 A the tenth meeting of the health and sport committee for 2018, we have apologies this morning from Alison Johnston. Can I ask everyone in the room to please make sure that mobiles are switched off or too silent? I am going to also remind everyone in the room not to record our photograph proceedings so that that will be done for us by the Parliament staff. We start this morning with agenda item one which is the consideration of four negative The first of the instruments is the duty of candor procedure Scotland regulations 2018. Members will recall that the duty of candor is an issue that was raised during the committee's inquiry on NHS governance. There has been no motion to annul and the Delegated Persian Law Reform Committee has not made any comments on the instrument. Can I ask if any members have any comments on this instrument? If not, are we agreed to make no recommendations on this matter? Thank you very much. The second and third instruments relate to the general medical services contract. The committee previously considered and agreed a draft approach to consideration of this contract. We agreed that following publication of the primary care improvement plans expected in July that we would then issue a call for written views. We have also agreed to hold an oral evidence session with key stakeholders to inform us about the implementation of the contract and delivery of primary care later this year. The second instrument is the national health service general medical services contracts Scotland regulations 2018. Again, there has been no motion to annul. However, in this case, the Delegated Persian Law Reform Committee has made comments on the instrument under general reporting ground. They have noted a number of drafting errors in the instrument. I know that the Scottish Government has undertaken to lay amending regulations in early course to correct these errors, but I wonder if any other members have any comments on these instruments. There has been none, and given the commitment of the Government to correct the errors in this instrument, is the committee agreed to make no recommendations on this matter. The third instrument is the national health service primary medical services section 17c agreements Scotland regulations 2018. Again, there has been no motion to annul. Again, unfortunately, there has been comment from the Delegated Persian Law Reform Committee under general reporting grounds noting several drafting errors in the instrument. Again, the Scottish Government has undertaken to lay amending regulations in early course to correct these errors. Can I invite any comments from members of the committee on this instrument? There has been none, and we agreed that we should make no recommendations on this instrument. The fourth and final instrument is the national health service primary medical services section 18c agreement regulations 2018. Again, there has been no motion to annul and no comment from the Delegated Persian Law Reform Committee. Are there any comments from members of the committee? There has been none, and we agreed that we should make no recommendations on this instrument. That takes us swiftly to our second agenda item. I welcome to the committee once again the Cabinet Secretary for Health and Sport, Shona Robison, MSP and Shirley Rogers, the director of health workforce and strategic change. This evidence session is on the impact of leaving the European Union on health and social care in Scotland. Members will have seen the letter from the cabinet secretary, which was circulated with papers, but may I invite the cabinet secretary to make an opening statement? Good morning and thank you, convener. I'm pleased to have the opportunity to give evidence on the implication of Brexit for health and social care in Scotland. We're now almost exactly a year away from the day on which the UK will withdraw from the EU. People in Scotland voted decisively to remain in the EU, and I continue to believe that this is the best option. Short of EU membership, the Scottish Government believes that we should stay inside the single market and the customs union. Given the announcement yesterday, it now looks certain that progress will be made at the European Council later this week on the form and duration of a transition period, and then talks should start in earnest on the future relationship between the EU and the UK. The outcome of these talks will have a major impact on economic and job prospects for current and future generations. The stakes could hardly be higher. As I said in my letter to the committee of the 24th of January, the EU does not have huge competence over health and social care. Nevertheless, the implications of withdrawal are manifold. I outlined five key areas of concern, all already drawn to your attention and written evidence that you've received during your oral evidence sessions, which have been following closely. The first thing that I want to make clear is that EU citizens currently make a vital contribution across the public sector in Scotland, including in our health service, where they often fill skilled vacancies in hard-to-recruit specialisms and geographical regions, as well as in our social care sector, where they fill many vital roles. The Scottish Government has been clear that our fellow EU citizens who have chosen to live and work here are welcome. This is their home and we want them to stay. The free movement of EU nationals in the UK is curtailed as a result of the Brexit negotiations. This could have potentially serious consequences for the recruitment and retention of health and social care workers in Scotland. It could also negatively impact the free movement of medical researchers between Scotland and other EU countries, and it could affect the ability of our academic institutions to attract medical students to come here to study and train, impacting on the provision of healthcare. The Government does not want any of that to happen. We have made it clear that, with concrete policies such as guaranteeing that undergraduate tuition fees for non-UK EU students will be free for the duration of studies even after Brexit, for those who are beginning their studies from now until the academic year 2019-20. We have also committed to looking to pay the fees of EU citizens working in the Scottish devolved public services who wish to apply for settled status. What we need to do now is to ensure that, come what may from the Brexit negotiations, Scotland is able to continue to benefit from free movement from Europe, and in addition to ensure that Scotland is able to manage international migration in a way that addresses our specific needs. The policy has been set out in detail in the recent Scottish Government paper Scotland's Population Needs and Migration Policy. A second area of concern relates to medicines and medical devices. As the committee heard last week, with 82 million batches of medicines crossing the UK-EU border per month, any decision that results in the UK leaving the EU's regulatory regime for medicines and medical devices could have a detrimental impact across our health service. The risk is that patients might suffer as a result of slower or reduced access to new medicines and equipment. There could also be an economic impact on the pharmaceutical and medical devices industries here in Scotland. The ability to continue to operate or participate within the range of relevant EU frameworks and legislation would be in the best interests of Scotland. In our view, the best way to meet the UK Government's stated commitment of continued close working and collaboration with the EU is for the UK to remain within the European Medicines Agency and to continue to secure access to the EU clinical trials portal. Withdrawing from the EMA is highly likely to be detrimental to patients. The risk is that pharmaceutical companies could be less attracted to the UK market than they will be to the larger combined states of the EU and the US, potentially resulting in delays to patients getting access to the medicines they need. We're also concerned that medicine manufacturers could be negatively impacted by additional costs as a result of having to work separately with the UK. This may mean that some manufacturers choose not to do so at all. I wrote to the Secretary of State for Health Jeremy Hunt in July last year, urging him to secure the UK's continued place within the EMA. Lord O'Shaughnessy's response to my letter in August setting out the UK Government's intention to continue cooperation with the EMA was less than reassuring given there is no example of a non-EA country having associate membership of the EMA. Against this difficult background, I can confirm that my officials are in close and regular contact both with the Department of Health and Social Care and the Medicines and Healthcare Products Regulatory Agency to ensure that we are as ready as possible for any of the possible scenarios that may arise in this area as a result of Brexit. A third concern relates to those areas where we may need UK-wide common administrative frameworks if EU law is no longer applicable. There is a clear issue of principle at stake here and what might seem like rather an esoteric argument. We have always been clear that common UK frameworks may be desirable or necessary in some areas on leaving the EU and that we would agree to them where it is in Scotland's interests, but we absolutely cannot accept the imposition by the Westminster Government of common UK frameworks, whether legislative or non-legislative, nor will we trade consent for consultation if there are to be such UK frameworks and Scotland must agree to them. In terms of the health and social care portfolio, there are a number of interests covered in the list of policy areas subject to discussions on UK common frameworks, which was published by the UK Government on 9 March. I will mention just two of them now, with the caveat that discussions on all areas are still on going and that no final decisions have been taken. First, changes to the current UK-wide system for mutual recognition of qualifications for a wide range of healthcare professionals could have profound effects on workforce recruitment and retention, on top of those that I have already mentioned. My view is that cross-border recognition of professional qualifications, education and training has to continue in order to support that workforce supply pipeline. If it does not, we would have an immediate and serious problem post Brexit. Second, on reciprocal healthcare, we also need to recognise that the rights of Scottish citizens to access state-provided healthcare across the EU and vice versa for EU citizens in Scotland should be guaranteed after Brexit. Some progress has been made in this area in negotiations with the EU, but uncertainty still remains. Again, my officials have been working closely with the Department of Health and Social Care and with other Government departments in these areas, both in the context of the negotiations with the EU and the UK Government on the possible need for common frameworks in order to ensure that Scotland's interests are fully protected. Fourthly, I am concerned that the Brexit negotiations have created uncertainty in relation to research and in particular access to future EU funding and collaborative EU partnerships in areas of interest for Scotland such as dementia and alcohol. The Scottish Government is keen to see on-going access for Scottish organisations to EU-funded research programmes. This will be important to ensure that Scotland can continue to be at the forefront of on-going international research collaboration. Loss of access to EU funding such as Horizon 2020 will significantly impact on research in Scotland unless mitigated. It is likely that international companies will be more prone to investing in facilities, including manufacturing within the EU, which is significantly a bigger market than the UK, rather than risk tariffs and other barriers to trade. Withdrawal from the EU brings the real possibility of creating a research funding gap. Only 7 per cent of research money allocated by the EU and European Research Council in the past decade has gone to non-member states. It is not only the scale of funding that is significant but also the locomotive effect that resources have to drive collaboration and forge partnerships that allow our researchers to achieve more than they would alone. There is also a concern that UK partners will be given less opportunity by other collaborators due to a perception of not being fully engaged. My fifth area of concern relates to the potential consequences of future trading arrangements entered into by the UK. The process by which any such agreements are arrived at must be fully transparent. No constraints should be placed on the devolved powers of this Parliament. I have two main portfolio concerns here. First, we share the concerns that have been expressed by many that any post-Brexit trade deals the UK enters into must not open up our NHS to privatisation. On 7 February, the Prime Minister at PMQ specifically failed to rule out opening the NHS up to competition. This cannot be allowed to happen. Second, we do not want to see post-Brexit trade deals being allowed to compromise the many public health benefits that we have realised in Scotland, such as in relation to alcohol and tobacco. In conclusion, I can confirm that our assessments and preparations for Brexit are well advanced, but they are necessarily constrained by the lack of clarity about what EU exit will finally look like. The challenge is complicated by multiple scenarios and uncertainty about the UK Government's objectives. In addition, many critical issues are reserved and the responsibility of the UK Government. We are seeking to mitigate some of the risks that we are facing by maintaining and strengthening our relationships with EU nations, both through the consular network here in Scotland and through our office in Brussels. We are also upping our engagement with UK institutions that operate across Europe, ensuring that, come what may, Scotland remains a progressive outward-looking nation. What I have presented to you this morning is by no means a comprehensive list. Either of my concerns or of the actions that we are taking to mitigate some of the risks that we are facing, but I hope that it gives you a clear sense that we are alive to all of the implications and challenges of Brexit. We are doing what we can to mitigate risks that we did not seek and cannot avoid. I would be happy to take questions on all of those and indeed any other related issues. Thank you very much, cabinet secretary. That is most helpful. Can I start with a general question in relation to yesterday's agreement? Clearly, it does not alter the substance of many of the issues that you have discussed. However, it does potentially provide a wider window within which to resolve some of the issues. Is that the view of the Government and how does that impact in particular on the areas that you are responsible for? I think that you are right in your expression that it provides a wider window in a period of time, but it does not give any additional clarity. It gives more time, but whether that time is used productively remains to be seen. We need to have certainty. I think that there is a welcome of having more time, but the devil will be in the detail of what that transition ends up looking like. We will continue, as I have laid out, a pace to try to secure Scotland's interests within that. Before I ask my question, it is interesting to note that, in our papers, Lord O'Shaughnessy was invited to be here today to sit alongside and a sustained effort was made to accommodate his attendance. He was unable to attend this meeting or various dates alternatives that were offered, as well as video conferencing. I find that interesting that we could not even get another date, but I thank you for being here this morning, Cabinet Secretary. You have outlined a lot of the issues that are faced as we proceed for this Brexit. I am interested to know what you would like to see as an immediate priority or immediate action in some of the issues that you have laid out. How is the engagement with the UK Government as this process moves forward? The reason I selected the five areas I did in my opening remarks and there are others, but I selected those five because for us those are the five most pressing matters. The issue of the movement of people is key here. We have many EU nationals working within our public services and we have tried, since the start of this whole process, to give out a message that they are most welcome here. We want them to stay and we have tried to give incentives and as much security as we can, but ultimately we cannot give guarantees that is not within our gift. What we have done through some of the measures that I indicated in my opening remarks has given a very clear indication of our desire for them to stay. Out of all the five, the key issue for me is maintaining that flow of people for our health and social care services. We will continue to do whatever we can to ensure that that is the case, but it is very difficult indeed. Is there any way that the Scottish Government can look at furthering our health and social care integration? We are already pretty advanced in that. There is social prescribing that is being developed, so these are quite good approaches that are taking place. Will any of that be impeded by this exit from the European Union? I think that if you look at our health and social care workforce, there is a varying threat to all of that. If you look at some of the specialties within medicine, there are more EU nationals within some than others. If you take areas such as pediatrics, such as surgery, there is a higher number of EU nationals working within those specialties. If you take dentistry in parts of your neck of the woods, we have over 40 per cent of dentists coming from the EU. Part of that is because of the recruitment campaigns that have taken place previously. People encourage others to come, so it has a domino effect. That is going to be very difficult. In social care, you have heard from Scottish Care about the impact in the here and now in care homes, particularly for care staff and nurses in care homes. That has been an important flow of people from the EU. From what I have heard from Scottish Care, the recruitment agencies that they would use in Europe to recruit have essentially closed their doors because nobody was coming through them because of the perception. That is the difficulty of perception as much as the reality at the moment. People are being put off coming, particularly in the social care field, is a worry indeed. We will continue to take action to do what we have done in terms of growing our own workforce, and we have set out that within our workforce plans. We will do what we can. We also benefit from the diversity of our workforce in health and social care. It brings our richness to our workforce when people from elsewhere come to work here and we do not want that to end. I am interested particularly in the negotiations themselves. The Scottish Government in the written evidence has said that you are continuing to make representations to the UK Government on issues relating to health and social care. I am interested in what level of involvement is there for the Scottish Government in the negotiations with regard to Brexit going forward. I think that you are probably aware that this has been a key point of contention because we have not had the ability to be part of the negotiations. The information that we get if we get it is second or third hand. We are therefore not able to put forward our unique needs and aspirations in the way that we want. If you look at, for example, the migration paper that has been written, it sets out clearly what we have met Scotland's needs in terms of migration policy. That would require the UK Government to enable the Scottish Government to have some of those powers around migration in order for us to be Brexit ready and to be able to develop our migration policy that will suit our needs. We have had no indication of any given that direction, unfortunately. We are in a very difficult position where we can see the impact. We know what it will be. We are trying to influence that through Europe directly and of course through our negotiations with the UK Government. As you have probably heard from Mike Russell and others, that has been a very difficult process and not one that we have found easy or productive unless things dramatically change, then that unfortunately may continue to be the case. In terms of intergovernmental relations, are there structures in place? Is there cross-government working at the moment already happening to ensure that Scotland's voice is heard into these negotiations or are you finding that you are not able to input into the process? For example, in the UK frameworks, there has been some co-operation, particularly at official level, around deep dives into those issues and attempts to try to find common areas of agreement. Then we come to the issue of consent and whether or not there is agreement on that. Of course, that is where there has been a divergence to date of opinion. We believe that there can be good progress made around UK frameworks but it has to have the consent of the devolved administrations because many of them impact on devolved areas as I laid out in my opening remarks. Without that explicit consent, we will be signing up to, essentially, another place deciding on those frameworks whether or not we like it and that is not something ourselves or the Welsh have been prepared to do for good reasons. Yes, there has been a lot of endless discussion but on that key point about who ultimately decides that has yet to be resolved and it is so important because many of those areas are absolutely critical as I have laid out. Thank you very much. That takes us to the key issue of common frameworks by going forward and I call Brian Whittle. Good morning to the Parliament. You touched on the common framework work that has currently been done. I am interested to know what role the committee, the Scottish Parliament, the Scottish Government, may have in the development and agreement in the Scottish framework policy. All of our parliamentary institutions should have a role and obviously you have attempted through trying to get UK Government ministers to come to engage with that. I think it is unfortunate that they have so far not agreed to do that, I think they should. I would suggest that there should be committee involvement but I think we need to resolve the issue of consent because if we can talk about frameworks, we can develop some of the thinking around them but ultimately there has to be, and not all of it is contentious, some of it actually won't be contentious, but unless we can agree the principle of consent that, particularly around legislation that will be developed to replace EU legislation, it is absolutely important that explicit consent is given by the devolved administrations. I think that that would create a better backdrop to the development of the UK frameworks and it would create a better environment for those to be brought. We absolutely agree the need for UK frameworks in many of these areas. It makes sense to do that but there has got to be explicit consent. I think that what I am really interested in is almost your input into what you think this committee would be able to do in terms of if we were going to produce a report here on the EU withdrawal with reference to health and social care, what can we do and to aid that process and fit into what the Scottish Government is doing. That is one of the reasons why we are particularly asking that we maintain a dialogue between yourselves and this committee in terms of progress that you are making. What can this committee do? Any pressure that you can bring to bear is a committee on any other committee in Parliament to try to highlight some of the issues that I know have collective concern around this table, which I have touched on in my opening remarks. It is a concern for all of us across the parties. Also, I would hope that you pursue the issue of the need for consent around those frameworks. We need to get that principle established so that when we get into the detail of what we will replace, it is agreed that the agreement of ourselves and the Welsh Administration will be required. I think that, as a Parliament, there is a role for this committee in looking at some of the detail as it emerges, but we have to get that principle established, which will create the right backdrop for us to have further discussions. I am happy to keep you as a committee, as informed as I can, as the detail of the issues emerge. We now have an additional agreement around the transition period. I am certainly happy to keep the committee informed of the discussions that we continue to have. It is also this committee's responsibility to hold the Scottish Government to account. It is important that we ensure that the Scottish Government is conducting the way that it conducts itself in this negotiation. That is why it is really important for this committee to understand exactly what the Scottish Government is currently doing in its interactions with the UK Government. As I am sure that you are aware, we have spent on our officials across all the areas of the frameworks. We have spent a huge amount of time and effort trying to move things forward. The deep dive exercises and all of that has taken a huge amount of time. There is no lack of willingness to engage on the detail, but we cannot get away from the principle that ultimately there has to be consent on those matters. I will make myself available as much as this committee wants me to over the next period of time as we take those matters forward to come back regularly to discuss the detail. We are trying to move forward on many of those issues as much as we can, but we have to come back to the fundamental issue of consent. I raise the issue of common framework in the debate from last week, because it is really important—professional qualifications, organ donations and various things as well. Medicine prices are another thing that we need a common framework for. Cabinet Secretary, you tell me what discussions have been on going between the Scottish Government and the Westminster Government. It is a pity that Lord Shaughnessy is not here to be able to ask him that question. Is there a date when we will hear if that is agreed or not agreed? I think that the framework is really important to ensure that we cover those very important issues. Is there an update on where we are at the moment and where we will hopefully get an agreement on those frameworks? I think that it is difficult to give a time frame. Obviously now we have time frames that are set out externally that we have to work towards. In terms of our discussions, we are trying our best to make progress on the detail. As I said earlier, there are many areas of agreement around what we need to establish. Not all of that is contentious, but there will be areas that are more contentious than others. There are areas where we would want to do things differently. On the issue of qualifications, as I set out in my opening remarks, we believe that it is really important to have common frameworks around qualifications. We believe that, around the regulation and qualifications, having that consistency allows people to work across these islands. That is a good thing. There are concerns about the qualifications of EU citizens coming in. At the moment, that is a very straightforward process. If that was to change, I can assure you that it is not a straightforward process. For those non-EU nationals coming in, it is quite a complicated process that we need to look at in itself, which we are attempting to do, but we do not want to lose that straightforward process of EU national qualification recognition. The detail continues to be discussed. We are doing that in good faith. Officials are spending a lot of time on this, as you can imagine. The political point at the moment is that, if we are going to bring those frameworks to a successful conclusion and be able to agree them, then there has to be a principle of consent to any of the legislative changes that require to be made. Shirley-Anne Somerville I can bundle together a couple of questions. We have been working at an official level very closely with colleagues in the Department of Health and the Home Office and various other places. I meet regularly with my team and my opposite numbers in the Department of Health to discuss a range of issues around things like qualifications, reciprocity, pharmaceuticals, general preparedness and preparedness for uncertainty, sometimes, to try and model various scenarios and see what that might take us to. Come into the specific issues in respect of the Cabinet Secretary's observations around the EU directive on recognition of professional qualifications. There are seven sets of professional qualifications that are given automatic read across across the European Union at the moment, and five of those are germane to the health and social care world. That covers in our world doctors, dentists, midwifes, general nurses and pharmacists, the other two just for interest of veterinary science and architects. The five that pertain to us are germane to all of our workforce planning because those are five key groups for us. I can assure the committee that we spend a great deal of time arguing very hard for the reciprocity of those qualifications to be immediately recognised. I'm happy to take any more detail on that if you wish, but that assurance that those conversations are taking place is absolute. Cabinet Secretary, you mentioned in response to Ash Denham the issue of migration and how significant that is in relation to those workforce issues. Is that a matter that comes within discussion on common frameworks going forward, given the existence already of, for example, the shortage occupation list in Scotland? The point has been put on every occasion that could be that referencing the Scotland population needs and migration policy paper, if we had those powers we could vary criteria and thresholds and decide what sits on Scotland's shortage occupation list. Those things matter in being able to flex the system to meet our needs and those discussions are raised and those asks are made, but to date obviously there's not been any movement on that, but we will continue to make that case. You're much moving on to a specific area around the research workforce and some of the implications. Clearly we've heard strong evidence of the challenges that we will face in maintaining partnerships and collaborations going forward. Can you tell us what specific areas you have been working on, for example with UK Government colleagues, on enabling that to continue? Also, going back to my very first question, Horizon 2020 clearly is relevant here and the wider window may have some benefits in that. I think that one of the difficulties here is that there is a concern of that impacting in here and now. The anecdotally you've probably heard this as well from some of the submissions that people feel that there is already an impact in terms of the success of research applications and that we're over there now and in terms of collaborations seen perhaps as a weak partner in those, and that matters because it impacts on decisions being made now. We all benefit from the research funding programmes. We are making that case very clearly both to Europe in terms of wanting to continue to be part of that and showing our goodwill and what we have to offer in research capacity and capability and to keep making the point that we're open for business still in that area and we want to be part of that. Of course, we're making that point very forcibly to the UK Government. Continued access to funding at levels that are at least equivalent to those currently available under the EU programme such as Horizon 2020 will underpin research partnerships and collaborations with European partners in Caria such as a mentioned dementia, where Scotland is a leading partner through the European Prevention of Alzheimer's dementia consortium led by a key academic from Edinburgh University and supported by the NHS dementia and the neuro-progressive disease research network. There's a risk, as I set out in my opening remarks, that diminished international competitiveness and influence of the Scottish health research sector coupled with exclusion from the networks with others. The EU may reduce the attraction of Scotland to potential partners to collaborate on research with. I think that for us this is a really key area that needs to be, there needs to be progress made, but again it's just part of the backdrop. I think that we understand how far perception and the kind of informal networks and conversations people have are influenced by their perception of what the outcomes of the Brexit negotiations might be. Rather, specific things the Scottish Government can do to encourage and enable researchers from other EU countries to continue to see Scottish universities, for example, or Scottish scientists, as partners and to provide assurance, regardless in a sense of the progress of the negotiations at a governmental level, of the things that you can do to assist Scottish institutions. The Scottish higher education institutions have secured over €316 million under horizon 2020 up to September 2017 based on the world class research and reputation, so we continue to promote that world class research reputation around Europe. Those points are being made all the time about Scotland still open for business and research. I guess what I started off by saying is that you can't get away from the fact that there is awareness out there in the research field, obviously, about some of these programmes that are coming at a time where it might be through the transition period and beyond, and that is a difficulty for us, but we continue to absolutely promote Scotland's ability, our skilled workforce, our reputation, and we're doing that as forcibly as we can. I think your point as well is what do we do about the rest of the world that is not just the EU component, and I think that that leads us to some of the conversations that were already embarked upon in terms of what migration policy might look like, and where we might seek flexibilities around UK visa regulations beyond Brexit and how that allows us to attract and work with the rest of the world, as well as those partners from Europe. Things like discussions around the existing tier 2 visa arrangements, discussions around the kinds of visas that might apply for people in training, some of our concerns around things like the immigration skills charge and how that might be a disincentive to people coming from overseas, and perhaps not as effective as it might be in terms of helping us to secure a medical workforce. There are a number of issues that go way beyond the relationships with Europe, but there's no doubt that the attractiveness of being able to have secure funding across a European basis has been a concern. I'm sure that the witnesses are aware that one of the positive things about research in Scotland is that Scotland is a net beneficiary for research and, in fact, has more spend per head than any of the other E28 countries. What is the cabinet secretary's view of becoming associate members of rise in 2020? I'm sure that the cabinet secretary is aware that there are non-EU countries who are members of rise in 2020, albeit that they are not voting members. Absolutely. I think that all of these possibilities are actively being pursued. Obviously, we would want as a first choice to continue to be full members and access, but obviously looking at what those other options may be, all of those are being explored. The closer we can align ourselves, the better that's why our ministers have been spending so much time speaking to the institutions within Europe, including those research institutions, looking at what those options might be and showing willingness to explore those options. Please be assured. Again, I'm happy to keep the committee updated as those discussions and others are taking forward. Come back to research issues in a moment, but first of all, Miles Briggs will have questions. Thank you, convener, and good morning to the panel. COSLA noted in the evidence given to the committee that, even before taking Briggs into account, analysts and commentators foresaw significant challenges for all sectors. Specifically, I wanted to look towards where the Scottish Government is seeing Scottish homegrown medical professionals. I wonder if you could outline, in terms of the workforce planning that we've seen over the last decade, where you see changes such as within the social care workforce and within the medical schools in Scotland to actually meet these future demands? So, since 2016, there's been 190 medical school places added, and we have continued to expand medical education, not just undergraduate, but obviously with the new graduate level medical school that is opening its doors this year, to build more resilience and robustness around growing our own workforce. We have taken those steps, also expanding training places, looking at nursing and midwifery, a commitment to 2,600 additional training places by the end of this Parliament. In terms of the social care workforce set out plans to try to make social care as a career more attractive, and the workforce plan sets out a number of mechanisms and ways of doing that. We're doing all of that, but I think that we also have to recognise that we benefit enormously from people who come to study here, make their home here, contribute to our public services. That in itself is a very rich seam of talent and experience that we don't want to lose, so yes, we will take steps and are taking steps to grow our own workforce, but we will benefit from people coming here, not just for numbers of people working in our public services, but also all the cultural benefits that we get from people coming and working here. Also, our medical schools have an international reputation since they were established. We have more medical schools per head of population than anywhere else in the UK, and part of the benefit of that has been the fact that they have an international reputation. People want to come and study at those medical schools, so many of them stay. Some go back to their home countries, but without a doubt our medical education system is world-renowned and we want to make sure that it remains so. On that medical school point, the number of Scottish domiciled medical students has gone down by 12 per cent since 2000. That's a decision as well around capping number of Scottish domiciled students, which are available, so we now only see 51 per cent of medical graduates being Scottish domiciled in 2000. Will you look towards lifting that cap, given what you said in terms of growing the medical workforce and projecting the need? At a second point around adult social care staff—that's where we've taken a lot of soundings on for our report—how many adult social care staff do you see Scotland needing because of Brexit and what's happening to make sure that the college sector is helping to foresee those posts? First of all, universities have always had the ability to recruit to their medical places freely. That, as I said earlier, because we have five medical schools, has been important in being able to ensure that they continue to do that in our world, leading in our scene as international medical schools. In terms of expanding the places, one of the reasons that we have done that, as I started off by saying since 2016, is that we have had 190 medical school places being added, with very much the intention of creating more opportunities for Scottish domiciled students. You'll also see from the graduate medical school programme that we have offered bursaries in response to a commitment to working in the NHS. No matter where someone comes from, frankly, it's about them wanting to work in the NHS. That's our motivating factor and, therefore, that offers an opportunity for people to commit to the NHS and we believe that many will do so. It relates to Mr Whittle's question about what the committee can do. I think that sometimes having some granularity on the evidence is helpful. If we take the 1,177 doctors in 2017 that were European primary medical qualifications, so those people who qualified for medicine in another part of the European Union, at the moment the dispersal across our specialties is quite uneven. That becomes very important when we're looking at the impact of withdrawal of the EU. If I take those categories, those specialisms that have the highest proportion, those are things like general medicine, emergency medicine, anesthetics and intensive care, occupational medicine, ophthalmology, pediatrics, pathology, radiology, surgery. One of the things that we've been able to do is to nuance our training places in those specialties. For example, if I take pediatrics as an example, rather than training one paediatrician for every paediatrician that we think we're going to need in order to look at and to reflect the changing nature of the workforce, we now train 1.6 for one. There are a number of things that we can technically do to try and encourage students to go into places to train for specialties that we particularly want to see. It's not simply a matter of saying we want to have an overall increase in the numbers. We want to target that on those specialties that we need. Clearly, from those of you who've sat round the committee table for a while, we'll recognise that that list is not dissimilar to the list that we want to see expanding numbers on in terms of our workforce plan in any event. So things like paediatricians, radiologists and so on are areas that we want to grow. Turning to the healthcare support work and social care question, I think that migration policy becomes very critical in that space, not just in terms of the EU, but across the world around having something that, of course, is point space to recognise highly technically incompetent people who come from a medical or other background, but in also giving us access to people who don't. And we want to be able to attract people who have high degree of skill and not. But again, coming back to the things that we've actually done, the introduction, for example, of through training to grow our own healthcare support workers in a programme which was developed in conjunction with SSSC and NHS Education for Scotland. That allows us to take people who have virtually no educational qualification and train them through to a professional level in respect of healthcare and social care. The numbers of those are growing every year. And also one of the areas we're also looking at is having a clearer pathway for people who've come in through that route who might want to go on to a regulated profession and that they should be able to have a clear line of sight towards that and more flexibility. We're very much looking at that. The workforce plans set out a lot of the detail around how to elevate social care as a career choice and the marketing around that. There's a lot of detail set out about what we're doing, which we would want to do anyway. But in the light of Brexit, it makes it even more sharper given the evidence from Scottish Care around the reliance on, particularly for nurses working within nursing homes. I should also add that one of the things we're been exploring working with Scottish Care around is the idea of potentially NHS nurses providing input into nursing homes where it's been very, very difficult to recruit and they're having to pay exorbit. Exorbitant agency cost, which is not sustainable. So we're looking at that. I think that Dumfries and Galloway is going to be one of the first areas that we're trialling that. So please be assured that we are trying many and varied things to try and make the professions more attractive. Miles Briggs' questioning. I brought this up at a previous session that just so happened that a couple of people came into my surgery saying that they had the qualifications to get into medical school. We couldn't get in because the places weren't available. And I just wondered whether there's been any research done into the number of people perhaps that were in that situation and potentially whether that is a resource going forward that is yet to be tapped into. Well, one of the issues we've done a lot of work around is around widening access to medical schools. You'd probably be aware, as I am, that actually when you look at the 11 suitably qualified applicants for every one place and there's then of course beyond the qualifications the issues that have come into play around who gets the place and who doesn't quite often around how people perform at interview, perhaps their work experience. And if you have relations working in medicine, you're more likely to get into medical school because you've been able to access that circle and that workplace experience, which other people might not have been able to. So the widening access programme, which Shirley's been very involved in, has been looking explicitly around how to make sure that people get a better chance of securing those, particularly from more deprived backgrounds. There's been the pre-med year that's been very successful and I met some of the young people that had taken part in that from a wide variety of backgrounds. So again, that's all about trying to make sure that everybody gets a fair crack at the whip in terms of being able to access medical education and I think it's showing some signs of success. The pre-medical course was introduced in 2017 and was full with 40 pre-med students. The early indications of those students is that they are likely to go on either to medicine or to some of the healthcare related science qualification. So we're optimistic about that. If you're saying that there's 11 applications for every one place, then it's an untapped resource there potentially. Well, yeah, but the issue I think is about, well, out of the 11, why is it that quite often young people from more deprived backgrounds, even though they've got the hires, they take all the qualification boxes, why is it that they have been less successful in securing a place? And I think the research and evidence shows that it's the wider application process. So the interview, for example, the wider work experience that that person might or might not have had within a medical environment. And you can see why if you're from a family where there's people within medicine already, you're more likely to be able to put that on your CV than not. So the pre-med course tries to level the playing field and it gives those young people without any access to those supports an opportunity to be able to get that experience prior to going to, if I might. These are important questions, but I'm keen that we press on. We can provide the committee with more detail. We will return to this, I'm sure, at some point, but there are some specific Brexit points we still want to cover in the time we have Emma Harper. Remote and rural, yes. When Joanna MacDonald gave evidence, she's from NHS Highland, she talked about the challenges that Brexit would bring for the remote and rural areas as well. So she talked about how the central belt is a draw for people going into education or medical school. So I'm interested to know about what the Scottish Government can do to promote or help the remote and rural areas. It would be interesting to hear a wee bit more about the graduate injury to medical school as well. I just spent the weekend at Wigtown and put William and Newton Stuart and people say that these areas might as well be islands as well because they are very rural. So I'd be interested to hear about that. One of the examples that I gave earlier on was the issue of dentistry and the fact that we have potentially a huge challenge where the success of our recruitment campaigns because there was a time. Not the case now, but there was a time where there was an acute shortage of qualified dentists and therefore there was a European recruitment campaign that was very, very successful. Particularly in our rural areas, both in the Dumfries and Galloway Borders and the Highlands, where many EU dentists have come to work and have stayed and have encouraged others to do so. So we need to be very alive to those pockets of success, but now particular challenge. So there's been very direct engagement with those professionals around trying to encourage them obviously to stay. Many of them have brought their families up here and they want to stay. So that's a very acute example. In terms of what we're doing around remote and rural, the Graduate Medical School of Scotland, you'll be aware that the rural health boards have been very proactive in securing training opportunities within their areas. Down in your patch, Dumfries and Galloway have been quick off the mark and have provided a commitment to take a number of trainees from the Graduate Medical School in general practice particularly. That will make a huge difference, I think, not just in terms of the numbers of trainees but the fact that they'll get the experience of working in remote and rural Scotland and will hopefully want to therefore do that on qualification and once they've finished their training. So I guess all of the areas that I've laid out in terms of the impact and surely touched on some of the specialties that we draw from the EU and are harder to fill, that's just exacerbated and highlighted more within rural and remote Scotland. So we will continue to do what we can with the trainees, so in radiology for example, we're expanding the number of trainee places and we're trying to ensure a spread of those, particularly in those areas such as the north of Scotland where there's been particular challenges in recruitment. Can I just amplify some of the comments from the Cabinet Secretary there? One of the issues that we need to face in the dispersal of how we train across Scotland is that you experience a different kind of medicine in remote and rural Scotland than you do in central belt. So you don't have big teaching hospitals where you go to do heart lung transplants in those locations. So it is about how we value general practice and put a parity of esteem around general practice. It's for that reason that the design of Scottgem for example not only incorporates work from the University of the Huns and the Islands but also has a huge focus around general practice. So if historically medical schools designed medics that were destined for specialties, our view is that general practice is in itself a bit of an oxymoron but nonetheless a specialty. So it's really important that we invest in that space. Graduate medical schools are designed to focus around those people who've already been through one kind of degree qualification, bit more settled in their lifestyle, choosing to live and work in a particular location. That's the other aspect that I just wanted to pick up on. All of the evidence that we've got about people from wherever they come around the world who want to live in rural Scotland are doing that because they're making a lifestyle choice around that. And wanting to locate their families in rural Scotland and experience the lifestyle benefits of living and working in rural Scotland. So uncertainty about whether or not they can continue to do that is a really big issue. Before we move back to research questions, Charlie Rogers mentioned a specific specialism where there had been a calculation done on how many people you need to train. In terms of the social care workforce, in terms of the nursing workforce and in general in terms of healthcare, what is the scale, how many people do we need to plan to recruit in order to compensate for the likely loss of many of our users? One of the reasons we've expanded the nursing midwifery training places to the commitment of the 2600 by the end of this Parliament was very much with an eye on Brexit and other challenges. The need to expand that workforce. Also the fact that the nursing workforce is expanding anyway in terms of the roles that they are taking on. Also when we're looking at the multidisciplinary team in primary care, we need more nurses for that. So we've tried to calculate in terms of as best we can in terms of expansion of training places a big commitment. It's a £40 million commitment to grow that workforce which will hopefully also help to mitigate against Brexit. In terms of the social care workforce, again the workforce plan lays out the scale of the challenge. I mean we have a need to really encourage many more people to work within social care. The workforce plan sets out how we're going to work to change the perception of social care. How we're going to attempt to recruit creates more career opportunities, clear pathways to, for example, regulated professions. We need to do all of those things to grow the workforce. I appreciate that you may not have numbers to hand but perhaps Charlie Rogers would. I can supply some numbers. In 2017 there were 762 EU qualified nurses, nurses and midwives operating in the NHS in Scotland which was approximately 1.76 per cent. So we would need to stand still to increase by that kind of factor. The data that we have around the social care workforce is a little bit more fragmented for obvious reasons but just to put some quantum around it in terms of the social work sector, specifically social work, 4.4 per cent of the social work cohort are EU qualified with a further 2.4 per cent from other parts of the world, not the European Union. 6.8 per cent in total of non-UK residents qualified in social work in that space and the estimates that we have from the social independent care home sector is approximately 8 per cent. So we would need to reverse by approximately those percentages in order to stand still. On research funding at Jenny Gilruth. Thank you, cabinet secretary, and to Charlie Rogers for coming to speak to us this morning. I want to start a bit about looking at public messaging. I know that we have touched upon this previously but in last week's evidence session I raised the UK Government's chief whips intervention when he wrote to every UK university regarding the teaching of Brexit and having names of those who were delivering the syllabus. I think that that sent a pretty clear message and I've got to say as well that Lord Ashon is not even bothering to turn up today or to respond to the committee's request. It also sends a pretty clear message in terms of how this Parliament is seen within the negotiations. In response to my question last week, Professor Anna Dominicac told an upsetting story of being asked after the Brexit vote by a colleague if she would now go home and home has been Scotland for the last 36 years. I pose a question to her last week if we were in danger of losing our academic edge post-Brexit and I wondered what your view might be on that, cabinet secretary. I know Anna very well and she's a great asset to us as are many of our colleagues and she works extremely hard to promote Scottish research and has been incredibly successful in bringing huge amounts of research opportunities to Scotland. She's a real credit to us and it saddens me that I think some of the unfortunate, the backdrop to some of this and I think we've seen it with some of the recent statistics about perhaps a rise in intolerance and comments and racism towards people from the EU. On the back of leave, I think is sad, upsetting, abhorrent, not where we want to be, not the kind of Scotland we want to be. We're not immune from that and we've all heard incidents, whether that's from Anna or from others, which is a very, very sad fallout from this. We have to work very hard to make sure that we continue at every opportunity to give the message that Scotland is an outward-looking, welcoming nation. We want people to come and work and make their homes here, as Anna has done for many, many, many years and has encouraged others to do so. We feel extremely strongly about that and that message that we can all give out is very important to reassure people like Anna that that comment is a very much a minority view and not the view shared by the vast majority of people here. In terms of what we can do about it, I think I said earlier on around the welcoming nation but also the fact that we have a very hard edge to that of wanting to ensure that we continue to keep that dialogue open with EU institutions and research institutions. We have a lot to offer here. We stand on our own merits in many respects in terms of what we have to offer in the research world. Those skills are often not found elsewhere, whether that's in the life sciences or the growing data skillset that we have here in Scotland. We are going to have to work hard to keep that message out there and to counter some of the negativity that has grown up around this whole issue. Can I just pick up on the messaging thing? I think that reassurance is terribly important and that nature of Scotland as an inclusive society is terribly important. I think that people are also looking for certainty. I was speaking to a couple who happened to be consultants in one of our health boards. Only as recently as yesterday I was hearing tell of them already deciding to go and move to North America. Because whilst they've enjoyed their training here and they enjoy working here and they're quite happy here, they know what they have to do in order to be able to stay somewhere and they're at the stage in their lives where they want to think about having a family. The messaging is terribly important but actually these are people who want to make lives in a place so they need to know that they can do that with whatever the rules are, knowing what they are. I think that we've tried, as I laid out in my opening speech, to give incentives around saying that we would, if anybody wanted to apply for settled status, we would pay the fees around making sure that we continue to pay tuition fees and so on. It gives a real message but I should have also mentioned, I thought, Dr Peter Benny's comment was spot on, which he gave in evidence when he said that the Scottish Government has been clear that it wants to protect the rights of European NHS staff and that this is welcome and appreciated by many. However, it is ultimately the Westminster Government that must act before further damage is done. I think that that captures both what Shirley and I have said about yes, we can put the message out but we need action to end the uncertainty. There were a couple of questions that I wanted to touch on regarding the research workforce. I concur with everything that Jenny Gilruth has said and also the Cabinet Secretary as well in regard to retaining and making sure that people want to come here. It was raised earlier on about a cap but there is also a current cap on the number of non-EU residents who are able to come here and work in the UK as well. Are we looking at anything in that respect? Can I just, that was a point that I wanted to go back to Mr Whittle's question earlier on in respect of numbers of medics in training because I'm sure that if I'm sitting in your seat thinking well there are lots of applicants and we only take a certain number of them, why don't we just take more of them? The last time we looked at the evidence there was about 47% of our medical establishment currently doctors in training. So we always have to balance the issues about making sure that those doctors in training are getting a good medical education and that relies on our consultant workforce to do that. So those of you who know medical education well will know that some of it is spent in the classroom but an awful lot of it isn't, an awful lot of it is spent on the wards, an awful lot of it is spent as being supervised by our consultant and senior training workforce. So there's always a balance to be had. We couldn't simply say even if there was all the money in the world and all the interest in the world that we're going to have an extra 10,000 doctors arriving tomorrow because there wouldn't be the process in place to give them a good quality education and a well supervised educational practice to ensure patient safety. So we're always open to suggestions about how we can increase our supply into our medical professions. We're always looking to do that. There is a model that the universities use in terms of those places that are funded through Scotland, those places that are funded through the rest of the UK and those places that are funded through the rest of the world and the universities have discretion to move somewhere along that line. We've particularly funded and targeted funded access places to Scots domicile students, but it isn't for us to tell Edinburgh University that it can't take X number or Y number, but by the same token trying to encourage people from Scotland to go into Scottish medical schools, terribly important. In regard to the cap on non-EU students, non-EU researchers coming here, is it something that the Scottish Government can look at or is this a UK wide? Well, it comes back to the visa situation. Again, the migration policy sets out that we would like to have more flexibility around that to be able to, for the shortage of occupation skills list, to be able to have more discretion over that. We have tried to forge some of our own initiatives, not so much on the research side, but on the medical training side. For example, the medical training initiative, which is an opportunity for people who are at the end of their training. They are in the last two years to come and finish their training here. We have been discussing with Malaysia, for example, who have a similar medical education set up that we would take, particularly those specialties that are hard to fill. We would take some of their trainees to finish their training. People with a high level of skill are at the end of their training, so they are really worth their weight in gold. We are looking at how we would, beyond Europe, create these opportunities. It may be in the research space. Of course, some of the discussions that we would be having with some of our ministers when they are going out to speak to their counterparts in countries where we have been targeting around our international engagement, research would be very much at the top of the list in terms of trying to forge new interests and new businesses, new opportunities. It is absolutely critical, but we have got other plans and engagement across the world where we have been trying very, very hard to bring jobs, to bring research here to Scotland and to forge those links. We can furnish you with more information if that would be helpful. We have other members who wish to ask about this topic, but we will maybe come back to that if time allows. What I would like to do is make sure that we do not miss some of the other key issues. Alex Cole-Hamilton Thank you very much, convener. Good morning, cabinet secretary. Good morning, Shirley. Thank you for coming to see us today. One of the areas that I had not considered, and I doubt perhaps other members of the committee had done, was the impact of leaving the European Union on clinical trials. We understand, obviously, that when you have particularly ultra-orphan conditions where there are too few patients for a sustainable clinical trial in Scotland that we look to pan-European trials to cover that. The shocking reality of this, and I think my colleague Jenny Gilruth mentioned the testimony of Dame Anna Dominicac, and I would like to do so too, because she actually referenced it as being almost criminal should Scottish patients be ripped out of European clinical trials. Can the cabinet secretary explain what representations have been made in, as much as there have been discussions with the UK Government about a future Brexit trade deal, that we are part of some kind of continuing clinical trial agreement, and what mitigation can we put in place to reduce the impact on Scottish patients so that they are not deprived of potentially life-saving therapies? You raise a hugely important point. The UK Government's stated commitment is to continue close working and collaboration with the EU, and they've said that they want, whether that's the European Medicines Agency or EU clinical trials portal, that they want to continue to have close working. What does that mean? We want access to the EU clinical trials portal. You can ask for the moon and say that you want to do this, but actually making it happen is another matter. I think that anything short of having access to the EU clinical trials portal will be a disaster. We absolutely need to secure that. We have been working hard around these issues, both with the UK Government. You're not going to get much disagreement, I would suspect, from the Department of Health, or potentially Jeremy Hunt himself, but he's not one of the key Brexit negotiators. Therefore, we need to make sure that this issue is up there. Mike Russell has been well briefed about it. He knows the importance of access to EMA and the EU clinical trials portal. We continue to highlight its crucial importance. We have done that directly to Europe as well by saying and making it very clear Scotland's desire to continue to be part of that. However, as I said in my opening remarks, there is limited experience of countries who are not part of the EEA. You might be described as having their cake and eating it. I think that's the difficulty. We need to use every lever that we have to secure continued access. We have a lot to offer. Scotland's ability to, in this area, in terms of clinical trials and offering, given our unique selling points of our NHS, is well underserved. However, it is one on a list of many critical issues. Without it, I think that you're right about ultra-orphan medicines, that we would need that wider access to patient information to be able to test these ultra-orphan drugs will require access to that portal. Thank you. It strikes me that this is a world away from the discussions and trade around dealing cars for whisky and the rest of it. Lives will depend on this. Is the Scottish Government in a position then, while these arrangements are being ironed out, to keep pace with the European clinical trials directive through making sure our standards are mirroring those of Europe so that we are ready to re-engage if we are ripped out of it? Are there any international trials networks that we could partake in if Europe was closed off to us? There are other international clinical trials, and we take part in them. A lot of those are now, through use of technology, able to be done quite far and wide. We can write to the committee with more information on that. In terms of aligning, we absolutely want to align, and that would be our intention. Obviously, the UK framework discussions are part of that. What would make most sense is for us to agree UK-wide to align and to adopt those frameworks, to adopt those regulatory and high-level and very well understood commitments and quality assurance that is so, so important. Again, all of that is caught up in the issues that we have discussed earlier on about the frameworks and the need for us to agree those freely across the islands. Discussions continue. David Stewart. Good morning. Can I raise the issue of medicines and treatment? Cabinet Secretary, you touched on that in your opening statement. I have been very interested and very concerned about the future for medical isotopes. The Cabinet Secretary will be well away from our own knowledge in last week's evidence. UK produces no medical isotopes, and we are part of your atom, which regulates import and export. Just for completeness, 90 per cent of the production of medical isotopes in the world comes from four EU countries, Australia and South Africa. Obviously, there are huge concerns about medical isotopes because they are used, as you know, to prevent surgery. Lack of security supply will mean a problem with longer waiting lists and more costs, and ironically, more surgery as well. We do not have these medical isotopes. What assessment have you made for the effect on cancer patients in Scotland for leaving your atom? Yes. Again, there has been specific work done around this, and I am happy to write to the committee with the detail, but it is a huge concern. I am really glad that you raised it, because you can imagine the delay if there was around customs points of these medical isotopes being caught up in delays at the border and not being able to. That would have a huge impact on treatment, and it is not easy to secure other supplies of medical isotopes as a very particular product. Obviously, the transportation of it has to be done in a particular way and has to be done safely. That, again, has been an issue that has been raised by officials, by Mike Russell in his discussions with me directly as well. Again, we need clarity. We raise those issues. We talk about the impact, and it would be an impact across the UK, not just on Scotland, but we have yet to get a clear route to resolution. One is a particular concern. You can imagine that there would be real concern about any goods and services being delayed in terms of customs points, but with this, that could impact, as you say, absolutely and now on patient treatment and cannot be allowed to happen. Again, it would be one of those issues. As discussions move forward, I would be happy to keep the committee updated on the detail and progress that we make. Your Government has a risk register for potential threats. Is this a comment rather than a question? I am sure that your ad to your risk register is the fact that they have a short half-life and they cannot be stored. If they are kept at the border because of customs, if that is what emerges, you can see very clearly how that would impact. It is high up on the risk register. Again, I am happy to keep the committee informed. Can you touch on your statement about leaving the European Medicines Agency? What is your assessment of the effect of that? How realistic is it becoming an associate member? I think that, as I said in my opening remarks, there is no precedent for becoming an associate member for non-EEA, as I am aware. Again, it is uncharted territory, but that is not something that has been done. You will have heard the pharmaceutical industry raise this very forcibly. There is an understood quality assurance here where standards are clear. If there was to be a development of a UK alternative to that, let's just say for argument's sake, there would be potentially questions about the quality assurance of that. Is it going to be pegged to the EMA? Will it have the same standards? I think those are questions that remain unanswered. How widely understood would that be by international pharmaceutical companies who well understand the standards of the EMA, but they might not understand this new thing that people are telling them is pegged to EMA, but is it? We don't know. I think that there are huge risks there because a pharmaceutical industry can go anywhere. Whether that is an investment, whether it is in terms of clinical trials, whether it is just of access to medicines, we need to have standards that are internationally understood. That is, in my view, best served by the EMA because everybody understands them. Again, we continue to discuss these. It is one of the areas that we have been discussing around the framework. Surely we might have more detail on that. I was just going to amplify the cabinet secretary's comments by talking about licensing as well, because the supply of something, and I was able to get that in a timely way, is one thing, the cost of things and their licensing arrangements across different countries. If we look at some of the biological drugs currently available, there are different pricing regimes in different countries depending on where they are in their licence cycle. There are drugs that are considerably more expensive when sourced from elsewhere. There may also be some drugs that are cheaper when sourced from elsewhere, but the majority of new biologicals and things like that are still considerably under licence, and it would be very dependent on cost and what those licensing arrangements became. I am conscious. I move on to reciprocal healthcare with the convener's permission. The cabinet secretary is well aware that there are two main positive cards for being part of the EU and the EEA, which is the EUHIC card, the European health insurance card, which all citizens can access because of the same rights of any other citizen in the 28, and just for completeness in Norway, Iceland and Liechtenstein, and a few others. The S1 arrangement, which provides free or low-cost healthcare for those in receipt of a state pension, is crucial if you decide to move from Edinburgh to Italy, Spain or one of the other EU countries. Just one example provides great advantages to those with medical problems for completeness 29,000 dialysis patients in the UK who are able to go abroad. If they did not have that access clearly, there would be huge medical insurance costs which might not allow them to go. The main issue that I want to raise is, again, talking about risk registers. If the S1 arrangement does not come to fruition, there is a traditional arrangement immediately, what would happen in terms of Scots who are living abroad, who are on pension age, coming back to Scottish healthcare to access primary care, social care and care homes? Have you worked out and done some estimates, cabinet secretary, of the possible impact that this could have on your budget and your hard-pressed front-line staff? If you were to take the total of Scots of pensionable age living in Europe, but if they were all to come home at the same time, then, of course, that would have a huge impact. I guess human behaviour is not quite like that. First of all, we would hope that there will be reciprocal arrangements that will finally be worked out and agreed, because I do not think it is in anybody's interest to see that scenario. People who have lived abroad for many, many years and have made their lives, whether it is on Spanish costas or anywhere else, we would want to try to reach agreement. We would expect the UK to be working very hard. We know that this has been a key priority to try to get those reciprocal arrangements. We would want to make sure that, however, we would obviously be doing the work to assess any flow of people who would want to return. At the moment, we are not getting any indication of a mass flow back from the Spanish costas. I think that people are waiting to see what transpires. They are probably picking up messages that this has been a priority area for the UK Government in terms of guaranteeing reciprocal rights. The S2 scheme and the S1 scheme, as you have set out, bring considerable benefits of people being able to travel. I would hope that there will be something that will be part of the transition period agreement in that space. The worry is the uncertainty at the moment that we do not know, but we know that it is a priority that has been discussed. We would want to continue to have access to those rights following the UK's withdrawal from the EU, but people need to see the detail and we need to begin to see that detail emerging. I do not think that there is going to be a mass flow back to Scotland overnight from people living elsewhere, but I think that it is a risk if people do not have certainty that people will begin to make decisions about their future. I cannot accept to my well have seen Brexit and the NHS report by the UK in a change in Europe, which was provided to the committee, which is an excellent report. As you know, it is an independent report. The figures that that suggests is that there are 190,000 UK citizens over 60 living abroad and that, if they came back, we would need 900 more care beds. Do you recognise those figures? Yes, we do. It is a key concern. I would hope that there would be agreements put in place before that, but people need certainty. At the moment, if you are sitting as someone who has retired to enjoy the sun somewhere, you will be worried about what the future holds. That is why we need certainty now before people begin to make decisions about where they are going to locate themselves. Frankly, if everybody did decide in the event of no arrangements being made, it would have a huge impact on our health and care services. The final issue is that I am very concerned about the effect of having those who are ill, those who have long-term illness or are elderly, will be restricted going abroad because the reality is that, without the EHEC card, health insurance will be beyond them, particularly those with a lower income. Absolutely. That is undoubtedly the case and we know already that some people have issues with securing health insurance if they already have a long-term condition or are acutely unwell. I would be very concerned about that. I think that those arrangements benefit both our own citizens travelling, but they also benefit citizens travelling here. They are a sensible set of arrangements that will need to either be kept in place or will, in some way, have to be replicated. I cannot see how we would be able to operate our systems without that being in place. As I said at the beginning, I would hope that that will be resolved. If it is not, we are leaving ourselves open to a huge impact on our citizens, both those who are here and wish to travel, but also those who are living abroad who wish to remain living there. I have a final area of questioning, Ivan McKee. Thank you, convener, and thank you to Cabinet Secretary and Shelly Rogers for coming along to talk to us this morning. Clearly, with all the issues that you have to manage in the health service with age and population, the last thing that you need is all the additional problems caused by Brexit coming along to make things even more difficult. It is a shame that we echo the comments of other members. It is a shame that we have got nobody from the UK Government here to talk to the other side of the situation, despite being invited and giving many options for different dates. The area that I wanted to focus on was about potential impact of future trade deals on health and social care. We heard evidence, as you have seen over the last sessions, that hard Brexit trade deals could potentially restrict the Government's ability to take forward public health policies. Clearly, there are areas around tobacco, alcohol, challenging obesity and so on, where the Scottish Government has got distinctive policies that we would want to take forward, but in a situation in which a T-tip type deal could be dragged into a situation in which we are unable to pursue those policies. Do you recognise those potential challenges and what you think can be done, given that we are still in negotiation with the UK Government about where we end up around whether there will be consent for common frameworks and what that situation might look like? On your initial comment about the worry list, it is in addition to the challenges that we already have, which we are trying to address, particularly in workforce. This just adds to it in spades, and it is a far cry from the leave campaigns claim to benefit the NHS of £350 million a week. The worry list includes the future trade deals. We would not want to see any mechanisms included in a future trade deal such as investor dispute mechanisms, allowing private companies to take Governments to court or tribunals to stop them implementing public health measures that they feel would damage their businesses. We have tried again to seek assurance that any post-Brexit trade deals that the UK enters into must not open up the NHS to privatisation or endanger public health initiatives. There was an attempt by Vince Cable to get the Prime Minister to basically rule out opening up the NHS to competition. Unfortunately, she did not do that. She said that we are starting the discussions with the American Administration, first of all, looking at what we can already do to increase trade between the US and the United Kingdom, even before the possibility of any free trade agreement. The right Honourable Gentleman does not know what the American Administration is going to say about their requirements for that free trade agreement. We will go into those negotiations to get the best possible deal for the United Kingdom. I do not think that that gave any assurance that, in her mind or in the mind of the UK Government, they were setting out with a clear ambition to have red lines around those issues. The frameworks are very important in enabling Scottish interest and requiring consent around those issues. If we do not, you could envisage a scenario where, despite our opposition to having our NHS opened up in that way through a trade deal that did not have the explicit consent of ourselves or the Welsh. I know that the Welsh have written to the Prime Minister, as I have, expressing concern about this and the lack of commitment in her response. You can see why consent is so important, because we would otherwise leave a risk that our NHS here and the NHS in Wales could be opened up in the same way, depending on UK Government policy on that matter. I do not think that that is a risk that any of us want to take, which is why, as I have said throughout the session, consent is so important. Thank you for clarifying that. I think that the danger is often that people see the debates that we have here about common frameworks and Brexit and the continuity bill about being something abstract, so it is good to see it firmly rooted in things that are very, very important to people on their everyday lives and something as important as the health service. I also heard from the Nuffield Trust that it felt that it was certainly possible to have a limit sector or limit geographies if the UK Government was going forward with trade deals internationally, but clearly, obviously, we said that it would very much depend on them signing up and allowing consent to the common frameworks. I also made the point that the health service in the rest of the UK was significantly more marketized than it is in Scotland. Is there a risk that we end up seeing a situation where there is significant pressure from those trade deals to Scotland's distinctive health service to become more like the rest of the UK with all that entails? Our policy towards NHS is very, very clear, and we would absolutely resist any attempt to do that. That is not something that we would want to see happen to our NHS here in Scotland, so we would do everything possible to avoid that happening. The best way of guaranteeing that is to have an explicit consent required for ourselves and, as I said, the Welsh have the same mind as we are around protecting the NHS from elements of these trade deals that would be against the ethos of how we run our NHS. We would be very strong in resisting any attempt to do that. I am looking beyond 2020. Clearly, there are many things that we cannot currently know about the landscape beyond 2020. Has the Scottish Government begun work on issues, for example, a replacement of research funding or anchoring of life science companies in Scotland beyond 2020 if we do not have the optimum outcome to the negotiations that you have described this morning? Yes, as you can imagine, a lot of work is going on in scoping various scenarios. As someone once said, it is the unknown unknowns. The things we do know about, we are obviously working hard on what we anticipate to be the case, working both Europe and international to look at other opportunities and scenario planning around a number of scenarios, given that, at the moment, there are so many unanswered questions as we have brought out in this session, but we are scenario planning around all of these. We will do our absolute best to ensure that we protect our interests here, whether that is on research, whether it is on the NHS, whether it is on the workforce challenges to make sure that we, as far as we can, mitigate the impact. That is going to be extremely hard to do.