 Good morning and welcome to the 32nd meeting in 2014 of the Health and Sport Committee. I would ask everyone in the room to switch off mobile phones as they can often interfere with the sound system. Although, for the perceptive, you will see some of us using the committee members and indeed officials using tablet devices, and of course this is instead of the hard copies of our papers. We have some changes in membership today, and we welcome Mike Mackenzie and Dennis Robertson to join us as new members to the health and sport committee. A genuine welcome to you both. The first item on the agenda today, of course, is to give the new members an opportunity to declare any relevant interest that they may have. Can I ask Dennis Robertson first, please? Thank you, convener, and I would just advise members of my membership interests, but with reference to health and sport, there really is nothing to declare. Thank you, convener. No interest to declare other than to direct members to my register of interests. Thank you both very much. The second item on the agenda today is subordinate legislation, and we have five negative instruments before us this morning. The first instrument is Public Body's Joint Work and Integration Joint Monitoring Committee, Scotland Order 2014 SSI 12014 backslash 281. There has been no motion to annul. The Delegated Powers and Law Reform Committee has drawn the attention of the Parliament to the instrument, and the details are in your papers. Are there any comments from members? No. Is the committee agreed to make no recommendations? Agreed? Thank you. The second instrument is Public Body's Joint Work and Integration Joint Monitoring Committee, Scotland Regulations 2014 SSI 2014 backslash 282. Again, there has been no motion to annul, and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Are there any comments from members? There are no comments from members. Can I take it then that the committee has agreed to make no recommendations? Thank you. The third instrument is Public Body's Joint Working Prescribed Consultees, Scotland Regulations 2014 SSI 2014 283. Again, there has been no motion to annul, and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Are there any comments from members? There isn't. Can I take it then that the committee has agreed to make no recommendations? That is agreed, thank you. The fourth instrument is Public Body's Joint Working Prescribed Days, Scotland Regulations 2014 SSI 2014 284. Again, there has been no motion to annul, and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Are there any comments from members? There isn't. Can we take it that the committee has agreed to make no recommendations? That's good, thank you. The fifth instrument is Public Body's Joint Working Integration Joint Board Scotland Order 2014 SSI 2014 285. There has been no motion to annul, and the Delegated Powers and Law Reform Committee has drawn attention of the Parliament to the instrument, and the details are in your papers. Are there any comments from members? I see Richard Simpson. I have two comments. One is that I'm not quite sure what the proper officer is under section 3E of this SSI. That's the proper officer of the integration board, as opposed to the chief officer of the integration joint board. I'm not quite sure what that is, presumably, as it's from the local government. It's in addition to the chief social work officer, so it's some additional officer. The other comment that I have is the fact that there is representation from two doctors—one nurse—but no allied health professionals, although, of course, they may be appointed under section 3E of this SSI. The integration board may appoint such additional members as it sees fit, but I'm slightly disappointed that there's no mention of allied health professionals, because, in my view, they will be quite fundamental to ensuring the success of the integration project. Any other members? Before we proceed to Richard Simpson's comments, can we agree that those comments should be forward to the appropriate minister for some clarification? We'll proceed to the next question, which is—despite those comments or those questions—is the committee agreed to make no recommendations? We agreed. Thank you. We now move to agenda item number 3, which is to return to our mental health Scotland Bill in our final evidence session at stage 1 with the Scottish Government. A welcome, congratulations in your recent promotion to the minister. I'm pleased to have you with the Health and Sport Committee here this morning, and I look forward to working with you in your new role. Welcome for me, Jamie Hepburn, Minister for Sport and Health Improvement, Carole Sibbled, mental health Scotland Bill team leader, Penny Curtis, acting head of mental health and protection of rights division, and Stephanie Verlowe Slewf—what is this? Slewf. Verlowe Slewf? Good. That was a difficult one for me this morning, I can assure you. Can we now invite an opening statement from the minister? Thank you, convener. Welcome. I should tell you that I had to check with Stephanie how to pronounce her surname as well this morning, so I understand where you're coming from. I also apologise—I know that this is slightly delayed. I think that this got caught up in the changeable minister, so I apologise if it's delayed the committee's consideration of the bill. I'm very delighted to be here as Minister for Sport and Health Improvement, appearing before the committee for the first time, and I do look forward to working with the committee's first minister. Of course, she stated that she will be seeking a consensual approach, and I hope that that can be a hallmark of our work together. Before I get to the bill, I think that your clerk has asked for a rundown on my responsibilities, which I'm happy to provide with you, along with mental health, which will be an absolute priority area for me. I'll be seeking to engage early with stakeholders in the sector, but along with mental health, my portfolio includes other areas such as dementia, restricted patients, autism and learning disability, sitting alongside other matters such as continuing the legacy from the Commonwealth Games, and action on obesity, physical activity and healthier working, lives policy for carers, self-directed support and older people's health will also sit with me. My colleague Maureen Watt, the new minister for public health, will oversee a wide range of issues, including health protection, alcohol, tobacco and child and maternal health, and I'm sure that Maureen looks forward to discussing her role with the committee too. Turning to the bill, can I acknowledge the work that's been done by the committee thus far, going through its evidence? I have to say that it's been very helpful for me coming to this issue somewhat later at stage 1. I'm sure that it will be helpful for your new committee members too. The overarching purpose of this amendment to the 2003 act is to make a number of changes to current practice and procedures to ensure that people with a mental disorder can access effective treatment in good time. It seeks to build on the principles of the 2003 act. The bill also proposes the implementation of a victim notification and representation scheme for victims of mental disorder offenders subject to certain orders. That means that the victims will be on the same footing as the victims who are currently eligible to be part of the criminal justice victim notification scheme. I welcome the high level of stakeholder engagement with the bill. There were more than 100 responses to the Scottish Government's consultation on its proposals for a draft mental will. I know that there were nearly 70 written submissions to your committee's stage 1 call for evidence. I am also aware of the four oral evidence sessions that you have had that have stimulated some interesting discussions. I acknowledge a continuing stakeholder input convener. A small working group has already been convened to look at necessary revisions to the forms flowing from the bill. A second small working group will shortly be convened to consider necessary revisions to the code of practice. I am very happy with that, convener, to do my best to answer members' questions. I look forward to reading your stage 1 report when it is available. Thank you, minister. The first question is from Richard Lyle this morning. Good morning, minister, and I welcome you to your post, and I wish you well. There are two submissions that have been made to the committee, one from the COSLA, and one from the letter from the finance committee. COSLA commented that MHO reports would be triggered in far more circumstances than the financial memorandum anticipates, concerned about the scope of new duties of MHOs and unclear at this stage. However, it is clear that additional cost set out in the financial memorandum is underestimated and the cost associated with the measures contained in the bill. It made reference that the total number of hearings requiring a report could be in the region of over 500, as opposed to the 20 or 40 stated in the financial memorandum. The financial memorandum estimates that the cost of 475 per report suggests that an overall annual cost to local authorities of over £281,000 instead of £18,000. That again was highlighted in the letter to committee from the finance committee. Could you advise us what your view is on those two submissions? Well, convener, as a member of the finance committee at the time of the letter, you might have thought that I had created a rod for my own back. We have looked at this matter in a nutshell. The COSLA analysis is correct, but I should clarify at that point because I have been advised that there is a discrepancy between the bill and the accompanying documentation that was resulted in some understandable confusion and concern about the number of reports that mental health officers will be required to complete. I accept that COSLA is correct in its assessment of the difference between the policy memorandum and the financial memorandum. I should clarify that the policy intention, convener, is that a mental health officer will be required to produce a report where the tribunal is required to review a responsible medical officer's determination to extend a compulsory treatment order or a compulsion order in two specific situations and not the three specific situations described in the explanatory notes accompanying the bill. The two specific situations are where there is a difference between the type of the mental disorder that the patient has now and that recording the original compulsory treatment order or compulsion order of where the mental health officer disagrees with the responsible medical officer's determination to extend the compulsory treatment order or compulsion order, and there was erroneously a third situation included, so that shouldn't have been included. To bottom that out, we accept that the COSLA analysis was correct, but on a practical level going forward we estimate that, based on the most recent figures for hearings from the Mental Welfare Commission, there are likely to be less than a total of 15 cases a year throughout the whole of Scotland, where a mental health officer will require to produce a report as a result of the proposed amendments and going with the £475 cost per report that Mr Lyle has referred to, convener, the global cost would be based on the most recent year £7,125, which would of course be spread across all local authority areas in Scotland. Can I apologise to the committee and to COSLA for the understandable confusion that the error would have caused? Just to be precise, can you remind the committee how many hearings there were last year? This is a slight revision to what was set out in the financial memorandum, because the figure at that time is slightly higher, but in the last year, Mr Lyle, there were 15 cases. My first question is on the same point. Even with the very modest additional work that has been outlined by the minister now and clarified for which it is very helpful, in Greater Glasgow and Clyde last year, something like 60 per cent or more of the detention orders, there was no MHO report. Indeed, the annual report on detention by the mental welfare commission has indicated a concern that the overall level is still only around 55-56 per cent. I think that that is the figure. It is somewhere in the mid-fifties anyway for Scotland as a whole. Clearly, the MHOs are already under enormous pressure. Even with the modest increase, I hope that the minister and his team will look very closely at whether there is going to be adequate funding to ensure that the MHO report is actually there. My question is really about the generality of the bill. This is a fairly narrow bill focused on the McManus report, but we heard evidence from Steve Robertson from learning disability and also from the round table last week that there is because of new information and new knowledge about neurodevelopmental disorders that it may be that we should consider a more extensive review of the Incapacity Act and the Mental Health Bill. My question to the minister is whether he and his team have been looking at that evidence and do they have any comment to make on whether a broader review is necessary or whether we should actually be trying to tackle this bill with some additional amendments that would broaden the scope of the bill at this point. In terms of the issue of a longer-term review of Incapacity legislation, the committee will be aware that the Scottish Law Commission has recently reported on adults within capacity legislation. The Government is actively looking at that report just now and we are considering and thinking about how we can look more broadly at issues of restriction of liberty and capacity and the best way to deliver this against a background of what is of course a complex operational landscape. There is work on that. I do not think that I can say much more in relation to that just now, Dr Simpson, but I do recognise that this is an important area. We will of course come back to the committee with details of the Government's consideration of this matter in due course, but I am acutely aware of the views of many people with learning disabilities and autistic spectrum disorders in relation to their specific conditions not being dealt with under this legislation. What I would say if those conditions were removed from the scope of this bill, protective legislation would of course still be required. You have acknowledged that yourself and that could be argued to add another layer of complexity to what could be felt to be on already complex legislative landscape. Indeed, it could result in some people with those conditions finding their care impacted by up to four pieces of legislation, mental health legislation and capacity legislation, adult support protection legislation and whatever new legislation it would have to be put in place. I will go back to the point that I made earlier in relation to wanting to have an open dialogue with the mental health sector. Equally, I want to have an open and on-going dialogue with the representative organisations for those conditions. Indeed, tomorrow I will be attending the autism conference in Glasgow, so I would say to those organisations. Indeed, to the committee, my door is always open and we are happy to consider and look at these matters. To be absolutely clear, we do not actually have any current plans to remove people with learning disabilities or autistic spectrum disorders from the scope of the act. That is very helpful. I can move on to something very much more specific, and that is the extension of the period in which people can, for the confirmation of orders, the proposed extension for five to ten days. When McManus proposed that, the number of mental health tribunals that had to be postponed or repeated was very much higher than it is today. Indeed, I pay tribute to the current president, who has reorganised the administrative approach in such a way that the number has dropped substantially, and hopefully it will continue to drop. My question is whether that is still an appropriate measure extending from five to ten days, or whether it might have the unintended effect that many more applications from RMOs or MHOs will, in fact, be just automatically delayed, so that it would therefore extend the period of detention. I know that the act also says that any additional time would be taken off the next order, but nevertheless that really is not any compensation to someone who feels that their order has been inappropriate in the first place. In passing, I appreciate that the number of emergency detention orders has been reduced by two thirds under the 2003 act, which is extremely welcome, and the short-term detention orders do not seem to have increased. We appear to have got it relatively right, but I think that the minister's question is whether we really need the extension now. If we do, should it not be under absolutely specific conditions, that is that either the applicant from the mental health side or the individual to whom this power is intended to apply or who is going to appear in front of the tribunal for a new order seeks to have an extension for some specific purpose? In other words, will the regulations define absolutely and clearly the term, so we do not get the unintended consequence that I have described earlier? Well, let me quickly, we will not want any unintended consequences with any aspect of this bill and regulations. We may want to touch on that later, but regulations will come before this committee again, the committee will be able to to look at that matter. I was trying to look through my notes, I have got a summary of the evidence that you have taken. As a committee, I know that this is an area that was touched upon. I would also share your welcoming that the number of repeat tribunals or delayed tribunals or rearranged tribunals has dropped, but I was still aware that it still can happen. I want to minimise that because it always has an impact on the person who is appearing. Our position is that we still think that this is an effective provision. I understand that, for good clinical reasons, that can vary from case to case because you are talking about clinical judgments in relation to very specific circumstances. Applications for compulsive treatment orders might not reach the tribunal until very late on, so that can create quite a tight notification period for the tribunal. Service users might not have sufficient time to arrange notifications and name persons might have difficulty in arranging a very short notice of work. That is what leads to hearings being adjourned. We obviously want to avoid that additional hearings for service users who can exacerbate the stress and the circumstances that they are under. In the round, I think that it is still an effective provision, but, of course, if the committee cares to offer comment in relation to this particular part of the bill, we will look at it very closely. However, to go back to the first principles where the regulations are in place, of course we want to avoid any unintended consequences. Again, the committee will have a crucial role in assessing that and providing your feedback. I accept that this is a fine balance. We do not want to put the person to whom the orders are applying in the position of having unnecessary repeat rearranged or delayed tribunals. However, it would be helpful to the committee if we were to get further information on up-to-date figures on this and an indication of the precise reasons for current delays, rearrangements and repeat tribunals, because that would inform us as to whether the balance is still right, because McManus was five, six years ago. In coming to a conclusion in our stage 1 report, that would be extremely helpful, if that is possible. Absolutely. I see that officials are assidiously scribbling either side of me, so they have already taken a note of it, and, of course, convener will get that information to the committee. Bob Doris, do you want to continue on this as well, Dennis? I will bring you in. Good morning, minister. I think that a number of MSPs have got matters in relation to the issue that was raised by Dr Simpson. I am minded to point out that the Mental Welfare Commission and Mental Health Tribunal both supported the extension from five to 10 working days. They said that, in a good week or in a good month, about 20 per cent of hearings still went to repeat multiple hearings, because reports were not prepared for a variety of reasons. Of course, we have to drill down on the reason for that. Anything that we can do to avoid multiple hearings, whether it is not getting the views of the named person, for example, and I am conscious that there are also reforms to the named person process within the bill that will create a knock-on effect, I would be keen for you to take a cognisance of if you continue to go with the extension from five to 10 working days. However, my question is twofold in relation to that. The first thing is that I am content that, as long as the extension from five to 10 working days is not just seen as an administrative convenience but is seen as being meaningful to those on undershort term detention, then it would be satisfied that this is a balance to proportionate step for the Government to take. I would look for some reassurances that the Government would seek to monitor the situation in relation to the reasons for the five to 10 working days being used or deployed by relevant professionals so that it was for the benefit of the person undershort term detention and not for administrative convenience for professionals. That is the first thing. If that can be assured, I would be content with it. The second thing, of course, is concerns that we have raised in relation to the ECHR compliance convener, which we got at last week's meeting. I made the mistake of asking two lawyers for their views on that and got 17 different views, which was quite helpful. That is maybe slightly unfair, because neither lawyer who witnesses at the committee should point out that it was not legal advice that the committee saw it. One spoke about it being potentially less compliant, and another lawyer was content that it would still be compliant and that it was clear as mud at the end of it. There has been a general feeling in terms of the opinion last week that, again, their concern would be that it was used inappropriately or was used uniformly across the board. I am determined to make sure that we do not just get this right in terms of the administration of the system, but in terms of the human rights of all our constituents who could be subject to detention orders that we get at right for them as well. Information in both those aspects would be welcome, convener. Of course, convener. Thank you for the questions, Mr Doris. Let me be clear that the provision is not—I note the point that you make—the mental welfare commission and the tribunal support that measure. I think that they support that measure for the same reason that the Government went to take it forward. It is not about their administrative conveniences, it is about ensuring the best provision of service for those who appear before them. I go back to the point that I made earlier about the fact that there are less rearranged hearings, but there are still some who want to absolutely minimise them. They are stressful for service users and we want to try and reduce them. That is the primary motivation here in terms of giving service users and their namepersons the chance to properly prepare for any hearing, so that is absolutely the motivation here. It is not about administrative conveniences. In terms of, I think that you asked the question, Mr Doris, about monitoring this. I can assure members of the committee that the bill team will discuss with the tribunal service the type of markers that can be put in place to monitor the throughput of cases as a result of this proposed change. We will, of course, monitor any list of provisions that we put in place to see if they are effective. Turning to the second issue in terms of ECHR compliance, I have to say that only getting the 17 views from two lawyers could be argued to be a pretty good job, Mr Doris, but we are convinced that the provision is ECHR compliant tonight. I think that this is of fundamental importance. I used to be this Parliament's convener of the cross-party group in human rights, human rights issues or something that I care very deeply about and I note the comment from the faculty of advocates in relation to compliance with the convention that would centre around whether the change was proportionate. The intention behind the provision is, as I have said already, to benefit the service user. On that basis, we do think that it is a proportionate change. We consider that the provisions of the bill achieve the end of being compliant with the European Convention on Human Rights across the board, so that includes the provision. I think that the general point that was made could be challenge because the current situation is compliant, obviously, but we are going into an area where it could be a challenge. I think that is what I took generally out of last week's evidence. I thought that last week's evidence was quite interesting, at least in the issues that we have raised and discussed. I am sure that your officials, if you have not had time to read the evidence, the last week is worth some consideration from practitioners in terms of how the process works and what time people spend in the system currently and whether that would be improved or diminished. I thought that it was interesting evidence last week. Let me be absolutely clear that every bit of evidence that committee has gathered, with a particular reference to your stage 1 report—I do not know if the committee will include that in its stage 1 report—we will look at it very carefully. I would suppose that I would say in relation to the point that you have made that it was felt that this could be subject to challenge. I would say that, of course, any legislation that this Parliament passes could be subject to challenge. It is whether or not, of course, that challenge would be upheld in the courts, but that is the nature of this Parliament's competence. Any legislation that we pass could be challenged through the courts. We consider that this is completely in relation to article 5 of ECHR, because article 5, I think that I am right in saying, does not definitively set out a time period in terms of which a person can be detained. We think that the extra five days in question, given the safeguard that we have put in, will not fulfil of ECHR requirements. To go back to the point, we will look at every bit of available evidence that we want to get this right. I have a couple of bits from members who are wishing to ask questions. I see Colin Mee's hand up on this theme. From what you are saying, Minister, I take it that we are looking at the extension is an exception rather than the rule. If we are looking at particular conditions that may arise for this to happen, would something like taking the geography of Scotland and some of the remote rural and taking in inclement weather give you the flexibility of the extension to take those factors into consideration? I do not think that accessibility in terms of rural areas is really the motivation here. No, it is not motivation. Does it give you the ability, obviously, if those things were to... We are not discriminating against people who live in remote and rural, far from it. What I am saying is, because of factors like the inclement weather or whatever, there could be possibilities that extension is necessary, not because of any mental health issue or anything like that, but because of the actual factors that maybe someone could not return home for instance or whatever. I do not suppose that you could rule out any possible. I suppose that I would make the point that, although I recognise that it takes longer to get to more remote and rural areas, I think that the extension of five to ten days is not really about that area. What I would say is driven. I repeat the point that I have made. It is driven in terms of trying to improve the experience for service users. I think that this is more the area in terms of getting time to prepare their get ready for their appearance before any tribunal. I think that that is the motivation more. We may well explore other areas where I think the issue of accessibility for rural and remote areas is more pertinent than in this particular area. Again, it is the extension rather than the rule. That is primarily what you are saying. I will maybe bring our fishers in a minute, but it would be the rule in the sense that it is automatically extended to 10 days. Of course, we will always hope that these matters can be expirited as quickly as possible. As Dr Morill said in his oral evidence, the tribunal will always continue to work at holding the hearings as quickly as they possibly can. As the minister has alluded to, the main point is to try and assist service users, unnamed persons, at what can be a stressful time to try and ensure that their case can be determined at the one hearing. I think that points about setting conditions that the committee might want to consider that we are looking at a relatively short timescale here. Sometimes you can overcomplicate matters on some written evidence that people would like certain specific circumstances set out, but then you are getting into a scenario of defining what those are. Does that have to be set out in legislation? It is not that they could not be considered, but I think that in the timescale involved, what we are proposing is a reasonable alternative. As the minister has indicated, we will certainly—should this proposal pass through the parliamentary process at monitoring the usage of this and matters such as the code of practice, which the minister has already alluded to, which is under revision—we would also be beefing up the text in relation to responsible medical officers submitting applications, mental health officers, et cetera, submitting applications at the earliest opportunity. The point that Carol is making is that it is important when we do not want to overcomplicate the system. I suppose that going back to the point that was made by Mr Robertson in terms of the exception, rather than the rule, I am aware that you took evidence. I forgive me if I am wrong. It might be Mr Doris who explored this in questioning on whether this could be an exceptional provision. I understand the intention of that, but I think that Carol has set out why this could be thought to overcomplicate matters, particularly, and this is important again. I make no apologies for reiterating the point. We want to make sure that this is an improved experience for service users and minimise the duress that the system could—let's face it—it is going to be placed under some duress and stress at any rate. We want to minimise that so far as we can. If you add another layer of exception circumstances, that starts to put it in the mind of the service user or their name persons. Is this something else that we need to apply for? We want to keep this as straightforward as possible. Of course, if the committee makes comments in that regard, we will look at the evidence closely. I want to ask a couple of questions on the issue of advocacy, which the bill is silent on. This was raised at all the evidence sessions, and it was clearly an issue of importance to quite a number of the witnesses. Many of them highlighted that the nature of advocacy provision is quite patchy across Scotland at the present time. The mental welfare commission felt that the 2003 bill gave a strong right to advocacy, but their question was whether it was being properly implemented across the country. The mental welfare commission's suggestion was that the Government might commit to proper auditing of the availability of advocacy and the performance of local authorities and health services in fulfilling the statutory duty. Comments on that and another question after that. Let me say at the outset that I am a strong supporter of advocacy. I think that it empowers people convening of work locally with independent advocacy organisations, albeit in probably a different context to the one that we discussed today, although it occurs to me that organisation might well interact with the framework that we have put in place to try to help people with a mental disorder. I am a strong supporter of the provision of advocacy. When the committee was looking at this, I think that it was – forgive me if I'm wrong – particularly in relation to the position of carers, if I remember correctly. What I can say is that there are preliminary discussions that have taken place between officials and the care inspector who are the independent scrutiny and an improvement body for care service in Scotland regarding the possibility of the inspectorate's programme of audit, including a review of how well local authorities are meeting their duties in respect of the provision of advocacy. It is something that we take seriously. That is some work that is on-going. If the committee felt that that was too narrow, we can of course look at that matter again, but let me assure you that this is something that I think is very important as well. The carer's question was actually going to be mine, my secretary. I think that there was certainly quite a strong feeling particularly in organisations such as SamH that there was nothing in the bill to strengthen the advocacy situation. I suppose that I will go back to the point that was made by the – I mean, this is an amending bill, so this is not starting afresh. This is amending the 2003 act, and their point is that the 2003 act is pretty strong in this area. The question is, are the actual provisions of the 2003 act being fully met, so we will look at that. I do not know whether that is necessarily a case for the necessity of any legislative provision at this stage, but again, and I suppose that this is a general point across all of our discussions today, convener, no matter what area of the committee comments in this area in terms of stage one, we will look at that matter very closely. I appreciate that. Mike Mackenzie. I am doing my homework for this committee. I was very pleased to note that a lot of the witnesses had placed a high emphasis on the importance of advocacy, but just picking up on this theme, I wonder in terms of looking at an accountability mechanism in terms of the provision for advocacy, how far that could be directed towards looking at the special issues of geography, the challenges of geography that we experience in the Highlands and Islands region. I am struck that the health formula, the birthnot formula, has a provision in there for rurality, as has the GAA formula, the local authority funding formula. Therefore, it seems reasonable to me that rural authorities ought to make provision for rurality in terms of deciding what resources they make available for advocacy organisations. Therefore, I am interested to hear from the minister whether it is taking forward this accountability mechanism or looking at accountability to see if there is proper provision of advocacy, how far rurality can be taken into consideration. The second point that I would make is that, although I think that we all agree that it is absolutely important that, if at all possible, we can increase the provision and access to advocacy and independent advocacy, how far it is possible to say that advocacy can be genuinely independent. Given that advocates and agencies are very conscious of the fact that funding may well come from the very agencies that they sometimes have to challenge. Well, let me say to Mr McKenzie that he is not the only one who has been doing his homework this weekend coming to this bill a little later than might have been felt to be ideal. Clearly, in terms of the legislative framework, those are matters for local authorities, given that they made the point that there are discussions on how we can look at how well local authorities are meeting their legislative duties. I suppose that we can try to factor in issues of rurality. I suppose that, with most things in life, it is just a little bit more difficult in the rural areas. That is something that we can certainly reflect on. In terms of how independent the advocacy agencies are, I suppose that, as with anything else, that is always in the eye of the beholder. My experience, despite often being the case that they require core funding from the very bodies that they may be making representations to on behalf of their client base, is assiduously clear on the need for them to be independent of those organisations and bodies. I think that they take that responsibility very seriously. Of course, they are dealing with a huge range of different organisations, so not every situation will be precisely the same as the other, of course. Just as a brief follow-up, the constructive criticism and analysis that advocacy agencies can provide if they meet common issues and so on can be extremely useful for the very authorities that they engage with. I am aware of some authorities that appreciate the value of that kind of feedback loop mechanism, but others do not quite appreciate the value of it. Is there anything that they can do as Minister to encourage that positive feedback loop? Criticism can sometimes be difficult to take, but if it comes your way, I suppose that you have to reflect on what is said. If there are areas that you need to improve on, you need to look at that matter, but it is obviously very difficult to comment. That is, I suppose, a general comment. I do not know if there is a specific situation that Mr Mackenzie has in mind, and even if there is, I am not sure that I will be able to comment in relation to it, but I think that a process of constructive feedback can certainly allow organisations to continue to improve their workings. That is not just an issue for local authorities, that would be an issue for the very bodies that are relevant to this particular bill, the commission and tribunal. Indeed, of course, as a Government as well, we need to hear what is said as well. I heard what the minister said earlier that, as a result of this bill, you do not expect any increased capacity in terms of advocacy as a consequence of any parts of this bill. It has been mentioned by members and reflected in the evidence that it is complementary to all of the Government's legislation about where we are actually delivering on the ground, particularly in terms of delays, where you can get good advice and avoid certain situations as much as anything else. Has the Scottish Government audited and evaluated the advocacy services here in Scotland? I think that whether it is predictive, whether it is too, whether it is a perception in rural areas that is likely to be patchy, or in areas that have more availability and the problem is access. There is an issue here in terms of the Government's objectives and policies to ensure that they are working effectively for the people that you are hoping that they work for. Advocacy is a key aspect of that. Is there any recent work that indicates a problem or has there been an audit of these services? Are health boards meeting the responsibilities? Is there any of that work being done? I suppose that I would first of all reflect that advocacy organisations—depends on what we are talking about here, because if we are talking about advocacy organisations in relation to this specific bill—and I have referred to some of the work that is on-going, but I am aware that they will interact with the elements of the public sector on a wider basis than just this particular area, but are wider than just the health service. What I can reiterate is that there is that dialogue with the care inspectorate in terms of assessing how well local authorities are meeting their duties in relation to this legislation, in terms of the provision of advocacy. The Government is also working on producing specific advocacy guidance for carers going back to the point that was explored earlier with the aim of launching this earlier next year. We do believe that that would be a useful tool in making people more aware of their right advocacy and the fact that those organisations exist. Joe, I am looking to the officials now. I have to tell you that I will need to look to the officials as well, because I am unsure. In terms of whether there has been an evaluation of effective advocacy services, where there has been funding properly? There is nothing that I am aware of. What the minister was describing is work where, at an early stage of discussion with the care inspectorate, we are very much reflecting some of the views that were coming in evidence on the bill. We will be working with the care inspectorate looking at their work programme to see whether that is something that we could accommodate within that, because we would absolutely reflect what we are seeing. Can I just clarify a review about advocacy organisations? I think that we would need to be clear what it was that we were asking about. If it is in relation to the provisions of this specific bill, then obviously there is some work on going. If we are looking at a much wider aspect, that might have to be something that we need to discuss with other countries and government. I was mainly in respect to the support from mental health patients as this bill is attaining up in the various acts that they need advice on. We have had practitioners in. It was not a review. I was trying to pick up on some of the points of Mike Mackenzie about the perception that advocacy might not be as available or as, indeed, expert or funded. We have had this at least claimed that services are patchy across the country. I think that both the Government and the committee would like to establish whether that is a factual position or not. I think that is what we are driving at because we all recognise that we can legislate, but there might be practical steps that we could address as part of the evidence that we have taken that highlight how that legislation could be more effective and subjective. Bob was going to raise some issues on the theme, and we can get a response on that. Minister, I was listening to the questions around advocacy. I do not know a bill yet, but this committee is scrutinising where advocacy does not come up. It is often spoken in very general terms and no-one really says what does it mean in terms of the provisions to the actual bill. I was given consideration as the discussion was on going with the convener on what that would mean in relation to provisions in the bill, and I think that you gave some indications of that. We had a fairly lengthy discussion in relation to the need from time to time to have the power to extend short-term detention orders from five to ten working days beyond the 28 days. I am just wondering if sometimes—I am not expecting to have this answer at your fingertips, convener, but it is a good exercise for us to be aware of whether sometimes the reason for the need for that extension might be that the service user or the service user's family did not have suitable appropriate advocacy to allow them to engage with services in relation to preparation of reports and therefore perhaps potentially greater advocacy could lead to not having to deploy the ten working days extension and avoid multiple reports and hearings, so that would be a concrete example of what advocacy could have an impact. I know that there are various other provisions in the bill, whether it is appeal against excessive security, whether it is transfer from one hospital to another, or whether it is preparation of advanced statements. There are certain pinch points within the bill where perhaps the Government could look at and go, is there additional advocacy responsibilities placed there, or how would advocacy be used? That would be more meaningful to myself rather than a general review of advocacy across the board. I wonder if you could give some consideration to that. It was my most limies out. I was not calling for another review, but I was addressing the evidence that we have and the points that we have made. It was not necessary in some of those specialist areas where it is a legal, very much illegal process that we are into and that our services provide that. However, what I was thinking about was that people being aware and encouraged to nominate a named person, for instance, being more aware of a lower level that would be complementary to the bill and, indeed, the Government's objective. However, I do not want to labour it too much. After your response, there has been enough said on it. Can I say—I do not think that you are labouring a point at all—that I absolutely think that the committee is right to look at this area very seriously and go back to my first remark. I think that the provision of advocacy is very important. The committee is absolutely right to look at this. What we will do is we will look very closely at any recommendations made and we will look, of course, again at the evidence session that you have had. I am inclined to agree with the points that have been made by the deputy convener in relation to absolutely playing a crucial role in improving the experience of service users at certain, I think, to use the word, pinch points. I think that that is a very fair way of looking at it. I am going to bring Caroline in a wee second, because what I am not quite clear on, given that what I have said in relation to the 2003 act already setting out the right to advocacy, I am presuming—Carol can get a comment on this—that that is a provision that will still allow for the interaction of advocacy agencies at these pinch points, as Mr Doris calls them. In relation to the issue of the named person, I agree that we need to make sure that service users are aware of the function of such. What I would say is that I am conscious that some campaigning body, some of the stakeholders have talked of having awareness raising campaigns. What does occur to me is that that can be quite good for a short period of time, but once awareness raising campaign is over and done with, the impact could be short lived. I really think that we need to look at how we can raise awareness from grass roots level and building upwards from there. Obviously, a number of organisations have a crucial role in relation to promoting the use of named persons in the NHS, local authorities, the Government and, of course, going back to the wider point, advocacy bodies themselves. Of course, they will want to be advocating for an advocacy. You have a right to a named person. Again, if the committee has used how we can better make people aware of the named person provision, then we will be very happy to look at that. I bring to the provisions of the 2003 act and the issue of advocacy. The smaller point that I will pick up on in relation to the comments that were made about the pinch points, which are absolutely correct, is that it is critical that people have access to advice. Part of the role of a mental health officer is to make individuals aware of their right to advocacy and to help to put them in touch with advocacy agencies. Quite often, you find that the nursing staff are familiar with the good work that is done by advocacy agencies. Assistance will be given to individuals when they are in the hospital setting in relation to helping them to access an advocacy service. I ask about the nomination of a named person. In the bill, there is the provision to nominate a named person and there is the provision not to nominate a named person. If the person has not done either, it reverts back to the 2003 bill where the next of kin is put into the named person role. I have taken evidence from both service users and carers that they do not like the reverting back to the 2003 act, because one, the carer may not be willing to take on the role, and two, the service user may not wish the next of kin to have access to their medical records. Have you given any thought to changing that in an amendment at stage 2? I recognise that this is a very sensitive area. I understand the strong views that have been expressed by stakeholders engaging with the committee that a service user should not only have a named person, where they want to have a named person. I think that the Government is generally very supportive of that. The provision has been made for service users to opt out of having a named person. You are correct to identify that if an individual has neither nominated a named person or not chosen to opt out, the role reverts back to the person's primary carer or nearest relative. I suppose that you have made the point that there could be many reasons why an individual, either the carer or the next of kin or the service user themselves, would not want that to be the case. The Government wanted to retain that provision essentially only in the best interests of the service user to try to have some form of protection for those who lack capacity. To be fair, I think that reflecting on what has been said to the committee, we have not struck the right balance and we will be happy to look at that matter again. Carers and the next of kin expressed the wish that they would have the ability to refuse to be the named person, where they were nominated as a named person but did not feel best equipped to carry out that role. There was also some discussion about what the role of the carer or the next of kin would be and that they should maybe have a separate role to the named person where they might be consulted and be able to speak but maybe not have the powers given to the named person so that in their own right they would be able to play a role that was, I suppose, one that they felt comfortable and able to do without encroaching on the rights of the service user but also not having to take on the full role of a named person. That obviously gives different people different roles but it might be in the best interest of the service user to have those different roles in play. That is the flip side of the point, is it not? I have just made a reflect on this matter further. Equally, it could be the case that a carer or the next of kin does not want to take on the role as you have made the point. We will reflect on that specific point as well. It would be understandable that, unless there were exceptional circumstances where a carer or the next of kin should not be involved, it would be understandable that they would want to continue to play a role in relation to the service user. What I would say is that the tribunal can hear from persons of interest, and that would include a carer or the next of kin. If that was not felt to cover the point that you are trying to make, we could look at the matter further. Essentially, the point is that such people can continue to play a role in the process without being the named person. I am just wondering sometimes if there may be some degree of conflict. For instance, if the relationship between the consultant and the family are not good and the name person is the next of kin, the consultant feels that it is not in the best interest of that patient to proceed to get a better outcome. Where do we stand in terms of the views of the consultant saying that the main barrier to getting a positive outcome is that named person? Do we have a view on that? I might bring in Caroline on that, because I do not want to say that something might be incorrect. Leading over the notes, I think that I remember that there was provision about the name person's removal, but I will bring Caroline on that. I could be wrong, I will bring her on that second. Clearly, in such circumstances where there is a disagreement between the qualified medical professional and carer next to kin, that is very unfortunate. If it is related to how that interacts with the tribunal, the tribunal will consider those matters and come to its decision. It also occurs to me that there is, under the bill, an increased role in providing reports to tribunals for mental health officers where they are applicable. That would be another point of view that would be put in there. Obviously, it is for the tribunal to rule that it is taking into account all the evidence that is placed before it. I do not know whether you want to comment on the point that I made. I think that you have covered the main points, minister, in terms of any disagreements between both parties. If I can phrase it that way, we will be fully explored at the tribunal hearing and then the tribunal will reach a determination based on the evidence that is presented to it. In relation to the removal of a named person, the minister is probably thinking of the provision that we have in the case of children who are under the age of 16. If they currently have a named person but it is felt that that named person is not acting in their best interests or is not carrying out the role, we have retained or there is provision for the tribunal on the basis of evidence that is presented to it to remove that named person and then to appoint a more appropriate person. That would involve discussions with the mental health officer, etc. With the new provisions going forward with someone only having a named person, if they wish to have a named person and with the person who is nominated to be the named person, having to sign to say that they are content to take the role, then our view would be that there would be less opportunity and less need for the tribunal to be stepping in and removing a named person. That was the provision that I was thinking of. I should have made this point before. We would hope in such circumstances that any disagreement, any problems between the medical practitioner and the carer or next kind of wider family could be resolved amicably before it got to that stage. Of course, there has to be provision in such circumstances. Colin Keogh. Good morning, minister, and congratulations on your promotion. Can I just carry on, just before I come to question about the under-16 aspect of the bill, just along the lines of what was being talked about, but there is a note that we have here on asking for. If any consideration was ever given to the inclusion on McManus recommendation 416 about the young person under the age of 16 who has adequate understanding of the consequences of appointing a named person should be able to do so, was any consideration taken on that? Well, I think that Mr Keogh congratulates him on my promotion because we used to share an office, so he's finally got rid of me after the three years. Yes, I mean that this is obviously a matter that has been raised. What I would say, whilst it is important to allow a young person expressive view on matters that will directly impact them, is equally important to protect those who are most vulnerable, and it could be felt that young people in relation to this area are particularly vulnerable. What I would say, convener, is that we are in the position where an overwhelming majority of respondents to the Scottish Government's consultation on the bill didn't actually say anything in relation to the matter, so what I would say to Mr Keogh and to the committee as a whole, if this is an area that the committee wants to make recommendations on or comment on and it's stage 1 report, we will look at them in detail. I'm trying to get through the bite of it. If you want me to come back. No, not on that particular issue. Really, as it had been brought, the issue of 1600s had been brought up in another context, I thought of, and asked that in itself. Can I just ask one more question? It's actually in turn, but I don't know if you've actually addressed this earlier, maybe you have, but in terms of the nurse-holding powers, I may have missed something because I'm a bit clothier this morning, and it was really in terms of the view of some such as chair of mental health nursing forum who was saying that the proposals for allowing the nurse extension powers effectively wouldn't work from what I can gather. Maybe there's any some comment you might be able to make on that? Sure. Well, I think Mr Keogh can rest easy. I don't think we have explored that thus far, so and in terms of the comments that made at committee, I don't need to look again, but I don't think the comment was quite as far to say that this provision wouldn't work. I think the question was whether or not it was felt to be necessary. I recognise, of course, that there could be concerns that the changes to the nurse's home power could be seen as a restriction of a service user's liberty. I think, though, I should make the point that the Government is very clear that the provision is up to three hours. The code of practice that will be put in place will strongly emphasise that the nurse must take all reasonable steps to contact a doctor and mental health officer right at the start of the period, and equally hospital managers should impress upon their medical staff that they should make themselves available to examine the patient as soon as possible. I think that I would also make the point that we would only expect the detention to last for as long as the period required for the examination that the full three hours should only be used if that is the time that is required for examination. I would also make the point that there is provision under current powers, although it is a two-hour period, it can be extended for an hour. If that extension takes place right at the end of the two-hour period, it is more or less three hours already. I think that several stakeholders have already recognised in their response to the Scottish Government's consultation that this change should allow sufficient time for a medical examination to take place, and they were hopeful that this could reduce the number of occasions in which doctors have to apply for what could potentially be unnecessary a 72-hour emergency detention certificate in order to complete the medical examination. That would be significantly more impact than a three-hour period. Again, I would make the point that this is driven by a desire to improve the experience for the service user. That change should also help to provide clarity for service users on the maximum period of time for which they can be detained under the nurse's holding power, rather than being felt just now that it is two hours, but it could be extended up to three hours. It should also make it clear that they are being detained for the purpose of enabling a medical examination to be carried out. I apologise for the fact that I have misquoted my memory. It is obviously not as good as the minister's. He is perfectly right in saying that the chair of the mental health nursing forum said that there was no advantage in the extension. They said that there was no advantage. It was not based on evidence, but it would impact on the nurse's workload. It was an idea that did not come from nurses. The Mental Welfare Commission in Scotland is opposing the move. There is an issue there, not just for the committee. On this specific issue, the Mental Welfare Commission reports that there were 177 occasions in which a nurse's order was used and that a no occasion was that a doctor was not attending within the prescribed time. However, the most interesting two things in that report were that, first of all, the massive variation, a quarter of all the nurse's orders were at the Royal Edinburgh hospital. That seems to me that there is something not right about the nurse's orders' application as it is currently occurring. However, the fact that the Mental Welfare Commission suggests that, probably under reporting on the appropriate form, we need a lot further detail on this and proper research into what is happening. We also need to see what is going to happen as a result of the Mental Welfare Commission's response to its report, which is to issue new guidance on the application of the nurse's detention system. I am minded with the evidence that you have already heard from Colin Kearney, quoted by the convener. It would be certainly my view at the present moment in our stage 1 report to suggest that we should not proceed with this change unless the Government can come forward with convincing evidence that there are a number of occasions on which an emergency detention order was employed because of delays, which is what the minister has just suggested. Given that a number of emergency detention orders have dropped from over 3,000 to 1,000, I would really like to see the evidence of when this is occurring before I was prepared to support this change, because it does involve a further small but nevertheless possible period of detention. I take on board the points that you make. I would say that the Mental Welfare Commission's recent guidance will be reviewing the numbers here. I would also say that just because the numbers have dropped and there might not have been any possibility as still there that an emergency detention certificate could be utilised. I would make the point that it is going from 2 to 3 hours where we are not proposing something that is drastic or not proposing an extension from 2 hours to 24 hours or anything like that. I would make the point again that right now the power is that it is 2 hours but it can be extended by another hour and if that happens towards the end, then you are already dealing with potentially a three hour period. Again, I think that the most important point, and I am sure that Dr Simpson would accept this as well, is that this is up to three hours. We want to make sure that this is dealt with as quickly as is possible. I suppose that we are dealing earlier about issues of accessibility in rural areas and the rest of it. I suppose that, when I said that I think that it was with Mr Robertson, we are discussing the extension from 5 to 10 days and released another part of the bill. I made the point that it might be other areas of the bill where it is felt to be more applicable in terms of rural areas and accessibility. I think that there are issues here in terms of making it easier in rural areas. We will take on board the points that you have made, Dr Simpson. We will certainly look at them and we do not want to do anything that is disproportionate or felt to be absolutely unnecessary. We just think that there could be some advantage in formalising the three hour period instead of having it as the possibility of it being extended. I go back to the point that I made. It might be felt not to be entirely clear to a service user that they could turn up their expectation that it is two hours and then suddenly find that it will actually bang. It is extended to up to three hours, whereas with this change it would be clear that it could be up to three hours from the outset. Thank you. Richard Nyle is on the same subject. Oh, it is another subject. That is good. We are moving on. Okay, moving on. It is something that we actually have not covered yet. The wider review of mental health and incapacity legislation, you made a statement earlier on that you are attending a conference tomorrow. A recent party conference service is actually in discussion with autism rights. Autism rights and psychiatric rights Scotland have called for the removal of people with learning disabilities and autistic spectrum disorders from the mental health law. Inclusion Scotland also commented that people with learning difficulties are concerned that they will be subject to compulsory treatment as a result of their learning disability alone. What consideration have you given to removing people with learning disabilities and autistic spectrum disorders from the scope of mental health legislation? Can you advise me? We touched on that earlier, convener. I think that I made the point that I understand that that is a view, and I certainly bear cognisance of that being a view. Out there, we do not have plans to remove people with learning disabilities or autistic spectrum disorders from the scope of the 2003 act. At this stage, I think that I made the point earlier on the case that, even if they were removed by virtue of the specific issue of them having learned disability or autistic spectrum disorder, they could still be encompassed within the bill in capacity legislation, adult support and protection legislation and new legislation, so it could be felt that that starts to complicate matters. Of course, that and itself is not necessarily an argument against those matters. I make the point that I made earlier. I will be happy to maintain an open and on-going dialogue with the representative bodies, such as you have just mentioned. I suspect that you might have been talking about a party conference. I was that. I have to confess that I did not have that conversation at that time, but the First Minister has made the point that she wants this to be an accessible Government, so I will certainly be looking to play my part in relation to my portfolio. I will be happy to speak with the representative bodies in relation to this area. I am sure that the organisation that spoke to me will be very happy with those comments. I am sure that they will, and I look forward to meeting them in your course. Any other questions for them? Richard Simpson. Question of the degree of security, the extension to medium security unit, and that is very welcome, but some of the evidence that we have heard suggests that that should be extended to low security units as well. I wonder if the minister has any comment to make on that particular area and the extension to civil orders. I think that the first instance is an area that we have to legislate on in terms of the provisions of the 2003 act. There was clear intent that we, as a Parliament, had said that there should be a right of appeal. The 2003 act was framed at the time that talked of the need to be transferred to another hospital, and I am sure that Dr Simpson will appreciate that. That does not reflect reality, because in some settings you could be just transferring from one part of a hospital to another. I think that I would hope that the committee would agree that that is a lot better for a service user. In terms of the subordinate legislation that we would have liked to put in place, it was not possible in the scope of the way that the primary legislation was worded in 2003. Of course, there has been a ruling at the Supreme Court, so that emphasises the need for us to act swiftly. I should also say that I want to be as transparent as I can with the committee convener. There is a petition now before the Court of Session on those matters. I think that that is as much as I can say in relation to that matter for two reasons. It is about as much details as I have at this stage. I do not want to fulfil all of the presiding off in terms of subjudice, but I just wanted to be transparent with the committee to say that there is a petition before the Court of Session relating to those matters. Clearly, we have to get this right this time in order to tell me to do that. I am also aware, convener, that these are affirmative instruments, so the committee will want to be able to assess their efficacy as well. That is another good reason for getting them in place earlier to allow the committee time to properly scrutinise the provisions that we put in place. In terms of the specific point in terms of patients in low-secure settings, what I would say is that the Scottish Government is not considering necessarily to be a problem with patients being held in conditions, because that is about conditions of excessive security—that is what these provisions are related to. We are not convinced necessarily that low security falls into the gambit of excessive security, particularly since the next step in progressing such patients onwards from a low-secure setting would be to get them back into the community, which, of course, is open to the tribunal to order as part of its on-going review procedures available elsewhere in the 2003 act. We are not necessarily convinced of the absolute necessity of extending it beyond the right to appeal to medium-secure to low-secure settings, but, again, as with the point that I have made—I do not apologise for making this point, convener, because I am keen to hear what the committee has to say. If the committee cares to make recommendations on that matter, we will look closely at them. The test of that minister will be your response to the committee's recommendation. I am aware of that. I could be making a rod from him back here. I will be the test for you as a new minister. Are there any other questions? There is only one, I think, for me in respect to the registration of advanced statements in section 21, which has been welcomed by the Mental Welfare Commission. It is a modest and perfectly sensible proposal, but it highlights some of the evidence that we have heard. We all see it as making these statements when you are well should improve your experience when you are unwell, but there is a very slow take-up and has been a slow take-up of the advanced statement. We have had some notions of that in terms of the evidence. People do not listen to them anyway, they do not act on them. Is there any work that the Government is doing to promote, support and advocate these statements, as the Welfare Commission says, that this provision in itself will not change the situation that it is saying? Is there any work that discussions with user groups about how we could do better in this area? Well, I am lost to coming to this news. I am not quite clear on what discussion there has been. I suppose I will go back to the point where we will always be happy to have dialogue. I should say, convener, that we do not have any particular plans, any current plans to undertake specific research on the issue of perhaps being felt that there are barriers or that advanced statements are underutilised. I do think that they form an important part of the process. What I would say is that the creation of a register of advanced statements to be held by the Mental Welfare Commission will help in relation to this matter, it will help to provide some data on the number of advanced statements in Scotland and the geographic spread on an NHS board basis, so that will certainly help to build a better picture about how widespread they are being used. We can certainly build up that picture on an on-going basis and, if need be, respond to those circumstances then. I think that, certainly in the future, we will have a much better picture. I am sure that you have some ideas for the future. Is there a historical position from your officials in terms of the advance statements on how they are working or the slow uptake? Some of it is quite difficult that having the register will help because you will have, in one place, provided that the health board submits the copy. We will then get a better picture, because anecdotally, some of the evidence is that it is quite good in some areas, perhaps not in others. There is probably some work that we need to do. There is a facility that what is in the advanced statement can be overridden. Now, data that is provided by the Mental Welfare Commission shows that that happens in a very small number of cases, but some people think, well, what is the point in making a statement if it is going to be overridden? We probably need to get that message out a bit better. I think that there are also reasons that we have got to remember, although we recognise the good work that an advanced statement can do. If you are an individual who has been suffering from a mental health episode, as you are leaving the hospital, you probably do not really want to start thinking about, well, what could I have been put in place if I am ill again, because you like to think that you are not going to be ill again. I think that, along with some of the comments that the minister made about named persons, it is about trying to build and raise awareness of how effective a tool this can be. I suppose that the point can be that this is one of the reasons that we are putting that provision in, so that we can monitor the picture much better in the future. I accept that, but I was just noting whether it was intentional or not, if the health boards provide. The duty is on the health board. The duty now is on the health board. The duty is on the health board, if they are available to provide them. The health board or the provisions in the bill require the health board to place a copy in the patient's records and, at the same time, a copy requires to be sent to the Mental Welfare Commission. I remember reflecting on the evidence session that you had, I think, again, that was the point that was made by the deputy convener. This can help to improve the patient's experience. Right now, they are not held centrally. They are held only by the GP. What we need to access and what the GP is not available. Again, this is driven by trying to improve the experience of the service user community. If you take note of what the vice convener in this committee says, you will not go far wrong minister. With him at least. Anyway, it was a pleasure to have you and your team here today for the first time. I look forward to working with you constructively in the future. Thank you all very much for your evidence in your time this morning. Thank you very much. We are now suspending for a short period of time to be set up for our panel. Thank you all for that. We now move to agenda item number four and return to our early years inquiry, which is one of our pieces of work under the health inequalities theme. Today, we have a round table of health professionals and, as normal, what we will do in a round table to try and help to promote a bit of discussion and whatever, but we will begin with introducing ourselves and just lay out the roles of engagement here that we are interested in hearing for our panellists who have been invited along today. I will, from the chair, give person and all occasions to our panel before the politicians that they come in and just say that for some new members. Of course, you will get an opportunity as members to come in and keep the discussion going, but I will look to the panel or guess on all occasions. My name is Duncan McNeill. I am the member of the Scottish Parliament for Greenock and Inverclyde and convener of the Health and Sport Committee. I am Ann Mullen. I am a GP from Govan and Glasgow. I represent GPs at the Depend Organisation. Bob Doris, MSP for Glasgow and deputy convener of the Health Committee. My name is Jane Sellers. I am a nurse team leader in Glasgow, working with homeless families and newly arrived asylum seekers. My profession is health visitor. Good morning. My name is Dennis Robertson. I am the MSP for Aberdeenshire West. Good morning. I am Ron Gray. I am a public health doctor in Glasgow and an associate professor at Oxford University. Good morning. I am Charles Saunders. In real life, I am a consultant in public health medicine in Fife and I am also chairman of BMA Scotland's Public Health Committee. Good morning. My name is Colin Kear, MSP for Edinburgh Western. My name is Annette Milne, MSP for North East Scotland. I am Lucy Reynolds. I am also from Glasgow on paediatrician and I work in Postal Park in North Glasgow, but I also have quite a wide area, including East Dunbartons, so I am more affluent. I see kids with disability and developmental problems, and I also, for 10 years, worked as part of the maternal and child public health team in Greater Glasgow and Clyde, and I am representing the College of Pediatrics and Child Health. Mike Mackenzie, MSP. I represent the Highlands and Islands region. Rhoda Grant, MSP for the Highlands and Islands. Trisa Fife, director of the Royal College of Nursing. Richard Simpson, MSP Mid Scotland. Thank you all for that. I think that just to set us off, the Vice-community Bob Doris is going to pose a question and I will look for responses and see where that takes us. Thanks, Bob. Thanks, convener. I could not inform you about four minutes ago that I was asking the first question, but I am delighted to do that. I thought I might ask a general question, as the convener suggested. I listened with interest last week to the statement by the First Minister in relation to the new legislative programming policies, and one of the things that jumped out of me in relation to health inequalities was the fact that the Government seeks to appoint a new independent adviser on poverty and inequality, which was of great interest to me now. I am keen to know what progress has to be made in the Scottish Government promoting policies that tackle health inequalities. We have, of course, heard that a lot of the rooted aspects of health inequalities come from income inequality, so there are a variety of policies not direct at the co-face with healthcare, but other wider policies which impact on the health and wellbeing of the people that we all seek to represent. Some initial comments and maybe how you think that role could fit in with the public policy development that we are all involved in here, in whether or not you believe the poverty impact assessment, which I believe is going to be on-going with the Scottish Government, a new initiative should have a specific reference to health inequalities as well. Any responses? Theresa Fife, thank you for helping me out of the vice-community. I think that anything that sets the agenda around poverty and sets out health and equality is a good message. The work that people are trying to do is there, but so much of it can be invisible and not easily then documented and said, this is what happens, so impact is quite hard. Though I was, I must admit, very pleased to see the research that came from growing up in Scotland, which talks about a couple of things that actually, within our own campaign around nursing at the edge, talks about the most important thing is to actually get as close to the marginalised groups and also to be very aware of what impact you can have on individuals, because too often we look at services for a whole and one of the things that out of inequalities for groups is understanding how individuals actually react to services and how the focus can be on them. I also think that, you know, what's very important when tackling inequalities for children, which would be in there, is to remember that it's actually the parents and the family is a big part of that. So when you look at strategies for children, not to look at them, so for example work that's done around women who are offenders in prison, who have children, is a very important crucial part to looking at the child. So they're just some of the things I would put as an opening, but your, I think, impact of policy and looking at that will be hard to do then. So I'll be interested to see how they would set out what measures they would to be able to say that they've made that impact, because it isn't easy to do that. Newer else? Yes, Dr Sundar? Yeah, from the BMA's point of view, if nowhere else, we would say that the vast majority of inequalities in health, whether they be early years or later on, don't arise from health. Health picks up the consequences of those inequalities. The inequalities arise from the effects of Government policies, both here and in the south, and also from other Government actions and actions within society. The social determinants of health have far more effect on the health people have than the NHS ever will. We're just trying to pick up the consequences and minimise the adverse consequences on people's health that those inequalities cause. Yes, and I think that this committee, given the evidence that we've had, will accept generally that, although we wouldn't accept that there's significant mitigation that can be a positive impact. Bob, did you want to come back? I suppose that, to help you, I was deliberately general. It's not for me to predict what witnesses might say and reply to questions, but there's a cluster of various policies that I could ask in terms of early years. I could ask how Dr Mullen thinks the deep end project in the link worker system helps those living in poverty and deprived communities. We could be asking about the family nurse partnerships. We could be asking about proposals in childcare and the balance between childcare for children developing or as an economic necessity to allow mothers and fathers to get into employment. We could talk about living wage. There's a cluster of living wage policies of the Scottish Government, but I was trying to give a wrap-around test by which, when this committee is looking at how we tackle health inequalities where it sits, there's the opportunity, I suppose, for witnesses to go look, hear something that we think is working well and would like to be extended, hear something that would like to be changed, or hear that income maximisation policy that has to be pursued. We are trying to, as a committee, I think that, given that it's reasonable to say, we think that there's lots of good spends out there, but what we're trying to do is work out, are we getting the best value for money and tackling health inequalities for the spends that we're putting forward. If people want to come in on that, that would be great. What's from Dr Reynolds? When you're saying, I absolutely agree that most of what we're picking up is the consequences of inequalities that then impact on health rather than helping the cause of the inequalities, but, as health services, the last thing we want to do is to then exacerbate those inequalities by the way we structure our services. If there is this post that's an adviser on poverty and inequality, if they could really deeply look into resource allocation models for how you fund the services that are then picking up the difficulties, I don't know if working as a pediatrician, I'm well aware of the barriers that we put up that are often trying to be more efficient. For instance, if Anne were to refer a patient into a specialist service, with a lot of them, instead of just sending out an appointment, they will send a letter saying, please respond to this letter in order to make an appointment so that it's only the people who are really motivated and will turn up for the appointments, will make the appointments and we won't waste all these other appointments. Of course, it's the most vulnerable people who are under too much stress, whether it be financial or lack of sleep or mental health problems or whatever, to actually get round to phoning and making that appointment, whereas if you just sent out the appointment in the first place, it's that kind of, sorry that's going into a lot of detail for one example, but it's the kind of thing that you're meeting again and again, we're actually putting up barriers and it's because we're trying to be more efficient and I think the real truth of how much extra time and effort it takes to engage with the more vulnerable, whether it be socioeconomic inequalities or whether it be disability or ethnic group or whatever, I don't think that our current formulae for calculating resource allocation really hit the mark. I would agree with that in working at the deep end that we have to think about progressive universalism in services, but you can't really have that unless you've got realistic universalism, so if we are working in health and we're working in area of high deprivation and we're all aware of the social determination of determinants of ill health, we still need the resource that we have to do to address the inverse care law, which is very prominent in where we work and that we need the resource to match the needs. Part of that is through making the policies right and some of the policies are very good, but it does come down to a lot of resource. For instance, in our south CHP, we're having to lose 500,000 next financial year from our children and families budget. You cannot run realistic universalism with those scale of cuts and that is really one of the very real issues that we face. Anyone else to leave that faith? If I can come back to the point that I was making was exactly that about access, because in the work that we've done around nursing at the edge, my colleague in homelessness might want to comment, it's around that chaotic lives, that inability to actually say, fit him with what we put in place as a service and how people have access. One of the things that we're asking for is where there are services provided, but there's greater authority to reduce some of that bureaucratic paperwork means that in fact that may lose that person who's already made the effort to get there, made the contact and actually then needs access to services but have to go through quite a convoluted process and often don't return then. Those kind of one-stop places where they can get those services have worked very, very well for that reason. Access is a big word and that's what I meant by the marginalised groups, because it's actually knowing where they are and who they are and understanding how you can actually go towards them. If you take this, what I meant by the women's offenders work that's been done in Perth, which was really focusing on those women and their children in a way that made them feel that even though they weren't in the community, they were receiving services as part of the community and similar work up in Grampian within the prison work there as well. So it's looking for those, but the issue often is, and we're showing this at our reception tomorrow night, is those projects sometimes are funded short-term and they're very dependent upon funding coming from a number of pots and there's not a wish sometimes to say, let's fund that and make it last long enough to show the impact of what it's doing. So lots of people we meet talk about being waiting for a year to know are they going to be funded for the next year, how do they stay that and for health professionals to go into that role. It's a bit of a, it's very risky if you step out of what is considered to be a good job and a safe job into these worlds, but most men do it because they are really, really keen to make that difference, but they do it more often at the end of their career because they feel they can, they're more confident and more able to work within that. So for me, they're some of the things that could be measured. If we don't change how we deliver the service, people will always fall between the the footstools of what is there for those who know how to access it. I'm going to take Dr Gray first and then Dr Reynolds because Dr Gray hasn't been in. Dr Gray. I just wanted to come back to your original question about what do you ask that adviser to do and I would say that that's a really, I mean it's a great question because I've sort of seen in my career, you know, advisers, zars and all the rest of it come and go and I'm never really sure to what effect, particularly if you operate at a national level because in my view, if you really want to make change, you have to do things at a local level. So I think if I were going to employ some of that, I would be looking at the evidence around what makes for an effective leader in those circumstances and perhaps look at people like, I think, Alleynsley Green is a good example of someone who did achieve something in the past and maybe look at some of the things that he did to do that. I mean, I don't know the answers to what makes a good sort of commissioner advisers are but I'm sure there must be an evidence base out there and I think, you know, you need to think the kind of person you want, what they might do, what they would require from you because, you know, unless you kind of listen to them and act on what they do, then, you know, they're going to be ineffective and, you know, you could set somebody up to, you know, they could be there in an office effectively achieving nothing. So I think, you know, I would, before employing somebody, I would think very carefully about what I wanted them to do and how to make the most effective. Dr Reynolds. It's kind of going back. I'm sure it's something that's said probably again and again but the importance of investing in generics at, you know, like universal services that, yes, there are fabulous things to be learned from projects but I again and again see good people from, you know, local health visiting services going off and being succonded into projects and you just don't have the most vulnerable families really, really benefit from continuity of care. So having the same GP for years, the same health visitor for years, et cetera, and if they're all being broken up into projects, you just don't get that continuity. Dr Maughan. I mean, I think that the joint working school and the children's schools get great potential for this work to be developed and I think they depend, we think, that the integration agenda is very important for this area of working because health and social care really need to work together much more closely and understand each other's language and how we work together and that relationship's been very fragmented for a number of years. So we have developed a project that we hope will get funded because we feel that it addresses a lot of the issues that we feel as practitioners are barriers to making access to families better, the shared understanding, sharing of information, addressing the issues, addressing the inequalities and that project is really quite unique because it's being built up from the ground upwards, it's not coming from a top-down approach. It does need support, it needs research support and we don't have that in general practice. We don't really have a lot of research that's well supported through the chief scientist's office or core funding that we can keep rolling on. You're talking about short-term funding for projects and that is a real anxiety about all these kind of pilots, et cetera, you know, where do you get the good evidence, the good evaluation that has international connotations as well as local ones and national ones so I think that's something that we would advocate for in the deep end as well. Yes, Dr Gray. Can I just come back on this? It's slightly changing the subject but I want to pick up on that last point. I've just come back to Glasgow after 12 years away and there's been sort of massive changes in policy and things are an awful lot better and I think in general across Scotland than they were say 12 years ago but I think what's still lacking is this culture of evaluation and I think you know there's so many different pilots on child obesity, on parenting and so on and I think sometimes these things get started and people sometimes say well you know which of these are effective and how effective are they and frankly we don't know because there's not enough resource put into evaluation at the same time as these things are commissioned so I think they need to be longer term in scale but I think they need to have evaluation built into that and I think that needs to be part of the setup moving into integration. There's lots of stuff that health and social services could do together for example on looked after children who are a really marginalised group who form a lot of the prison population and so on. Will they do that? Well I think it depends if they're prepared to share information so that we can actually look to see what outcomes there are across the the piece and again with education as well if that's possible but unless we can bring all that together then we can set up all these projects and we'll never really have any idea if we're making any difference or not. Can I test some of that then? You know I mean we are here under the general banner of looking at child poverty and we see it every day of the week that it almost becomes meaningless to people. Professor Marmot made the point that being in poverty is defined as having an income of less than 60 per cent of medium income and it's unlikely that a country would have a distribution of zero no child poverty that country with the lowest levels are Norway where there's 10 per cent child poverty because we use that measurement and we have heard the evidence in the past that because you're dealing with that situation and almost hiding these very vulnerable by ethnic background or children coming out of care you know so you're almost blurring the edges and losing the focus because you're dealing with that generality and governments do it as well. We're all very hot at this point so the one question is how we measure it should we have a greater focus on what we're tackling and therefore a greater chance of dealing with those very vulnerable groups. The other one is about what government do. We're all very hot that the living wage is going to solve poverty at the moment I say. The whole lot of us are all rushing to the living wage. It doesn't measure at all household income. It can actually in some cases not reduce poverty but increase the gap between the less well off and the better off. The lack of clear objectives of government policies whether that well understood inverse care law can be applied to education, the economy and everything else you know so I don't know whether there was a there is a question in there do we need to do we need to understand as politicians what we're actually talking about do we need to evaluate it do we need to do better in ensuring that the measures that we take as politicians actually do the job that they say they're going to do because currently I don't think that they're achieving those ends when when the gap between rich and poor has been growing despite all of the well-intentioned policies from all shades of government right across the board anyway I throw that in there and see if we can warm this up anyway any takers dr mullin and then dr gray sorry Dr Atkinson who's a children's commission in England last year wrote a very interesting report and you can all read it's online about the effect of welfare reform on children and wrote it from a children's rights perspective which is a very interesting way to look at the welfare cuts and how it affects families and poor child outcomes etc so anything that you do is undermining your rights of the child and the legislation you've signed up to you're opening yourself up she put that as a very interesting question the government is in danger of breaching its own children rights policies and that it has signed up to which is an international agreement because of the the retrogression and the nature of the policies that are discriminatory they really affect the poorest children so that's the sort of thing as government I think you have to try and how are you going to address that then because we are creating inequalities through a number of policies that are making the gap wider and it's poor children that are being disproportionately affected rather than other children Dr Gray well I think that's right about poverty but I think you've also got to think about the other side of the equation as well and that's wealth I mean what's really perpetuating these inequalities is not just people staying in poverty it's people getting tremendously wealthy and you know there's been a lot of literature on this I'm sure you've seen as politicians Thomas Pinkett he's written a book on this and various other people talking about this huge increase in wealth in a certain group in society which is fueling the inequalities as much as you know problems at the other end and I mean it seems that one of the ways that the problems are mediated is through lack of opportunities for education right and really although we're talking about health inequalities I mean education is one of the single most important things and we know from figures from Glasgow and elsewhere that you know poor children are beginning to fall behind you know by two or three years old in terms of you know early literacy vocabulary and so on and the fact is that even with the best well-intentioned early childhood programmes you know and they are effective and they are cost effective they still do not completely make up for poverty I mean you know I was looking at something recently suggested that the effect of two years in preschool might reduce the effects of poverty by about a quarter on various outcomes but that's all so really to some extent you do need to tackle poverty at root but you also need to tackle increasing wealth Dr Reynolds yeah I'd like to pick up on that because the you know after the UNICEF report in 2007 on the wellbeing of children in 21 OECD countries where the UK came bottom and then UNICEF UK followed that up with research looking in more detail comparing well travel being in the UK with Spain and with Sweden and particularly looking at the impact of inequality and of materialism so picking up on what Ron's saying about there's a problem with you know it's the inequality the fact that there is so much perceived wealth as well that I mean that that report one of the recommendations of that report was to ban advertising to directed at children so this is not just you know unhealthy foods or and it's just all advertising directed at children when I if I come down to a single kind of thing that I'd like to change in order to be able to improve health and wellbeing of children it's reducing stresses on parents that's yes the stresses of poverty the stresses of poor housing the stresses of trying to maintain their their their their job problems with childcare whatever but advertising materialism puts additional stresses on on parents and and what they found in you know in the UK was that the the more affluent parents who were rather time poor they were working really hard and then because they felt guilty that they weren't spending enough time with their kids they were then buying them expensive things whereas the poorer families were feeling a real stress that if their child didn't have Nike trainers they'd be bullied and you know I've had had patients who have failed to turn up for an appointment you know the mum hasn't brought brought the child I've phoned the mum on the mobile and she's Christmas shopping because she thinks it's more important that the child gets some flashy piece of plastic instead of instead of seeing the pediatrician that you know we've got a culture where people queue up overnight to get the latest electronic gadget and that is a factor of this inequality the fact that there is the perceived wealth and then the people who don't have the wealth are trying desperately or feeling stressed that they're not getting those things and that they're therefore maybe not spending their money on I don't know that sounds terribly patronising but on things that would be more appropriate you can't I mean I don't know that you can actually ban advertising to children because our borders are so porous that you know even if we did it in Scotland they'd be accessing other ways but it would be a good message that we're a child-centred nation that we care about our children if we did something like that but I think more importantly it's building resilience so that people don't feel so impacted on by that the inequality and the materialism and the night there was some of that touched on I think and we looked to my committee members that you know from Harry Burns about the difference between you know between you know the Glasgow situation and maybe down south and he highlighted the lack of compassion in our society now people in Glasgow are less likely to trust their neighbour less likely to be you know having these discuss you know so so we've we've got that how do we how do we go back to my original fingers if we're just generalising the problem how do how do how do we measure and how we communicate this problem to some effect as you know to me of some importance at least in health now I'm not saying that that's the right measurements but at least in health the only portfolio we measure inequality in terms of smoking early birth weight mortality whatever whatever there is no other measure in any other portfolio now suppose the question is is that the right way to measure this inequality in health stats or is there other measurements that could be applied to other portfolios that would actually you know you know communicate this problem more effectively well almost you know yes and then there is for me it's much easier for me to pull data to illustrate inequalities in whether it's what we deliver or what or outcomes for children according to their the Scottish injection multiple deprivation so you know the deprivation of their of a postcode sector where they live than to demonstrate it by anything else so in a way I'm kind of yeah there could be better um uh there could be other ways of measuring it but at least we have a measure and we can report whereas there's so many families there's clustering of risk there's um there may be disability you know the childhood disability is more common the more deprived a population uh if they've got childhood disability it's more likely to be adult disability in the family um the ethnic minorities asylum seekers more likely to be poor et cetera but we and we've touched on looked up and accommodated children as well but you can't pull any data on our routine delivery of services according to a child's disability status we don't even know how to record a child's disability status we haven't even decided what a definition of disability is we're not recording ethnicity well um yeah I could do it by by gender I can do it by age and I can do it by Scottish index of multiple deprivation so at least we've something for poverty whereas the other risks that are clustering in these families we're not measuring there's a number of generalizable things that need to be done that we've known for decades need to be done and haven't addressed there's as we've said earlier you know parental employment parental income there's nutrition from the woman before she becomes pregnant through pregnancy after pregnancy of the family where we still we know exactly what food we would like people to be eating but by and large a lot of the people who are most deprived don't get to eat that either because it's too expensive or because it's not available or because they know if they buy it and they feed it to their family and their family won't eat it they haven't got the money to replace it there's the socialisation of children that we significantly fail to achieve particularly in terms in very deprived areas in terms of being able to even just play outside in a safe way it's not feasible large parts of scotland are very rural and the deprivation data doesn't actually show rural deprivation terribly well and it's quite easy for pockets of rural deprivation to be hidden amongst relatively less deprived areas and just not appear in the statistics one of my colleagues at work has a particular interest in that they spent a large amount of time showing to his owner and other people satisfaction that the data we currently collect misses a lot of people who are deprived in rural areas and there is no simple way around that to dig this data out but I would go back to we actually need a cross-government to try and bring everybody up while also trying to focus on those who are the most deprived I mean some of the initiatives that have been set up are working very well this child smile that I'm sure you're aware of with dental health where the decayed missing and filled numbers in children of all categories but particularly the most deprived are being addressed and dealt with and their dental health has improved immeasurably there are other programmes that are working particularly well family nurse partnership for example but that's restricted to women under 20 you know the people over 20 who need that service don't get it that there are other programmes in place which again have time limited funding and some of them finish next year and we have no idea yet whether that funding will be continued but there's a lot of joined up thinking needed from the as I said the more generalizable things that will help all children whether you whatever the degree of relative deprivation and the specific issues for the most deprived that do need long-term funding in order to actually work well I mean to go back to child smile that does have long-term funding and I'd say its future is pretty well established but there are a lot of other programmes that need that sort of certainty in order to be able to achieve the same things to ease of faith there's a common theme coming through which has been said by a number of people is that we we're not we're not very good at knowing what data we have and how we use it we don't we also have a gap in the research evidence that's why I mentioned the growing up in Scotland research was good to see but there isn't actually a body of research that would enable people to know what's the best impact which is why I made the point earlier how you measure impact you need to have an evidence base that helps you understand what the efficacy is and what you can do and I would support child around the child smile programme because that's one of the ones that really has demonstrated a significant drop so what's gone right in that and why did it get actually long-term funding what did it do to succeed with that when other projects get short-term funding and are not sure and I don't believe at the very beginning they do enough about the evaluation and with family nest partnership it's it's been shown as an evidence base to say it works but right now my position would be as a law college of nursing I'd right want to see the impact of that very focused expense research on a targeted group which leaves others out does it really achieve that will it make that difference to support that because one of the areas that we've been looking at is where for example with health visitors where they would wish to maybe provide more specialized services on top of what they do with their ordinary day is quite hard to do it's a very hard case to make so the work they did in Grampian around the prisons came from a wish by the teams up there to do something different it wasn't coming from this is the goal that we need to do so I think if I go back to your point about what the advisor needs to do is actually have some clear goals that cross all government and hold people to account now when the children's young people bill was was was under consultation we were one the groups that felt there should have been more about actually the right spaced approach to children and it has got a duty on ministers to demonstrate how they're going to do that and I that's where I think and mullins points being around where they will be challenged how are they going to do that what activity are they doing to demonstrate that they have taken a more right space we as an organization believed that should have been more embedded in that in that legislation and thereby would require those activities to be more across government and in order to get a more as I say it's a constant approach where we've said that already continuity with who's providing the care but a constant approach to those services that will take years to make the difference we know that we know it's not going to buy a couple of years we know it's going to take a long time if you want an intergenerational shift you're going to have to work at it for quite some time but at the end know what difference that's made and what difference it hasn't made and what more can you do anyone else committee member Dennis Robertson how are I think maybe just picking on that point I'm just wondering and it's a point that I think that the sun doesn't be made as well some of the foundations I think have been laid if we look at getting it right for every child and we look at curriculum for excellence mentioning education don't agree some of these initiatives that are there do you think that these are the foundations for starting to move in the right direction but what we're requiring at this point you were just making it's a behavioural and cultural change which will take quite a number of years and I'm just wondering if the role in schools we've seen a tremendous change in the role of school nurses for instance but I'm wondering you know is it school nurses we need or is it maybe health visitors within schools initiatives like that so I'm just wondering if we're getting the foundations right and we're just taking a while to start building on it any takers dr Gray well I think we know quite a lot of the things that we should do and Michael Marmot's kind of listed out a number of the interventions and I think you know they start off in the anti natal period you know thinking around alcohol drugs smoking during pregnancy stress and so on and then going on to breastfeeding and weaning and so on and then on to parenting early education and so on I think we know all these things the issue for me is that it's really kind of joined up and it's very rarely that we see although we have evidence for a number of these things what you often don't see is local evidence of effectiveness because I mean we need to know a number of things we need to know not just if they work but how well they work and what kind of size of effect we get from we need to know if the people who need them are really getting them you know the reach of the intervention if you like to get into the right people and then are these things actually being implemented properly on the ground because sometimes they're not sometimes we're the best one in the world people don't implement things properly and you know they therefore have no effect and I think for a lot of things we just don't know that kind of detail and the only way we can ever get that is by getting you know our data systems such that we can look at that and we can look at a broad series of outcomes across health education and social care and I think you know something you alluded to earlier looking at maybe positive outcomes as well as negative ones like you might want to look at things like happiness, aspiration, quality of life for children you know if we look you know how does aspiration look in the lowest quintile of deprivation as opposed to the highest one and you know that would give us information I think we could we could start to to act on and we could start to see whether we're being effective or not. Anyone else? I was too polite and mudged me in there and I'm always looking out this way. Dr Mullan and then Dr Reynolds. I think that's right, we need to know what we're measuring and how we're going to measure and what evidence and we do lack a research base particularly in primary care that can cuts across all the disciplines and see what we're actually doing because despite the strategies and everything the work goes on at the front line and we deal with the consequences and the pressures on budgets and the lack of resource and we have to somehow try and muddle our way through all of that and you know primary care general practitioners particularly are a universally accessible unconditionally accessible service so we are a useful contributor to this debate and yet it's only three percent of our contract usually to do with child health really in some respects it's given very little attention and yet we do a lot of pediatrics and general pediatrics and general practice and our relationship with health visiting is extremely important in the early years as well and there's also very good things in education and nurturing corners and nurseries are very good and the two programmes that do have evidence base are unassailable it is the family nurse partnership in incredible years the rest of them have some promise triple p's been slightly controversial so um we don't have much to go on and and actually what we're asking from the front line is is you know realist at universalism so we can have progressive universalism there's no point having specialist services for for children and families who are vulnerable if you can't actually get the rest of it right and this is the problem i think that you know that we have at the moment what's your definition i mean we've heard this before universalism plus realistic universalism what is your what is your definition of realistic universalism i mean i think that we you know from the gps point of view working in the deep end we understand we need more time to to provide the service that we need and there's been Stuart Mercer's work in the care plus study sort of estimating how much more time gps needs and i'm not here to just talk about general practice obviously but because other services under the same sort of pressures but unless we have realistic times to see people deal with the problems and actually what the government project is trying to do is address that um the links does another aspect of that work which is very good and is going to be properly evaluated unless we have that time though and it can be flexible and there's a flexibility there as well then we aren't going to do the work that is needed it's a unmet need all the time is it a challenge to you know i'm not a challenge but you know a debating point with Dr Sander who says everybody needs to move up because you know i think one of the problems in my own humble opinion that we of course is that as everybody moves up we don't address the gap the gaps frozen in time everything we add on none of it reduces the gap well i mean there's Danny Dorrling who talks about the one percent isn't there sorry that top one percent that inequalities gap needing a gap in there is massive and unless that's sorted but that's an international agenda again you have to do something with capitalism i think but meanwhile we can still work with the inequalities that we have and do positive things about it Jane Sellers and i'm going to give Dr Sander an opportunity to come back but Jane hasn't been in so i think just just from a practical point of view thinking about what universalism means to me as a practitioner on the ground being a health visitor it means that every single child has a health visitor who is accessible to them and is able to that health visitor is able to use their sort of professional judgment about how much time a family needs some will need less at differing times and some will need considerably more and access and ability to have that health visitor facilitate access to to specialist services that might be necessary and i think that acceptability of everybody in an area every child has a health visitor no matter who they are and no matter where they sit on there on the socioeconomic spectrum is is what i think i mean by universalism and allowing the health visitors to make that professional judgment about about who they see and how they do that and just your point Mr Robertson about school nursing i think school nursing we have very few school nurses particularly in Glasgow and from my point of view in terms of being able to look at the the broader aspects of of health and wellbeing for school aged children aside from their education the pastoral care that they get within school the the capacity for school nurses to do any of that work i think is is absolutely minimal once they've delivered the immunisation programmes and those things they have absolutely no capacity to do any of the other work and i think we need helpers just to specialise in the in the preschool years in in that aspect of health and development and we need school nurses to be able to do not only the immunisation but to do that wider support work for families in the in the in the school age years do you see a role for the health visitor within the school as well as out in the community though not necessarily because i think school nurses is a professional well able to deliver what health visitors deliver in the in the pre in the preschool years but you know that aspiration avoises dealing with the issue about transferring resources isn't it the better off the better educated the more articulate get a disproportionate amount of or maybe a fair amount in comparison to poorer people they get a bigger share of the health budget they get a bigger share of the education budget they get a better share of the jobs they get better pensions they get you know is it time to be tackling something Dr Son, you were everybody moving up and the the challenges that the gap doesn't get any in arawa well i think everybody does need to move up it's just somebody to move up slightly more than others you know the the whole of of society and children in scotland do need to improve their health some of them have a desperate need to improve it more than others but everybody needs to be moved up like certainly take very much on board my colleague said about school nursing the school nursing service has been very largely subsumed into into delivering immunisation in schools in recent years and there's very little time left over for anything else if i could just make one other very brief point currently from sort of population perspective the directors of public health at health board level have that responsibility and the very large part of their job is to bring up the population health aspect and inequalities and health and deprivation to health boards in future new appointments as directors of public health won't be executive directors of NHS boards and will lose a great deal of authority within the NHS board on that and in relation to the health and social care partnerships again the directors of public health will have no formal role there and while putting together health and social care would seem to be intuitively a good idea taking out the person who has had historic responsibility for the population health that's the director of public health which i'm not one but but taking them out doesn't seem to be a sensible step when as we're all aware the inequalities and health and particularly in the early years in Scotland are increasing. Teresa Fife and then I've got Dr Reynolds and I see a bit from the net Malone. Thank you. Going back to a point made about actually how you have your universal service and how you understand how you respond to deprivation so for example for health visitors they're trying a new tool at the moment that at least might assess the workload and take into account social deprivation because before this tool came along there was no means of doing that so your case load could be very high but could be extremely demanding because of actually increased deprivation in some parts so we had health visitors who had a different case load within some parts of Scotland to others just down the road from them because of deprivation so we're trying to find a measure that at least says this is what you need in response to that or otherwise you don't there's no doubt about it that no matter what an individual practitioner will do the demand comes from those often who make the most to you and who require more which is your more articulate and often then miss the very people that you're trying to get near. School nursing is unfortunate because it has been hijacked by a need and they'll get me wrong there was a need for immunisation so when that came along everyone said well that's actually what school nurses can do for forgot that they were meant to have other functions within that and they have been totally consumed and unfortunately in some areas they have been reduced so even though there's been an emphasis on that within schools school nurses have actually not increased in number in fact in some areas in Scotland have decreased in number so that's you know again a measure but I come back to the point though about I think what they were saying earlier and others have said it is that if we don't find a way of joining up all these policies and being clear because one of the risks we've got is lots of policies again I keep coming back to impact and not knowing what impact they're meant to have for children and really and truly understanding whether those policies connect and my final point is around integration of health and social care it's as you know we've been here in front of you with the evidence we gave around the move to that very supportive of a move to integration of health and social care but we are going to have to keep a very very close sign as partnerships work and as they look at what they believe the services are to be how they will ensure that continuity because you've got areas where you will have several partnerships and you know how you get for Glasgow for example is going to have a number of partnerships how you're going to actually ensure that you have a cross Glasgow approach to some of these very issues it's not impossible to do but it will be challenging and I think that that's at a time in the next couple of years you need to keep an eye that the very things that we're talking about because they are the more expensive and they demand a very different type of resource actually get shortchanged during that period and that would be a concern. Dr Reynolds. The universalism I would agree absolutely how crucial health visitors are in being universal and proactively going out to seek patients whereas I mean GPs are also highly important but they're not going out into the home to find to find families and so in identifying the increased level of need health visitors absolutely crucial for the people who aren't going to necessarily present themselves and so of course really welcome increased investment in in health visiting and health visiting that health is being the named person of course I work a lot with school nurses I wish there were more but at the same time we've got to remember that under GERFEC once the child in school education provide the named person role so we've got to be thinking about how we're supporting them and not thinking oh you know well we've just got to recreate health visitors for school because because that's you know children once they're in school every day the people who are providing their education will have a much better idea of the child and hopefully form relationships with the family as well um but also that the those it's important and the the Shinari you know the safe healthy active respected responsible that those indicators um they're just pretty much from the UN convention the rights of the child you know wherever you work whether whether in other parts of the UK whatever they'll have similar kind of well-being uh outcomes that they're aiming toward we should be thinking of those not just on an individual basis we should be thinking of those at population level what are we doing to make our children safe healthy achieving the active etc um and those health visitors or or professionals in a local area should be able to be building up like what Anne's saying about bottom-up initiative in in in govern um there's also initiatives um there's the richer project in Vancouver where they uh put additional resource in having um identified which areas are to population scale were more needy given the um the early development index that EDI scores for their their population and made services more accessible because going back to what I was saying at the very beginning to do those assessments um of of need to put to um to support families um the more complex uh the um the circumstances the more time uh the professionals are going to need and then overall in building up that population view it's it's all about raising the status of uh of of children and supporting the gps and the health visitors on the front line by having easily accessible services the more you know when there are like pediatricians more specialist services that were accessible for the consultation and advocation advocacy at the population level as well as for um managing individual children so I feel I get quite I've got so many things to say I get them all rather jumbled up together I'm better on paper that's okay your passion came through um as no other panel members I'm just going to move to Nanette for another question Nanette. I'm just going to follow up with the Jane Sennillers I think you mentioned about perhaps health visitors specialising I mean I have experienced in my husband's former practice which was a mixed practice it wasn't you know some deprivation but not obviously not entirely and I remember years back the real efficacy of practice based health visitors and I think when when that then went into more community role I didn't think it was so effective I just wondered what your comments are on that and you think that health visitors are better based within practices or within groups of practices or how do you see the best way forward? Yeah I mean I think that's I mean I've always worked as prior to this role in homelessness as an attached health visitor to a practice and I think it's a very reasonable way to for health visitors to work and it promotes a really good relationship with the GPs and is a good identifier of of the people within that within that local area. I think when there was an attempt to sort of you know that more sort of public health agenda around health visiting a number of years ago and I think what we lost there was that some of that ability to direct contact with families and I don't think there is anything that can anything that can come close to those home visits that you do with families on a regular basis I think developing a relationship with the family and seeing you know how they live their lives and trying to support the best way that they can they can live the lives that they want to to live particularly for their children and for us to be able to facilitate with the GP and the other services that locate around that hub of a GP practice I think are probably an ideal way for health visitors to work. To carry that out would it require a lot more health visitors or not? I'm not sure whether it would require a lot I mean maybe it would because I think to be able to do that you need lower case loads particularly in city areas in areas of high deprivation. I mean I've never worked in a rural area but presumably in terms of rural areas it's it's less about numbers and it's more about spread and time and travel time and things like that but it's that's not an experience I've ever had I worked in Liverpool as you might have been able to tell and I've worked in Glasgow so yeah I think and for health visitors to be able to work their case load and really offer those home visits not only to those people who can demand it because of their you know their ability to demand services you know because of their articulate and and everything else but also to be able to give because they they have needs as well as as those more vulnerable people I think to be able to do that and to address some of the community work some of the this sort of very localised groups that we can that we can offer to people on the ground you do need you need smaller case loads. I do understand the looking back at the attached model to say that might work but our world has changed and the way services are provided we would say that we're aligned you have to have the team model working but I don't I've never agreed that everyone has to be within the same place with the same filing cabinets and the same processes because the way services are now going to be you could never fit it always within wherever GP practice is but absolutely aligned absolutely working together and sharing and that's where e-health improved technology can enable people to do that some places have done something very different within their community because they've used a building they've had a hospital they've turned into something bigger and they've been able to actually have everybody together because they've had the premises to do that but I in my own local area when I talked to them they couldn't fit anybody more in there in order to do that so I think we need to be careful to think that worked but what we need to do is be absolutely clear where those teams work together and that's not just obviously health justice and actually share that working and that intelligence and doing that that can still be achieved without everybody actually believing they have to be in the same place I've used to think that model but I must admit I've seen lots of places now and not just health justice where people are better working at team working rather than saying they have to be within that and that's what we should be promoting. Yes, just to agree with Theresa there I think I think that you know my experience has been in years gone by where we had health justice working in cupboards and things in GP surgeries I do think we have we've moved on considerably from that and I suppose what I was meaning really was what Theresa alluded to and it's about relationships and sort of hubs and wherever that hub is is where I think the health justice should be. I do agree with you about the teamwork and also health justice is our forming relationship with a lot of other people not just GPs so that the importance I mean Jane or one of her team might phone me you know about a child with who's from one of the homeless families and who has developmental or problems or disability the same you know I'm based in Possible Partners a load of GPs based in Possible Partners for various health visitors there but they'll health justice will email me about cases that we we share I was at case child protection case discussion just Friday with a health visitor who's not in the same building as me but she'd been emailing me in preparation for that and for me seeing the child and just thank goodness for that health visitor who has stuck at her job for years because that family had had about five different social workers attached to them in a period of two or three years and the health visitor was the person who really held that discussion together because she's the one person who's who's seen them through a whole variety of different changes that's on a 35 page chronology that nobody you know was able to read through in five minutes but the health visitor had it all in ahead. I would just agree with that and I think Lymon isn't a toxic word and we do work as teams but we still have that relationship where our practice has our health visitor who is our health visitor although she works in the team within the health centre and that's working absolutely fine. We just need more over I think. The question was asked would you need more and that's the issue isn't it? We're thrilled with the investment in health visiting and we've got to train them now though because it took a long time to get around to it so they won't appear on the stocks and we have to get the caseloads right but actually we have to it comes back to a point to me about refraining people. I think that we've got too many bureaucratic processes sometimes people can see they could do something for vulnerable families but they've got to go back through the routes which in fact as I say loses that moment of when they might have worked with a family and said they're nearly at the point to get them to agree that this would be a good step to do and by the time they go back through knowing whether they can access that they may have lost that moment and these people who are working within that kind of world know that and I think anything we can do to reduce bureaucracy on any measures that would actually be more accessible to them at the time would be a good thing and there'll be good practice and there'll be indeed you know in every you know we hear about all the best practice when we're sitting here as a committee and we recently visited a project in Edinburgh I can't remember what was in name of it and we were asking about family and partnership and they were dealing with older slightly older younger women and children and there wasn't on it's kind of evidence there wasn't that integration so there are projects there's family and there's partnerships there's specific project you know there's a lot of resource there it's maybe not necessarily working to the best of effect sometimes but that was a point that was made by my colleague everyone that we end up with too many projects and people then so the next thing that we pilot I have to say and I've been part of pilots for years and think that it value they're very important but when we get too many pilots and not enough clarity about that's working that's going to and give it time to work give it the time to produce the efficacy do we know then we could we could make a difference but we do tend to kind of get the next thing that people think is is important to do and I I would agree with you I've gone out recently to visit a team where they were not connecting across the area with each other it was almost like their pilot was the one that was more important and that's because it was short term funding and they thought if we focus on that we might get the funding rather than that looking at the whole service in a very different way so I would wish that we could get a better way of setting up these projects and get them into more sustainable funding for those services but it's sometimes a problem we've heard in the committee it's about not the new projects are the problem it's about letting go of the old of the old so we want the old that are not it's not as effective and we know the the new project is effective and you know it's an ability to to discuss and and agree best use of funding and the priorities and what works that doctor the two things that have happened in the last five or six years that have most helped me to coordinate the care of vulnerable children and families were not things that were introduced for that purpose it's been secure email that I can email colleagues I can email health visitors gps consultants in the hospital now it's even secure between us and the council so I can be emailing social workers and teachers etc and also clinical portal that I can so IT system whereby I can be rather than having to write to people at York Hill to find out what they're doing their their letters are up on a night so those you know if we're always thinking of a project that's going to do this or a project that's going to do that I'm not saying don't do them absolutely great evaluate and then we bring in the the try and mainstream the stuff that works well but sometimes there are things that going on just generically that we've never we've never thought to kind of evaluate evaluate and yet they're the most valuable things that we're doing and if we had better if we were better at looking at our routine data perhaps we'd be able to build up more of an evidence base to some of the things that we've been doing for ages or that we've started doing for another reason not because they've been mandated through some project that's been done so it's an important point Jane I would just agree with Dr Reynolds that from our point of view when we're a centralized city-wide service so those constant phone calls to everybody else and I think email secure email has made things considerably easier for us the week yeah absolutely you keep missing people and is that available or necessary even for the for the dupies practice to get that type of information the portal in yeah it does it doesn't help with everything and I think the govern project what the govern project is trying to do is recreate a relationship that existed when I first started general practice and that was the attached social worker in the health centre and they made a massive difference to how we worked and a part of that is about professional relationships and building up that professional relationships but also the availability of be able to discuss cases and the government project has recreated that again because we have no evidence to see that works but all the gps who remember working at that thought it was a much better way of working it was much better and it was easier to sort patients issues out etc if you had attachments like that Dr Reynolds I'm looking at members the panellists are what he's speaking to you you need to sit and be patient and Richard Simpson's first Dennis the thing about social because we used to have a social work resource worker in our child development centre we did in each of the ones in Glasgow and they were never kind of evaluated any kind of way and eventually come 2008 and the money went from social you know social work thresholds have just gone up and up and they pulled that service and then the healthy wealthier children project came up and came into Glasgow now it is fantastic you know I I now refer to income maximizers all the time but part of me was sitting listening to their presentations when they're saying oh look you know we've increased the income of these families and and particularly the ones with disability and the disability living allowance and we've brought in all this that's what the resource worker used to do you know like so we just we lost our resource worker who used to do that and a lot more and then but but because healthy wealthier children was a project that was evaluated and whatever you know I'm going and listening to oh isn't it fantastic and it is you know I don't want to say anything away from healthy wealthier children but the resource workers were fantastic and they used to do all that you know but nobody ever noticed any other responses from panels in there but nope Richard Simpson was not in the last 15 minutes so we'll get some questions sitting here feeling it's groundhog day you know the 1975 Sir John Brotherson did his report on widening health inequalities, 1980 black report, 1998 aged in report you know we've been through this so often and I think the point that you were making just now about recreation of things is important is is is you know this this really keeps happening. I mean what I find astonishing is the fact that when you had a situation in which you had health service health visitors attached and social workers attached that the health visitor and the social worker actually were the key people managing the children as a GP the input was all about the background to the family often the history you know the historical situation because you had experience within the practice within the partnership about that it seems to me that whatever system we have and to raise us sort of mentioned it okay we've gone it moved to a geographical basis when social work moved to a geographical basis the relationship collapsed because we didn't have a named person so whatever system we have surely well I don't know if the panelists would agree with us we need two things one is we need continuity so that we don't have a different person dealing with this family and cases being opened and closed which you never do in general practice they're registered with you often for life actually generations in the one practice whereas social workers open and close cases and if health visitors open and close cases then you know it's really problematic so how do you get that continuity and the second thing is everybody here today in this panel is medical or medical related but actually the fundamental and what we're talking about in terms of health and social care integration is going beyond the issue of just the family and the families downstream problems it's actually the upstream problems what do we do about traffic calming measures separation of pedestrians and vehicles child resistant containers installation of smoke alarms affordable heat and damp houses and i'm just quoting one section of the McIntyre report of 2007 you know what input do you all as as medically oriented medically trained individuals have to the upstream aspect of health inequalities and if you don't have it what are the barriers do you want it and what are the barriers to it do we need it are we going to solve these problems without public health being actually based in local authorities as there used to be where they can influence all these things or are we should we you know are we really aligning health visitors and social workers adequately within these new geographic teams sorry i've just been around it so often in 35 40 years jane er just to make the point i don't think health visitors ever close cases in the same way as social workers do and i think it's appropriate as a different it's a different kind of work we do so just just that point once a health visitor is allocated i mean and as lucy said that the you know the ideal situation would be for a family to have the same health visitor from you know from when the baby's born or before in an ideal world thinking about how the family nurse partnership works and how when i started health visiting how we worked the gp would give us a list of the women who were pregnant and we'd make sure we went out and and touched base with them and is that still happening it's not not routine and that's we've lost that so we have to create the family nurse partnership because we've lost that sorry i do feel a little bit i mean i know that the family nurse partnership has got 30 years of evaluation and things in the states and is apparently very you know very successful but there's a little bit of me that thinks when i've read quite a lot because i did apply for one of the posts in the family nurse partnership because i was really interested in it because to my mind it does mimic what health visiting should be and what to some extent what we used to do and probably not yeah i would very much agree with richard it's like this had by brief but many many decades ago i2 was a gp in a deprived rural area and we had attached health visitors and attached social workers and they were invaluable in helping us to help the most deprived members of our practice population that they were very good the only thing i would add is that putting public health into local authorities has been done in england and it's been an abject failure with local authorities are trousering the budget and sorry to use a different term local authorities using the budget for different things and the public health workforce disappearing at a rate of knots it's not worked well talk to reynaw um i was working in in as part of the public health team at the time when we had chcp's in in in Glasgow city and that was the time when there was the health visiting review and so our health visitors were being managed by social work managers um and whilst i you know absolutely okay i do occasionally prescribe the odd melatonin or laxative or something i'm mostly a very social pediatrician not just that i'm sociable i you know i'm uh i'm forever writing letters in support of rehousing uh and support of asylum claims or um uh i don't know and and wanting a support from you know more kind of social type social work type support but it isn't really there but um but my observations um when there was social work managers managing health visitors was that it was not successful because they do not come from a background of universalism um and so because they've they've got this concept of isolated episodes um that you know i think that's partly why our health visiting review was i think it's been concluding that was pretty unsuccessful and it went the wrong way and you know it's it's now been reversed and i also reflect with the sure start um children's centres uh what was it sure some of the sure start evaluation down south um some of the most successful projects were led by health i mean i know i'm from you know it's you know i i love social workers and i love working with them and everything but but but and also you mentioned you about alain'sley green as a leader um is a pediatrician um that i think when it comes to the universalism side of things people in people from whether it's general practice health visiting whatever get it and that whilst there are aspects of integration which i would welcome having non health people try to manage universal stuff when they don't have any experience of that i i think has been unsuccessful in the past to these are faith and i'm going to come back to my point about the difference between attachment and alignment when ronick happened it did break up in an ordinary amount of the way healthless does had worked in some areas because some areas proceeded with ronick faster than others so it led to a breakup without questions since the review that's been done and it's been stopped it's been brought back to the idea that healthless does work as a team working aligned with the gp practice and others because it's a multi agency world that they're in now which in fact will bring what you're talking about because through that they would get be able to understand better the things that they see that could make a difference but what didn't happen was the when social worker was taken away as that resource was taken away that was not seen then as an aligned relationship anymore it became something over there and that's the point i made about integration if we come back to integration and the intention is we're going to try and bring that together we're going to have to bring that aligned relationships back together in a way of working but there is a principal difference in how health has been about need and sometimes within obviously within in local authority funding it's not been about need it's about available resource so you can have a very different view we've talked about this a lot when we were talking about the change over so at the moment the health service would say we respond to the need and we must do that a universal service at core but that wouldn't be the case necessarily within other services so that's what i meant by that coming together when we do that it was not a success when it was seen as because it was said that's what happened they would say you don't need you have to close your cases that person no longer has a need of you or we don't have enough resource we have to find a way of measuring the workload understanding the need and demand and then looking at how we best do that when when in the past health services were attached the evidence showed that if they were attached in some areas the deprivation was greater somewhere else and the resource was elsewhere and it was really hard to say to one area could you give us back that resource thank you because we need it over here because it had been part of that so i could never want to go back to that because it should be about those aligned relationships but you know and understand what your need is how you measure it and then how you allocate the teams to work within that but it has to be multi-agency too because that's the best way to get the breadth of understanding of families and situations just to support what teres has been saying and i think pan might want to comment on it the way the inverse care law is absolutely critical to all this that unless you apply the resource in scotland we're very lucky we have a gp for every patient in scotland they didn't have that in england they had real problems with it so we do have it but it's a it's an equal distribution not to do distribution on the basis of need and that's the problem and really we have to find a system whereby need and resource are aligned you know and i think you know and may want to comment on that that we do you know the resource applied to gp practices in deprived areas even the link workers are just really at the edges i think i think that i mean obviously i would talk to the gp wouldn't i mean that the day general practice is now becoming stretched and stretched and stretched partly because of the the demographics of the population we're serving now and you'll know about the complexity of care etc but the assumption that somehow these complex patients can always be managed in the community with limited resource is just not realistic anymore and general practice does need more resource i more gp bodies and more gp time and i don't really think you can get away from that and Stuart Mercer's work has shown the benefits of that it's not that people get better because you give them more time but it delays them getting worse and that's what a lot of what we're trying to do is delay this you know constant going into hospital becoming secure earlier you know for us to do the job that we're supposed to be doing you do need more gps and you do more gp time it's just becoming an impossible job to do now and i've worked in general practice for 20 20 odd years now and you know for the first time i've had a distinct nursing to me i can't go and see that patient i just don't have the time you know and this is what's happening at the front line and who's the default position when all that happens and services are not meeting the service users needs it comes back to the general practice to sort out we are the default position for just a bit of your other service so i think that depends on being very clear on what we think we need child health inequalities as part of that issue the contract could be more robust i think the gp contracts around child health health visitors it's great that investing more health visitors is actually really really welcome but it will take about time for them to bed in the government project is really trying to rationalise under severe budget cuts how we can better work with social work because we realise that that's a relationship that's been missing for quite a long time and we can do more around that but in terms of the day job i think gps they do need more gp time and more gps that's expensive but that's the reality i agree with everything that's being said about you know targeting resources to deprived areas and you know about improving universal services and so on but one thing i feel and it kind of relates to something you said well you know are we really you know we might be moving anything up but are we making a difference and i think i was reading the evidence on the website from the centre for excellence and looked after children and they point out you know the 16 000 of these children in in scotland 4 000 in in glasgo alone for years i worked in the in the in the prisons and you know most of the people i saw had been looked after at some stage in their their childhood i think you find that their suicide rates something like 100 times the suicide rate in the general child population i think we do need you know people say mind the gradient as well as the gap but i think that's a group where we can identify them fairly easily although getting kind of routine data on them is another matter there's now the shared agenda around integration um you know where where social work and health are you know meant to be worked together i mean maybe that's a group where it's possible to put some resources to try and make a real difference in the way that some scandinavian countries have achieved where they find you know very little difference between the outcomes of looked after children and those who aren't i mean i would say we need to aim for something like that so coming back to the initial question about what could this new advisor do i mean i i i still stick by what i say you know go by the evidence and so on but if if they were to say to me what one thing would you do i would concentrate on that particular group and try and improve things for them particularly since we're going to be corporate parents for them um and i think you know we've got we've got a kind of um an expectation i think i think we i think we should do a lot better by that um by that group than we do have it you um we're into their last you know five or you know ten minutes and what what i will do i think it's only fair to you know given social words i'd be bashed about a wee bit here denis is bracing us how you see it and he's back there you see denis roberson's a former social worker who's with us today and i sat patiently there for about 15 minutes so i'm going to i'm not you know deciding what question you're going to answer denis but denis denis has wished to ask a question and then i intend to come back to the panelist i think and dr gay give us a useful you know a step there that i'm going to ask people if they've got to to wrap up that you know that that that that one thing you mean one two three four five things but you know just something that they would wish to place on record today i think that is useful and it gives us a bit of a round up to our discussion denis roberson former social worker inverclyde? thank you very much convener i'm glad it's on public record that someone loves social workers i was a social worker for over 30 years and yes i did start Glasgow inverclyde which was a wonderful experience now i'm just wondering i mean basically i i actually endorsed the whole aspect of multi agency and identifying the appropriate key worker and i had a great deal of empathy with Richard Simpson when you know he was saying he'd you know gone around this several times um you know because we have in many ways in many forms but i'm just wondering if coming back to maybe an earlier point that dr gray made and i think it was basically it was about the localisation and do we need to sort of focus more on looking at the local solutions for the local problems without then pointing the finger to say that we've entered into a postcode lottery because that's a dreadful term anyway but you know sometimes it is important to have the local solutions for the local problems and you know we need maybe a framework yes but have we moved away from that localisation i wonder is there any response to Lisa Fife? i think that's a really good point but you see it comes back to localisation sometimes is funded by the short term funding so i think that there's a lot of these projects stem from local activity or people think that's a good idea let's do that but they don't actually get funded and they don't get mainstreamed in the way that would help them localisation is a big part of the integration agenda it's intended to get us close to communities where they are which in turn supports our activities so i think that's a good point to see maybe you can respond to this professor marmot when he was here pointed out although he was very skeptical at the time that Birmingham and I think tower hamlets are one of the inner city areas had adopted his principles and were working through that and he was impressed how they had you know delivered on those principles in those localities and they had actually made the difference does anyone know about that in terms of your response to Dennis's local initiative Dr Saunders? I wouldn't like to speak about those particular areas but I would say that while yes local action will help and will help a number of people it also allows government to get off the hook and a lot of the problems that people get arise from government policy and what local action does is help mitigate those effects and again I would go back to saying we need to improve the lot of all children in Scotland and some children more than others but you know by lifting everybody up you also lift up the people who are at the bottom who most desperately need help they need additional help but like a great number of of benefits in the benefit system that have existed by making them universal it's much easier for people who are on the margins to access them it's much less socially stigmatising for people to receive them and it makes life generally easier now there are other yeah as we've said that the people who are most deprived need additional help but you're going to get most of the people by giving stuff to all of the people and there's a small number who need extra if you just try and focus on the tiny number who perhaps we could call them the deserving poor there's a number of undeserving poor that we're going to miss out on and I would really suggest that we go for a let's improve everybody approach with a bit of extra for some yeah she's talking about it yeah that I mean an issue with things being local is that whenever you start talking about localities you start talking about boundaries and and therefore I suppose because I'm a specialist therefore I've got to cover a load a load of localities because you're not going to have one community pediatrician for for um Postal Park and another community pediatrician for Springburn and another community pediatrician for Ruchill or whatever I've got to cover a large area because I'm I'm a specialist and then if you're more of a super specialist at a children's hospital you're going to cover an even wider area and so as soon as you implement things that are only within a certain locality then what about the people that are just over the border of that locality or how do you coordinate things between the local thing that's here and the local thing that's there so I think it makes sense for different things to be done at different levels you know yes there are some things that it'll make sense to do locally but you've got to do some things at a national level so that they're you know this what we're saying about universalism anyway regardless of its you know local or that wider community you know that multi agency approach to resolving the problems you know is that the solution yes you know to talk about the government project again sorry that hasn't even been funded yet but I mean our idea is that if you work within the locality with a cluster of gps within a reasonable sized population number it's about 30 000 you can start to determine what the needs of that population are so you have to do the sort of super epidemiology stuff but you also have to do the localised epidemiology as well so we look at what our population needs are what are the what the third sector agencies in that locality of population you know what are the specific issues we have in government it could be a large asylum seeking population that it gets very variable but we need to respond to where there's no services attached to that you know things like that so there does have to be that at that kind of local level that links international politics it's an understanding of where the links are I think and again embedding all of that is these long-term professional relationships that are really important to make interagency working work this patient are they in eastern bartonshire or do they live in glasgo if they're in glasgo do they live in north west glasgo or north east glasgo you know before I decide who I liais with or what they might be entitled to it's actually well in it's Richard said we've been dealing with this for how long to do this since Richard was a boy and maybe not just as long as that you know but it you know it fits in with many of the things that the committee do struggle with about you know that we'd all argue that we should defend and you know the health spending we should be you know protecting it from any of the cuts but you know we've recognised this morning that delivering on this agenda is not just about the funding of hospitals and whatever you know there's a you know the health service is protected local government isn't so you've got a problem there right away in terms of our ambition to deliver more services in the community but it's been an interesting discussion I don't feel any particular pressure to respond to this question but if anyone wants to you know that that one single thought that you want to leave with us this morning or your top priority or whatever now's the chance don't wait until you're on the bus going home and say that I wish I had said that. I've come back to what I've said it a couple of times I think it's the evidence and the data and the evaluation and I think if we can really grapple with that we might know better what we're trying to achieve and what's working and I thought your point made about understanding that work that had been done I've seen I saw a tv programme that described what they were doing it sounded great but do we know did it sustain did it stay and my final point is community I was here for part of your evidence session on communities working together and what community empowerment looked like and I think that we forget the power of that there's a whole lots of things happen within health that happen because of community support by individuals or by groups and I think if we can harness that together we've a better chance of tackling it and not see divides between who's got which bit of it. For me the overriding thing on how we improve the wellbeing of children and reduce inequalities in child wellbeing is about reducing stresses on parents and reducing the unequal stresses on parents because the stress is cluster and that that some of that's at a societal level so making having a society that is more financially equitable and some of it is at an individual level and that health visitors, GPs etc are key in terms of going out there and finding out what those stresses are and advocating for them to be dealt with because all the programmes we bring in if their parents are under too much stress to actually do them they're not going to work. Anyone else? At the risk of probably repeating myself more than once I do think there's a great need for a healthy public policy and that will come from government where people who can be helped through education and equality, equity of education and opportunity they need to have a healthy public policy creating an environment in which healthy and choices and choices that will help them and their children's health are made easier rather than more difficult so that the healthy option isn't the more difficult one as it currently is for all too many things. Dr Ghee you've had your say would you like to add anything? No no no just just accept to combine a bit and say the evidence data and evaluation I like that too so I would add that on to that particular group using that to improve outcomes for that particular group. Jane? I'm just I mean I suppose from a professional point of view and now I'm believing that best outcomes for children health visitors are really well placed to deliver the best outcomes for children and just anecdotally I suppose what Dr Gray said about looked after children just my experience working both I worked in base 75 which is a project for women involved in street prostitution huge number of those women have come through the care system and also my work in homelessness and homeless families particularly in the individuals we see ex-prisoners lots of whom have been through the care system and also the families that we see so I think it's an area certainly of deprivation that could. Dr Mullen last but not least. Can I say two things well can GPs have more time but also can we imagine things within the child rights perspective because that's a really interesting question that focuses people's minds on on what the impact of policies are I think. Well I'm going to bring this session to a close and I thank you all very much for your valuable time and evidence provided today. Thank you all very much indeed thank you. We are now going into private session as we previously agreed. Good thank you.