 Welcome everyone to the health, social care and sport committee's 14th meeting of 2021. I've received no apologies for this morning's meeting. We do have a number of members joining us virtually, though. Our first item on our agenda is to decide whether to take item 3 in private. Are members agreed? We are agreed. Thank you. Our second item today is an evidence session with stakeholders as part of our short inquiry into perinatal mental health. All our witnesses this morning are joining us remotely. Welcome to the committee. We've got Selina Gledo Ware, the perinatal faculty chair of the Royal College of Psychiatrists. We've got Mary Ross Davie, the director for Scotland's Royal College of Midwives, Dr Aaron Chopra, the Executive Director of Mental Welfare Commission, and Professor Marian Knight, the Professor of Maternal and Child Population Health for Embrace. First of all, I would like to ask a question of all our panellists and go round you all just to get your views, just to kick things off. Then my colleagues will ask you questions on themes, and they will probably direct their initial question to someone in particular, but then if others want to come in on the platform that you're logged into, if you could use the chat box and just put an R or a request to speak in the chat box so that I can see it and I'll know to come to you. That means that you're not sitting there with lots to say and I'm not noticing you. That seems to be the way that we're able to manage things in this hybrid situation. I was wanting to ask you all in terms of what needs to be done in two ways. One, what needs to be focused on in the short and medium term in perinatal mental health care? Obviously, we've got the backdrop of Covid and we welcome on to Covid specifically, but what your view is that what needs to be done in the short and medium term. A supplementary question to that, what needs to be done to ensure consistency of good practice and good service across the whole of Scotland? If I go down my list of you all in the order in which I introduced you all, if I go to Selina first of all, could we unmute? We can hear you now, on you go. Well, thank you for inviting me today here, convener, representing the Royal College of Psychiatrists in Scotland perinatal faculty. I think you've raised a very valuable and pertinent question that we need to think carefully about. In Scotland, as you've mentioned, we're not only addressing the developing services that the need was highlighted prior to the pandemic, but also the need for services to have that support and resilience to recover from the pandemic. There are a number of key themes that are required to, for the short and medium term. Primarily, workforce support and development are both in terms of recruitment. Some services have faced delays in recruitment due to the pandemic, but we may also need additional resource as the workforce has been stretched during the Covid pandemic and we know staff wellbeing has faced a particular challenge. We need to think nationally how we support the increased recruitment and retention of the specialist perinatal workforce also across the different tiers of the perinatal pathway. Alongside that, we need to think about the infrastructure that services need. Services need safe spaces in which they can work to deliver safe and effective care to women and their families. If we think about how services have responded to the pandemic, they have had to be very nimble in adapting to the blended working environment of remote and face-to-face working. Although that has increased access to care for some populations, we know that there are particular groups in the population that may still have particular barriers to access to care. That may be those excluded digitally, those on low incomes, those experiencing domestic violence or particular vulnerable populations such as women affected by substance misuse, our diverse communities, particularly where there might be language barriers, literacy challenges, sensory impairment or disability needs that might disadvantage access to care or contribute to experiences of discrimination or delay in access to care. We particularly need to make sure that our service developments support the most vulnerable in our population so that we do not exacerbate any pre-existing inequalities in care that we know have been likely increasing during the pandemic. Alongside that, we need to think how specialist services can support universal services across the joined-up care pathways. We have welcomed the investment from the Scottish Government, both with perinatal specialists, community and MBU services but also with maternal and neonatal psychological interventions and infant mental health services. We need to sustain protected investment across those areas to ensure that we do not roll back on the gains that we have made and that we try to consolidate and make continued robust progress of change. We know that failure to do this, unfortunately, will lead to adverse outcomes for not only women but also their infants and family networks. In summary, there is a range of supports and interventions that are required, both in terms of workforce planning, recruitment, estate provision, ensuring that joined-up care pathways and ensuring that staff wellbeing is supported. We are fortunate that we have the managed clinical network, which I think can help with consistent high-quality standards and the support for the professional groups delivering those services, but continued investment that is protected is required. Thank you very much for inviting me today. I am Dr Mary Ross Davie, and I am a director of professional midwifery with the Royal College of Midwives. I was previously the director for Scotland for the Royal College of Midwives. I have also previously been a perinatal mental health specialist midwife in the past, so I have a particular interest in this field. The first thing to note is the significant investment that is made by the Scottish Government in this area over the past year that we have welcomed. There has been a huge amount of work that Salina has identified with the national network, which has definitely really helped to move things forward. The pandemic has had an impact on the pace that those developments can go ahead, and that needs to be acknowledged and real restoration. I think that Salina is absolutely right the need to focus on staff wellbeing. For us in midwifery, we work very much at the interface between universal services, but we also have a role in specialist perinatal mental health services. We need to have consistent investment in midwives to be able to provide really evidence-based, high-quality perinatal mental health support. That is a universal service as well as a specialist service. We need midwives who have the time and the skills and training to be able to provide support adequately during pregnancy, so that involves time and training to focus on prevention of the development of significant mental health problems, to support women and families' wellbeing during pregnancy. One of the approaches to that is definitely continuity of carer, which is one of the mainstays of maternity policy in Scotland. That has also been delayed partly by the pandemic, but also significantly affected by a chronic shortage of midwives across Scotland, which needs to be addressed urgently. I think that the other area for focus in terms of midwifery support is as Salina was identifying the need for specialist facilities, where services can be provided for women with very acute illness and to ensure that women continue to receive midwifery support to normalise as far as possible their experiences. Another key area is the prevention of ill health. One significant area of perinatal mental ill health is PTSD—post-traumatic stress disorder—from childbirth experiences. We have now in Scotland very few consultant midwives, only two consultant midwives working in Scotland. Consultant midwives have a really key role in having birth reflection clinics, talking to women about traumatic birth experiences and preparing them for subsequent births. That is an area that sits in universal services that is really key to focus on the recruitment and development of consultant midwives across Scotland. Good morning. I am from the Mental Welfare Commission, and the commission is part of the assurance mechanism to ensure that mental health services are working well with people of Scotland. Two critical ways in which we do this are through visiting the settings where people are liable to be receiving mental health services and monitoring the mental health act and promoting best practice with regard to that. On the basis of those two things, I would like to make some observations in response to your question about the short term. To start, I echo the point that Mary just made. The commission very much welcomes the additional funding that has gone towards perinatal mental health services. Through our visiting function to mother and baby units and speaking to those who deliver services, we can really see the impact that that is already having in helping people. I would also echo the point that Selina made about staffing and wellbeing of staff. The pandemic has put pressures on the health and social care sector like never before, which I think that we all know about. Having said that, I think that there are things that we could do to improve things in the short term. One of those things is around—this fits very well with your supplementary question around consistency—is about having clear pathways. This is something that the Embrace report spoke to about clear explicit pathways into perinatal mental health care. If we had those clear explicit pathways into mental health care, that would make an improvement. It would remove any uncertainty about what women and their families might need to expect. Another thing that I would like to add to what we have heard already is about monitoring and data. The commission has a role around monitoring the act. We have got some of the most progressive legislation in the world. We have got some absolutely fundamental brilliant ideas around ensuring that women are offered the chance to be admitted with their baby. We do not always have the required notification systems to make sure that that is being delivered. I think that there is work that we can do around data and monitoring. We might pick that up later. I think that it is also important to ensure that staffing is on a secure footing. Training is vital, not just within specialist perinatal services, because often people are engaging with other parts of the mental health system, whether that is primary care, secondary care general adult mental health services or whether that is even CAMHS services, because that is something else that has come through in the Embrace report about younger women. That is important. Crisis teams or IHTTs ensure that their staff have knowledge about the particular challenges and the particular risk assessments around the perinatal period. I think that that would make a difference. I would also say that, in the short term, as we recover and restore, we need to think about equity and equitable access to all parts of the perinatal system and whether that is for women who misuse substances or whether it is for women coming from more socioeconomically deprived backgrounds or minoritised ethnic communities. I think that there is an opportunity for us, in the short term, to build back better. I think that it is also probably important to—and this goes back to the very first point about consistency in pathways—is to actually make sure that we have a very clear national service specification that operates across Scotland so that people can know exactly what to expect. That will provide a really good benchmark for organisations like ours to assess how things are progressing. I will stop at that point. Thank you. Thank you. Again, it is very helpful for my colleagues to dig in deeper. Finally, on this question, I want to ask Marion Knight. Thank you very much. I was obviously going to pick up on a number of points that Aran just made. For those of you who are not aware, Embrace is the organisation that has responsibility for investigating the care of all women who die during pregnancy or up to a year after the end of pregnancy. Just to put that in context, maternal suicide is the leading direct cause of death in the period six weeks to a year after the end of pregnancy. If we are thinking about substance misuse and suicide together, they represent more than a third of maternal deaths in that period. Perineal to mental health is absolutely crucially important to preventing maternal deaths. The overwhelming theme that we see when we are investigating the care of women who died is gaps in the services. The number one short-term thing for me is to minimise those gaps in the services. They include a variety of themes. There may be thresholds so that women are denied access to specialist services because they are considered not ill enough, which essentially is to do with capacity of those specialist services. We need to make sure that the specialist services have sufficient capacity to accept referrals, which might be at a lower threshold in the perinatal period. It is also important when we are thinking about exclusions on the basis of diagnosis, and particularly women with comorbid conditions. Too often we see that substance misuse services will not accept referrals of women with mental health problems and mental health services will not accept referrals of women with substance misuse problems. If you have both, where do you go? The other big theme for me is not a big gap in perinatal services. I imagine that clear Harmer will talk about that later. He is thinking about women who have experienced a loss event. We know that a loss event—by that, I do not just mean a miscarriage or a baby death or stillbirth or near-natal death. I also mean child removal. We know that that makes women extremely vulnerable. Yet perinatal mental health services do not typically accept women who have had a loss event, and yet they have all of the needs for perinatal mental health care of women who have living babies. Bridging that gap and ensuring that the pathways are able to cope with the needs of all individuals is the number one thing for me that we need to think about in the short term. As Aaron mentioned, having a service specification that means that those pathways are very clear and the communication between the different services means that those gaps no longer exist is going to be one of the most important action. Thank you for that. There are lots for us to think about. I want to pick up before I hand over to my colleagues on one thing that was mentioned, which I was aware of as being an issue. The Government and the policy around the continuity of carer—for example, knowing that, when you go into labour, the midwife is not going to be someone that you have never met before, is something that, as you say, is still to be rolled out. Can I ask any of you, just raise your hand if you want to come in first, in terms of the practical aspect of that? Given what you have said about shortages of midwifes, I know that it is not going to be easy. I am not asking how easy that is to roll out, but is that something that we think that is going to be doable within the next couple of years as we come out of the pandemic? Can you reflect on the importance of why, in terms of mental health, that could make a difference having that continuity of midwife, midwifedicare? Thank you very much and thanks for focusing on that key area. We have real concerns about the practical implementation of continuity of carer at the moment, with the significant shortages of midwives and the huge pressures that the pandemic has brought. I think that there are a number of ways that we can make that happen more effectively than we have so far. I think that greater investment focused ring-fenced investment in the implementation of continuity of carer is needed. There has been less investment in that regard than there has been focused on perinatal mental health. That is one key area. When you are implementing such a significant service-wide change, it is really important that there is ring-fenced investment in the process and in the leadership of that process. As mentioned earlier, we have a lack of consultant midwives in Scotland that could have a real role in implementing that service change. Another area that we need to focus on is ensuring that continuity of carer—if we cannot go whole hog all at one time—focuses on those women who are particularly vulnerable of having poor outcomes. In that regard, women who are vulnerable to mental health problems are key. What we need to do initially is focus the implementation of continuity of carer teams. Midwives, generally, when we are implementing continuity of carer, will work in small teams, so that enables women to get to know their midwives really well during the pregnancy and have a much higher chance of having a midwife that they know with them during labour. That is particularly important for women with mental health issues. The implementation should focus on those women with particular needs and women with living with deprivation, who have much poorer outcomes than Maryam would be able to speak to very well. Black and brown women and women from ethnic minorities as well need to make sure that we focus the implementation of continuity in those areas first. But real ring-fenced investment is required to make this happen. Just when we think about the women who die, the majority of those women have complex adversity, so they are women who have had adverse childhood experiences. They are women who are victims of domestic abuse, substance misuse and social services involvement, and to ensure that the best outcomes for them are a trusted therapeutic relationship. Somebody who you really trust who can help you to navigate the system and be your advocate is absolutely crucially important. The main point that I wanted to make—I agree with Mary that focusing on those vulnerable groups is really important, but the midwives will need training to have the specialist skills to be working with those extremely vulnerable groups of women, so it is not just the continuity of carer model, it is the continuity of carer model with specialist trained teams. That is very helpful. My colleague Evelyn Tweed wants to come in on questions around funding. I would like to ask a question about mother and baby unit. I see that there is only a couple in Scotland. Do you think that we need more mother and baby unit? Dr Shopra, please. Thank you. It is a good opportunity for me to drill down a little bit into what we found through our visiting function for the two mother and baby units, and that will help to build up to the question around whether we need additional resources. As I mentioned in my introduction, the commission visits both the mother and baby units to see how they are working and to understand the experience of women and families who are using those services. We were very encouraged with what we saw in our last visit to the west of Scotland, and we have a visit coming up to St John's in Livingston early next year. We have seen improvements in staffing, in ability to have parent and infant mental health nurses, and we have seen improvements in PIS support workers. That is also coming online, and we also saw really good care plans. The reason perhaps around that is because of the fact that women are being admitted to these two units. However, one of the things that we have seen quite clearly is that there is a difference in the rates of admissions in these mother and baby units based on health boards. If your health board has a mother and baby unit, you are more likely to have admissions coming from that. To put numbers around that, for example, Lothian, NHS Lothian and NHS GGNC, Greater Glasgow and Clyde, have rates of admissions above 3,000 birds to their units. However, if you look at other health boards, the numbers are lower. They are sometimes 2,000 or sometimes lower than that. The availability of a mother and baby unit leads to a greater awareness of what that mother and baby unit will offer to the mother and to the infant. That is quite clear from the data that we are seeing. When we looked at the reasons for why mothers were sometimes not admitted with their babies to mother and baby units but were admitted to general adult wards, one of the things that became quite clear to us is that sometimes it was choice, other times it was about particular disadvantages. If travel is an issue or if childcare is an issue, they would be factors, distances that people needed to travel. However, another factor that would come into it is a lack of awareness from the referring unit about the advantages that a mother and baby unit might provide. That came through to us quite clearly, both when we did this work in 2015-16 and more recently when we have been discussing what the reasons might be around people not being admitted to mother and baby units when they should. A question that arises—and that comes on to your question—is whether there ought to be a greater provision. When the network looked at delivering effective services, there was an estimate that Scotland would probably require around 16 beds and currently we have 12 beds, so there was a question about whether we need greater provision. We were in contact with NHS Grampian, who provided us an update on the number of admissions that they had from the north to the units, and they provided a number around, I think it was, about nine per year. That does not fit with our modelling, which would suggest that the numbers might be higher, but if you remember what I was saying about the awareness, it actually leads to a greater number of admissions. That brings on to the idea around an options appraisal about whether we ought to create more beds in the north—perhaps a bespoke unit—or at least, because I think that you need a critical number in order to develop the infrastructure, the staffing, the knowledge, the skills or whether it might be better to use that or to build that resource into the existing mother and baby units. What we need to see now is a detailed options appraisal. My understanding is that that is coming in early 2022, but I think that that will be critical to making a decision about whether there is a new unit up in the north or whether we might want to increase provisions in the two existing mother and baby units. Everyone, I believe that Selina Glade of Ware wants to come in. Thank you. I echo Dr Chopra's submission that members have highlighted at times that it can be difficult to admit to the mother and baby units, particularly that availability can be stretched, although that fluctuates over the course of the year. As Dr Chopra has highlighted, geographical barriers do disproportionately affect those women in more remote and rural living areas. As Dr Chopra has highlighted, careful consideration is required as to the location of where the additional beds should be. That also feeds back into the staffing, recruitment and retention issue. To have a sustainable, safe and effective mother and baby unit, you will need a much larger pool of specialist trained workforce, if units are to be developed in areas where they do not currently exist. We are very appreciative of the work that the Perinatal Infermental Health Programme Board is doing in terms of the options appraisal. As a faculty, we will be very keen to see the results of that. I also ask the panel which areas of perinatal mental health services would benefit from further investment. Mary Ross Davies, please. I think that you will not be surprised that we need further investment in universal services and in prevention. The focus is on making sure that we have a midwifery workforce that is adequate, appropriately trained and appropriately supported to do the work. Unfortunately, so often, when there are reports around perinatal mental health, midwifery is sidelined or not centred in the descriptions of what that service could look like. We believe that it is absolutely key that every health board in Scotland has a specialist perinatal mental health midwife. They are a really key link between universal services and specialist services, making sure that those services are able to speak to each other and that any pathways of care are appropriate for the universal services and relevant. They also have an important role in ensuring training of midwives in the local area and providing that midwifery input where women are admitted to mother and baby units or needing more specialist care. Unfortunately, that was not a key centred recommendation from the initial plans for the perinatal mental health services. There is a lot to do in ensuring that that midwifery input is centred. Also, what we have seen in the pandemic is that it has been midwives who have continued to go out in person throughout and where other services have become virtual. Midwives have needed to step into those positions and ensure that that support for women with mental health problems is provided in person on occasions. That is put particular stress on the midwifery workforce, but it has identified how key it is that we make sure that that midwifery workforce is adequately prepared, trained and supported to provide that care. I just wanted to emphasise the importance of the non-specialist services because a recurrent message that we have identified is the lack of training, lack of understanding of perinatal mental ill health among crisis liaison and home treatment teams. It is important that actions are not just focused on the specialist perinatal mental health teams because many women will be seen initially by a crisis liaison or home treatment team. They do not particularly understand the rapidity with which mental health can deteriorate in the perinatal period. Too often, we see symptoms dismissed and yet women get very ill very quickly. It is just to emphasise that we also need to make sure that we are training our non-specialist teams about the particular features and the need for urgent care amongst women who have perinatal mental ill health. I echo the points that Mary and Marion have just made. The additional point that I wanted to briefly make was around the voluntary sector and ensuring that statutory services pathways also make reference to where we can use and people may benefit from voluntary sector involvement, because I think that there is a hugely important piece of the puzzle here. I would like to highlight the role of the specialist professionals, particularly psychiatrists, in supporting universal health care professionals to have that specialist awareness, to be able to pick up those vulnerable women who maybe need that enhanced support, who can do the teaching and training with the intensive home treatment teams, the crisis teams, the health visitors, the GPs. That is why we need the investment in supporting them to be a resilient workforce so that there can be benefits across the whole pathway, because we do need that expert knowledge to be shared, as Professor Knight has really helpfully highlighted. The other areas that the faculty would like to highlight that have already been mentioned this morning that probably do warrant additional assessment and potential investment is the care pathways of women who have substance misuse difficulties. They have not traditionally fallen within hoi natal psychiatric services and, as yet, there is no specific national care pathway for them, although there are examples of good practice across Scotland. That is by no means implemented across Scotland, particularly given that they are at increased risk of maternal death and adverse outcomes for their infants and families. I think that that is an area that warrants attention, particularly given the context in Scotland of our particularly high rates of death due to alcohol and substance misuse. As has already been made evident this morning, the experience of women who have had loss events and, traditionally, those women have not been part of perinatal services, but I think perinatal specialist services have advice to give universal or voluntary sector pathways in the support that could be provided to them and where, for example, they may then require more specialist perinatal mental health interventions, but many of them may benefit from more universal or voluntary sector support in the first instance. Those are particular areas of need that I think may require further attention. We also need to consolidate the work of the existing pathways, as we are still in the very early stages of those being robustly implemented across Scotland. I want to come in with a supplementary question on the issue, Stephanie. Thank you very much, Gillian, and hello to the panel this morning. It was Professor Knight that my question was for—you mentioned earlier on about baby loss and babies being removed from mums, and that being included there, too. Now, I know that quite high numbers of care-experienced mums lose their babies at birth or very, very soon after birth as well. They have not had those stable and protective relationships themselves. Quite often, there is that perceived risk of significant harm to the baby. I am wondering what your thoughts are on. Would, for example, expanding access to mother and baby units be helpful to offer support to those mums and help them to keep their babies? Or what other perinatal health services could we look at that would actually maybe be a positive support to those mums and keep families together? I hope that you have all heard that. I think that we are having a drop-out from time to time. You addressed that in particular to Professor Knight. Was that correct? Professor Knight, were you able to hear all that? I hope that I heard most of the question. It broke up for us a couple of times. If I understood the question, it was that the children are often removed from mother's care for their own protection and it is whether there was additional support needed at that stage or additional family support. Was that the gist of the question? Yes. In particular, the high numbers of care-experienced mums lose their children at birth or very close to birth. Would mother and baby unit expansion be something that would support that or what other perinatal services could help to keep those babies with their mums? I am probably not the best person to comment on mother and baby units. There is a very definite pattern for me that the children are removed and then all focus on the mother is gone, so the mother then has no support. It is often a very valid decision around child protection, but then the mother has no support. Effectively, the rug is pulled out from under her feet and she has had very intensive support throughout pregnancy. The child is removed and then all support for her goes. That is the gap that for me is really important to fill in to ensure that those women continue to get the support that they need, whether or not their children are at home with them. Mary Ross wants to come in. I think that there is very patchy provision in Scotland in this regard. There are some really great examples of specialist teams where midwives work in conjunction with social work and child protection and health visitors to provide a wraparound service for women that are identified as being particularly vulnerable and where there are concerns around safeguarding. Women with severe mental health problems, women who are care experienced, who have substance misuse problems, and learning disability. In Fife, there is a great team, but what we have seen is that where there have been really good examples, for example in the borders in the past, that those services have not received consistent, sustained funding and that they are often seen as a short-term project and that funding is removed or time is needed to be spent to try and seek additional funding for those teams. It needs to be seen as an integral part of what we provide in terms of maternity care across Scotland. We have specialist teams where midwives have particular training and expertise and they are working within those multidisciplinary multi-agency teams to provide support for the women and to prevent babies being removed where possible. We have certainly seen cases where that has been the case. If you have those specialist teams, you see fewer babies needing to be removed because those women and families have that additional support during pregnancy, but also in the postnatal period, where you have family support workers who are able to go out several times a day in those first weeks and months to provide that really focused support and that that can lead to safe environments for those babies, but that certainly is not provided consistently across the country and certainly does not seem to be factored into the overall maternity policy. Dr Gledel, where wants to come in? Thank you. I would echo the points just made. There are certainly some examples of good practice and we know, for example, early intervention and preventative work to prevent relapse of mental health illness can make a big difference and that is a big part of the work that specialist community perinatal teams do, in particularly care co-ordination with midwives, social workers and health visitors to try and ensure that as much support is around women and families, prevent relapse and prevent that impacting on the infant. We have also seen areas of good practice and substance misuse such as the prepare team in NHS Lothian. Again, they have very early preventative work to engage the hardest to reach women with chaotic substance misuse with input from maternity health visiting and social care and integrated model of care that continues with women during that antenatal and postnatal period, but, unfortunately, that remains the exception rather than the rule. I think that there is a need to look at the social care supports that these women and their families need, particularly around parenting support and provision. Certainly, during the pandemic, we have really seen that statutory services have really often had to prioritise the highest tariff cases, but there has not been that scope to do the early and preventative work that could help ensure that women and their family and their infants remain together. I would also like to highlight the point that mother and baby units are for the provision of acute psychiatric care to women who are acutely mentally unwell and their infants. When there is a clear determination that mother will be the main carer of the infant, and this is separate from a mother and baby unit that would be a parenting assessment, that would be determining whether a mother would be able to meet the needs of her infant. I guess that we have seen in the social care environment that those parenting assessment units have in Scotland generally been moved into more community-based provision that, as I have mentioned, the pandemic has significantly challenged. I think that that is an important distinction for the committee to understand in terms of the role and remit of specialist psychiatric mother and baby units compared to the broader remit of a parenting assessment unit. Thank you. Before we delve into workforce issues that you have all mentioned, I just wanted to ask Mary Ross Davie for something. We have spoken to some parents who have had mental health issues as a result of pregnancy and childbirth. One of them mentioned something to me that I was not aware of. An additional support midwife had support from an additional support midwife when, during pregnancy, she was established that she needed that extra care. On the problem further, additional support midwives are not available throughout Scotland. Is that your experience? Are you able to shed any light on where that is happening? It sounds like good practice to me that an additional support midwife is given to somebody who knows that they are going to have some particular difficulty. Absolutely. Obviously, there are different titles that are given to midwives who work in this particular field and in this way providing additional support to women who have been identified as having particular needs. In some areas, they are called SNPs midwife, special needs in pregnancy service, and in the past they used to be called Sure Start midwives when there was Sure Start funding. Whatever the title, what is vital is that we identify those women who have particular support needs and that we provide additional midwifery support to them from a known midwife as Marion mentioned earlier. It is so key for women and families who have not had positive experiences in their lives in terms of their relationships with health, with social care and with authority figures that they can build a relationship of trust with a midwife. It is a great point of entry in terms of building a relationship of trust with authority and health figures. For a midwife to be able to provide consistent presence and support during the pregnancy is absolutely vital. You are right that it is patchy. It does not exist in every area. I think that the focus over the last at least 10 years has very much been on trying to have midwives generally across the service providing universal care rather than really identifying the benefit of those specialist roles because midwives working in those areas do need additional training to provide really high quality care around perinatal health, mental health, substance misuse and safeguarding. Not every midwife is going to be able to provide that high quality care in that area. Let us make sure that we have those specialist services in every health board in Scotland and have consistent long-term funding for those services. Thank you. That is really helpful. Can I pass over to Gillian Mackay? Thank you, convener. Is the panel satisfied that sufficient long-term workforce planning is taking place since Sure Scotland has the perinatal mental health workforce that it needs? Can I come to Mary Ross Davie with that, please? Thank you. There is a focus on workforce planning and there is increased work to make sure that our workforce planning tools in maternity are fit for purpose and reflect the direction of travel and maternity services. Previously, the workforce planning tools that we have had in maternity focus very much on acute care. Maternity is generally provided in obstetric units in maternity hospitals but maternity care is much more than that. It crosses into community. In fact, it is largely provided in community settings by midwives. There is a huge amount of work that is done in primary care and in conjunction with other services. There are improvements being made in that regard but there is much more to be done to make sure that we have long-term planning to make sure that we have the right professionals in the right place. We did see a huge drop in the number of student midwives in Scotland from 2011. We have been working ever since then to try and address that to make sure that we have enough student midwives coming through and being trained across Scotland. There is still an issue about being able to attract student midwives particularly in the north of Scotland and in remote and rural areas. There is still a need to address that. There are only three universities in Scotland that are providing pre-registration midwifery education. There was a real opportunity provided in Inverness over recent years with a pilot project to provide a shortened programme for student midwives. We want to see the new shortened programme that is being provided from Napier University encourage remote and rural development. People who have been nurses in the past take a shortened programme to become midwives. There is more to be done. There are positive green shoots in that regard. The other key factor is that we retain the experience of midwives that we have and that we do not have enough in that regard. We cannot just have student midwives coming through and newly qualified midwives. We need to retain the experience of midwives in the service by offering them decent working conditions and flexible working opportunities, which is not being done consistently everywhere. Does the panel more widely have concerns about workforce morale and wellbeing and how that will impact on retention? I know that many of us have said there a wee bit about focusing on recruitment and retention. Is there too much of a focus that you feel just now on recruitment and not enough on retention more widely? Dr Chopper, if you would like to come in. Thank you. I think that it is important to focus both on recruitment and retention. I would like to speak to some of the commission's work. We operate an advice line for professionals and for people with lived experience and their families to phone the commission when they have particular issues around their care and how the act is being used or the law is being used. We take about four and a half thousand phone calls a year, so we get a sense of what is happening through that as well as through our visiting and monitoring function. One thing that is coming through is the complexity of what people are working with and the lack of resource. To put some numbers on that, the sharper end of mental health and mental illness continuum. Year on year, there is usually a 5 per cent rise in the number of people who have been detained under the mental health act in Scotland. Last year, in the Covid period, when we published the data in July, we showed that there was a 10 per cent rise, so it is almost a doubling of the people with more severe illnesses. That has been echoed through the system in that there has been an increase in anxiety, there has been an increase in particular conditions such as eating disorders and OCD, which have relevance to the perinatal population. What we are seeing is to bring a broad perspective to place perinatal within. From the commission's monitoring data and from our advice line, is a workforce under pressures that they have not seen before, and that makes it really important for us to see how the act and how care is delivered when the workforce are having particular difficulties. Yes, it is important to train more people and recruitment, but what we are also looking to see across the professions in health and social care is compassionate leadership and retention. There will be issues around ensuring that the funding goes into the right places, and there was also the point that was made earlier about training, specifically around perinatal things, but training will need to be more broad so that everyone has that experience that they can then fit in to perinatal pathways. One thing that I think is also important to mention at this point is thinking about, as well as capacity, what professionals do we have in Scotland and can they meet the demand, but it is also to think about demands on services and whether there are alternative models. We are seeing people coming forward with mental health difficulties, but we also have to operate with mental illness. Those things do sometimes synergise, but they can be quite separate. Someone having a mental health difficulty does not necessarily have a mental illness that might require secondary care or tertiary care when it comes to perinatal. We need to think about alternative models of providing people the help that they might need, so that might be for support workers, it might be positioning people with primary care who might be able to meet the emerging needs as we emerge from the pandemic. It is also around thinking about those wider issues, and that will then have a knock-on impact on secondary care and perinatal services. I wish to highlight, as building on the earlier points, that recruitment has rapidly expanded over the past 18 months in services across Scotland. We need to think about retention and staff wellbeing to maintain and expand the services. In particular, we need national training pathways and numbers. At the moment, we have benefited from the work that NHS Education for Scotland has done and the perinatal curricular framework, that there is clear educational resources across the different professions and pathways, such as specialist services, but we do not yet have clear pathways that are discipline-specific that highlight the numbers that we need to train to ensure that we have sufficient numbers that account for drop-off or loss or changes of careers. For example, in perinatal psychiatry, there are no national perinatal training numbers. At the moment, we are very vulnerable to the other challenges in the mental health workforce such as general adult psychiatry, which means that we could lose the gains that we have made. There is a real need for national training pathways and regional training placements so that the students of today can become the perinatal workforce of tomorrow. At the moment, we do not have those training pathways for Scotland. Stephanie, do you want to come in on this particular issue? That would be great. I really wanted to ask about what impact workforce issues are having on patient care and on the ability of GPs, midwives, health visitors and so on, to work together effectively as a team. I know that some of the women that I spoke to last night felt as if people had all had a little bit of their jigsaw but that was not necessarily coming together so that the whole picture was being seen and it found it difficult to get help as a result. Would you like to direct that to anyone in particular or my colleagues? Can I maybe come to Mary Ross Davie initially on that and then if anyone else wants to come in on the back of that, please use the chat function and I'll take you in town. Mary. Thank you. I'm sure that all of you will be aware of what's been described as a crisis in maternity services across the UK, with the chronic shortages of midwives becoming acute during the pandemic. That has a huge impact on the quality of care that midwives are able to provide. If you are a midwife who is doing the job of two, you need to cut your cloth accordingly in terms of the length of appointments, particularly in relation to perinatal mental health. It's absolutely vital that you have time during an appointment to build up rapport, to spend time getting to know that individual and to build that trust, an impact on the quality of care. In some respects, the move to some virtual working and being able to have virtual multidisciplinary team meetings that has arisen through the pandemic has been of benefit. I've heard where it's been much more possible during the pandemic to get together a meeting with all the professionals and support people involved in women's care—GP, health visitor, midwife, obstetrician, perinatal mental health team—are able to get together on a virtual platform like this to have a planning meeting. There are some silver linings that have made that multidisciplinary working on occasion easier during the pandemic. The pressures of time and the shortages of staff are vital to those who are addressed as a matter of urgency. I think that Dr Shopper's point about the need to invest, support and work with voluntary sector organisations is vital. It's clear that universal services like Midwifery can't provide everything and that we need that investment in those other support areas so that we can all work together really effectively to provide the right level of care. I would agree that the pandemic has really affected women and their families significantly in terms of the support that they've been able to receive. That's both been in terms of the informal support and to NATO groups meeting other women, peer support, particularly voluntary sector support, stopped quite abruptly at times but is, fortunately, restarting. As Mary Ross-Davies highlighted, there have also been interruptions in continuity of care. All women have not had as much face-to-face contact as she highlighted to develop that trusting relationship to open up with those more sensitive topics or particular areas of difficulty that women might be experiencing. In specialist services, they have adapted as much as possible to retain as much face-to-face contact and were often the only professionals at the start of the pandemic aside of Midwifery that were seeing women regularly. Certainly, women have been challenged in how easy it is to see their GP and whether they are able to make appointments to see them face-to-face. There is certainly a lot of information that is lost through telephone consultations and, for example, video consultations that can be hard to fully assess the parent relationship. The pandemic has had a number of aspects on the availability of support, both socially and in the voluntary sector, as well as statutory and specialist services, but also how that support has delivered has varied. That has particularly affected women's experiences and had a knock-on effect on their mental health. Anecdotally, that might be one of the contributing factors to women raising the concern about significant levels of birth trauma, because it has not had that face-to-face continuity of care that would have helped to be buffered against particular trauma during childbirth. Those are the particular vulnerabilities that our members have highlighted. Certainly, as Mary Ross Davey heads back, there have been some silver linings and teams have been nimble in how they have been communicating, and we have continued the disciplinary and multi-agency and the care coordination. It has been easier to continue that with some professional groups than others. I just wanted to pick up on the role of the GP and thinking about pre-pregnancy and what an important substantial impact it can have to have all the planning around mental health care made before pregnancy. We have not really talked about pre-pregnancy, but we see very clear examples where risk mitigation strategies have been discussed and planned for pre-pregnancy between GP and mental health services. That means that all actions can be put in place if women's mental health deteriorates during or immediately after pregnancy. The GP capacity in particular has been lost to be thinking about the pre-pregnancy. All too often, we still see the structural biases in pregnancy care such that women's stock medication or are told to stock medication inappropriately. Nobody thinks about the impact that that will have on their mental health. They are solely thinking about fetal risk. Really concerningly, nobody even thinks that they should restart medication post-pregnancy even if they make it through pregnancy. That, for me, is where the GP is a clear linchpin in continuity, pre-pregnancy during pregnancy and particularly post-pregnancy. We are going to dig in further into training, Emma Harper. Thank you, convener. Good morning, everybody. It has been really interesting hearing in responses so far and touched a wee bit to Dr Chopra on training. I am interested in looking at what training is available, what training is being delivered and what the barriers are, if any. My understanding is that there is a Royal College of GP perinatal mental health toolkit. There has been information produced by NES and all those e-learning modules. I know that there is an Edinburgh post natal depression scale that is used to assess women once they have delivered their baby. There seems to be so much information out there, but how is it being delivered for health professionals, whether it is midwives or GPs or other practitioners? Thank you. It is a bit of a shame that Selena had to leave at that point because I am sure that she would have much to say around the perinatal curricula. I am familiar with some of the training material that was mentioned there, but not all of it. What I would mention is that the NES perinatal mental health curriculum, which I have had a look at in the context of some other work that we did, is brilliant. It is really good training. It is pitched at various different levels to allow people to determine what sort of training they need at what level and it builds gradually, which is exactly the sort of training that you need when you think about the earlier point that we were making about ensuring that training is available, not just to specialist perinatal mental health services, which I think is a point that the whole panel has echoed, but is available to general teams, primary care and general mental health services, so that people understand the different risk levels that operate at perinatal times and the need to refer to specialist services and get people the support that they need. That is one of the key points around training that I would like to make there. Mary Watt wants to come in on that. Yes, we have seen a huge increase in the amount of education that student midwives have in their degree, pre-registration degree, on perinatal mental health issues over the last 15 years. From a time around 15 years ago, when a student midwife might expect to only have about three hours of training on perinatal mental health, they will now expect to have all modules focused on perinatal mental health needs. Perinatal mental health will be included and woven through the whole curriculum of the three years. However, we have a large number of midwives in the workforce who did not have that sound grounding in their initial education and training on perinatal mental health. There is still work to do to ensure that those midwives have a really sound understanding of perinatal mental health. What is difficult when you have staff shortages is that that reduces the amount of time that midwives are given for continuing professional development. What we see is that midwives are expected to undertake continuing professional development in their own time. Having ring-fence time for education through your career is an absolutely vital element. I would also echo how brilliant the NHS education for Scotland resources are. They have been developing over a number of years, and the curriculum framework addresses different needs for different groups from those providing universal care right up to specialist perinatal mental health workers. It is a really good system of support and education that is provided through NERS, but it is about enabling people to access that education in their work time. If they are providing that level of care that they are offered support and supervision when they are providing care to women with significant perinatal mental health problems, that is key to prevent burnout and to ensure that the care that is provided is high quality and evidence-based. NERS has done a huge amount of work, and I would say that Scotland is ahead on that in relation to the rest of the UK. I think that what you have said about education in work time is really, really important. I probably need to remind everybody that I was a clinical educator before I was an MSP, and I did provide education to midwives as well. However, it is really important that we offer education in work time. I suppose that a comment around whether you think that providing education directly in the workplace and not expecting people to continue professional development away from their workplace in their own time would also support retention of the workforce, which you previously mentioned. Thank you. We have certainly found models that use that work-based training. We have the SMMDP service in Scotland that is run by NERS that provides clinical skills training from maternity teams that is done locally and has a nationally accredited quality curriculum. We also see that with things such as the prompt training, but they tend to all focus on those obstetric emergencies, which is absolutely vital that we have that continued training for maternity teams on how to deal with those obstetric emergencies—postpartum, hemorrhage, shoulder dystocia. However, we should use that model for other issues, such as perinatal mental health, substance misuse, supporting women where there are child protection and safeguarding concerns. That should be the model, and it should be part of the mandatory expected training for midwives and other maternity professionals and support workers. What we need is far greater number of clinical educators out in the services than we have currently, and we have a real focus on developing those roles across Scotland. Thank you. It is just on what Emma Harper said, but my question is about ethnicity and what training is being given to ensure that the differences in ethnicity are being picked up and are being assessed and are being treated, where previously, certainly as a doctor, being trained in the 2000s, that is not something that I received. Do you want to direct that to anyone in particular? Probably to Dr Chopra and Maeve Mary. Thank you. MSP's members of the committee may be aware that the commission published a report on racial inequality and mental health in October of this year. It is a wide-ranging report that looks at racial differences in accessing mental health care in the way that people experience the use of the mental health act. It also talks about the lived experience of people coming from ethnic backgrounds and their experience of mental health services, differences in representation from people in the workforce in mental health and how they progress within mental health services, and it also talks about training. There is a whole chapter where we focus on what training is available to people around what we have called cultural competence. What we have found is that the majority of training is done through what is called LEARNPRO, which is an e-module that people are expected to complete. What is 70 per cent of staff who responded to our survey on training around ethnicity and mental health? It was not specific to Perinatal, it was ethnicity and mental health, but they found that it did not meet the needs. The goalposts have changed in 2021. People are much more experienced and understand a lot more about how ethnicity and race impacts on healthcare. What is currently being delivered through Scotland through most health boards—we focused on health boards in this area—is a module that was considered to be inadequate to meet the needs. We have made recommendations around that to the Scottish Government to consider asking NES to provide modules that are more bespoke. We have spoken about the needs of asylum seekers and refugees and particular modules that are focused on primary care as well as secondary care to meet their needs so that they do not get retraumatised by having to tell their story several times. There is a lot of work that the commission has undertaken around racial inequality and mental health. I would be very happy to send the committee a link to that report and address any questions that arise from that. On Perinatal specifically, we are going back to the NES module. The NES curriculum for Perinatal mental health contains a section about culture and meeting the needs of people who are coming from different cultures and ethnicities. It is brilliant because it shows at various different levels what sort of competencies you might want to achieve to meet someone's needs. At the most basic level, it may be an understanding of someone's background. The level above might be about the use of advocacy and the use of interpreters. There is a whole kind of specialism about how you use interpreters well. The level above that might be about understanding the power dynamics that take place in a clinical interaction when people are coming from different backgrounds and it develops accordingly. I welcome the question and I think that there is a lot of work that we need to do as we build back fairer and create more equitable access to all parts of services. I would definitely like to see that report because it will inform our wider work on mental health. I come to Gillian Mackay, who wants to come in on the training issue. When a woman is pregnant or is recently given birth, she will be in contact with a range of health professionals, potentially creating lots of opportunities to identify if she is struggling. Is the panel confident that staff have the training to take up those opportunities? For example, do you think that primary care teams, in particular, are equipped to identify perinatal mental health issues? Will you come to Mary Ross-Davies for that first? As we discussed earlier, there are real opportunities in Scotland in relation to some of the resources that we now have that are suitable for primary care for midwifery and other health professionals in terms of raising awareness about perinatal mental health. The issues that I have rehearsed today are that people need the time to do it and that we need enough staff to do it effectively. We need to have systems of care that enable health professionals to build those relationships. At the moment, we do not have all of that in place, and we do not have the staffing or the opportunities for education or support or the systems of care that enable us to maximise what we want to be able to do in terms of identifying those women who are struggling and then being able to offer them really adequate support. What feels really difficult for midwives, health visitors and GPs is that if a woman does disclose that she is struggling through something like the Edinburgh postnatal depression scale that was mentioned earlier and the conversations around that, if you are then not able to get them the support that they need, so they have disclosed to you, you know that there is a problem, but you do not have anywhere to be able to refer them to where they are going to be able to be seen quickly and get the support that they need. So, so often, midwives and health visitors feel that they can be left holding someone's care needs and support when they are needing more specialist support. I would also, if it is possible, like to come back to the previous question in terms of ethnicity and the impacts on maternity outcomes. Professor Knight will be able to talk about that very eloquently, but we do know from the embrace reports that black women are four times as likely to die in childbirth or postnatally. There are huge inequities in terms of the outcomes from maternity services for women from ethnic minorities. That is something that we are seeking to address from the RCM perspective in terms of providing much more focused education and training for student midwives and midwives about the issues of racial disparities and their impacts in maternity care and in perinatal health care. However, there is much to be done and there is much to be done in Scotland. We know from recent reports that ethnicity is not being adequately recorded in the antenatal period, so we are not able to identify what those disparities are in Scotland adequately. We need to improve that recording, the conversations that are being had and the confidence of health professionals in talking about race and ethnicity and addressing their own unconscious bias. There is a huge training need across Scotland in relation to that. I wanted to pick up on the previous point. It is important that we recognise how complex it is to a service user, the whole system around maternity care is. The pattern that we see among the women who die by suicide is that they have had multiple contacts with different individuals. They might have seen the GP on one occasion, the emergency department on another occasion, the health visitor on another occasion, with concerning symptoms that have been either normalised or dismissed, and nobody has recognised the overall pattern. For me, the phrase is that it only takes one person, but there needs to be that one person who knows an individual well enough to be able to recognise that deteriorating pattern of symptoms, whether it is the GP or the midwife. We have seen fantastic examples of health visitors who have been the linchpin in ensuring that women get the care that they need, but it is ensuring that there is that one person. When we look particularly at what is affecting the care of Black women who die, it is that individualised care, that recognition of the cultural nuance and the recognition of the woman as an individual to make sure that she gets the care that she needs. The recognition that there is no one-size-fits-all, if I was going to summarise the main message for me in terms of perinatal mental health pathways, there will never be one solution that is right for every woman. We have to make sure that whatever an individual woman needs, she is able to negotiate those pieces of the pathway, and that her symptoms are not normalised by every person that she meets as she goes along. I want to reiterate a point that we made right at the beginning of this session, which I think will be helpful in response to that question. That is about clear explicit pathways, which is one of the things that the Embrace report speaks to. Notwithstanding the need for nuance and the need to individualise it, I think that one thing that would help everyone is to have very clear explicit pathways into perinatal mental health services at all different levels. That mitigates some of the uncertainty. It allows universalism. It still allows for nuance, but I think that it would be great if every health board had very clear explicit pathways all the way from primary care into secondary care into perinatal care and also to mother and baby units, which is one of the points that we made in our evidence around service-level agreements, so that there is not any questioning or misunderstanding when someone needs specialist care in an inpatient facilities to where they need to go, what might be the right pathway for them. Yes, there should be ability to be patient-centred and have nuance, but clear explicit pathways going right back to the beginning would make a huge difference. We are rapidly running out of time. I want to address some of the issues that have come up as a result of Covid-19, because we had a substantial amount of testimony from mothers and fathers around that. Carol Mawchen, can I come to you? Thank you, convener. Morning to the panel. Yes, as the convener said last night, we had a number of people with lived experience, and what was very striking is that we are all affected and talked about the effects of Covid-19, but it seemed that for the women in this category and the fathers in this category that there were some major things that we need to address for those people now and going forward. I just wondered if the panel had any advice that they could give us on the return to services, which seemed very different across Scotland, and anything that might need to be put in place to support those people as we go forward in the next year or so? Will we address that to Marion at night, first of all? One of the things that we found last night is that the impact of not having partners to be able to be with them at anti-natal classes and throughout the pregnancy was quite acute. I was just going to reflect on what we saw particularly in the initial phase of the pandemic, where face-to-face services and, indeed, mental health services were not recognised to have the priority that they needed. We had women whose appointments were cancelled because of the pandemic, and, subsequently, two months later, letters were sent, giving them leaflets of a device, and, again, the thresholds being imposed such that the letter that I vividly remember was that it said, we do not care for women who are not acutely mentally ill, despite the fact that this woman had known long-term mental health problems and, sadly, she took her life two weeks later. There did not seem to be a recognition that you cannot do everything remotely. There needs to be a triage system. Even if we are continuing with some remote consultations, we have to recognise that, particularly with mental health, there will be a need for on-going face-to-face services, and we have to ensure that mental health services are prioritised for the return to face-to-face consultation. It is not assumed that it can all be done remotely, so, for me, that is the most important thing. Family support, as you have highlighted, is crucial for women who have mental health problems and who need advocates because of their complex background. Ensuring that the ability of others to be with them is also going to be really important. I am really pleased to hear that you have heard the direct testimonies of women and families of their experiences of giving birth during the pandemic. We, too, have heard extremely distressing stories from women who have given birth during the pandemic in terms of their sense of isolation, loneliness and difficulties in accessing care from health professionals, but also those more informal sources of support that come from antenatal support groups, antenatal classes and post-natal support groups. In the past, those elements of maternity provision have been under-supported, under-appreciated, have maybe been seen as a nice-to-do, nice-to-have when there are midwifery shortages and pressures in the service. We see antenatal classes being one of the first things to go and being pulled back from. If there is one key lesson that we can have from the pandemic, it is that those support classes and education classes, antenately and postnatally, are not just nice-to-have, they are an absolutely key part of the provision of decent supportive services during the perinatal period. What we have been able to do during the pandemic is rapidly instigate more virtual appointments through the near me programme, being able to provide virtual antenatal clinic appointments. There have been positive elements to that, but it is really key that we do not become reliant on those virtual appointments, because, as was mentioned earlier, it is very difficult for health professionals to pick up on some of the non-verbal cues and nuance in virtual appointments. If someone is not wanting to open up and give things away, it is much more difficult to get beneath that veneer and in virtual appointments, not least because, as many women do not have access to good wi-fi like we are experiencing today and good data availability, so often it will revert to a crackly mobile phone consultation where you are not going to pick up on those issues. As was mentioned earlier, being able to pick up on that relationship between the mother and baby in those early days postnatally, postnatal care, postpartum care has often been described as the Cinderella element of maternity services. It is so important that you have skilled midwives going in regularly to the home in those first days after the birth. That is carried on by health visitors to really support the development of that relationship and to really pick up on how the woman is. You cannot be just popping in and out or just having the odd telephone call, so postnatal and postpartum services are absolutely vital. They are not just nice to have, so those need investment again and they need adequate staffing to provide. In terms of the role of partners, that has been hugely distressing for women because it has become the norm in maternity services over the past several years that partners are there at every scan, every antenatal appointment, throughout an induction process, throughout labour and birth and then on the postnatal ward. We have had open visiting in maternity services for many years now and that has become an expectation. I would say that maternity services focused very hard during all parts of the pandemic on making sure that partners were able to be there during active labour and birth, and that was always there. However, that did mean that there were some women who had longer induction process on the antenatal ward who did not have their partners with them at all times and also women who were attending scans where they perhaps received bad news where their partners weren't with them. Again, we have been able to really recognise that partners are part of the care team and that maternity services should be seeing the family as they are providing care for and that that will hopefully bring those changes and ensure that we return as rapidly as we can to having partners throughout the journey. I echo the points that the previous two panellists have made. The commission in its intelligence gathering has heard very clearly about the isolation that people have experienced during the pandemic. In a practical sense, we have also heard about the difficulties that it has had in terms of discharge planning from mother and baby units and leave because of the impacts of potentially getting the virus and then coming back, it means that it is more difficult to organise leave. I was pleased to hear the emphasis on partners, including fathers, because they have experienced that same sense of isolation too. Having said all that, I think that there is an opportunity now to think about how we adapt to this new normal. The idea that we are going to go back to some sort of old normal increasingly seems distant to me. I think that we may experience further variance, further disruption, but I think that what we ought to be thinking about is how do we build back fairer and how do we adapt our system. I think that in terms of those virtual appointments, I think that there is the opportunity to really build choice into the system, but rather than one size fits all that it is either face-to-face or it is virtual, wherever possible, giving people that choice as to how they want to accept aspects of their care that could be delivered in different platforms. It is the centrality of choice that I would like to emphasise, and that is perhaps the opportunity that this difficult period that we have lived through now provides us. We have run out of time in this session. We could go on for another hour, but what you have told us has been hugely helpful and hugely valuable. We thank you very much for your time this morning. We are going to take a short break while we allow our other panel to come back at quarter to 11. Welcome back everyone. We continue item 2 of our agenda now with a second evidence session with stakeholders as part of our inquiry into perinatal mental health. We have a second panel joining us. Good morning everyone. I welcome to Cat Berry, the group facilitator and volunteer coordinator for the Juno perinatal mental health support. I have Joanne Smith, the chair of maternal mental health Scotland. I have Fiona Chilicom, the patron of maternal OCD, and Claire Harmer, the chief executive of SANS. Welcome to you all. I would like to go round the panel person by person with my opening question to you all about the role that your group plays in supporting women and their families in the perinatal period. We have heard from our clinicians and our academics, and they have referenced the third sector many times, if you were watching the panel before. If I come to each of you, can I come to Cat Berry first of all? Hello, hi. I am Cat Berry from Juno. We are a purely voluntary organisation and we run support groups for women in the perinatal period. Anything from conception up until when their child is about two years old. We run general support groups online and face-to-face. Obviously, the face-to-face groups were not able to run during the pandemic and we had to come up with an online solution. Because the online solution has worked quite well, we have continued that and we have also brought a face-to-face group back as well. We are purposefully unfunded. The reason being that we realise that funding can be given and it can also be taken away as well. The fact is that we do not want to be dependent on funding and then for it to be taken away. Women in the perinatal period need support full-stop permanently. We have had to find a way to survive whatever Government we have, whatever their policies are. We are keeping going. We have two types of support groups. We have our general support groups, which are anything like prenatal anxiety, postnatal anxiety, postnatal depression. We cover OCD although it is less common in our groups. We also have a birth trauma group, which, unfortunately, we have not been able to bring back post-pandemic. We desperately want to, but our general group is facilitated by trained peer support facilitators, whereas our birth trauma group is facilitated by professionals who are not just trauma-informed but trauma-skilled. It is a slightly different structure. The reason why we have those two separate groups is because, after running groups since 2015, we realised that if we had a woman with prenatal anxiety and a woman with postnatal PTSD in the same room, it is not a good match. Both women will need to be supported in a very different way separately. There are three themes that we have identified pre- and post-pandemic. Those things existed pre-pandemic, but they have really been exacerbated by the pandemic. The first one being isolation, which has really been exacerbated during the pandemic, particularly as not only the shortage of NHS services and third sector services, but also in terms of friends and family who were not allowed to visit in the full lockdown. You know how it is with a small baby. You need as much help as you can get, and it just was not there. We had a lot of women very isolated. Secondly, the second theme that has really come up is birth trauma, a massive rise in that pre-pandemic, but that has been really exacerbated during the pandemic with, again, less support, has led to more PTSD. Thirdly, lack of support, which has been exacerbated during the pandemic. I will go into those in more detail later on, but those are the three themes that we have identified. That is helpful, and my colleagues will probably come back to quite a few of the things that you have brought up. I come to Joanne Smith. Hi, everyone. My name is Joanne Smith. I am the chair of the General Mental Health Scotland. We are a coalition of statutory services, third sector services and also women with lived experience of perinatal mental illness. Our role is to come together to provide a strong collective voice to campaign for prioritisation and increased investment in perinatal and infant mental health services. We are entirely falling to the run, and we have evolved over a decade from a professional group, a clinical forum, into quite a significant lobby operation, but it is done entirely by volunteers, and I hope that we offer a distinct overview of some of the intertwined issues that are facing statutory services, the third sector and also care support groups. Our aim is to create continuum pathways of support for families running from family support through to specialist care, and that is obviously massively ambitious, but we believe that that is a bright ambition to have, and we will get strong foundations to build on in Scotland. Thank you, and can I come to Fiona Chellwcombe? Hello, good morning. I am here representing the charity Maternal OCD, which has been set up by two women with lived experience of Maternal OCD. In order to raise awareness of this very common condition, I myself am a clinical academic at King's College London, and I'm lucky enough to be patron of this charity. We have been working over the past 10 years to raise awareness amongst women and professionals, so the key barriers are that it has gone from a lesser known condition, but the research is showing us that it is a very common presentation in pregnancy, particularly in the postnatal period, and it can be characterised by intrusive thoughts of harm coming to the infant, and sometimes horrible intrusive thoughts of deliberately harming the baby, which obviously is very distressing for women and can be misunderstood. Getting a good understanding of this quite common condition that can present across all aspects of the perinatal pathway in primary care right up to MBU specialist care level is really important. Maternal OCD has done a wonderful job in assisting with developing trainings for professionals, disseminating information to GPs, people who might be the first point of contact for women with this very horrible disorder, and we have sedated peer support groups alongside a national charity OCD action that continues those specialist groups for women and have done so through the pandemic. That's been the main role. Before I move on to your colleague Fiona, can I ask you, in maternal OCD, is it the case that, because of the nature of it, that's almost a barrier to be women seeking support for own mental health, because they're worried about the consequences of admitting some of the challenges that they have in those intrusive thoughts? Yes, absolutely. At all perinatal mental health issues, career stigma with disclosure, but it's quite clear that obviously there's an additional issue of potential misunderstanding, inappropriate risk assessments and sometimes very inappropriate treatments. So educating professionals about the right questions to ask to really ascertain whether this is OCD or perhaps another problem is really crucial and, of course, has a huge, potentially preventative function. The other issues that we do have treatments that work very well for this condition, so disseminating that information, there's obviously been a lot so far about workforce training, but it's really key, I think, in a message to women that there is help that is very effective and should be available to all women. Thank you for clarifying that. Hello, yes. Sands offers support to anybody who's been affected by the death of a baby, and that's pregnancy loss and baby death. I just want to start by thanking the committee for recognising the fact that bereaved parents do have specific and different needs, because in the past they have often been overlooked, so it's wonderful that you are recognising this within this space. We offer support to parents through a range of channels, including group support, which face-to-face or via Zoom across Scotland, and we have special Scotland groups. Increasingly, we're offering support digitally through online community, Facebook pages, but also through Instagram, Messenger, people reaching out to us in lots of different ways. I think that it's really important to recognise that not only different channels work for people, but that different levels of support are needed. Whilst we provide support ourselves and we provide a level of counselling, we know that many parents go on to experience quite severe mental health issues, such as PTSD and depression complex grief. We don't support those levels that need specialist psychological or psychiatric help, but that is a gap that it would be interesting to discuss further. It's important that parents can access the support that they need. We also work with healthcare professionals to provide the training and the resources that they need to provide bereavement care. That has been quite challenging during the pandemic over the last couple of years, but it's incredibly important that, in those first days and hours after the death of a baby, parents are supported, often by midwives, but it can be by a whole range of professionals and that those professionals also get the support that they need. In a nutshell, that's what we do. My colleagues will be wanting to ask you a range of questions. I want to remind my colleagues and make them aware that Fiona has to leave at half past 11. If there are particular questions around OCD, you've got a window of half an hour to ask Fiona. If there's anything, we want to ask specifically that we don't get to, we can always get in touch with Fiona after this meeting. I move on to my colleague, Stephanie Callaghan. Thank you to the panel for coming along today. My questions for Joanne are about the fact that you cover third sector, statutory services and so on. I'm interested in the evidence that we got from women about the importance of the role of the third sector. They spoke about home start and peer support. Sometimes, with health professionals, there was that worry that Gillian, whom I picked up earlier about my being too honest, and too upfront on what the consequences of that could be. There was really very real fears about either the mum being taken away from their baby or the baby being taken away from their mum. They felt very much that the peer support gave a bit of trust on either side of it there, that they felt much more comfortable being open there. I know from my own experience providing breastfeeding support as a volunteer peer support that the midwife who led that said, you know, that mum spoke to her very differently in her midwife role from the dead when she was doing peer support there. What I'm wondering is, as far as the third sector is concerned, are they picking up services that really are NHS boards should be delivering? Or is there, you know, where does the balance of that lie? Also, what can our NHS boards actually learn from third sector organisations? Thanks, Joanne. Thank you, Stephenie. Yes, I think that that's a really kind of critical point. Organisations, you mentioned home-stack but also Aberlour, Drosreach. They've been providing very little mental health support in communities for decades, probably before we were referring to it in those terms. Do they bring a huge amount of specialism in expertise? There is no question that their position within communities means that they are alongside families and able to identify that scarily and intervene appropriately, often prevent problems escalating and therefore stripping out the demand for specialist services. They play an absolutely critical role and very often specialist services take a very clinical view of social and emotional wellbeing. People don't necessarily identify with some of the clinical terminology that's used within specialist services. Having those local third sector services available means that women can overcome some of the real impressing barriers that are to them disclosing that they may be struggling during this really critical life stage. So the role of the third sector is absolutely critical. The delivering effective services report carried out by the managed clinical network included that. Short-termism and funding for third sector services had meant that well-established community services were sometimes unable to be sustained and therefore we are losing some local specialism in expertise because of the short-term funding structures. That's obviously hugely problematic in terms of increasing demand for crisis services further down the line. I think that it's probably worth saying, Stephanie, that we agree with the approach to prioritise investment in specialist services. I understand that's the right thing to do. Of the £50 million that was invested by the perinatal and incremental health program board, only £2.3 million was earmarked for the third sector. There were 95 applications for that fund and only 16 organisations were successful in securing funding. It indicates that there is a willingness within the third sector to provide local support. If we can get it right, then we are going to drive a shift towards prevention that we have long aspired to in Scotland. Currently, national investment is not sufficient to provide that sustainable long-term third sector offer. I think that it's absolutely right that we can't understate the role of the third sector and it's really critical that we can recognise and respect their role in that spectrum of support that women need that runs from that whole moderate need up right up to a status list here. Sandesh Glehani has a question. I've just realised that Cat Berry has put a request to speak in the chat box of Sandesh Glehani on the second and I'll come to Cat first and then I'll come to you. In terms of the third sector working with the NHS, a lot of work has been done recently by the Lothian perinatal collaborative to join up those third sector organisations, particularly Juno, Crossreach, Homestart, Dad's Rock and the Fards Network Scotland and a few of the others. I work with the NHS to enable those mums and families who are currently falling through the net in terms of services to, well, if we have a more joined approach, then those people won't fall through the net quite so much. What we have been noticing since pre-pandemic is the women that we are seeing at Juno. They are on very, very, very long NHS waiting lists, not just for CBT or EMDR like through the NHS, but also for other third sector organisations who provide counselling. At the moment, it's about a four or five-month waiting list for the third sector organisations for one-to-one support. For NHS, it's much longer, it's up to a year at the moment. We try not to have a waiting list and we are able to see people when they come to us. I know that some work is being done at the moment by various NHS departments to recruit more psychologists and counsellors, which, hopefully, should plug that gap and enable the waiting list to be not quite so long, but it is a real problem at the moment. The thing is, the more that we can see people at the time when they need it rather than making them wait and wait until their conditions get worse, it's best to get it early because then it's so much more treatable if we get them early rather than the conditions getting worse. The other thing that I would say is that our birth trauma group model is being used by the Make Both Better campaign as a model for best practice, and it's in the Make Both Better handbook, which Midwives are currently using in the NHS. We are trying to join up a bit more with the NHS to try and enable for that model to be brought into the NHS, but, of course, that needs funding as well. Thank you. I can no hand over to Sandesh. Works quite well because my question is for Cat Berry. You talked about birth trauma and we went through a very difficult birth of my first child, and the support really wasn't there, and my question really to you is, whilst we all recognise it's the woman that goes through the birth trauma, the men associated, the partners associated, I associated, also suffered trauma through it, and was wondering what support is in place, not only from yourself, but from perhaps other health boards when it comes to the partners of the women going through the birth trauma? That is a really, really important key question because what is not really talked about or recognised is that birth trauma can happen to partners and dads as well, and there is something about the person that you love most going through something absolutely horrific and, as a partner, you have no control over it and no way to help them, and that is very, very traumatic. The thing that's really important to say is that it's possible to have a traumatic birth but it not lead to PTSD if the right support is in place. However, it's possible to have a text book totally normal birth and for it to lead to PTSD in both mother and father or partner, but it does lead to PTSD if there isn't the right support in place. What's really, really crucial is PTSD is preventable in these circumstances with the right support. At the moment, there is not the right support in place and that is why we're seeing a rise in PTSD. I know that Dad's Rock at the moment, which is a third sector organisation, they already provide groups for dads anyway. They have been looking at providing groups for birth trauma but, obviously, it's a question of these birth trauma groups. They're not straightforward peer support, which is what you know and Dad's Rock are able to provide. It requires professionals to facilitate these birth trauma groups. At the moment, the NHS provision for birth trauma is there's nothing specifically for birth trauma, to treat birth trauma. I know that a lot of work is being done behind the scenes by Kirstyn Coole and Melanie Martin to create a structure. I know that money has been put in to create more provision for trauma-skilled workers who are able to give people treatment on the NHS, one-to-one services but also groups. Obviously, that takes time. From the perspective of parents who are experiencing birth trauma and PTSD now, it's not coming soon enough. I hope that answers your question. Can I come to Paul Cain, who has a question? Thank you, convener, and good morning to the panel. My question really is, and I think that we've heard quite a bit about the work that it's done and the huge support that the third sector provides. I'm keen to just understand thoughts on the sustainability of third sector organisations. Obviously, we've had the perinatal and infant mental health fund launched in May 2020, and £665,000 to support 16 organisations. Is that fund providing the sustainability that it's needed, or do we need to go further and find other ways of mainlining that funding? I'd direct that to Clea and to Cat, if possible, if we've got time. I think that, undoubtedly, funding is really appreciated and helpful for the third sector, but I think that it's going to be part of, if the third sector is going to be an acknowledged part of referral pathways, and certainly talking about bereaved parents, the national bereavement care pathway, which is funded by the Scottish Government and which we lead on, that the bit within the hospitals is funded really well. However, what midwives' obstitions and neonatologists find when they try and refer people back into the community is that that's where things start going wrong because the funding hasn't established the structure in the community. I would say that, if it could be more formalised, as it is now in the bereavement care pathway within the hospital, if a similar structure could exist in the community, it would prevent parents and families from falling through the gaps. At the moment, it's incredibly difficult to provide enough support and services for everybody. Obviously, the challenges within Scotland, geographical and the diversity of the groups that we're trying to reach and their different needs, means that it is a struggle to be there in every part of Scotland for everybody. I do think that the commitment to funding that allowed the third sector to provide a safe and secure structure everywhere would be a good thing for parents. Thanks for your question. That's really helpful. I think that the priority and investment in bereavement care in neonatal health has been considerably being official to third sector organisations. It's worth saying that what we're trying to achieve is a really ambitious culture shift. It's a huge task. It requires investment in the expansion of the workforce across all tiers of health and the third sector. We need to start where we can have the biggest impact. The third sector fund is a one-off fund. I don't think that one-off fund can deliver the culture shift that is required to move the act to integrate services towards prevention. The Scottish Government has, however, committed £500 million wellbeing family fund. That's in advance, but it is one-off if it's not recurring. What is interesting in advance is the commitment within the programme government to redirect 5 per cent of the community's health and social care project towards preventative services. That could be an interesting approach to embedding support for third sector services into the universal funding streams to make them much more secure and to begin to build that integrated health and social care partnership that will have long aspired to in Scotland. However, the fund in its current form is not sufficient, especially coming off the back of the pandemic, when it needs to increase significantly. I would absolutely agree with Joanne that prevention is really important, particularly with regard to birth trauma. When it comes to third sector organisations being in support to the NHS, when it comes to treating particularly birth trauma, unfortunately around Scotland, third sector organisations who deal with birth trauma are very patchy. It's something that the NHS should be providing. Obviously, we have a model that we can work with the NHS to ensure that that model is followed, as tried and tested model. However, it is something in this case that the NHS should be providing also when it comes to prevention of birth trauma. One of my colleagues, Dr Jenny Patterson, wrote a paper called Traumatised, Midwives Traumatised Women in 2019. She found that the biggest cause of PTSD in birthing women was a lack of care from midwives because midwives are so stretched at the moment. That's only got worse during the pandemic. We saw the march for midwives last month and these awful stories about midwives not being able to look after them, their own basic human needs. They don't have time to go to flu, lunch break or working other people's shifts. There are just not enough staff. If midwives are looking after their needs, how are they meant to be looking after the needs of birthing people? That is what is leading to a lot of PTSD. The adequate support needed for birthing people is not in place at the moment. Delving in more to the support for at-risk and vulnerable women, Emma Harper. Thanks, convener. Good morning, everybody. Thank you for coming today. In the submission from the Mental Health Foundation, they recommended that the development of perinatal mental health services be equality-proof in order to reduce the social inequalities that may prevent pregnant and postnatal women from experiencing good mental health. I am interested in your thoughts on what the gaps are and in the delivery of perinatal mental health, especially in relation to at-risk or vulnerable women. As with all those questions, if anybody wants to start off, just raise your hand. If you want to come in and use the chat box on the platform that you are on, but if anyone wants to start off there, let me know. I will be going to Cat. I think that Joanne might have been before me. Okay. I will go to Joanne then. Thanks for that question. That is an important point. I think that it is an area that we do not really understand enough about and we have heard from others today about that we are not sufficiently disaggregating data about who is accessing our specialist services. We do not really know how inclusive we are or accessible we are, so we do need to get better at that. We, in my kind of full-time role with any PCC Scotland, we did an intimate health needs assessment in NHS Lanarkshire. It had interesting findings. It showed that the women accessing specialist perinatal mental health services, in areas with the fewest number of vulnerable pregnancies, the highest number of successful referrals to specialist services and, conversely, in areas where there was the highest number of vulnerable pregnancies, there was the fewest successful referrals to specialist services. It is a really complex picture, but what it indicates is that an in-bear care law is at play in perinatal mental health services and that in some ways it may be the case that social class or race who undermine a women's ability to access specialist support. I am sure that there is a range of reasons for that, but we wonder about medical professionals and about a women's ability to prescribe our difficulties in a way that resonates with the medical professional and whether that increases the likelihood that women will be able to access specialist support. I raise that because it is a complex area, but we are guilty as professionals of assuming that if a woman is experiencing mental health difficulties alongside other adversities, such as substance misuse or material deprivation, it can be easy for us to assume that if we remove those wider adversities, we have addressed mental health issues. Of course, in many cases, that is true, but it is also true that women who are experiencing disadvantage can have long-standing mental health difficulties that are further exacerbated by the arrival of a new baby. Those women deserve the right to access specialist mental health care, and in many cases, they are not receiving it because their mental health difficulties coexist alongside other adversities. I think that there is an issue around the accessibility of the specialist services. Who is able to access specialist support and why they are able to access it? I think that it is an area that warrants more research to help us to understand what we can do in the local sector, as in Scotland. There are two categories that are at risk of vulnerable women, which, at the moment, we see are being missed. The first is women with a history of rape and sexual abuse, particularly because when the midwife asks the question, the birthing woman may not feel comfortable disclosing her sexual history in front of her partner or husband. We see women who go through childbirth and, to them, childbirth should be a wonderful, joyful occasion to bring a new life into the world, whereas the sensation of giving birth gives them flashbacks to the rape that they had previously. The service is being absolutely pummeled during childbirth. I will not go into it because it is really, really depressing, but it is an area that is not being addressed at the moment. It is really important to ask whether there could be some way of introducing a protocol for midwives to ask those questions separately from the partner so that they are prepared for that and that they can give them adequate support, particularly when it comes to invasive examinations. Informed consent is really important because women who have had rape or sexual abuse in the past may be re-triggered again by staff who are not giving adequate informed consent for why they are performing those examinations, etc. The other group of parents is parents who are going through miscarriage or stillbirth. I know that it has been publicised a little bit in the news, and the Scottish Government has promised to introduce specialist baby loss units for parents who are going through miscarriage and stillbirth. In reality, the NHS says that they are not going to be implemented until 2024. The reality is that parents who are going to hospital know that they are going to have a stillbirth or going through miscarriage. At the moment, they are told beforehand that they are going to press the buzzer of the door and that they will be greeted by a specialist bereavement midwife. That is not happening. The reality is that they are pressing the buzzer on the door. It is the maternity ward, the normal maternity ward, and they are being greeted at the door by happy fathers with balloons saying, congratulations, welcome to the world. They are having to run a gauntlet of balloons and teddies and all those things saying congratulations. It is not fair. It is really inhumane that parents who are already going through the trauma of losing a baby are having to go through that added trauma. It is like adding salt to the wound. Having to go through a stillbirth or a miscarriage in a ward next door to parents who are giving birth to perfectly healthy babies, it should not be happening. It is really, really easily solvable. I do not know why it is taking until 2024 to solve this problem because it could be solved much earlier than that. It is something that I would flag up to the Scottish Government. Please implement them earlier if more people have to suffer. Kat, Sandesh wants to pick up on that point. You have just made, Sandesh. Thank you, convener, for taking me. I did my training at the Glasgow Royal Infirmary, and when I was in the maternity obstetric unit, they actually have a separate area for mothers that are going to be experiencing this exact problem for stillbirth and not seeing the happiness that other people have. It is very much a closed, sort of a closed unit. I was wondering if you feel that was an appropriate thing that we could roll out to have that separate unit a little bit further away from the main ward. Kat? Yes, absolutely. Dedicated baby loss units are vital, and parents who are going through the process of losing a baby should not have to be going through that in the same wards as parents who are going through normal, healthy childbirth. Yes, I think that there needs to be a separate entrance for a start, but yes, a separate unit completely for a separate baby loss unit for parents who are going through miscarriage and stillbirth. I am sure that Sands will have an opinion on the subject as well. I am going to come to Clare now. I think that Kat described beautifully the issues. I would say that this is what the national bereavement care pathway is. The idea was that national bereavement care pathway would be rolled out in Scotland, and it coincided with the start of the pandemic. Some hospitals already have both bereavement suites and separate areas. The idea is that that will be rolled out across the whole of Scotland. One of the problems has been during the pandemic that a lot of the rooms were redeployed and had to be used in different ways. It has been very frustrating to see that that has not been prioritised and put back on track, because it makes an enormous difference to parents not only to have the space to give birth but also to have the space to be with their baby and make memories and take the time that they need afterwards. Again, that was very difficult during the pandemic and the compassionate care was difficult because everyone was wearing PPE. I think that a lot of good intentions and plans were put on hold. I think that it is really important that they are prioritised as part of getting back to normal, rather than seeing as nice to have and extras. The other thing that I was going to say about the gaps in services is that, for those who are most vulnerable—I mean, in one sense, you could say that any parent whose baby has died is vulnerable. However, as I am sure you know, the groups that are at higher risk are those that are cast as vulnerable in deprived areas. We know that domestic abuse is associated with increased risks of miscarriage and stillbirth. As I am sure you heard from Embrace earlier, certain groups—black babies, Asian babies—are shockingly much more likely to die as well. The combination of all those groups finding it difficult to access support, particularly after the death of a baby, combines with the fact that there is very little understanding of what support is needed after a baby has died. Given how many people are affected—one in four pregnancies, ending in miscarriage and 14 babies every day dying in the UK—this is a massively hidden problem. Parents have been told that their thoughts were unhelpful and that they needed to get over it, but they had not lost a loved one. They were told to come back to the hospital where their baby died in order to seek psychological support. Obviously, they were having to wait long times, but I also just wanted to share this. My mother said that she walked out of the hospital and nobody ever contacted me. A letter from the GP congratulating me with the dates to bring my deceased baby for jabs and check-ups. I called for counselling, but it was told that I would have to wait six months. I got no support. Endlessly, the gaps are there for bereaved parents because they are invisible a lot of the time, and the groups that they represent are more at risk are also invisible. It is a double issue, if you like. I think that there are massive gaps for these poor parents who need to be filled. Clare Haughey, why are you talking about that? It costs to me. One of my colleagues, Angela Crawley MP, is trying to get paid miscarriage leave. I assume that that is something that your sense is fully supportive of. Absolutely. We are supporting her and we are working with her on that. I think that it is the very least that we can do as a society is to give parents that space. You never get over the death of a baby or the loss of a pregnancy in one sense, but being given the time and space that you need to start on that journey is absolutely crucial. It is a society that holds parents at a time when they need to be held more than any other is so important. We are absolutely working with 100 per cent behind what Angela Crawley is doing. Thank you. Can I come to Fiona Know? It was just a minor addition to what everybody has been saying in terms of what we needed to understand more about the inequalities and the groups where their special consideration is needed in terms of the buildings and what help is available and how that is presented. It was just to emphasise the importance of embedding experts by experiencing services in the design of any services in the design of training going forward and having that as an on-going dynamic process as well. Thank you. A couple of colleagues are going to come in with very specific questions on training. Emma, you had a supplementary question before we move on to that. Sure. Thanks, convener. It is quite distressing to hear about what is happening as far as access for dealing with bereavement and stillbirth. I just had another thought about people who are new Scots, whose English might be as any of their first language. They are coming here and ending up going through our NHS in Scotland. What work is being done or needs to be done to support folk who are English as any of their first language or new Scots that are having babies in our country? Crucially, without family networks as well. Without family networks to support them. Would any of our colleagues want to come in on that initially? Can we go to Joanne first? I don't know if I'm the best place to answer that, but there are those that I can just reflect on with the barriers to access that we really need to do a lot more work around. I would acknowledge that the programme board is making efforts to understand the quality and diversity that NHS is designed to do the creation of an evaluability and quality framework. That work has not progressed at the pace that we would like to see, but it is not surprising given Covid in a global health pandemic. However, there are huge issues within our national care services, so the services are not necessarily meeting the needs of the women that would most benefit from them. A range of third sector groups am a birth project that we have heard from who are doing really important work to try and take down some of those barriers and to ensure that women can access local pathways to care. However, the reality is that the whole large groups of women who will not be able to access special support because health-seeking behaviour and self-care are learned behaviours, so we cannot just assume that people are able to access the support. If the referral pathways start with the GP, for example, we are assuming that people are seeking help from the GP or would go actively and contact with the local practitioner when, in fact, they know that very often that is not the case, especially in more marginalised groups. We have to have those reach-out services and step-up, step-down services to support families and to bridge that gap between the community support that we currently offer and to be able to tap into that specialist care. You raise a really important point, Fiona, because the question is that we are expanding our specialist capacity, and that is a feel of significant advance. Currently, I do not think that we can be confident that that expansion is going to benefit those women who are the greatest needs and who are managing the most complex range of traumas. We have been wishing to get better at this, but it has not been prioritised to be in a setting area where we certainly need to do a little more. I just want to flag up the importance, certainly for us of translators in this area, because very often, if a family member or a member of the community is involved, it is either fairly inappropriate if a baby has died and we have a lot of instances of children having to be the translator until their parent mother that the baby has died, which is clearly totally inappropriate, but also instances in which the community maybe has a different perception of either mental health illnesses or baby death. Perhaps it is not the right person to be translating and supporting, so the importance of having a supportive translator who understands the issues—either baby death or perinatal mental health issues—can not just translate but support in a really person-centred way, is crucial, because it is agonising seeing children having to act as translators. Sometimes the community themselves have norms that they are expecting mother or parents to respond to that, but they are not always helpful. Thank you for that, and Kat, we would like to come in. Thank you. I totally echo the need for translators. Also, recognising the cultural changes for new Scots, it is more important than ever the ease of access to these services. If we had an ideal world, we would have a 24-hour helpline for parents run by the NHS where parents can phone up and it does not cost them anything, and there is a translator if necessary. They can report any concerns at all, be it my baby is not sleeping or I am not feeling it. The smaller things before they build up to bigger things, because when they get to bigger things, then social services get involved. It becomes a question of, as people's health conditions get worse, there is more of the fear that their baby might be taken away and that is compounded if you are speaking a different language as well. I think that it needs to be something really from the ground up. It should be acceptable for all parents to ask for help over the smallest things. Particularly those parents who are new Scots, they have not necessarily got their family around them, their aunts and uncles and grandparents. They have not got that. They have not got free childcare. They need that extra layer of support to ask these questions when you are going through having a baby for the first time. You are not necessarily taught how to look after a baby. There should be a really simple phone line. It is just to ask questions so that they do not turn into the bigger things, but I know that those things cost money. It should be something to think about. We are going to delve into workforce training in particular. I am just looking at what Stephanie would like to lead on that aspect of things. Quite a lot of the women find that breastfeeding journeys have a huge impact on their mental health issues. They talk about the need for support so that they can make informed choices on their individual circumstances. A big thing seems to be having that important skilled hands-on approach to breastfeeding and getting the right support from health professionals in that area. What workforce training do you feel is needed to give the practical support that women need with breastfeeding? I do not know who would like to go in. I was not sure who, but I will take anybody who wants to come in on that rather than pinpointing anyone. If they want to raise their hand, I will come to you. Is it something that has been flagged up to us? We are feeding as a trigger to mental health issues if that support is not there. Joanne, can I come to you first? It is not an area that we can lead on. To be honest, I do not think that I am really well pleased to answer that question because we live in a membership organisation. I would debate with some of you. That is fine. Cat, I would like to come in on that. One thing that we are hearing from our volunteers who are seeing these women every week is that there is a disjoint between the narrative of breast is best and formula feeding being not quite so good. However, if breast is best, there is not the right support really for breastfeeding. You are getting this narrative of breast is best, but there is not the support there. Breastfeeding is not easy, particularly if your child has tongue-tie or even the easiest of circumstances. Whether there needs to be more support for breastfeeding, yes, definitely, but also maybe the narrative needs to change slightly. Fed is best, is it not? As long as your baby is fed and thriving, there is so much judgment in all, is it not? There is a lot of shaming around breastfeeding or not breastfeeding. Is it not more important that the welfare of the mother is looked after so that she can make that choice of whether to breastfeed or bottle feed? I think it's a very emotive issue for most parents. While there might be ideals or wishes, parents need to be supported in the situation they're in. For many of us, it's perhaps not our direct remit, but we certainly do see the consequences of women who feel very guilty about making one choice or another, particularly with the interaction of medication issues. This is an issue that, non-stigmatising education and support from any professionals or other services in contact with women will be helpful to be educated about and support women to make the best decisions that they can in the situation that they're in. It might be breast, might be bottle feeding, might be a combination to help to support women with what can be a very difficult, physically, emotionally exhausting issue. Thank you. Stephanie, do you have another question or will I go to one of your comments? No, I just really wanted to thank people for their answers. They realised that there's not anybody necessarily as particular expertise, but just a small comment there as well. I would absolutely agree that a happy mum means a happy baby. Supporting mums to make the right choices for their circumstances has to be right at the top of that. I just want to say as well that there's huge evidence around the benefits of breastfeeding for babies that take them right through into adult food as well, so I just wanted to say that. Gillian Mackay. Thank you, convener. What role does the panel think health visitors and midwives can have in prevention and proactively identifying people who are at risk from developing perinatal mental health problems? Does the panel feel that they have the training they need to do this, and could I put that to probably CAT first? Okay. Joanne would like to come in on that as well, so we'll go to Joanne first and then we'll go to CAT. That's okay. Joanne? You don't appear to be able to do that. Yeah, that's really it. So we just had a little bit of a medley in putting your microphone live, so if you want to start again, Joanne. No problem. Thank you. I think the upstilling of the primary care workforce is a really critical first step in building these special services and embedding them locally. I think that training for health visitors, but also GPs, midwives and maternity staff, really can assist with that early identification. It's absolutely critical that we have that local specialism because the universality of these services can secure, appropriate and primarily referral, reduce admissions to inpatient care, reduce maternal deaths. Frankly, we really need to be prioritising the training of these primary care staff within our training plans. In Scotland, ambitions are incredible and really far-reaching, but we do need to cut off accordingly and we do need to think about where we could have the biggest impact. I think that it is getting that in a primary care right and getting that local specialism right, but it can really drive up standards across the pathway. I think that it's really important that we prioritise that. I think that there is good work under way. Neds has obviously went to great efforts to develop online modules, but I think that everyone is in agreement that it's not at a scale or a pace that would realise the recommendations in the delivery and effective services report, so we need to expand the workforce across all the tiers that I've mentioned there and we also need to make sure that we are investing in the correct level of specialism within that workforce because, again, that really is critical to strip out the demand for crisis-like services and to prevent the year-on-year toll that we see in the embrace report of maternal suicide. Thank you. And Cat, and then I'll come to Fiona. Midwives, GPs and health visitors have a massive role in, first of all, prevention of these various conditions but also identifying them when they do come up. One thing that happened during the pandemic was, and this is really, really important, is that anti-natal classes were cut and they were just put online. Not only are anti-natal classes important in educating the parents as to what's going to happen, but it's a massive preventative measure that you can use to prevent birth trauma as well. Much as we love the NCT, the NCT has a certain agenda when it comes to anti-natal classes and vaginal births being best and breastfeeding being best. It's also important that the NHS is able to provide proper anti-natal classes so that parents are shown the hospital environment. They're given all of the different scenarios that might come up. Yes, you might have vaginal birth, but complications sometimes do happen. You might need four sets. You might need emergency C-section. Being forewarned is forearmed in all situations. If you're not prepared for a situation, again, that can lead to trauma. Anti-natal classes can have a real role in preventing birth trauma. During the birth, there can also be preventative measures in place, enough staff being on duty at the time, enough staff being trained in how to pick up on certain vulnerabilities or more at-risk women or men. I think that there's an element in the NHS. As I was saying before, Dr Jenny Paterson's report on traumatised midwives traumatise women in that if midwives are not given, if their basic human needs are not being adequately supported, how can they possibly support birthing parents? That can have a massive impact in preventing perinatal mental health conditions as well. There's street after the birth. There should be someone coming in saying, How did the birth go? How are you doing, mum or dad? At the moment, it's not really happening. It's all to do with, okay, is baby all right? Is baby thriving? I hear a lot from women who have just given birth in the period when they're pregnant. It's all kind of like treating her like cotton wool, this pregnant woman, and then as soon as she has the babies, it's just suddenly like that. It's all about the baby and not about the mum. Suddenly, all the focus is on the baby. The six-week check-ups from GPs pre-pandemic, they were already kind of not really properly happening, and they're completely not happening. They haven't been happening over the pandemic. When they are happening, because GPs are so squeezed at the moment, it tends to be all about the baby and not about the mum. How is your birth injury doing? How did the birth go? How is your mental health? These questions are not being asked at the moment when they should be asked. Health visitors as well, they're short staffed at the moment. We're hearing from a lot of women who are attending junior groups. When they're phoning health visitors, the health visitors aren't getting back to them, and when they are getting back to them, they're only given five minutes or 10 minutes at maximum. It's generally all about the baby. They're not given adequate time for these questions to be asked, like how are you, mum, and for the mum to answer. Unfortunately, it comes down to the same thing. It's short staffed, and people are not being trained in perinatal mental health at a quick beat. Just a point to add through a perinatal OCD lens. I think that particularly health visitors could have a crucial role to play with many things, but thinking about that in particular, because we know from the background literature that post-natal period, particularly around six to eight weeks, is where the prevalence is really high in terms of lots of intrusive thoughts, and there's an opportunity there for lots of normalising information. I think that the health visitors are really key. It's a non-stigmatising service that people might be going to check out something about the baby, but they have eyes on the mum as well before it could get to engaging the mental health services and all that entails. They need as much support as we can give them in terms of their profession and being so well placed to offer that appropriate normalising or signposting where needed. I think that additional training might be helpful in some areas, so looking at healthcare professionals being able to identify the difference between grief and it going beyond grief and needing further specialist help. Obviously, grief is a very natural response to the isolating bereavement of your baby dying, but there is a point where you may need more specialist help, and that's often missed. It's easier to think, oh well, it's normal to be sad, so we're not going to provide any more help. That would be really important. Wider training for all healthcare professionals in how to offer bereavement care after pregnancy loss and baby death, because although midwives and especially bereavement midwives are brilliant at it, often these mothers' families are coming in through A&E or through gynywards or in the community, and the care that they're getting there is not compassionate or good enough. Another area is those who are pregnant after loss, which is a particularly difficult time. I think that health visitors often support mothers who are pregnant and have a new baby after loss. Being able to understand the anxiety literally minute to minute day to day about your baby would be really helpful. Finally, I'll go back to one of the other conversations that we had earlier about training, about looking out for the needs of men and of fathers and partners. I think that they are often unable to acknowledge their feelings after a baby has died. They feel that they have to be the strong one. They never feel that they should seek support. In the survey that we did a couple of years ago, 62 per cent of men reported feeling suicidal because they were unable to say how devastated they felt and that they needed support. If those four areas of training would be really useful. That's very helpful. We are going to move on to talking about particular challenges due to the pandemic. Eveline Tweed. Thank you for that, convener, and hello to the panel. Obviously, we are in a really difficult period just now with the pandemic. We have heard a lot of evidence of how that has affected women. My question is about have there been significant regional variation in a return to face-to-face services? As we move forward and we are dealing with new variants, how can we provide the most effective service, whether it is factual or face-to-face? Can I maybe direct that question to Kat? I may not be the right person to answer this, because Juno was very much based in Edinburgh, so I can only speak for Edinburgh. Even within Edinburgh, it seems to be patchy when it comes to face-to-face services returning, but someone else might be more pleased to answer that question. Maternal mental health Scotland, as a membership organisation, does have a geographic spread across the country. In the early stages of lockdown, we did survey local specialist perinatal mental health teams and also women's groups and peer support groups to try to engage how well national policy has been implemented locally and how it has been experienced by women. It is fair to say that there was a buffer initially, and perinatal mental health services were prioritised within the Scottish Government. That protected us from some of the worst effects that we have seen around this workforce in England and elsewhere. There was prioritisation within policy. How it was implemented locally was variable unsurprisingly. Some areas appeared to make a smooth transition online, and we were able to more or less deliver their contacts to the same quality, but just virtually. In other areas, we were hearing from women that contacts were as limited as a text message. While that would be recorded as a contact happening, it is not providing any support to women in any meaningful way. There is that variability in that we need to go beyond what the DAS tells us has happened during the pandemic, because how that transition online has been experienced by different women in different parts of the country is variable. I think that the offer of online support is irresistible in many ways for professionals, for some women, for local budget holders, and it works for some areas. In many areas, it is not sufficient, particularly where there is health protection concerns. For example, health visitors and those front-line staff are critical in being that front-line identification and surveillance of vulnerable families and vulnerable children. Some of that richness of insight has been lost by the move online, but inevitably it will become a significant part of the health offer to women. My plea would be that any decisions made around a move to online are based on the best available evidence. To say that the pandemic has affected the way that bereavement care is offered, and that affects people's perinatal mental health. One of the things that we have heard most—this is both those who have been affected by baby deaths during the pandemic and those who are pregnant after the loss—is the fact that partners have not been able to attend appointments and scans. That has caused enormous distress, and we have picked up quite a lot of mental health issues off the back of that. I think that the Government encouraging everybody—all health boards—to allow partners back in has been implemented in very different ways by different health boards, and we are hearing that in some areas partners have been absolutely welcome back in, and others are still not easy. That makes a big difference if you have to hear the news that your baby has died when you are on your own or having to attend appointments on your own. I wanted to flag out that it feels very variable, but staff are incredibly stretched. It depends on the estate for the health board, as well as on what kind of rooms it has and what is available. We now move on to a question from David Torrance on access to services. David, I know that you have been having problems with your internet. I hope that it will hold up. Thank you very much for that convener, and good afternoon to panel members. We have heard about variations in local services, but delivering effective services acknowledges timescales for a permanent mental health services. How is the timescale adequate? It is variable across the country, and I think that there is recognition that the current definition in the game for the birth to 12 months is not sufficient because mental health difficulties can arrive at any time for the birth of a baby. It is my understanding that the timescales are being reviewed, and the divergence across health boards is going to be brought together. I think that timely and appropriate care is absolutely critical. Getting it right in the early years is well recognised as the most efficient and cost-effective way of improving outcomes across the life course, with a wealth of policy in Scotland that recognises that. We will have really strong foundations to build on, but there are specific issues around our ability to adhere to timescales that have been exacerbated by the pandemic. We have long-standing issues around recruitment and retention that we have heard about in our universal workforce. Those have been exacerbated by issues related to Covid and Brexit, putting a undue stress on the universal services. Whilst we have seen advances in specific timescales being introduced around the newly created special services, there is a risk that that fragile progress can be swept away by the demands that we are seeing on our statutory and universal services. Timescales are important, but they obviously do not exist in a vacuum. We have to be thinking about the ability of our universal services to intervene at an appropriate and timely point, and to provide appropriate and timely care. Otherwise, our advances in specialist care and the timescales that are associated with that will not have the impact that we hope to see. Thank you. David, are you happy to leave it there? I will move on to other questions, or do you want to come back in? I have one more question, and it is too clear, actually. It is surrounding clear what input has the national brave and care part of the Scotland project so far had on increasing brave and care and reducing local and national inequalities. I think that the idea was that it was going to be implemented initially in three pilot areas, earlier doctor areas, and those areas made a very good start. As I said, they only had a couple of months before going into the lockdown and the pandemic, but already the feedback that we were having, and we have done surveys both before and continuing from both the healthcare professionals and the parents in those sites, show that the experience of bereavement care was greatly increased. We are moving, instead of using pilot areas, because of the pandemic, to encourage all health boards. There are nine bereavement care standards that are part of the pathway, and I encourage all health boards to consider implementing as many of them as they can. It feels that if we wait and do pilot areas as we go in and out of different waves, parents are not getting the benefit that we can see that they have had in the pilot areas. It clearly makes a difference. I think that the issues around workforce numbers and the space and the room, all of which have been affected by the pandemic, are very real. We have spent a lot of the past six months supporting staff who themselves are traumatising if they cannot provide the care to a bereave parent that they want to. The pandemic has had a terrible effect on lots of people, but holding on to those nine standards and doing the very best that you can for all of them has really started to make a difference for parents in Scotland. Off the back of that, this is a good opportunity for me to ask a question that my colleague Sue Webber, poor Sue, has lost her voice completely. I am going to be that voice today, Sue. Sue wanted to ask Claire if it is normal practice in Scotland for mothers who have had previous baby loss on their file to be a symbol, a butterfly symbol. Is that happening throughout Scotland? You are absolutely right that it is a stand's teardrop that goes on the notes that indicates that there has been a previous baby death or pregnancy loss, so the parent does not have to tell their story again and again. The butterflies are really important for twins for twin loss. Where there has been one twin who lives and one twin who dies, the butterfly is used on the cot to show so that anybody who comes up and can see a beautiful baby knows that there was another baby who died as well. The butterfly is incredibly important because there are so many difficulties with the joy and grief of one baby dying and one baby living. We are experiencing some challenges with electronic records and trying to work with Bajonet and the various other electronic systems so that there can be a red flag as well, but that does not seem to be working as well across the board and we are carrying on pushing that through because it just needs to be up there before you even say the first thing to a parent so that the tone and the approach of those conversations that you are having with parents is right. We will ask questions from Stephanie on public awareness of the services that the third sector groups provide. First of all, I would like to ask what gaps is it that exists in the information that is provided by the NHS Scotland and the Scottish Government on perinatal mental health? I am not sure who wants to come in on that one. I will allow our panellists to raise their hand if they want to come in on that first and then I will look to the chat box for anyone who wants to follow up. I do not want to put anyone in the spot so volunteers are always better. I think that signposting is clearly really, really important but it is really using at the moment and I think that if you were looking for the right support and obviously a lot of people going online, whether it is after baby death or just for perinatal mental health support, if you are not feeling particularly like going through lots and lots of information anyway. I think that there is a key role for midwives and health visitors to help with accurate signposting because otherwise it feels like you are backling yourself to try and find whatever support it is that is out there, that is right for you, that you can get and the kindest thing that we can do is to help those people to find the information that they need. I think that sort of skilling up midwives and health visitors so that they can signpost correctly would be enormously helpful. Thank you, Joanne. Just to say that I think that we are quite good at providing information around perinatal mental health. When the pandemic hit, the programme board did set up a virtual rapid response hub to ensure that women had a timely and appropriate information and were being signposted through available services. I think that we are very good at providing information. The difficulty is that we have been sufficient in levels of service on the ground. From the perinatal and mental health fund that was made available to the third sector, that is providing support in eight of the 13 health boards. There remains large parts of Scotland where women can access specialist support and people, for example in the North East, as I am sure you have heard a lot about, a particularly disadvantaged. We hear harrowing stories about women who need to access specialist support but are unable to do so because it is hundreds of miles away and they have other children and financial barriers that go into social support. They are not able to access that support. We also hear of fathers' camps and tents near mother and baby units because it is hundreds of miles from their home and they do not have the money to do anything else. I know that we do have the family support fund but, again, there are real questions about the equity of that because it is £500 and if you are hundreds of miles away, then your experiences to pay in or around a mother and baby unit are significant. I think that we are quite good at information. It is always helpful to have that data and we appreciate the effort that has been put into providing that information. However, what is really important is that we have services to the fair for women on to unless they are in a critical life stage. As you are speaking there, I am thinking about people in the island communities as well. I have added an issue, which I am sure we do not have any island representatives here. Can I come to Cat and then Stephanie wants to come with a final question? I would echo in island communities that there are not those third sector organisations. Certainly within Edinburgh, a lot of work that we do within Edinburgh is signposting. There is a long list of local and national services that we have on our website to signpost people to. However, even that is patchy because funding comes and goes and it is a job to keep that list up to date. Within the NHS, there could be a really good opportunity for health visitors to give that—sorry, the cat—for health visitors to be able to impart a lot of this information. For nationally, I suppose, it is somewhere for this information to be kept up-to-date. I know that there are various organisations like Health in Mind that try to keep things up-to-date. I wonder if there can be some sort of collaboration with the NHS with that, I do not know. Thank you for echoing a little bit now. Thank you very much for those answers there. I suppose that I kind of fall on from that as well. Certainly when I was speaking to the women, what I was finding was that the third sector services that they got were really excellent and a massive help and a massive support to them. However, the biggest issue that they seemed to have was the fact that that support came a bit too late and a bit too far down the line. That seemed to be down to the information and the guidance around it, that the health professionals did not necessarily know about the local organisations that were in a best place to help them there. The other point that they made was about some of the literature that they get about terminology. They have been outdated and are a bit insensitive in talking about baby blues and things, which made them less likely to seek help, because they felt it undermined how they were feeling. From your point of view, as far as the third sector and NHS services go, how do we work together to improve that and get mums to the people who can offer the best support as quickly as we can? Maybe the national virtual hub is the way forward, as was commented earlier. Since this is the last question, I think that I will go round everyone just for your thoughts on that. Congratulations to Joanne first. Thanks. That hits on the heart of the issue. Individual women require very distinct needs, and it is really important that we have a fleet of services available that can support women and families and babies in a way that they require it. It is right that there are real issues around terminology. In Scotland, we have aspired to create a multi-agency approach to supporting families. It is absolutely the right thing to do, but it is complicated. We have to begin to break down some of the professional barriers between health and social care and create space for meaningful collaboration and meaningful integration. Women are experiencing a seamless service response rather than not feeling at home in any one of the services that are being offered. If our services are not meeting the needs of women, then they are not fit for purpose. I think that that collaboration that we have aspired to is not going to happen on its own. We need to incentivise that, whether that is around shared budgets or one way of doing that. Multi-agency training is certainly really helpful in doing that. Collocation of services in some areas might be appropriate to ensure that women are getting the wraparound care that they need and that they deserve. The NSPCC in Scotland has developed an integrated mental health service, multi-agency. It has seconded NHS staff and social work staff at its third sector staff. That has been tested out with a randomised control trial for 10 years in Glasgow. We really await the publication of the findings of that in the next two years. It is an exciting example of how meaningful multi-agency services can work in practice. We need to create space for different professional groups to develop a shared language and culture to operate using the same thresholds in terminology, as you mentioned. It is complicated work, but there are great examples of that happening throughout Scotland. I would reference the work of the mental health implementation advisory group. There is real ambition to create specialist systems around families rather than any one type of care. We really need to look at the best available evidence and be ambitious in order to create those local specialist systems to offer the best support possible to families. We know that the return on the investment is massive. This is a time when women and families are in contact with services. The maternity experience is the time of increased risk and prevalence of a whole range of mental health problems. It is a huge opportunity and we can predict that we know that a huge percentage of women and partners will be experiencing difficulties. We need to have that information and the wheels turning at a really early stage. It is such an opportunity for prevention and early intervention that makes such a difference. Having the information there right from the get-go as to what services are available locally and keeping that updated is absolutely crucial. All the thinking that is going on today is obviously fitting into that. Yes, thank you very much and clear. Yes, I think that the idea of a hub is fantastic, because I think that there needs to be a central place where everything is so that you can find it easily, both healthcare professionals and parents and families. There is also something here about knowing what is happening with the very local areas. Alongside the more national hub, there needs to be a way of sharing what is happening on the ground, particularly thinking about some of your the Highland communities and the islands and how they can find—we have particular groups, for instance, in Shetland and various other islands, but they are often really—in fact, I was talking to one of them yesterday—how distressed they are that people still do not know that they are offering face-to-face support on the island. There is something about what is happening very locally and healthcare professionals needing to know in their patch what is happening and what is available, as well as the bigger picture across Scotland. Thank you. I will come to Kat, finally. Yes, early intervention is key. We know that some of these mental health difficulties are preventable, and that requires changes within the NHS—more staff, more trained staff, but also more joined-up approach between departments and also between the NHS and third sector organisations. I was on a birth trauma working group recently with third sector organisations and the NHS. Something that came up was that people can forgive the NHS for being short staffed up to a point, but at the end of the day, when you are going through a very traumatic thing, really you need people to be kind to you. If people around you are stressed and they are not able to look off their basic needs and they are—stressed people tend to take things out on other people—kindness costs nothing. Again, what Dr Jenny Patterson said in her report and also make both better said and their report, kindness and compassion costs nothing. Kindness and compassion are really, really, really key, as well as employing more trained staff. I want to thank you all so much for your time this morning and for the help that you have given us in looking at the issues from your perspectives. That is the end of that particular session and our meeting. At the next meeting on 14 December, the committee will take further evidence on perinatal mental health, but we will also undertake stage 2 proceedings for the transvaginal mesh removal cost reimbursement Scotland bill. That concludes the public part of our meeting today. Thank you all.