 The final item of business today is a member's business debate on motion 7373, in the name of Elaine Smith, on thyroid patients' deserve fair treatment. The debate will be put without any question being put. I would ask any member who wishes to speak in the debate to press their request to speak buttons now. I call on Elaine Smith to open the debate. Thank you, Presiding Officer, and thanks to the members who signed my motion, allowing me to bring this important issue to the chamber as my first members debate this session. As far as I'm aware, it's also the first time thyroid issues have exclusively been debated, and that's surprising, since hypothyroidism affects 2 per cent of the population, and as 95 per cent of sufferers are female, it's also a big issue of women's health. However, that may be explained why not enough attention has been paid to it, either by politicians or by the medical establishment, both of which, as we know, are male-dominated. Claire Puller, who wrote to me recently, summed it up well when she said that this is a male-dominated profession, actively silencing a female-dominated patient group. Perhaps if 95 per cent of thyroid sufferers were male, causing them to become economically inactive, then diagnosis and treatment might be dealt with very differently. There are, of course, some men with thyroid problems, but it is undoubtedly a medical scandal affecting thousands of women, and the lack of appropriate diagnosis and treatment is a matter of gender discrimination. However, women are now fighting back in ever-increasing numbers, despite being ill, that are becoming experts in the field of endocrinology, and the current threat of withdrawal of lyothyronine, or T3, as I'll refer to it now, has driven them even more. The improved thyroid treatment campaign has also motivated people to become involved in demanding appropriate treatment, and campaigners have also been motivated by the fact that so many women—mothers, sisters, daughters and constituents of MSPs—are suffering unnecessarily, being wrongly diagnosed, living half-lifes, dying of heart failure, mixed edema coma or committing suicide. There are some patients in the gallery tonight, and others are watching the live BBC feed. I hope that the minister will seriously address the issues raised and not stick to a script perhaps prepared by civil servants based on information from the intransigent male-dominated medical establishment. The thyroid gland controls total health and wellbeing, and it has been described as the body's engine. In the 70s, the standard course of treatment for hypothyroidism changed from natural-desicated thyroid, or DTH, to levelothyroxine, or T4, as I'll refer to it now. That is a synthetic hormone that is inactive and requires the body to convert it to T3, which is the active form that is needed to function. It is difficult to get a thyroid diagnosis in the first place, as many of the symptoms mimic other conditions such as depression, menopause and even Alzheimer's. Many women are told their borderline, and they are not given any treatment despite displaying hypothyroid symptoms. They are untreated and are likely to be costing the NHS in other ways such as infertility treatment, antidepressants and obesity, because some of the problems associated with thyroid disorder include depression, insomnia, infertility, anxiety, hair loss, weight gain, breathing problems and extreme fatigue. I have personally experienced all those as I have an underactive thyroid. I was originally on T4, but I would not be standing here as an MSP if I had not challenged a misdiagnosis when I became symptomatic again a few years ago. I was finally put on T3, and that brought me back from the dead, quite literally, and my full story is available on the Petitions Committee website if anyone wants to look at it. When I started helping Llyrion Cleaver's petition in 2012, I thought I was doing it for others because my situation seemed to be resolved. Over five years later, along with many other women, I am facing withdrawal of my life-saving T3 simply because of cost, not because I do not need it. Unbelievably, we are now going backwards in diagnosis and treatment. We are not moving forward with the up-to-date research that is readily available. It is officially admitted that 5 to 10 per cent of patients on the usual treatment of T4 do not do well, and many are unable to convert it. Since the medical establishment will no longer allow the use of DTH in the UK, the only alternative course of NHS treatment for those patients is T3. That is an entirely different medicine to T4. The human body has got to convert T4 into T3, and we know that some patients just cannot do that. Therefore, to suggest that patients on T3 can be safely moved to T4 is appalling, and it shows a complete lack of understanding of thyroid function. Eminent Scottish Endocrinologist Dr Anthony Toft has recently said that he suspects that time will be going back to using DTH, which some patients are currently buying privately from abroad, but in the meantime, all we have is T3. It is a terrifying prospect that for many women, this life-saving medicine is no longer being prescribed on the instruction of health boards, aided and abetted by NHS Scotland. Most patients cannot afford to buy it privately, and they should not have to, but the alternative is unthinkable. The British Thyroid Association recognises that the main reason for the withdrawal is not medical, but it is the astronomical cost that is charged by the company, who, until recently, were the only producer of T3 in the UK. In Germany, 100 tablets cost £25 in Norway, £15 in Turkey, £1.25. Concordia charged the NHS an unbelievable £922—a point helpfully highlighted yesterday by the BBC. That is a near 6,000 per cent increase over the past few years. Why cannot it be sourced from abroad? It must be resolved by tackling the price and not by attacking patients. Turning to NHS Lanarkshire, which I have mentioned in my motion, there are no clinical guidance on hypothyroidism that has been written by two diabetes experts and a GP. It is full of wrong information, out-of-date research, including an irrelevant paper on overactive thyroid issues. They have admitted the errors when I have challenged them, but now it must be recalled from all the GPs that it was sent to. Then they must ask thyroid experts, preferably those who know about T3 and who know the difference between hypo and hyperthyroidism, to rewrite it. Frankly, it is shocking that that could be produced in the first place. I also got wind last year that the board might be issuing instructions to the GPs not to prescribe T3 and to remove it from patients currently on it. They denied it. It was only after lodging FOIs that I discovered that there had been such correspondence, including an email saying that T3 is an expensive medicine and telling a GP practice they would have to bear the cost themselves if they prescribed it. There is no doubt that the underlying message to GPs is to stop prescribing T3, and that is outrageous. However, it is working because many women are now telling me that they have been taken off it and they will probably be coming to all their MSPs to tell them the same thing. GPs have got a duty to prescribe the drugs that their patients need, and they should be guided by the principle of do no harm. The BTA's 2015 statement has been misinterpreted by medics, and because of that, it has recently had to clarify its position as follows. The BTA position statement on hypothyroidism should not be interpreted as a recommendation to not use lyothyronine or as an endorsement for its discontinuation. That is pretty unambiguous. It goes on to say that patients on it should continue and that new patients can be treated with T3. Let's be clear. There are numerous rigorous scientific studies showing that T3 is a safe and effective medication. There are hundreds of Scottish women on T3, including me, who have been saved from a slow, lingering death. There are hundreds more who could be saved. The medical establishment admits that up to 10 per cent can't function on T4. Therefore, in Scotland, that means that they admit that well over 1,000 women can't function on T4. What is the choice for them if they take their T3 away? Without thyroid hormones, patients die, and taking away T3 will undoubtedly result in patient death. Will the minister put a stop to the removal of T3 and send a clear message that GPs must prescribe it? I am going to finish with the words of Morag Webster, who wrote to me. She wrote bravely about her own situation, and she said at the end of her letter that she had taken my twenties, my career and my friends, but I am a better person for it. I am just disappointed that she has robbed me of a chance to have a family of my own. That is a massive women's health scandal, which must be urgently addressed. Thyroid patients deserve fair treatment. Thank you very much. When I call Angus MacDonald to be followed by Miles Briggs. Thank you, Presiding Officer. I hope to be here for the full debate this evening. I'm actually hosting an event this evening, so I apologise if I have to leave, but I do hope to be here. So I'm pleased to be able to contribute to this member's debate this evening, not least because petition PE1463 by Sandra White, Marion Dyer and Llyrion Cleaver on effective thyroid and adrenal testing diagnosis and treatment has been live with the Public Petitions Committee for nearly as long as the time that I've served on that committee, which is just over five years, in which time we've taken large amounts of evidence on the subject. Can I take this opportunity before going into any detail to congratulate Llyrion Smith for bringing this issue to the chamber for debate tonight? Can I applaud her for the way in which she's championed this issue, both within the Parliament and by attending the PPC Committee, as well as raising the issue out with Parliament, most notably with her own and other health boards? Llyrion Smith. Thank you, Presiding Officer. I thank the member for taking that intervention. Could we also maybe just clarify that the Petitions Committee will be bringing the issue to the chamber so that there could be wider issues debated at that point? Indeed, yes. There's a draft report coming to the committee within the next few weeks, and we look forward to discussing it further in the chamber at, hopefully, a not-too-distant date. I'd also like to thank Llyrion Smith for outlining in some detail this complex issue in her speech just now. As I've said earlier, the Petitions Committee has taken extensive evidence in this issue over the years. More recently, Dr John Midgley, who believes that there should be an unbiased review of present protocols for treatment and diagnosis in the light of new evidence that shows that the single use of thyroid stimulating hormone as a test for thyroid deficiency and for treatment is unsuitable and misleading. Dr Midgley has stated that the test for thyroid stimulating hormone is now overreaching, resulting in a significant number of patients he believes being wrongly diagnosed, wrongly treated, or not treated at all. I have a constituent who has contacted me, who is a thyroid patient, and was diagnosed with autoimmune thyroiditis Hashimoto's and hypothyroidism in September 2016. She is taking level thyroxin medication, which is a monotherapy drug that supplies the thyroid with an inactive hormone T4. As a patient who does not convert T4 into the active hormone T3, the level thyroxin drug is, she states, next to useless for her. She has had to lobby hard for months with her GP practice and, if it was Valley Health Board, in order for them to provide her with even one other thyroid medication option. Now, NDT or Natural Desiccated Thyroid is controversial due to its animal content and unlicensed, it does not have UK status. However, I understand that a number of patients are sourcing it abroad, whereas synthetic T3 is not entertained at all because of the cost. As a result, my constituent has had to pay for a private endocrinologist to speak on her behalf with her GP and the Health Board before it was approved for her to even trial synthetic T3 as an alternative treatment. She is understandably annoyed at the way that she was forced to, as she calls it, jump through hoops to have her condition treated more effectively. As a result of her experience, my constituent feels that thyroid patients should not be limited to a singular medication option that may not work for them. Clearly, as Elaine Smith has mentioned, there is a cost issue and I was shocked yesterday to see that Canadian Drugs Giant Concordia, one of the producers of lyothyrhonyn, has been hauled over the coals by the Competition and Markets Authority for overcharging for the product. It turns out that the NHS paid around £4.46 per pack in 2007, however, the cost has risen to £258.19 per pack by July this year, an increase of almost 6,000 per cent. The CMA chief executive, Andrea Costelli, said yesterday, and I quote, that pharmaceutical companies that abuse their position and overcharge for drugs are forcing the NHS and the taxpayer to pay over the odds for important medical treatments. We allege that Concordia used its market dominance in the supply of lyothyrhonyn tablets to do exactly that. That is scandalous in anybody's book. Until earlier this year, Concordia, I believe, was the only supplier of the drug, but clearly any future competition will be welcomed by the 2 per cent of the population that suffer from hypothyroidism, not to mention the NHS. Elaine Smith, you have a brief clarification, because, as far as I understand it, it has set the price at a similar price. I look forward to improving diagnosis, easier and cheaper access to drugs, treating hypothyroidism and the easier availability in this country of natural desiccated thyroid, which has currently been sourced, as I said, abroad by sufferers who are desperate to find any form of relief from the symptoms. As I mentioned earlier, I look forward to debating petition P1463 further at the future meetings of the committee and, hopefully, seeing some positive action in the future. I would like to start by congratulating Elaine Smith on securing today's debate and to acknowledge her passionate work on this important issue on behalf of her constituents with thyroid conditions and also for sharing her personal experience this evening. I also pay tribute to those behind the 2012 petition to the Parliament's Petitions Committee for the work that they have done in highlighting the serious concerns around the quality of care and treatment for hypothyroidism. I commend the work of the British Thyroid Foundation, which provides advice and support to people with thyroid conditions throughout the United Kingdom. Hypothyroidism affects hundreds of people in every constituency in Scotland, and, as the motion suggests, is a condition that will affect around 15 to 20 in every 1,000 women, but only one in 1,000 men. The risks of initial misdiagnosis can be significant as some of the common symptoms mirror symptoms for numerous other conditions, and early access to acute blood tests is therefore vital. Hypothyroidism is a serious condition, but, if treated correctly, as Elaine Smith said, in the vast majority of cases, those with it can lead to normal life as long as their treatment is monitored appropriately. The original petition urged the Scottish Government to take action to ensure that GPs are able to accurately diagnose thyroid and adrenal disorders and provide the most appropriate treatment. I think that all of us will be able to share that aim, and while some progress has been made since 2012, there is still much more that needs to be done. The lack of specific and formal Scottish guidelines on the diagnosis and management of the condition has been a key issue raised by many patients ahead of this debate. While Sine is not required to follow the lead of NICE in providing a full guideline on the subject, I understand the concerns that have been expressed and which focus on the specific needs of a significant minority of individuals who do not successfully convert T4 to T3. I hope that Sine will be prepared to engage with campaigners on this issue in a positive manner and look at how we can make changes. I very much share the concerns that Elaine Smith has expressed with the guidance from some NHS boards that have implied that T3 should not be prescribed when this treatment or its use in combination therapy is essential to maintaining the health and wellbeing of patients who are not helped by T4. The decision to prescribe T3, or indeed any non-standard treatment, must be an informed clinical one made by a GP based on the individual circumstances and best interests of their patient. The work of the competition and markets authority in relation to the costs to the NHS of the only T3 product available in this country is welcome. I look forward to the CMA's findings in due course. In preparing for tonight's debate, the big theme that emerged was the need for more research into a range of aspects relating to diagnosis and treatment of hyperthyroidism. As Elaine Smith has said, I apologise, I would never accuse someone of being a Elaine Smith, the biochemical process is involved with thyroid function and the interaction between all the respective hormones are extremely complex and not yet fully understood. Again, there is a significant amount of concern that not enough research has been carried out into the specific group of people who do not respond to the standard T4 treatment, a subject on which there is little information known internationally. In addition, some people would like to see more research into the safety of the desiccated thyroid hormone, which has been used to treat hyperthyroidism in previous decades, but is now unlicensed. I would welcome an indication from the minister this evening as to how the Scottish Government is working with academia and pharmaceutical companies to try to take forward new research into the area, because I think that it is over time that we saw this. I thank the member very much for taking intervention, Presiding Officer. I would welcome new research into some of this and particularly research looking at patient experience, too. If you look at the ITT campaign standard letter, there is a lot of current research that has changed its mind since previous research was done saying that combination therapy works and that T3 is necessary for those who do well in T4. I think that, for that intervention, what is important—as she has passionately outlined—is that, for patients across Scotland, they feel that their voice is not being heard in this and that research and pathways to treatment are not properly being considered. This debate is very timely to make sure that we look towards how we can transform that treatment for so many people across this country. To conclude, Presiding Officer, I again welcome today's debate and very much welcome the focus that Elaine has allowed to be brought on what is such an important health issue for so many thousands of people across Scotland. I hope that this debate will help to increase awareness and as we look to make more progress in the diagnosis and treatment of thyroid conditions across Scotland. Presiding Officer, clearly Mr Briggs is getting ready for the Christmas Pantos season, referring to Elaine C Smith. I am sure that he will not mind if we refer to him as Rab C. Let me thank Elaine Smith, as others have done, for bringing this member's debate to the chamber today and for her very passionate speech on the issue. This debate is hugely important, is long awaited for the many people who suffer with thyroid conditions, some, as we have heard, who have been following the progress of the petition on this issue through the Public Petitions Committee since 2012. It is thought that almost 3 million people in the UK suffer from a thyroid problem and, as we have already heard from Elaine, about 95 per cent are women. Hypothyroidism is a crippling illness and many people are being failed by poor and inappropriate diagnosis and poor treatment protocols. Indeed, some people are left completely undiagnosed and untreated. Currently, patients in the United Kingdom are waiting more than three times longer to receive treatment than their peers in the United States. In America, they are treated much earlier. We know that thyroid problems can progress slowly over time, which means that many people are left suffering a debilitating illness for many months or, indeed, even years before they receive treatment from the NHS. The problems do not stop once a patient is eventually diagnosed. Current guidance that has been referred to already suggests that thyroxine T4 is the standard treatment for the majority of patients. That means that alternative treatments such as T3 and NDT are rarely offered. Despite the fact that there are many patients who do extremely well on T3, many more patients who require combination therapies. One of the concerns for patients is absolutely the threat of T3 being removed from the prescribed medicines list due to the extortionate costs associated with the drug. As you have already heard from Elaine, I think that it bears repeating because it is just so shocking and stark. In the UK, 100 tablets of T3 cost up to £922. In Turkey, the same dose costs less than £1.25. In Greece, it is £3.24. The NHS is being ripped off by Concordia, the company that, until earlier this year, was the only supplier of T3. Just yesterday, the competition and markets authority found that Concordia abused its dominant position to overcharge the NHS by hiking the price of T3 by nearly 6,000 per cent in the past 10 years. That is a truly shocking position. We need to remember that there is a very real human cost at the heart of this debate. Let me tell you about one of my constituents. She is a hypothyroid sufferer. She is currently prescribed both T4 and T3 as a treatment for her condition. She has been prescribed the same treatment since 2005, despite tests showing that she has a genetic abnormality, which means that her body cannot convert T4 to T3 as well as it should. Her doctor refuses to increase her dose of T3 and, instead, has twice doubled her dose of T4. There is no clinical reason for that. It is making her worse. I have no doubt that that is because of the cost. I know that there are patients not just in my area in Greater Glasgow and Clyde, but there are patients in Lanarkshire, in Tayside, where the health board has withdrawn T3 completely. What are those women to do? Are they to book flights to Turkey? That would probably be cheaper for them than having to access it through the NHS in Scotland. I know that the pricing of medicines is reserved, but it should not stop. The minister or, indeed, the health secretary from engaging in robust discussions with her UK counterparts, because women across the UK need T3 to give them any kind of quality of life. The only reason that the drug is being withdrawn from patients is the cost. Let me urge the minister to implement the recommendations from the improved thyroid treatment campaign group. Ensure that T3 is not withdrawn from the prescribed medicines list and that doctors can continue to prescribe in the clinical interests of their patients. Ensure that the treatment protocols include T3 as a standard option and that it delivers better and more effective treatment for thyroid disease. If that was happening to men, there would be a riot. I urge the minister to make sure that women are not penalised and that they receive the T3 that they need and deserve. I thank Elaine Smith for bringing this important debate to the chamber and for her personal and moving speech. It is very brave for any member to come to the chamber to talk about personal experiences and you can tell from her speech how much Elaine Smith's life has been affected by this terrible condition. As a member of the Petitions Committee, as my colleague Angus MacDonald said, this petition has been running for five years and at times we have been at a loss to know how to make headway with it. I do not profess to be a medical expert on the rights and wrongs of the drugs that have been used to treat this condition, but I know that this is a condition that has blighted the lives of women because 95 per cent of women are affected and have been for decades. Like so many quotes, women's conditions, such as menstrual problems or the menopause, which of course is not an illness but a normal part of women's lives, thyroid problems have, in the past, been dismissed by clinicians as, oh, it's just your age or it's normal for a woman of your age. I've been on the receiving end of that advice, as I'm sure have most women. Thankfully, in 2017, those attitudes are changing and the medical profession is taking a very different attitude to problems affecting it. Let's face it more than half the population, where at last starting to talk about them. I believe that the core of the problem with hypothyroidism is that, when it comes to diagnosis and treatment, the medical profession is, to an extent, stuck in the past with no clear pathway for diagnosis and treatment. What is clear is that one size does not fit all when it comes to treatment. As we've heard, the effects of unmedicated or poorly-medicated hypothyroidism are horrific—fatigue, weight gain, depression, anxiety, stress, lack of concentration, dry cough, insomnia and much more. The bottom line is that the medical profession must listen to patient groups and individual patients. For example, when any of us are prescribed antibiotics and find that they're not working, we go back to the doctor to be prescribed a different type, usually with satisfactory results. If one drug doesn't work, then it's feasible to keep trying to one that does is found. If that drug is T3, as Elaine has described, then that is what should be prescribed, regardless of cost. We've heard today of the shocking controversy surrounding drugs companies and the drug liothranine, or T3. That is a terribly serious issue. Patients should never be held to ransom by drugs companies and it's our duty, the Scottish Government and the UK Government's duty, to ensure that they are not. Buying drugs off the internet is surely the last resort and patients should never have to go there. They end up risking their safety and it's costing them a fortune. For those who can afford to buy the drug, it transforms their quality of life, but what about those who can't afford it? Are they simply doomed to suffer? In Scotland, we pride ourselves entirely correctly that we have free prescriptions thanks to the Scottish Government and no one should have to pay for good health. In conclusion, I'd like to thank the women such as Elaine and the women in the gallery who have spoken out about this to help other women as much as themselves. They've highlighted a serious issue and I hope that we finally see the medical profession sitting up and taking action now before any more women are forced to suffer. Bill Bowman, to be followed by Fulton MacGregor. Thank you, Presiding Officer. First of all, I'd like to thank Elaine Smith for bringing this debate forward. It gives us an opportunity to gain clarity about the treatments of thyroid patients and the challenges that they face, both of which are complicated issues. Many of those problems are highlighted in petition 1463, which has been under consideration since 2012, as I understand. I also would like to acknowledge the work of Sandra White, Marion Dyer and Lorraine Cleaver that they have put into that petition. As we have heard, in the UK, the condition affects 15 in every 1,000 women, one and a half per cent and one in 1,000 men, about 0.1 per cent. In Scotland alone, the figure is roughly 100,000, so it is vital to ensure that they are receiving the proper treatment. For an underactive thyroid, that involves taking daily hormone replacement tablets, which should allow for a normal, healthy life. Unfortunately, a lack of proper treatment can lead to complications. We have the expertise and tools here in Scotland to test for and treat thyroid illnesses, such as the state-of-the-art research facility at Ninewells hospital in Dundee. Similarly, a Dundee business acts as shield as a leader in early diagnosis of critical illnesses and hormonal imbalances such as those. Those facilities are a major boon not only for Dundee, but they are an even bigger boon in helping us improve lives here and elsewhere in the world. We must nurture and support them wherever possible. Sadly, it appears that there are a number of patients across Scotland suffering from thyroid disorders who are not receiving adequate treatment. The current T4-only treatment, prescribed by the General Medical Council, is inadequate for patients who are unable to convert T4 to T3. We have heard about that earlier. T3 being the active form of the hormone. To put a figure on that, 5 to 10 per cent of patients do not respond well to T4, according to the Royal College of Physicians. The current T4-only approach is at odds with the work of Dr Toft, who is considered a global expert on dochronology. Dr Toft stresses the importance of allowing GPs to have the freedom to treat their patients according to their individual symptoms. Dr Toft also makes it very clear that GPs should look at their patients and not the blood tests, because often the blood tests do not show up what the issues are and they certainly do not show if they are not converting to T4. The blood tests will say that they are absolutely fine, but we do not even know what absolutely fine is, because everybody will be different, and Dr Midgley suggests that some kind of test should be done, not just the pin, the hill prick test that is done in babies about thyroid, but also some kind of test maybe in people's teens, so that we would know what was normal for individuals. Thank you for that clarification and enhancement of our knowledge. I feel a little bit like a student teacher who is being observed from the back of the classroom. Unfortunately, the Scottish Government's listening exercise and undertaken by Thyroid UK revealed that many patients who do not respond well to T4 have difficulty agreeing alternative options with their GP. Dr Toft also makes the point that using blood tests alone as a basis for recommending treatment does not always reveal the full extent of a patient's needs. Basic thyroid testing needs to be improved to include options other than thyroid-stimulating hormone test TSH. Those TSH tests measure how much of this hormone is in your blood. However, doctors can make incorrect diagnoses when using THS levels as an indicator, so good to say it twice. If we are to resolve the situation, both alternative testing and treatment options must be available for use. Fundamentally, that motion is concerned with the need for personalised treatment. We must trust in the expertise and experience of GPs to prescribe treatments suitable for individual patients. It is entirely wrong, the wrong approach, to tie GPs' hands by only allowing T4 treatment. Therefore, it is worrying that the motion notes that some health boards are believed to be issuing controversial guidelines that imply GPs no longer prescribe T3. When patients are denied access to treatments, they sometimes experiment with unregulated unlicensed products. Lorraine Cleaver from Thyroid Petition Scotland has said that patients, including herself, are spending huge sums of money on their health, either paying for private tests, seeing specialists or buying medication that are not available on the NHS. That is something that should be of great concern to us all. In conclusion, knowing that a simple change in treatment can mean the difference between a patient living with debilitating systems or leading a normal life, it must be our aim that every patient receives the treatment that they need. Let us hope that we can trust the Scottish Government and our doctors to treat patients as individuals and to treat those conditions properly. I did not intend to speak in today's debate, so I might not need the whole four minutes. You will be glad to hear. There were two things that inspired me to contribute to today's debate. The first was my colleague Elaine Smith's contribution, which was very powerful. As a fellow co-bridger, I felt inclined to contribute with what she was saying. The second thing was that, just before the debate started, I received an email from a family member through in-law connection. I am just about this debate, and that also inspired me to speak, because she has emailed in some of her story. Several years ago, she was diagnosed as requiring T3 and T4 treatment. She was on both for a while and removed for T3, and I lost, she felt, a dip in her symptoms. After removal of T3, she was okay and off. However, in June this year, the register of T4 medication from 300 milligrams down to 50, and she noted a dramatic reduction. However, instead of getting more medication or back on to T3, just recently, she was actually taking off medication altogether. She is currently off work, unwell, with a whole range of symptoms that I do not need to go into that have been described by other people. I know that personally, because, as I have said, I know her. She puts that down to her treatment. I think that there is an issue here that we need to look at. I have every confidence in the minister and the Scottish Government that we will do that. However, this is a NHS board difficulty with a particular case, but the individual that I am talking about, when she went for treatment, her GP was not even aware that the reason why she required treatment was that she had her thyroid removed in the past. There is a whole issue around what priority thyroid treatment is given in Scotland and in the UK. That is the point that Elaine Smith is making. Just a couple of points that I noted down. I am no expert on thyroid disease, but I suspect that that is 2 per cent that are diagnosed. Are we talking about an even bigger issue here? I would imagine that that is a worldwide problem, just when I have done a quick search on my phone as we now do. We can check Google right away. I noticed a connection between the mineral iodine and the risk of iodine deficiency, which can perhaps lead to thyroid problems. Again, I do not know, but what I am doing is picking up on what other members have said and saying that we perhaps need more research in that area as well. I conclude that what others have said is that this is a gender-based issue, and we need to head on. I do not think that any of us in the chamber here can deny that, if it was 95 per cent men that were getting this, we would probably be looking at different treatment options. I will conclude by saying that we can take on the big corporations. We have shown it with minimum unit pricing. We took on the big corporations here. We can do that for the drug companies as well. I hope that we can all work together to find a solution to this. Because I have done this at last minute, I should also declare that I should just say that you are looking at me, the PLO to the health secretary. Thank you very much. Thank you, and I would like to call on Eileen Campbell as minister to wind up the debate. Thank you, Presiding Officer. Like others this evening, I am happy and privileged to take part in this debate. Before I start, I would like others to have wanted to commend Eileen Smith for bringing this debate forward and recognise the passion and commitment that she has shown in raising awareness of the issue and bringing in her own personal testimony to the Parliament to outline the struggles that she and many other women have undergone through having this condition. Many members have described the debilitating consequences of the condition and the suffering that many women have to endure. Therefore, it is incumbent on us all to do what we can to support women and to help as best we can. I also want to welcome the women in the gallery this evening. I know that some of that might not be all that Eileen wants to hear, but I recognise—I hope that she recognises—that there will always be a commitment to work with her as best we can to make the improvements that we all seek. I also know that the petition on thyroid disorders is still being considered by the Public Petitions Committee, and I sincerely look forward to that report coming through, which should be imminent. The Scottish Government is supportive of those who continue to do vital work towards raising awareness for thyroid patients. I am again encouraged to see so many people showing their support to the petition, to this debate and, of course, to the on-going work that will happen as a result of the petition's committee's work. Many members have mentioned guidance for clinicians as a concern. The British Thyroid Association position statement on 25 June 2015 set out recommendations on the management of primary hypothyroidism, based on a current literature review of the published positions of the European Thyroid Association and American Thyroid Association. That is the leading UK body for thyroid disorders, and its guidance is endorsed by a number of expert bodies, including the British Thyroid Foundation and the Royal College of Physicians. Further to that, in 2016, NICE published their clinical knowledge summary of hypothyroidism. That provides a concise, accessible summary of current evidence for primary care professionals and focuses on the most common and significant presentations in primary care. NICE also intends to develop a guideline on thyroid disease with an expected publication date on 20 November 2019. Wide consultation across stakeholders, very importantly with patients and service users, will be conducted. I would encourage anyone with an interest in thyroid conditions to engage in the guideline development. I am happy to meet Elaine Smith to consider ways in which we can enable women to ensure that they can take part in that process. Elaine Smith Thank you very much, Presiding Officer, and thank you, Minister, for giving way. Llyn Cleaver is involved in that process, but I wonder if you might commit to having a meeting with us just to talk about some of the issues following the debate. Llyn Cleaver Absolutely. We probably want to make sure that we reach out to ensure that as many women who are suffering in the way that many members tonight have described, if they feel that they have been disempowered in their diagnosis, they get the opportunity to feed into the developing guideline that we enable that to happen. If Elaine Smith wants to accompany her to that meeting, she will absolutely set that up. The chief medical officer's report on realising realistic medicine describes how we ensure that the people are firmly at the centre of the decisions about their health and care. It sets out how we help people to make decisions about their care and making care focused on what people need and asking them what matters to them. It is about giving people the treatment that is right for them at the right time with the right support. It certainly odds with what we have heard some of the testimony tonight. We want to ensure that it is embedded across all practice. Thank you very much for taking intervention. You will have heard tonight that people have been told that they cannot access the medicine that they require. They cannot access T3. The suggestion is that this is because of cost. Would you be willing to write to health boards to confirm that they ought not to be excluding this as an option in the meantime while the process is going on? Thank you, Joanne Lamont, for her contribution. I was going to come to some of that in response to the points that Jackie Baillie made in her contribution, because I think that Jackie Baillie outlined that there was a concern about concerns about this being removed from prescribed medicines list. NHS England might be considering this, but there is no question of the approach that has been taken in Scotland. In terms of treatment, the BTA position statement that I mentioned earlier takes into account—I want to make sure that I get to the issues of T4 and T3 as well, if that is okay, and I have taken a couple of interventions. If I have time, I will come back to Jackie Baillie. In terms of treatment, the BTA position statement that I mentioned earlier takes into account the wide range in international evidence space and concludes that T4 provides a safe and rational approach to the correction of hypothyroidism and that that improves the physical and psychological wellbeing of the vast majority of patients. In August 2017, the effective prescribing programme looked at medication for a wide range of conditions, including best practice in the management of hypothyroidism. The EPP board concluded that there is currently insufficient clinical evidence of effectiveness to support the use of T3 either alone or in combination as the first line option treatment of hypothyroidism. NHS boards were therefore asked to review the position of T3 in their formularies to ensure that T3 is only initiated on the advice of an endocrinologist, given the potential for causing adverse side effects and to consider switching use of T3 to T4 at medication review. However, that must be carried out in a person-centred manner with full engagement and shared decision making with each individual. Face-to-face consultations are essential before any change is made, and there should also be an assurance that the change is for a trial period and that the individual can return to the original treatment if the mutually agreed outcomes are not achieved. It is recognised that a small proportion of patients do not tolerate T4. T3-US remains available as an option where the appropriate clinician is satisfied that this is the safest and most clinically effective treatment option for the individual. However, people on T3 are on it because of medical reasons. If they are on the NHS and to take them off it even for a short time, it will really have a detrimental effect on their health. What the medical profession does not seem to be aware of is that patients who are not on T3 or on T4 are then putting themselves at risk—the medical establishment is putting them at risk—of strokes, osteoporosis in later life, heart attacks, etc. That is hugely dangerous. I was pleased that the minister said that there was no question of T3 being taken off prescribed medication. However, we need to tell that to health boards and the women need to know that, if they are on it or if their endocrinologists are putting them on it, they are to stay on it and not to be taken off it. I recognise the real passion with which Elaine Smith makes her points. Of course, the primary duty of clinicians is to do no harm, and that is why we expect, through the approaches that are outlined through realistic medicine, through making sure that there is adequate and proper and meaningful engagement, that those circumstances that are outlined can be avoided. We make sure that there is a clinically effective treatment option for the individual who can tolerate T4. Members have mentioned also NDT, which was used up until the 1980s. Again, there is a lack of robust clinical evidence that this has any clinical benefit to patients beyond that, which is delivered by the recommended medication T4. I recognise the serious concerns that are raised here today, as that treatment is currently not licensed for use in the UK. We urge anyone who is using that treatment or is unhappy with their prescribed treatment to again talk with their healthcare practitioner responsible for their care. Other members have also recognised an issue around research, and I recognise that there will be a minority again of people who cannot tolerate T4 and that further research on that is required. In Scotland, the Scottish Government's chief scientist office is responsible for funding high-quality research projects. The CSO's research funding committees consider application from all areas of medicine, the only stipulation being that the research is led by a Scottish-based clinician or scientist and that it has the potential to improve the health and wellbeing of the people of Scotland. The CSO does not initiate research, but we welcome applications for research projects aimed at the management of hypothyroidism that may include clinical trials for both P3, monotherapy and T3, T4 combination therapy. We look to academic institutions to seek funding to lead on well-designed research to address those evidence gaps. The endocrinological community in Scotland would also be happy to consider and assist with those proposals. To draw my remarks to a conclusion, all decision-making about an individual's health and care should be focused on the individual and discussed and agreed with them and their clinician. There are clearly areas that can be improved, especially when we consider the human cost involved and which have been so well articulated this evening. There is also much that we need to do to ensure that people's voices are heard and that they feel meaningfully engaged with. I thank Elaine Smith again for bringing the debate to the Parliament. The members who have contributed and those in the gallery will continue to work together across the health and social care services to make the differences that we all want to see. I reiterate that I would see opportunity in the nice work. I confirm that we will continue to work with Elaine Smith and others who want to be involved to ensure that we can get meaningful representations to that process. I look forward to the committee's work, because I think that there will be a further opportunity to reflect on the wider issue that people have expressed today about this being something that has not been taken forward adequately enough because it has been more commonly felt within women across the country. We do not want that to be the feeling that people have. This has been taken incredibly seriously. There are clearly areas that we can do more and must do more to ensure that people do not feel that they are being ignored, that they feel engaged and that they can make the progress in their health so that they can contribute and not have that feeling that they are somehow being ignored or that their concerns are not being taken seriously. So there are opportunities to make improvement and again I will commit to working with Elaine Smith and others on that. I thank the minister and all the members for their contributions and that concludes our debate. I now close this meeting.