 Siarad gyntaf yn ddifio ar gyfer y 13 ymyrgyrch yn Gwithgavensbaith, y camera gynnwys ygaf wahanol i chyfnod digwydd ein blynyddu i dangos y pelbyn i fynd i'r ffordd o'r ffordd o'i fachodol, fel y gallwn cyffredinithu. Aello'r unrhyw ond mae'r meistagau beth oedd o'r ffordd oedd Gwyrraedd Cymru yw efo chi wedi gynnwys yr eich Gwyrraedd Cymru. Dac oedd Cymru, Cymru, Gwyrraedd Cymru, faelwyr wrth gwrs fel gyflymu yn canwys wrth IPinsol, ond esau wrth NHS Scotland. Rwy'n fawr, Murdoff Yn GwchffIK, i ffwrdd hyn o'r pwyllus privacy mewn syniadau mlynedd yn y maes yn Ysgrifredig Cadw, ac yn netoedd yn y Llywodraeth nid, ein ffordd dysgu gwleiddoedd yr unedigau hefyd, ac mae'r ffordd gwasgen yng Nghymru i gael y Llywodraeth ddigonion arall, byddwn yn y Llywodraeth Ysgrifredig Cadw, ond y Fithredig Ysgrifennig Fodol, oedd ymwysig yn ei ddodol yn ysgrifennig ysgrifennig ysgrifennig ysgrifennig. The advantage of that was having within the one body not only the function that looked and synthesised evidence, but then trying to use that to translate it into usable knowledge to improve Scotland's health. Ieithaf, oes oes oeddaeth i chi'n ddweud i'r organisatio, fe wneud o'r strategiae organisatio ar 5 ymgylchedd, ac wedi gweld rhan o'r ffordd hyffredigiddau ysgolwyr. Mae'n ddifydd i'r cyflwynt yn y teimlo. Mae'n ddweud i'r cyflwynt pobl yma ar y dyfodol i ydy'r 2010 o'r 2011, wrth gwrs, o'r ddwylog ar yr enw i ychydig yn ddwyngiol ysgolwyr i'r newydd a'r newid yng Nghymru hefydolol i'r Minister ddwyngiol, ond describe health inequalities in Scotland has been Scotland's biggest health challenge. We took that as something of a cue and looked to try to develop the evidence that we both analyse and produce ourselves. Focused much more on the nature of health inequalities and even more importantly on what it takes to reduce health inequalities. Felly, we have just come to the end of that first five-year organisational strategy and set out with a second five-year term, very much sticking with that general theme. An important development within the last year has been following the Government's announcement of the health and social care delivery plan, plans for a new public health landscape in Scotland. We are both welcoming and enthusiastic about that because it follows on one of the main recommendations from the public health review in Scotland, which commented on the challenges of having the national functions for public health sitting with different bodies. We are bringing them together and we believe that we will strengthen the public health contribution to public services transformation in Scotland. That is about as far as I can work out delivering improved public health in Scotland. Over the last five years, what tangible delivery has there been as a result of the work of your organisation that any of us could point to and say that is what happened and that was good value? Let me start off with the generality. I think that concern about health inequalities has never been more central to the... The concern for health inequalities is very well established. You could fill this room with reports that have been written on health inequality and I worked with your organisation in producing one of those reports. The assistance that I got was fantastic, but we know the problem, we know the generality. What tangible difference is there? Okay, so what we've been doing is working both within the NHS but increasingly with public services more generally, trying to ensure that that evidence is able to be used both nationally and in particular locally. So we've worked significantly with a number of community planning partnerships about how they use both their local population health profiles but actually to use them to make different decisions. So we've worked with a range of community planning partnerships. More recently, along with a couple of other national boards, we're supporting integrated joint boards in helping them understand the population health challenges in their area in order to make different policy decisions and indeed resource allocation decisions. We've used a number of ways of doing that. We have and we've left you with a series of inequalities briefings which point not only to an analysis of the problem but ways of making different decisions, as I said. I think that the report you may have referred to, Mr Findlay, may have been about the triple I report. Was that the investments in reducing inequalities? I'm just looking at a number of reports that you've published. Okay, because that very clearly set out, I think, quite a different approach. So the actions that we need to take to reduce inequalities clearly go way beyond what we do to just improve the general average population health for the reasons that I think that this committee has rehearsed well. So one of the things that we've tried to do has been to produce less published information simply to distribute it to people and sit down much more with people about saying, what do you do differently with that? So we are now working with teams and a couple of examples of that would be, you'll be aware that there have been a number of fairness commissions across Scotland and we've been specifically invited to help with that. And as recently as the last couple of weeks, we had one of our senior staff involved as commissioner with the Perthyn Cynros commission, very specifically making contribution around the importance of good work and fair work towards improving health in a local community. So I think that there are just some examples. So I have to go back again. What I was asked before was some tangible example. So for example, in, let me pick, a random place in Scotland. In Perthyn Cynros, have they implemented a recommendation from you that makes a difference to reducing health in it? So have they done something in housing? Have they done something in transport? Have they done something in any field? Similarly in Highland or Glasgow or Edinburgh? Where have they done? Enacted something specific that you have recommended? Okay. So the Perthyn Cynros one is perhaps a little early because it was published literally just before the election period. I'll only pick that random one. No, exactly. But I can give you an example. So in Dundee where I sat myself as a commissioner on the Dundee Fairness commission, one of the outputs from that was that Dundee declared itself a living wage city and worked not only within the public sector but encouraged private sector employers to adopt the living wage, specifically because of the evidence that was introduced about the impact on health of a city whose health challenges are well known. Okay. Thank you. Yes, of course. If I could, I mean it is always quite a challenge to attribute specific actions to things we've done. We work with others and we influence others and whether Health Scotland was the main influence or not is sometimes in doubt but examples might include the place standard, putting the health dimension into physical planning and decisions around physical planning and also the process of involvement in defining a good place. Court evidence for minimum unit price. I think we have been a substantial supplier to Government lawyers or lawyers acting on behalf of the Government in the court process. On e-cigarettes, I think we've altered the balance of advice about the use of e-cigarettes in smoking cessation efforts. On child poverty, directing attention towards adverse child experiences and also rolling out an initiative called healthy wealthy children, which started in Glasgow but we have potentiated its effect, shall we say, across the rest of Scotland. Do you have a final example from me? We are aware that we have a long-term strategy to make Scotland a no smoking country. One of the challenges that the Government gave us was to help to lead the NHS as a model contributor to that and you might be aware of the policy position about removing smoking from NHS campuses, which was always going to be a big challenge. We led, on behalf of other NHS boards, a fairly major marketing exercise. You may have seen it as a TV advert, for example, which was never going to immediately stop smoking in and around NHS grounds, but we have seen a significant reduction in that as part of that longer-term programme. I will bring in my colleagues at the moment. Just to confirm it, you have worked with four community planning partnerships, haven't you? Who would like to come in? I will follow up on the place, which, to my mind, is important. I see that in my constituency and in other places around the country. Where has that got to in terms of having a specific impact on planning regulations or on processes? That is great, and we will agree with that. In reality, on the ground, it does not often happen because of the way that the planning process is constructed. If people make decisions on that, they fall on a set of rules and tick boxes that do not necessarily take account of any of that stuff and its impact on health. Where have you got to in terms of influencing that and making changes to the input to the planning review process that is going on or specifics where planning decisions have been changed and taking account of that impact on health? I do not think that the place standard was ever intended to influence legislation, although one would hope that legislation would be complementary to what it is trying to achieve. In a way, the place standard is slightly a misnomer because it is not about standards but involvement in the process of defining what people want in a good place. It was conceived and developed jointly with Architecture and Design Scotland and with planners in the Government. It is a shared ambition and it has also influenced well outside the health sector. What is it doing at the moment? It was launched to great support. We believe that there is quite a lot of work at local authority level and planning level to apply its principles and processes. The outcomes are, again, a little early to tell because its launch was only about a year or two ago, but I think that it will feed through and make the planning process influence the process in terms of bringing local people's say into the definition of what the place could be and its attributes and its positive features. We have tracked the local authorities who are actively using the place standard and 70 per cent of local authorities are now doing that. They are coming back to us for further advice. However, the importance of that is clearly in planning our new communities and indeed thinking about our existing communities and recognising that the environment in which our children are growing up has a direct impact on health. We have had an incredibly enthusiastic response from local government who are welcoming the fact that they have an evidence base to plan differently. You think that it can influence, but it is early days for that. It is just because I am on the reality that what you see does not reflect what you see is planning and going in, building lots of houses in their own place without regard to facilities or amenities or green space or anything just to get houses up. You are hopeful that that will influence at some point. My experience of sitting down talking to planners is that they often are the ones that are as concerned as any of the rest of us about some of those developments. What they need is a very strong evidence base to demonstrate why they might resist particular planning applications, but perhaps more positively about the value of the investment in, for example, a new area to live in, a new housing estate that has paid attention not simply to the needs of car users but to be physically active because of the way that it is designed. The benefits of having planned green space in new community development have an evidence base on the impact on health for it. It helps planners to shape some of those developments. I have been closely associated with the Go Well research programme, which has been led from Glasgow's centre for population health. Health Scotland has been a co-funder of that research. One of the big lessons from that has been not just the regeneration, and there has been billions of pounds within that programme in Glasgow, but not just about the bricks and mortar and putting up new accommodation and converting and improving it, but about how it is done, the process of how it is done. That is a very strong message that has now been put around a lot of Scotland in terms of lessons learned on regeneration and its relationship to health. You are not going to get an immediate health benefit from regeneration, but in the long term the lessons are that if you do not, health suffers. That is one of the studies that we have been jointly involved with between Glasgow's centre and ourselves on the Glasgow effect. I know what you are saying. There does not need to be changes to legislation or guidelines to make a positive impact, which I care a bit counterintuitive because I thought that you would need to do that. If you take, for example, the community empowerment bill, which has done stuff that has got the potential to make a difference in terms of how space is utilised, what you are saying is just by the process of influencing, do you think that that is enough to make a difference? We were jointly chaired a side meeting to the housing conference in March this year. I was particularly struck by the housing associations—principally about housing associations—how they have changed their culture and how they are reflecting on the change of culture towards being community empowering organisations and thinking about the quality of their service to tenants rather than just this major capital investment machine that they may have been perceived as. I think that they have changed a lot. I would like to think that that research has helped them to enlighten, describe and challenge them on the way through and, certainly, anecdotal accounts that I am getting suggest that that is the case. Okay, thanks. Donald? I am interested in that point. The cross-party group on health inequalities has had lots of evidence on the place down and I think that it is one of the most interesting things that is going on in terms of health and equalities. I want to take the discussion on the Scottish Government's health and social care delivery plan, which, as you will know, foresees that by 2019 there will be a new public health body. My question is, where do you fit into that vision? At the moment, there are a number of domains of public health. Health improvement being one of the very significant ones. We are currently the national body for health improvement in Scotland. We will go alongside the health protection function and the health intelligence function into the new body. We will cease to exist as health Scotland when those plans are implemented. Our hope and our desire is that we leave a very strong legacy for the new public health body on the basis of the work that we have been doing over the past 13 or 14 years. Thank you for that answer. One of the impressions that I have got over the last year or so, and we have seen a lot of the non-territorial health boards here, is that it is quite a cluttered landscape. There is a lot of overlap, a lot of duplication. In terms of your role and its survival, what reasons can you give for surviving, as it were? I think that in any orthodox approach to public health, health improvement would be seen as one of the important functions. The Government, indeed, in the review on public health, stressed the importance of the health improvement function, but that being operated and managed at a national level, at least in a separate body from the other important contributors, has been suboptimal. That is the conclusion of the review and the Government's response has been as a result of that. I have been very confident and optimistic that the national health improvement role will be strengthened by its inclusion in the new public health body. It is one of the reasons that our organisation has. I do not mean simply in the leadership of the organisation, but our staff across the board have been enthusiastic about the plan changes. If I may add to that, if you review the body of evidence about what is effective in tackling health inequalities, particularly health inequalities, yes, there are lots that you can do at local level, very local level, and there is more on that, but there is a great deal that you can do at national level on legislation, regulation and influencing policy. I think that a national agency such as ours needs to exist in order to press that case, to assemble the evidence, to influence fellow national bodies, for instance in the environment, natural environment, as well as things like planning and so on. I think that there is a role. I believe that there is a role at national level for an agency focused on tackling health and equality and improving health at national level. I mentioned the long-term monitoring of health and equality's headline in the years of October 2015. The Scottish Government noted that, in relation to health and the healthy life expectancy, there have been no significant changes to inequalities in male or female healthy life expectancy since 2009-2010. That is not a good legacy, so who is failing? I would like to say not us. It looks as if we are associated over our last five years with no change. Are we getting a message across? That is a question that we need to ask ourselves. Are we trying to improve or become more influential? Are we doing enough there or producing usable knowledge? I think that your message is crystal clear about how you change health and equality, but somebody is not listening and nobody is taking action. Therefore, as I said before, we could fill this room with reports on health and equality. This is the bloody, frustrating thing about the whole thing, that all of us have concerns about health and equality, yet they grow wider and wider and we see no action. Who is failing? We need to take radical and focused action, but we are not, so who is failing? I think that we are building consensus in order to try and succeed. That is our job, rather than we are building the evidence on which other people can take decisions. We are not a political organisation, we are a health service. Are they taking those decisions then? Are they taking those radical decisions that are required in your opinion? You are surely here to give a commentary on that. Not all the decisions that we would like to take are taken in favour of health and equality. Clearly, we have a very keen eye on all decisions, whether in the health sector or the non-health sector, in many economic and social policies. Very few of them are potentially damaging to health and equality, but some, and especially some outside this parliamentary remit, I would argue, are risky in terms of whitening inequalities. Can we just add a couple of things? I think that it would be fair to say that we at times share your frustration around this, but I think that there are positive signs around this. In terms of the current work around creating a different approach to fair work and good work, we have been able to influence some of the thinking in Government and, indeed, we have made a number of contributions to the fair work convention. Those messages seem to have been taken on board. They are, I think, quite powerfully made by our own organisation since we have hosted the healthy working lives programme for a number of years now, so I am encouraged by that. Likewise, there has been an open mindedness about the extent to which some of the impact of the new welfare powers coming to Scotland and the ways in which they could be used in order to certainly mitigate at least some of the worst aspects of inequalities. We know—indeed, the World Health Organization would say that there are some very fundamental causes for that, which we are very familiar with. We need to then think about, with the powers available to us in Scotland, what can we do that would allow us to make different decisions? I remain optimistic that— So what would you do with the powers that we have got? I think that I would ensure that we do all that we can to reduce the levels of inequality in income. Give me a specific policy, then. Okay, so what would you do? Would you increase taxes? Cut taxes? I am not sure that it is for me as the chief executive of a public body to say that, but what I would do is certainly to say that in relation to much of the work that Andrew cited, the healthy and wealthier children, we know from the evidence that taking every step within public services to maximise the level of income that is available to families makes a difference in their health. We have supported Glasgow in that, but in the roll-out of that, about the benefits that we would accrue from ensuring a much closer integration, so that front-line healthcare and other public service staff are able to direct people to the sources of support in a much more integrated way to maximise their levels of income. In your publication, The Right to Health, Tackling and Equalities, it states that we are committed to supporting the Scottish Parliament and Scottish Government's efforts to tackle social injustice, working with a variety of partners to address the issues in this Can you tell the committee what is your relationship with the UK Government and what engagement you have with the UK Government? We have no direct relationship with the UK Government. Given that we are a national health board, which is an entirely devolved matter, our relationship would be, from a Government point of view, be directly with Scotland. That is an interesting intention to say that it is an entirely devolved matter, because in what causes health inequalities within the same publication, there is widespread agreement that the primary causes of health inequalities are rooted in the political and social decisions and priorities that result in an unequal distribution of money, income, resources and power across the population and between groups. The fundamental causes result in an unfair distribution of power, money and resources. That is often leads to discrimination against and marginalisation of individuals and groups. We know the impact of UK Government welfare reforms, and we know how cross-cutting and cross-sectional challenges to health inequalities are. Do you think that it is possible to achieve your aims of reducing health inequalities without engaging with the UK Government, particularly when many of the levers that they control and control solely have such a huge impact upon health inequalities? I appreciate that we will use the international evidence around the causes of health inequalities that go beyond the UK as well. We have a global phenomenon of that unequal distribution of resources. In terms of our own constitutional arrangements, we are responsible to this Parliament rather than to the UK Parliament. I appreciate that. What I am asking is, can you realise your goals of creating a fairer, healthier Scotland and reducing health inequalities without having any engagement at all with the UK Government? To give you one example, the family cap is going to divide thousands of children into poverty, but you will have no engagement for the UK Government and no input that will have not sought you advice in this matter. We are an agency of the Scottish Government and our primary relationship is with it. We work through it to try to influence the UK Government. We also work with our colleague National Public Health Agency, Public Health England, and they are constrained in the agenda that are set by their Government, and there are constraints around that. A number of years ago, I represented directors of public health as a professional group at the welfare and pension select committee in London. That is one way of finding a route to influence and comment on Government policy. We have also done solely amongst the UK health agencies, health improvement agencies, to work on the potential impacts of welfare on health. I have to say that it is supported by the other agencies because they do not feel they are in a position to do so, partly because the challenges of relating to a Government, which is set in a particular direction, we have distance and that brings with it some freedoms, limited freedoms, which we are trying to exploit. We have done work on the potential effects of welfare, and those effects are becoming evident, but I would say that the reports that we have produced so far have not been definitive on that, particularly the trends in mental health do concern us. We are trying to get our message across. We have also produced work on taxation and the relative effects of council tax rise or income tax changes. Our feeling is that we can present this evidence, but we cannot necessarily say do this, do that. I think that it is for parliamentarians, politicians to take judgments and the public and commentators to take judgments on what we say, the authority with which we say it, the quality of the evidence behind it, and we are there to influence what they do, what they think, how they act. In that case, would you accept that we are limited in what we can do within the confines of a devolution settlement? I will give you one example. I had a constituent come to a surgery of mine, a woman who was forced out of work due to chronic ill health, and she wanted to get back into work, but she needed time to recover, but she had lost a particular benefit that she was on, and having to go through the indignity of assessments, this was exacerbating existing hypertension. It was also affecting her mental health, where she was in tears at my surgery, telling me that she was feeling suicidal, but she didn't want to tell her son because it wanted her son who was unwell to get further stressed. Given that is something that we cannot fundamentally do anything about in this parliament, and it is having a massive detrimental impact upon her health, would you accept then, on that grounds, that we are limited to what we can do within the Scottish Parliament? The Scottish Government is limited, and ultimately, have I ever been able to, as the best way for it suggests, undo some fundamental causes where merely we just have to mitigate them? I am not inventing excuses for what we do and the limitations that we perceive of what we can do and the influence that we can have. We have seen changes, and we have described changes. Our work on welfare makes the point in the first report that we do not have certainty over the health effects, but we are looking in the following directions. Our second report showed that it was still too early to see changes. We have to accept that we look back on data about events that have already happened, rather than predict them because there is no modelling to help us to predict the effects of welfare. I entirely accept what you say about constituents and people's personal experience, and I use some of that from the deep end practices in my testimony to the Health and Pension Select Committee. We are extremely worried and frustrated by the direction in which welfare is going. That is a professional judgment, but we need the evidence, we need the data, and we will describe the data in future reports about what is actually happening at a population level, which is where our job is, and to square it with individual accounts, such as we get from your cells and from deep end practices and other research bodies and research knowledge to create a picture of what is happening. I too am extremely frustrated and worried at the direction in which welfare is going, but that would be putting it mildly. I will pick up on where Tom left off. I am thinking about issues such as the Resolution Foundation has commented that, over the next five years, it expects income inequality to grow, and in fact, for this UK Parliament—we are now going to get a new one, aren't we? The UK Parliament could be the worst for income growth for the poorest half of households since comparable records began, and the worst since Margaret Thatcher for inequality. We have a Government in Westminster who are decreasing benefits. The welfare reform has targeted disabled people, the poorest and most vulnerable in society. Today, we are talking about the impact of welfare reform on disabled people. Tomorrow, we will be talking about the impact of a reduction in housing benefit for 18 to 21-year-olds. It is nion impossible for this Parliament to tackle health inequality when income inequality is so impacted by the Parliament in the UK. Is that not the case? I accept that. We have limits to the powers that we can take to protect the vulnerable, and that is exactly what is happening. We are damaging the income prospects of vulnerable groups and vulnerable people. However, our job is to study, describe and advocate on the basis of the health effects that we know to be happening. My earlier point was that we are searching for these effects, but they have not. In terms of how they appear in data, they have not come up yet because partly it took time for welfare reforms to feed through. The real bite came in two springs ago, so we are now going to see the effects of these now at this time because they will feed through to health events, the sort of events that we will describe in future reports. I think that you will see from our publications that we are not likely to demur from the general principle that reducing individual or family income potentially has a negative impact on health, and that is our real concern. Our approach is to recognise that, in addition to some of those fundamental drivers, there are other things that we can do in terms of the decisions that we make. If we look at some significant areas of policy that are available to us in Scotland, the way in which we approach housing policy, for example, can have a real impact on individual and family health, and communities' health. When we look at the impact of, for example, homelessness on public health, we see the negative impact of that. Those are areas that we can draw attention to the evidence. In addition to Mr Arthur's description of the fundamental causes, we have a middle column around prevention. There are things that we can do where we could make different decisions that would have a positive impact on health, we believe. Across a number of areas of policy that are within our gift in Scotland. I know, but it is just so striking that the fundamental causes are not within our gifts. I look at this in the front page of this publication from you. What works to reduce health inequalities? One, introduce a minimum income for healthy living. We do not have control over that. Ensure that the welfare system provides sufficient income for healthy living and reduces stigma for recipients through universal provision and proportion to need very little control over that. A more progressive individual and corporate taxation, we have control over part of income tax, which is given to us in such a way that it is almost impossible for us to exert any different policy on that. The creation of a vibrant democracy, a greater, more equitable participation in elections and local public service decision making very little of this is within our gift in this Parliament. It is extremely frustrating. As I say, I am sure that you will not be surprised to hear that we would share that frustration. I would point out, though, that perhaps it is because I am an inveterate optimist, but partly because I would look to say, where can we make a difference? In some of the other briefings that you have with your pack, you will see that some of the areas we have been doing work to assemble and synthesise that evidence and say, what do we need to do differently? We have given you some examples of that today, but we would be happy to give you more and we will continue to look at various areas, particularly where public services in Scotland, responding to Christie's challenge, could make different decisions that would drive improvements in health in a way that was much more equitable. One of the reasons that we moved away from a focus simply on average population health is that our health, if you compare it across European countries, has improved at a slightly slower rate than many other countries, but, for me, the big challenge is that it is those whose health is poorest and whose health needs to improve most that are actually doing least well in all of that. That is fundamentally the challenge of why we are not making as good progress as many other countries in Western Europe. Miles Scott Thank you, convener, and good morning to the panel. I was interested, one of the documents in place in communities talked about community empowerment, and this is an area of work as a committee we've done quite a lot of work on in terms of all the organisations involved in health in Scotland and decision making around health decisions in general. I wondered if you had a comment on how people actually are being engaged in reforms around health in Scotland. Will that start? We are primarily an intermediary organisation, so we are a national agency working to help people at local level, and you've heard that we are engaged with specific community planning partnerships and so on. We have marshaled evidence, as you've just heard from your colleague, that community engagement empowerment is a very important part of creating improved health amongst individuals and communities. What's our part in making that happen? I think it's to supply the tools and means for people to take local action. It is to work with voluntary organisations at national local level to help them and empower them because they are in a very good position, close to people experiencing the effects of inequalities. We are looking at the potential of the community empowerment act and how one might evaluate its effects. Clearly, it's new, and it's quite a complex piece of legislation. We found out that people aren't particularly aware of it on the ground, so we've got a job to do to enable that new legislation to have an effect, and that's really starting from the ground up. Our job is to marshal evidence, advocate, facilitate, get people on the ground to modify their plans for action, influence practice amongst health professionals, particularly health improvement professionals. That would be my interpretation of our role on community empowerment. Maybe I can say a couple of other things. One specifically involves me personally. The North Ayrshire community planning partnership recently produced its community plan and formed an advisory group of people who are involved in a number of aspects of the business of community planning, including health. I was invited to join that. At the most recent meeting of that advisory group, a very specific discussion point was the extent to which local communities can be engaged in both identifying areas for improvement in their communities and finding a release of resources to support them. That's a very good example of that. Another one would be that one of the programmes that we host within Health Scotland is Community Food and Health Scotland, which supports local community groups across Scotland around the importance of food in local community life, both access to affordable food and the importance of food in social cohesion. A number of those local groups are heavily involved in their local community councils and local community planning arrangements. In terms of my line of questioning, it was more around the reform of health services. For example, here in Edinburgh, the Scottish Government is centralising a gender of health services. Edinburgh cleft palate and lip surgery for children being centralised through to Glasgow. For me, on a daily basis, I'm finding people who are complaining about the centralisation of our health service. I was more wondering in terms of your organisation how you are making a voice heard on that. I will attempt to add something that is perhaps at the limits of where we are in Health Scotland, but it may also be contentious. Four jobs ago, I did a job with the National Services Division about highly specialist services. We have got to take courageous decisions about interventions on rare diseases for which there is a need for expertise. The expertise is gained largely through seeing a lot of the same sort of condition and driving up expertise. Unless we take those decisions and have fewer centres doing better, the outcomes will not improve and the resources will not be freed up to do other things that we would like to see done in tackling health inequalities. We in Scotland have to make some very difficult choices. We will always have limits on the amount of resources that are available, unless we do that. Patients do largely accept that they have to travel for highly specialist treatment. You heard last week that even non-specialist treatments such as cataracts are a necessity to journey to the west of Scotland from the east of Scotland. I think that, largely, patients will accept that if we put the case clearly about the consequences. The consequences are outcomes and resources are freed up to do other things. Can I maybe mention about the local aspects of public health? I think that this is an important part of the development of the health and social care delivery plan. The Government's announcement so far has been simply to reform the national landscape. I recently embarked on the first stage of ensuring that we see the positioning of public health in a very different space between local government and the NHS. I was invited to an event where senior local government leaders were involved in helping to shape what those public health priorities for Scotland would be. I wonder whether that might bring some more of a local dimension into shaping those national priorities. The extent to which I expect to see a shift is that we have seen the public health resources relocate in many cases to within health and social care partnerships, but the relationship between the national priorities for public health and the local delivery landscape is a crucial issue. What do you think is key to people not feeling that they are empowered when it comes to those decisions? It is quite clear that people do not feel that their views are taken into account. Frankly, I am not going to bring very much new thinking to this. I think that I would just go back and read the Christy commission about what he said. In moving towards having specialist centres and centres of excellence, which I think is commonly accepted, if we are going to be able to deliver the kind of care and the health technology that is now available, it will require reconfiguration. What role do you think politicians have in being able to communicate that to their constituents? Do you think that that further action collectively has to be taken to communicate the benefits that will follow such changes of service? I will attempt to answer that. I will try to fold it back into our area of focus. Quite a lot of our recommendations, where the evidence is about tackling inequalities, is very plain and simple, and it sounds very straightforward to implement such as legislation and regulation. At local level or the effect on the individual or the way that they see the world, that is much, much more contentious. In the clinical side, you have a grateful patient and also a very skilled doctor and their medical team around them. They do not like to see change unless it is explained in their case one over. There are stakeholders and players, and I think that the role of MSPs is to understand what all the dynamics are and to represent their constituents. However, there is a bigger picture here about the future of Scotland and its public services and its health service. One of the justifications that I would make for staying as a national public health agency is that we can do once and well what other people could do 14, 22, 31 times with less skill or less expertise. I think that there is an efficiency, effectiveness and a better outcome from some functions taking place at national level or regional level. It depends on the intervention and the type of thing that we are looking at. For a highly specialist evidence, such as the health effects of welfare, such as refining the evidence on interventions to tackle inequalities, such as cleft lip and palette interventions, those things need to be held at national level so that we get the best out of the public pound. Several times, local issues are there. What impact has the budgetary decisions made here then passed on to local government having on health inequality? Local government has historically been in the very front line in addressing poverty and health inequality. I can only take my own local authorities example in West Lothian. We have had £90 million removed from the budget, so what impact is that having on the ability of local government to address local health inequality? I do not have to hand detailed information on that. Clearly and empirically, less resource available means that they can do less to alleviate the effects of inequalities. The things that local authorities do, apart from their role in integrated bodies, let us say in transport, in planning or in schools in education, are fundamental to alleviating or mitigating the worst effects of inequalities. How can they prevent them? There are roles, certainly in the targeted social work, for instance, and the population wide housing and planning side, where they can take evidence-based measures to prevent inequalities getting worse. We have a growing relationship with COSLA as the national representative agency in local authorities and local public health colleagues to try to get that message across. I believe that the closer links with the integrated authorities and some joint appointments between local authorities and health boards will bring those groups closer. The review took on board and paid particular attention to local authorities' concerns over the influence of public health expertise on what they did. That is a particular area where we want to see improvement once things settle down after the review and the implementation of the review is under way. Obviously, it is recognised that if the Government is going to play a role in tackling health inequalities, that needs a cross-departmental approach, but there is still that perception that the Government policy on health all too often focuses on what the national health service can do rather than what the Government can do. A recent example is probably the mental health strategy, which I think was widely criticised for not being as transformative as it could have been. Do you think that there is enough cross-departmental work when it comes to tackling health inequalities in Scotland at the moment? The short answer is no, but I see a number of policy areas in which there is real room for encouragement. The current policy focus around educational attainment has broadened the discussion quite significantly from what happens specifically in the classroom. Indeed, we have been invited into a number of related areas of work in understanding the impact of family income, as I mentioned earlier on, but also in the way in which other important dimensions—for example, earlier childcare—can impact on future educational attainment. I think that that would be examples that are at least encouraging signs. I do not think that people do not get that intellectually, but they do. It is sometimes just very hard, especially in the way that we allocate resources, which are often very much within particular channels. At a time, particularly when those resources have been reducing, it can be quite difficult to get those resources freed up to focus on that joint effort. Since we started on our work on health inequalities, we have said from the start that this is not a job that we can do alone. It is collaborative. Again, an area of encouragement is the extent to which, particularly local government—I think that local elected members, for example, often have a very acute sense of the health in their local communities. Local government has been hungry for the kind of evidence that allows them to promote different decision-making. That is a range of functions. I think that there is also a role for other public services beyond that—anything from environmental protection to transport planning. If, for example, we want to have a more active population, simply telling people to be more active—we actually know from the social attitude study that people know that they need to be more active, but simply telling them to do that is not going to be what will achieve that. The people that we need to get to most are the least active. Therefore, one of the things that we need to do is think about how we design a different approach, including our public transport policy, our travel policies, but also the environment in which we are building new communities. How do we do that in a way that will make people more active? I am encouraged by, at least hearing from those organisations and across Government about the willingness to consider that. It is often much more difficult to deliver in the reality. How do we break down barriers to making sure that it becomes a reality? For example, one of your resources is a health and equality impact assessment. How widespread is that used by people other than, frankly, health policy? Does that use right across Government? How do you break down barriers that has every department of Government putting health and equality at the top of their agenda? I think slowly, gradually, perpetually trying to gain influence in places where we have not been before. Two jobs in 18 years ago, I was in the Government as a health policy adviser, and we started to break out of the old mould about health policy being about health services and little else. I think that comparing where we are now with where we were then, we are a lot further forward, but there is lots, lots more to do. Internationally, Scotland is seen as way ahead on integrating children's policy. Health interests have a real influence on what happens in schools, for instance. It is more than many other countries. However, we are talking to the energy officials and the energy minister about efficiency there. We have heard before about housing. We want to have more influence over climate and sustainability, and we are being heard. We are largely welcome because people accept that if there is a health case, there is more power to the case that they can produce as a global reason to do things and change things. Those are areas where we are just getting into it, but 18 years ago, I do not think that I would have ever dreamt to have had such an influence over planning policy makers as we have over the place standard. There are cold areas, but we have warmed up a lot of areas. Health in all policies is a slogan, but we would like to be the embodiment of that. We would like to be everywhere and doing anything, but to come back to a point that Jerry made earlier, we need to look at our priorities and where we can get the most influence. Part of that is strategic, part of that is tactical and opportunistic. Where we are heard goes back to the other point of welfare and devolved powers and non-devolved powers. We have things to say whether we listen to or not and whether that ground is fertile. What our job is is to create the conditions in which health can improve and we can effectively tackle health inequalities. Those include the political, as well as the public and media tenor of debate. We are there trying to get into other areas with policy makers and local authorities, just as much as we are trying to influence other audiences. Maybe one of those other audiences is, for example, employers. I mentioned the healthy working lives programme. We were in touch with 7,000 employers last year who were seeking advice on how they create a healthier and support a healthier workforce, not least because that will make them a more productive workforce. We also host the healthy living award, which supports retailers in promoting better choices in retail food outlets, particularly in the fast food sector. We are working across a whole range of public services. Third sector organisations have worked very significantly with Shelter Scotland, with the Poverty Alliance and others, in order to bring evidence to them to help to support them in pushing for particular changes. We are first and foremost a public services organisation, but we are supporting other aspects of civic life in Scotland. You are a public service organisation, but is it not a bit strange that you have to lobby public service to tackle health inequalities? You are a lobbying organisation by the sounds of it rather than a Government organisation, because you haven't to lobby the Government to carry out, frankly, the reason you were set up. I have worked for a lobbying organisation in the past, and I am very clear that we are a public service organisation. However, we have the resources that help to examine the evidence of what makes a difference and where that is not happening. It is an asset for Scotland's public sector to have organisations like ours, which, with a very small fraction of the total budget that is being spent, points out and identifies, perhaps, unintended consequences of particular decisions that are made or where we can make a difference, for example, in access to public services and then in the quality of service that some of our communities experience. Dr Fraser, you said just a moment ago that help policies impact what happens in schools perhaps more so in Scotland than elsewhere. I note that, from your delivery plan, number two is children, young people and families. You will both also be aware of the Government's priority at the moment in terms of closing the poverty-related attainment gap. I wonder if you could give us some concrete examples of where the work that you have done has impacted upon healthcare within education. There is a good deal of work going on, not really closely associated with what we have done, but on school nursing and schools generally. One specific is on the HPV vaccine, where there has been a joint enterprise between public health and, particularly public health, health services and education, and that is a great success. The data is very encouraging on that. We are increasingly in close cooperation. I think that we could go further with Education Scotland about curriculum and integration of curriculum with health topics. We are also doing work around childcare and the quality of childcare and influencing policy around that. So, it is working progress. You are asking for specific instances. I think that it is almost, it sounds negative, but it sounds almost as if we are invisible, but we would like to move things and change things and not even be found out for being health reasons why curriculums change or why the content of school activities change. It would not necessarily be for health reasons if other good reasons exist and are more attractive to decision makers. Closing the attainment gap, it is not just about schools. It is not just about what happens in schools. It is what happens outside. Certainly children coming to school in primary 1 are ready to learn. That is not a function of the education system as we have it. In many ways, I have to say that there is mitigation to be done when children arrive aged 4 or 5 at the gates of the school and they are already behind. We have to understand that but also see what more we can do in schools, primary and secondary, to help people to catch up and not to widen further attainment. However, those are functions not just of the education sector. I could add to that because we host Scotland's public health network and it produced a very influential report last year in May last year addressing childhood experiences in Scotland and talking about the impact of adverse childhood experiences on learning and a number of other factors. That brought forward recommendations about ways of focusing and introducing other different actions that helped to mitigate some of the impact of those adverse experiences that many of our children have in their early years. I think that my own personal experience in dealing with your organisation is that the professionals that you have working for you have produced some terrific pieces of research and I can only compliment them on that. However, I have a great sense of frustration that some of the stuff that you are doing is not developing into policy and having an impact on the deep city to health inequalities that we have in this country. I think that you summed that up when you said that we have an opinion and we just wonder whether anyone is listening. I think that sums it up. Thanks for your evidence and could we suspend briefly? The agenda item 2 is subordinate legislation. We have one affirmative instrument, as usual affirmative instruments. We have an evidence taken session with the minister and officials on the instrument and then we will have a formal debate on the motion. The instrument that we are looking at today is the public body's joint work in prescribed local authority functions etc. Scotland amendment regulations 2017 draft. I welcome to the meeting Shona Robison, Cabinet Secretary for Health and Sport. Peter Stapleton, carers act implementation manager and Kate Walker, principal legal officer all Scottish Government. Could I invite a brief opening statement from the cabinet secretary? Thank you convener. Thanks for the opportunity to speak briefly to the committee about these amending regulations. You will all be aware that when this parliament passed the carers Scotland act 2016 last February, the integration of health and social care was already under way across Scotland. As the committee will recall, the purpose of the existing public bodies joint working prescribed local authority functions regulations 2014 is to prescribe the mandatory delegation of adult social care functions to integration authorities so that these functions must form part of their strategic commissioning plan for delivering health and social care services locally. We have put forward this instrument to amend the existing regulations so that they take account of the provisions in the carers act in the same way. If approved, it will specify that the function of preparing local eligibility criteria under section 21 of the carers act is one that must be delegated by local authorities to integration authorities. The committee will be aware that the purpose of setting local eligibility criteria is to determine whether a local authority is required to provide support to individual carers to meet their identified needs. As you know, the carers act will commence in full on 1 April 2018. Most of the provisions in the act are already capable of being delegated to integration authorities. Indeed, carers support services are already part of the integrated arrangements across Scotland under the existing regulations. Mandatory delegation of this function to local integration authorities will help to ensure that the synergy between the strategic planning and commissioning priorities that integration authorities are setting and the legislative requirements to improve outcomes for carers that we, as a Parliament, supported during the passage of the 2016 act. We are happy to take questions on the regulations. Questions from members? No questions? Okay. If that is the case, can we move on to agenda item 3? This is the formal debate on the affirmative SSI on which we are just taking evidence. Can I remind the committee and others that should not put questions to the cabinet secretary during formal debates and that officials may not speak in the debate? Can I invite the minister to move motion S5M-05457? I move that the Health and Sport Committee recommends that the public body's joint working prescribed local authority functions etc. Scotland amendment regulations 2017 draft be approved. Okay. Thank you. Any contributions from members? No. The question is that motion S5M-05457 be approved. Are we agreed? That's agreed. Thank you very much. As agreed previously, we'll go into private session.