks to my facebook friends for sending in questions this week. We'll do it again. I promise and I hope you find it helpful remember any step Toward what you value today Toward the life you want and away from that reflective irrational fear response Counts no matter how small it is every little step adds up the top of every other little step You can do this. You can get better. I believe in you. See you next time


Hello everyone and welcome to Outsie 2022. I am really happy to introduce today, Brendan Masterson and Matt Jones from Middlesex. They are here to talk to us about the Middlesex iPad Project, a case study in digital pedagogy, transformation for inclusive maths education in the face of digital poverty. So without further ado, I'd like to hand over to Brendan and Matt. There will be a short question and answer session at the end of this. So please pop any questions you have in the chat and we will come back to them at the end. Over to you, Brendan and Matt. Good luck. Thank you very much. And it's good to see so many people here today. So thank you. We're going to talk about the Middlesex University iPad Project. So I'm Matthew Jones. My colleague here is Brendan Masterson. He'll take the second half of the presentation today. So the iPad Project is really... There are a number of kind of ways to describe this. And so what we're going to do is just going to go through a journey of how we use this to solve a number of issues. So next slide, Brendan.  It has kind of a broad range of students in particular as it takes a number of students that are predominantly from poorer socioeconomic backgrounds. For example, nearly three and five students come from backgrounds where the index of multiple... The multiple deprivation is in the lower two quintiles. Or another way as well, we have the second highest proportion of students who were eligible for free school meals while they were at school. So there's a lot of students who come to Middlesex from poorer backgrounds. Next slide, next bit please. So there are a number of policies that Middlesex has that help this kind of thing. So for example, they offer a laptop loan scheme for 24 hours. They offer free printing for students. And this has been going on for about 10 years or so. Next bit, please. And then during lockdown, which we will talk about quite a bit, that was extended to loan laptops for much longer period of time. And these were couriered to students. So next one, please. So why is that important? Well, it's important in this context in particular because students from poorer families have a number of disadvantages, not just their socioeconomic background, but the way they relate to digital education. So students, they're much... findings from, for example, the 2018 Ipsos Things survey found that students were much more likely to be online from poorer families, but the time they spent online was less quality time, I guess. So less time learning, more time on TikTok. TikTok are not learning. So they come to university with a lower kind of expectation, I guess, or lower skill set. Next slide, please. Now, given that, okay, in 2017, something like that, Middlesex introduced a standard TEL threshold for all modules and modules were expected to produce videos before and after learning sessions, they were little snippets who helped to give students a chance to get something to consume. Yeah, so I'm recruiting the chat half-way. So that caused problems for the maths team in particular because, of course, it's quite difficult if you know anything about developing maths for web consumption, then it's quite difficult to do that. I mean, there are ways around it, but it's consuming and awkward. So we introduced... we phased in the use of iPads at the department, used iPads, gave iPads to staff throughout 2018 in order to help with this. Next slide, please. And what we were using them for was we were using them for creating slides, we were creating videos, we were using them in class to record lectures. So the kind of things that we were doing were pre-pre-pre-preparing PDFs and recording kind of annotation on these PDFs using various apps and providing students with a video and full audio of these things after class to work on. And this was hugely popular. This was hugely popular because... and I think it didn't have the effect we were worried about. So we didn't see any drop in attendance, the fact that we were recording these lectures. And in fact, what we found was that students were attending class and were attending classes, but then also viewing the recordings of these same classes on average three times. So it was really being used back then. So next slide, please. We were using... because what it allowed us to do is it allowed us to then kind of make use of some of the apps that are available for iPads. So for example, using the graphical calculator apps. This is Desmos that you see here. But what we... which is kind of standard, you know, is kind of straightforward the use of something like this. And it's the kind of thing that you could have done before anyway. But if you go to the next slide, then you can see that what we were finding was that actually we were able to use interesting and exciting ways of engaging students such as augmented reality using the iPads as well. And because if you move on, Brendan, because the university has a subscription to Microsoft 365, we could use the facilities of OneDrive and so on to really, really streamline the feedback that students were getting. So we were producing shared OneDrive folders for students. They were then able to get formative feedback on their work almost instantaneously. And importantly, this kind of thing made it easier for staff as well. So it wasn't this extra layer of difficulty that staff had to cope with. It became this more efficient way of doing this. And it dealt with the kind of difficulties of mathematical notation because you could just write on these things. And so we carried on extending what we could do if you go to the next slide. We were in a department or maths in a department that includes engineers and product designers and so on. And product designers were using the iPads in a slightly different way because what they do a lot of the time is they do kind of these workshops where they're being all creative and stuff. And they do this kind of thing that you can see here is where you've got a bunch of post-its and I don't know. I don't know what the product designers do. But they do something like this where they're coming up with creative ideas basically. And this was then moved... They were using the iPads in a slightly different way. They were using Miro whiteboards. If you've seen Miro whiteboards, these are these kind of big unbounded whiteboards. And they were using them to mimic what these creative activities were doing. But in a way that allowed you to have a persistent version of the ideas that were being created here. So again, not just using... not just kind of replacing what was being done offline with online but embellishing in it and making it a lot better. So next one, please. And this was used in the maths... on the maths side to kind of do the same kind of thing to get students to think more creatively about what they were doing. You could zoom in on... You could have entire lectures on these big whiteboards. Can you move on as well now? And then... And it led to us to create what we call problem-solving spaces which were just really large, these unbounded whiteboards where students were able to work together in groups and individually. And then COVID happened. So next slide, please. And COVID happened in... The UK went into lockdown in March 2020. We very quickly realized that everything that we'd been doing although we could translate everything that we were doing online it was a problem for students because they... coming back to the background of our students they didn't necessarily have the technology to engage with it. So the department rented and... or bought a kind of subscription from Apple to allow students to have their own iPads and pencils. And so these were all returning and new students in 2020 were given iPads and were allowed to engage. Can you carry on? And again, basically the overall idea was to allow them to engage with what we were doing and really improve how they collaborate. Next one, Brendan. And again, coming back to the makeup of the students at Middlesex, this had a huge impact. So you went from doing what we can do in class and presenting it online making sure students could do it as well. Next slide please. So in March 2020 when we first went into lockdown we went from realising students didn't have even a device to engage with the work to being able to essentially stream live lectures like you can see here use the kind of technology that we had and kind of take notes, for example. This is just one example of how you might use it. Other examples, if you go to the next slide then you can see that using these MIRO boards again there are other things that we used as well but MIRO boards are particularly impressive. You have this online tutorial where students are working live solving problems and kind of collaborating. And on the next slide you can see that students working together the green writing and the black writing are two different students giving each other feedback telling each other well done at the end of it basically. And so using these kinds of ideas using this this kind of new approach allowed us to really improve the teaching. If you carry on then actually I won't say any more about this but essentially just kind of using these boards that are used to collaborate and I'll let you carry on Brendan. Okay, so then in February 2021 when we were coming back to on campus we decided to survey the students and see how useful they found the iPad set they'd been using during the pandemic. And the survey was of all our undergraduate maths programs and our MSc financial maths responses in total and the first thing we asked students was well when you first got the iPad what did you think would help with and what we see here from all of these responses is pretty much that allowed them to collaborate with each other allowed them to access their material and allowed them to interact with their lecture so really just they seem to think that this would really just help them to learn during the pandemic. Then when asked how effective the iPads were at solving these challenges well you can see here everyone Laura said it was very helpful, it was very effective improved how interactive things were there were some issues perhaps around poor internet connections, the university did send out internet dongles for some of these students who really offered due to poor internet connections but the iPads themselves the students found very, very effective. When it came to how good the iPads were at supporting their mathematics you see here some students saying it's game changer, it's shortened their coursework and again it was all about student collaboration and allowing them to engage with the material so that seems to be a repeating thing is that the ability to engage and how has the iPads improved the way in which you learn again it's really here we see that students are saying it's made them more efficient, that it's helped them get feedback quicker allow them to collaborate again and efficiency and really one student up here saying that really took the stress out which was particularly important during the pandemic to really just do anything we could to ease stress for our students and what we decided to do is now that we were coming out of the pandemic although we're still coming out of the pandemic we were going through a revalidation process of our undergraduate maths programs and what we decided is well since staff these iPads are very popular with staff and are clearly very popular with students why not try and design our programs to include these and build our programs around them so that all the work can be completed on the iPad by the students staff can give all their feedback on the iPad and all the reference material the notes, slides what I'll be in an iPad accessible format so the first step of this was to allow the students to work directly on the BLE so by this I mean for each of the module a student received a personalized folder which only they and the module leader had access to the student could simply just upload work there the lecture would get notification when this happened and they can just go in and scribble some notes, scribble some feedback and upload that again for the student and really it just streamlined things student would get notification when they've received feedback and again the important thing to know is that this didn't create any extra work for the staff member if anything, as Matt said it would make it a little bit easier, a little bit quicker and then also convert the material into into a format that would suit an iPad with Leitech this was relatively quick and easy which this being if you're familiar with maths notes most of our lecturers use Leitech anyway so for most people this was relatively painless for the word of PowerPoint that perhaps took a little bit more work to make sure that the layout was correct and cheat sheet so often when we have we prepare notes for our students in past there have been pages and pages of notes and students would have to scroll in here with the iPad we could just create a one page or two page cheat sheet where students could just zoom in on the relevant material they need so when it came to getting the material ready and providing feedback it really wasn't that much work at all to really do it but when it came to assessment is where we were currently working on this and we have been working on this for the past year or so and really we decided to take advantage of the fact that we knew that all students had the same piece of hardware and the same access to all the software so previously when we talked about assessment and trying to include technology can be often difficult because you don't know what students have access to here we know that all students have access to iPads and they all have the same exact same software on these iPads so with that really allowed us to change things and first way in which we did this was to take more what we thought was a more inclusive approach to assessment so what we did here was allow the students to have optional modes of assessment so if a student could be given a report or some sort of thing to could either write a report or we could give them an option to make video commentary or if they were doing a mathematical problem we'd ask them to show their work in a kind of traditional math mathematical way or they could record an audio explanation if they were giving some reading material they could write a critique an article or they could record a commentary and it's just about building that little bit flexibility in so the students can really choose to which mode of assessment really best demonstrate that they had achieved a learning outcome and again this doesn't bias one student against the other because again they all have the access to the same hardware and software and also reduces the need for reasonable assessment reasonable adjustments because the flexibility for reasonable justins already baked in from the beginning okay and then this also further allowed us to be a bit more creative even with our more pure mathematics course works so well this is an example from one of our third year multi barrier calculus course works so if you have ever studied maths you may be aware that this traditionally is quite an abstract and pure module whereas what we decided to do is try and make a bit more authentic bit more real world so traditionally in most multi barrier calculus course works you'd be given some sort of surface and you'd be given some sort of integral associated with that surface and the student would just be asked to evaluate the integrals and various different statements to do with the integral but what we've done here if you look at this surface is this surface is actually pendant where our campus is based the little blue dot denotes where the local tube station is the red dot is where our campus is and you can sort of see the steep walk our students have to make the campus whenever they come to on campus lectures and even that little change straightway makes a bit more real world for the students they now have an appreciation that this sort of topic does have real world application in terms of material like ordinary survey maps and then when you come to the actual material itself you can see that for instance question 5 students are told that all multi barrier polynomials are differentiable at every point in the domain but again they're given the option to either write an explanation draw an illustration record or audio or visual explanation of so to demonstrate why this is true so again it's just about allowing them the option okay so perhaps it's a little unsurprising that this position is perhaps a little bit unpopular with the learned societies associated with maths and statistics they've basically come out with statements saying that they would prefer that we return to on campus in person traditional exams whereas what we believe is that we should be taking the lessons that we learned during the pandemic and really trying to build on those this generation coming through university at the moment are digital natives so we should be teaching them how to use that and really where we can try and base our assessment on through that medium and we did also receive some pushback from our external examiners but we were able to make the case and explain where we were coming from and convinced them that this was the way to go so it took a bit convincing that we got there and just this past year we conducted a survey on students on how they found this approach to assessment okay and the main things that we were concerned about were the students first of all aware of the choices that they had and if they were how did they make their choices that suits towards these different modes of assessment and what obstacles prevented them from choosing a mode of assessment that they may have initially considered okay so when it came to what mode of assessment best shows their ability it's perhaps a little bit unsurprising that no student liked tests either short or long or take home but what we saw was that most students really preferred just traditional mathematics written coursework so the kind of coursework we've been present on math degrees for a very very long time perhaps surprisingly multimedia submissions and portfolios works were very unpopular and this was when we were looking at feedback this was because students felt that multimedia submissions in particular would be time consuming and stressful and a lot more work they felt to get it up to the standard that they would wish in order to submit it so perhaps that's something that we might want to bait and try first and second year really encourage the students there to just get them used to it okay and then when it came to actually completing the work this is feedback we actually had so again it's not surprising that math students here tend to be in general very good at writing line by line mathematical explanations but when they're asked to then put their explanations into words that's where a lot of math students traditionally struggle and it's what we're seeing here with our students that the written English explanation is something they found very difficult but they also had issues with time management and the anxiety of stress when it comes to actually starting coursework but perhaps encouraging they had no problem doing that actually doing the calculations or understanding the question what they maybe struggled with finding the appropriate theory so I guess the idea is once they understand the maths they complete the question they found relatively straightforward but it's noteworthy that most of the responses from this survey were mainly third year students where optional assessment was new in their final year so that goes back to what I said previously but maybe perhaps in the future we should be trying to introduce this a little bit earlier and then some of these opinions might shift okay so in summary we have really taken lessons from these iPads they've proved very popular with staff and students and we've used this technology enhancements to really give students options on how they demonstrate how they've achieved learning outcomes okay and again this really promotes equality of access because we know that each student has access to the same hardware software and everything they need for their studies the iPads have really become a one stop shop for them and from feedback has changed how students approach their coursework because of the iPads but we're also getting feedback from students on the assessment so it really makes them partners in this so primarily results is that technical material students understand well when it comes to actually expressing in English how to approach a maths it's a little bit harder but we're going to try and bake that into level 4 and level 5 and hopefully that will change over time but yeah and that's ish so thank you for listening to us and any questions thank you so much Brendan and Matt that was wonderful I really loved all the interactive videos you put into that presentation to let us actually see how the students use the iPads I've got two questions I'd love to throw at you before we have to wrap up first one is from Peter Hartley who asked how are you going to develop this further yeah I mean this is a good question because I the student numbers on the maths are quite small at that scale it's possible to do this kind of thing but we are looking at how you scale this up so we have some of the big modules that we teach in support as the in the business school and we're looking at how looking at ways in which you can scale that really because that's going to be the difficult thing I think you know it's making sure these things work so there are difficulties with making sure equal types of assessment are marked in the same way but that's actually not too difficult that's more about designing the rubric well but yeah I mean there are issues we are looking at this is a continuous this is a continuous thing that's the thing this is just where we are at the moment really and we are looking to ways of improving these approaches and I'll share one last question from Alistair McNaught perhaps we can carry on the rest of the conversation on this card which says great examples of inclusion in these pedagogies but I wonder if the technologies might create barriers for other disabled students for example poor motor skills who can't use a pen or speed meter users was this a problem you experienced if not has there been a discussion about how it might be handled without losing the benefits of the current approach one of the students who does use this is actually quadriplegic it can only has some movement in one arm but they arrived at the university already having answered many of these questions you know how they were going to deal with it and they were using they were using iPads anyway if you know there are issues and if there are you know going back to what Brendan was saying it needs we will look at how you bake all of this in at the start of at the start of these things I mean it's possible of course we have an example of how it's been done for really a pretty extreme case but you know a lot of the problem with a lot of these things is that you often end up trying to solve the problems when they arise I think there are solutions out there the screen reader we have had experience of that as well working with screen readers with handwritten maths that's difficult but the way we would normally do it is treat it as a case by case kind of approach really all right I'm so sorry to have to cut you guys off it's been a really interesting conversation might I suggest anyone who wants to carry on that conversation head on over to our discord and we can follow up on questions there but it's just left for me to say thank you very much to Brendan and Matt for that presentation and I hope you all enjoy the rest of the conference thank you everyone