 I welcome everyone to the health, social care and sport committee's 15th meeting of 2021. I've received apologies from David Torrance for this morning's meeting. The first item on our agenda is to decide whether to take items 4 and 5 in private. Are members agreed? We're agreed, thank you. Our second item today is an evidence session with the Minister for Mental Health and Well-being and the Minister for Public Health, Women's Health and Sport as part of our inquiry into perinatal mental health. I welcome to the committee Kevin Stewart, the Minister for Mental Health and Well-being from the Scottish Government. Milly Todd, Minister for Public Health, Women's Health and Sport and joining them we've got Hugh Masters, chair of the perinatal and infant mental health programme board for the Scottish Government. Ruth Christie, head of children, young people and families unit improving mental health and well-being, the directorate for mental well-being and social care from the Scottish Government. Kirsty Campbell, head of maternal and infant health improving health and well-being for the directorate of children and families. Carolyn Wilson, for the unit of health supporting mothers and maternal and child health. Sorry about that. Ahead of asking questions, just to remind members that if they have got a supplementary question to anything, another member is asking just to use the chat box and put an R and L, try and take as many questions as time allows. If I start things off, my questions to Kevin Stewart about the progress that has been made. There was the delivering effective services needs assessment and service recommendations report, which made 28 recommendations. That was in 2019. I would like to ask what the progress has been on those recommendations and how they have been put into policy. I wonder if it is appropriate to make some opening remarks first before answering your question. Would that be okay? That is fine, so I realise that you had an open remarks to make, but carry on. I welcome the opportunity for my colleague, Marie Todd, few masters and I to assist the committee with the inquiry into perinatal mental health in Scotland. Before I begin, I thank everyone who responded to the inquiry. The huge range of responses from professionals, organisations and individuals is just how important the issue of perinatal mental health is right now, and I am pleased to be able to provide my support by coming here today. I would also like to express my gratitude to those who kindly shared their own personal experiences. By doing that, it helps us to open up the conversations, address any stigma and, most importantly, it helps us to get a better understanding of what works well and what we need to do better. We recognise the impact that the pandemic has had on the mental health of new and expecting parents and the responses to the inquiry highlight the sobering reality of what that can look like on a daily basis. As a Government, we are making significant investments in our mental health services to encourage recovery and renewal as we emerge from the pandemic. It is from that context that I would like to share a brief summary of my vision for perinatal mental health in Scotland. Since 2019, the Perinatal and Infant Mental Health programme has overseen investment across community perinatal mental health services, the third sector, mother and baby units, infant mental health services and maternity and neonatal psychological interventions. In October, we published the new perinatal and infant mental health programme board delivery plan, which sets out the next steps in our ambitious and compelling long-term role to not only develop and sustain perinatal and infant mental health services in the most challenging times but also to ensure a systems approach to service development and delivery of vital services. We will continue to build on the achievements of the programme board that offer the right kind of support to those who need it at the right time. This year, more young parents, infants, fathers and those who have previously experienced pregnancy and neonatal loss, are receiving support thanks to the organisations funded through our small grants third sector fund. The programme board will also continue to experience the very heart of service development, implementation and on-going provision. As I mentioned earlier, it is incredibly important to us that the service provision is led by the needs of women and families, building on good practice and learning from positive and negative experiences of current services. We will take forward the work of the new delivery plan in collaboration with our partners and ensure a continued focus on raising awareness, promoting understanding and reducing stigma. I am extremely grateful to our statutory and third sector services for their continued passion and co-operation in delivering our strategic aims during the pandemic. With continued collaborative working, we can offer invaluable support for perinatal and infant mental health services across Scotland to provide a lifeline to parents, carers and families when they need it most. The responses to the inquiry are also touching the subject of pregnancy and baby loss, and Marie Todd will answer questions on those issues today. I would like to assure the committee that the Scottish Government, Marie Todd and I recognise the tragic impact of baby loss and the profound effect that this can have in the lives of the bereaved families. We are committed to ensuring that women and families are provided with the right information, care and support, taking into account their individual circumstances. I look forward to working closely with you all as we work on our important agenda for perinatal and mental health to ensure that we are not just listening to the women and families of Scotland, but that we inform our policies with their own lived experiences to deliver quality person-centered care. If I can turn to your question, I think that we have made real progress in terms of delivery since the report and have looked to its recommendations to move things forward. Since March of 2019, we have invested over £16 million in perinatal and infant mental health services to develop a range of different services from specialist acute inpatient to third sector support to women and families in the perinatal period. We are focused on ensuring equitable access to sustainable mental health support throughout folks' pregnancies and ensuring that we get it right during the perinatal period and in infancy. At the heart of our approach has to be those voices of lived experience, and I will probably say that again and again today because I believe that that is immensely important in getting it right in terms of policy development and service delivery. The programme board is making good progress in terms of meeting the recommendations in delivering effective services. For example, providing £6 million of funding in 2021-22 across all health boards to establish specialist community perinatal mental health teams. In health boards with over 3,000 births a year, we have also funded enhanced psychological support for maternity and neonatal settings. Five boards, five greater Glasgow and Clyde, Lanarkshire and NHS Lothian among them, are also in the process of establishing dedicated multidisciplinary infant mental health teams, with the majority of others embedding an infant mental health focus from within their perinatal teams. We have funded increased staffing for mother and baby units and created the mother and baby unit family fund, which supports families to visit their loved ones in inpatient care. We also established the perinatal and infant mental health third sector fund, which so far has supported over 2,000 parents to be an infant, and that comes with £1.8 million of funding. Beyond that, the other thing that the committee will be interested in is what is going on in the ground. We are looking very closely at the overview of service development across Scotland. That is improving. Some parts of the country were slow in using the resources that were allocated to them, but Hugh Masters, the board and I have been in fairly regular contact with some boards in order to ensure that they are back in track. On that front, we are looking at four key areas of service development—perinatal mental health, infant mental health, the neonatal and psychological interventions in those larger boards, as I said, and most importantly, the lived experience and the level of engagement that boards are having with parents and families around service delivery. I want to come back to what you are saying. We have spoken to some parents, and one of the things that has come up that you have alluded to is a difference in consistency throughout the country. You have just mentioned that you are looking at areas throughout Scotland, and you are just checking that there is that consistency of service delivery. On how you are actually gauging progress, are you able to tell me a little bit more? Obviously, you are doing this by getting feedback from mothers and fathers in their experience. What form has that taken? Your questioner covers a number of issues, convener. It would be fair to say that, coming into post and looking at that and looking at it from a constituency basis as well, we can see quite clearly that some areas we are doing better than others in terms of delivery, in terms of recruitment. Recruitment was key here in terms of developing some of those services. Some areas had used the resources that we had given them well, and it would be fair to say, convener, that some of the health boards had barely spent any money at all. Recruitment was slow, and the level of engagement with those folks who lived experience was poor. That has changed. I am not saying that everything in the garden is rosy, because I still think that there is work to do in certain areas, but we are beginning to see recruitment of folks. North, Hyland, Grampian—who were pretty slow—was changing. They are now recruiting. Beyond that, from my own view, some of the levels of engagement there with families with lived experience were not as good as they should be. I met the Latin women's group in Aberdeenshire not so long ago, and I know that you yourself have had contact in the constituency basis from some of those folks. They had mixed experiences of services, and they did not feel that they were being listened to enough. I think that that has changed. Hyland has sent me just this week, after speaking to them later on last week, at work that they have been doing in terms of communicating and consulting with families with the third sector that shows real improvement, and their recruitment is getting better. I am a bit of an old-fashioned boy. I am a bit simplistic, some would say. What I have is a set of report cards that we will update all the time, just to look at the progress that is being made across the country. What I am seeing in the overview is more greens than there were. Some ambers, where we have got to make further improvement and less reds than there were at the very beginning. The committee can be assured that I will continue to engage with those areas. You have been a bit slow in developing services and not quite good enough in allowing those folks with lived experience to help to develop those services. If Hugh Masters wants to add to what you have said, who can I come to you? Thank you very much, convener, and just to add to that in terms of the work of the programme board, you are absolutely right that one of the key drivers—this came from the maternal mental health change agents that I also want to pay tribute to in terms of the work that they did in bringing this issue to the fore—was the need for a national approach, a national spread of services and to avoid areas where perhaps those services were not in place. That was a key driver. As a programme board, we have identified executive leads in each board, we have asked them to set up implementation groups themselves and we regularly monitor and ask for returns, as the minister has said. We also do twice weekly, twice yearly visits, and we will be doing them early next year. Just in terms of why some areas have been, as the minister said, slower to use the funding and to get services set up, it is clear that this is also setting up new services during a pandemic, which has been challenging for many places. In different areas, there were different stages of development. In some areas, there were existing services or rather individuals and professionals who were providing a service, so that could be built on. Moving forward, there is no doubt that we want to really focus on evaluating the impact of this next year as a key priority for the programme, both in terms of hard data but also in terms of the experience that women and families and whether the services fit with what it is that they want and expect. Moving from the what, so what have we been able to do to the so what, so what impact does it add? Thank you. I will hand over to my colleagues who are going to go into some of the detail of this. Obviously, colleagues, some of the questions will be more appropriate to minister Mary Todd, so keep those questions directed to the appropriate person. Of course, if individuals, both their officials or ministers, want to come in, then use the chat box, and I will make sure that I bring you in. We want to look at support for at-risk and vulnerable women, and Sue Webber is going to lead on that, too. Thank you very much, convener, and those of the witnesses' votes are quite upsetting for many of us, and we heard of quite believing in terms also of how the services are set up for those people that know they are going to give birth to and stillborn, sadly, or indeed at that moment when they have a conversation with the healthcare professional. So, what improvements are being made to ensure that the new parents are treated with compassion consistently across the country and in every health board, and then we're not retraumatised as well when they're coming in to the services later on. I think that those are a very vulnerable group of people, and I'd like to know what support we're doing to really drill down and help them consistently, irrespective of where they live in Scotland. Right, your sound was a little bit patchy there, but I imagine that it's directed to Mary Todd. It's a bit consistency of approach to families and parents that have had a stillbirth across the country. Can I come to Mary Todd and that, obviously, we'll try and get Sue's sound sorted? Thanks, Gillian Martin, and thank you, Sue Weber. I apologise for your sound. It was a little glitchy my end. The first thing to say is that the Scottish Government recognises the impact of baby loss, and it's absolutely clear that women who experience baby loss need to have the right information, the right care and support taking into account their personal circumstances. The loss of a baby up whatever stage of pregnancy is an absolute tragedy, which has a profound effect on families, and that does include on their mental health, as well as their physical health. The Scottish Government recognises that, and we're very clear that women and their families need the right care and support. There's a lot of work going on across the country to ensure that women and their families are provided with tailored care, including following nice guidance and our called guidance. In terms of consistency across the country, you'll be aware that we have a programme this start, which we have started to implement. It's an incredible programme that really encourages family-centred care, person-centred care, flexible, suited to the needs of the individual, and that will undoubtedly improve the situation. Unfortunately, in terms of implementation, the pandemic has struck mid-implementation, and although some health boards were very far advanced in their work on this, other health boards were really at the early stages of implementing this start. We are keen to pick up this start from next year, and we expect to see a great deal of improvement in the consistency of services when that is applied across the country. We have also been working with third sector organisations such as SANS to develop the national bereavement care pathways for bereavement and loss. Those pathways provide health professionals with evidence-based care pathways, and they describe the best practice for bereavement care. We are also working on rolling out those across the country. As I said, there is a great deal of work going on across the country. It has undoubtedly been impacted by the pandemic, but we are on the right path. Once we are fully able to implement the start, we will see progress in that front. Thank you. Is this better? That sounds a lot better. No problem. One of our witnesses, who came to speak to us at Cat Berry, suggested at our meeting a week ago that the timescales for implementation of the specialist baby loss units can and should be shortened. Do you think that that is possible, Ms Todd? I recognise the urgency to work on that. I absolutely do. I recognise that every individual affected by baby loss is in absolute trauma. We want to get it right for women as fast as we possibly can. I think that it would be foolish of me to make promises, particularly today, as we are facing—this pandemic has not finished with us yet. We are facing further challenges that we had not predicted and had not expected. Although we have been living with uncertainty for the past couple of years, it seems to me that it would be foolish for me to promise certainty over the next couple of months, when it is very clear this week of all weeks that that is just not possible. What I can do is assure that witness that I recognise the urgency. We will work as fast as we can to ensure that every woman right across Scotland can access that flexible person-centred, family-centred care when she needs it. Thank you. I follow-up from that, Marie. It is just to make sure that you spoke a lot about women in that, but there is also the father. That was one of the messages that came out as well, so it is just making sure that they are included. In terms of one other question, there are all sorts of trauma that can happen during pregnancy that makes women reticent next. There are subsequent visits that they come into the unit, and it is not always, sadly, really resulting in baby loss, but there is a lot of trauma that can take place during pregnancy. What are we doing to ensure that the mental health of those women who are in that traumatic group who have experienced something quite significant are taken into account in that perinatal period as well? You are absolutely right to highlight that baby loss impacts not just the mum, but it also impacts the father as well. I said very clearly that we talk about family-centred care, so I include the father in that. In fact, the entire extended family babies are born. You will be aware that I was an antenatal teacher before I came into politics, so I talked a lot about how sometimes babies are born in a medical event, but they are always born in a social event, so they are always born into a community, they are always born into a family, and the whole family and community will need support when things go wrong. The solution to many of those challenges and to many of the traumas that people face during pregnancy because you are right, it is an uncertain time and sometimes things do not go as expected. Since 2017, we have provided over £16 million in funding to support the implementation of best start. The best start, that five-year plan for maternity and neonatal care, was published in 2017. As I said, it still remains a firm programme for government commitment. That person-centred high-quality care for mums and babies throughout pregnancy birth and following birth can have a marked effect on the life chances for women and babies and families, and on the healthy development of that child throughout their lives, it really is gold standard care that we are aiming for. It is truly family-centred care that will maximise the opportunities to establish building blocks for strong family relationships and for confident and capable parenting. Some of the cornerstones of that type of care would be continuity of carer, for example. There has been a lot of discussion around continuity of carer with regard to baby loss, because it makes a significant impact and difference to the experience of the person and family who have lost a baby. We are continuing to introduce continuity of carer within maternity services, and that is the care that midwives have told us that they want to deliver. That is the type of care that midwives want to be involved in, but it is also the type of care that women have told us that they want to receive. They want to build a relationship with a midwife, not just through their pregnancy birth and beyond, but also in subsequent pregnancies. Where there has been loss or trauma in one pregnancy, that continuity of carer becomes absolutely vital in subsequent pregnancies. I am going to move on to the theme of care pathways. Paul O'Kane, over to you. Thank you, convener. Just to start off last week, we heard quite a lot of important evidence. As whoever said, it was quite emotional at points to hear. We heard about the plan development of specialist baby loss units as well, which are obviously not anticipated to be fully available across Scotland until 2024. My starting point would be to understand what percentage of parents are getting access to specialist baby loss movement midwife at this stage, and what can we do to speed up that intervention around specialist interventions, particularly those baby loss units? I will bring in Kirsty Campbell to give you the most up-to-date picture that I possibly can of the delivery across the country. Kirsty, are you able to give them some up-to-date information on where we are at the moment and where we are hoping to head early next year, although I am aware that we are in uncertain times again with regards to the pandemic? Yes. The minister has already outlined what we are taking forward in terms of work to support women who have experienced a loss in relation to the national bereavement care pathway. The national bereavement care pathway has been developed and co-produced with SANS and a number of other third sector organisations representing baby loss. The bereavement care pathway sets out a package of standards for maternity units to aspire towards and to achieve in relation to delivering high-quality bereavement care for women who have experienced a loss and women and families who have experienced a loss. There are a number of elements to those standards, including taking a parent-led approach, providing training and supportive materials, emotional support, providing a bereavement lead in boards, providing bereavement care facilities, having supportive and informed discussions, memory making and so on and so forth. The bereavement care pathway has been piloted in four boards and we commenced that piloting over two years ago. Unfortunately, the piloting has slowed and paused in some boards because of the impact of the pandemic. What we do know is that it has not stopped but it has potentially slowed progress with the bereavement care pathway. Our bereavement care pathway leads Catherine McRae's working with the four boards that are on the pilot to try and continue to make that progress. We are really hopeful that, given the progress that has already been made and the evaluation that is under way in relation to that implementation, we will be able to roll out across all 14 health boards in Scotland in the early part of 2022. Obviously, that is dependent on capacity within boards, given the progress with the pandemic. That is a key part of what we are doing. What the introduction of bereavement care pathway will do is to provide a consistent approach in all boards to implementation of support for bereave parents across Scotland. Just in terms of the specific percentages, as perhaps the minister is able to write to committee, that would be really helpful, so that we can have that empirical data as well. I would thank the minister for that, and I notice that she is agreeing, which is great. If I can just pick up on a further point about more specialised pathways for women, particularly perhaps around mental health and increased vulnerability, particularly substance misuse issues, what specific pathways or interventions are being developed to support people either in terms of mental health or substance misuse? It is the same approach that best start approach equips midwys with the skills to care for women with socially complex needs and their babies. They have reduced caseloads, continuity of carer, additional training and clear pathways of care and co-ordinated multi-agency support. The best start for any baby is that women receive continuity of care from a primary midwife who is supported by a small team. That primary midwife is really important for women with additional complex needs like substance misuse. As I said, work is under way to produce nationally consistent guidance and pathways and to cope with different levels of complexity where lead carers—the midwife is always going to be the lead carer, but there may be a greater need to work closely with other services. Early access to care is really important for building that high-quality, anti-natal relationship between the mum or the family and the midwife. It is really important for both mum and baby. For women with a whole range of medical, social, psychological complexities, early intervention and co-ordinated multi-agency care, it makes a massive difference to outcomes. That begins at the booking appointment. At the initial booking appointment, when the midwife first sees the mum during pregnancy, women are asked about a variety of wellbeing questions in order to assess their likelihood for additional needs. It may be that my colleague Kevin Stewart asked specifically about some of the perinatal mental health approaches to anti-natally. That supports a woman from the anti-natal period right through to post-natal period. Thank you very much, convener. The perinatal mental health clinical network has set out a series of five national pathways. Those pathways cover preconception advice, psychological support for milds to moderate concerns, specialist assessment for severe complex needs, emergency assessment, MBU admission and specialist assessment intervention for parent-infant relationship difficulties. We are developing animations at this moment to increase accessibility and awareness of all that. Four health boards have fully developed local pathways for perinatal mental health, and a further seven boards have pathways in development. Additionally, boards are developing specific pathways on birth trauma, neonatal loss, anxiety and need-of-phobia. Thank you. Paul, have you got another question, or will I move on to one of your colleagues? No, convener, that was more helpful. I move on to questions from Stephanie Callaghan on access to services. Thank you very much, convener. Thank you to the panel for being here today. It was reassuring to hear the cabinet secretary put such a clear commitment and focus on taking into account women's lived experience and making sure that there is equitable access across the country. You did answer my first question about where the boards were with that recommendation. What is the Scottish Government doing to improve waiting times for perinatal mental health services and to align them with the timescales of pregnancy? I wonder whether the thresholds for referral to specialist mental health services have changed because of that increased demand. I have gone on record many times that we do not want anybody waiting. We are doing all that we possibly can to ensure that we are delivering for people. We will continue to invest in the recovery and renewal phase in bringing waiting lists down, whether that is in cancer services or psychological therapy services. However, we have got to take the right actions. In service delivery, one of the key things that we need to do is to make sure that we have a joined-up approach to dealing with perinatal mental health. The work that we are doing and developing in health boards is extremely important, but we need to go much further in ensuring that those folks in the front line know exactly what services are available and to direct folk to those services. Let me give you an example from discussions that I had with the Latin and women in the north-east, where there were mixed responses to some of the questions that I asked. It would be fair to say that some women thought that their GP services were absolutely fantastic in terms of getting it right for them. In other cases, folks were very, very unhappy indeed with their initial contact with GPs and were not signposted to the right services. We have got work to do on that, we need to change that and we need to make sure that all we are doing across the country is being filtered down to those in the front line so that they know exactly what services women need and to signpost them and refer them on to them. Again, in terms of the developing of services, what we require is not only those acute services, which we tend to concentrate on when we are talking about waiting times and waiting lists, but community services. We need to get it right in the communities across the country. That means that the investment that we have put in needs to be spent wisely in developing those community assets. Beyond that, we also need to ensure that our investment in the third sector is there to allow them, with their expertise, to play a real part in helping women and their families. For example, in a constituency capacity, I met with home star Aberdeen on Friday. Without doubt, as is always the case, we strayed on to ministerial matters. Those are folks who have a lot of experience of dealing with women and families. Their experiences and the information that they are gathering have to lead to the improvements that are required to get it right for women and families right across the country. Quite possibly, Hugh Masters will have something more to say in that for Ms Callaghan, I would imagine. I think that the thing to bear in mind is that, for the programme board next year, as I have said, it will be a key focus for us to see what are the access arrangements. A lot of those services, a lot of those developments are very new. As such, we need to see what processes are being put in place to make sure that they are meeting at least the managed clinical network for perinatal mental health, which is that it should be no longer than six weeks from the time of referral to be seen. We will target support to those boards where that is such as an issue. Just to go back to that, if I could just briefly on the pathways to the substance misuse, I think that it is really important that we are able, as the minister has said, to make it clear and publicise that these services are now in place so that people understand that seeking help will be help and support that are available. We are well aware of substance misuse that has been identified in a number of settings, both from delivering effective services and the very first report highlighting the need to develop services. From feedback from women and families, we are in the process of looking at the recommendations and the report from the managed clinical network around supporting women and reducing harm. We will be working with our stakeholders at an event early next year to look at how we take things forward. That may include a specialist care pathway or not, but we are in the process of developing that. Early next year, we will have the actions emanating from that. Just to be really clear—that is good and positive information—the thresholds for referral have not changed due to the increased demand. What supports are there in place just now while people are waiting for referrals to come through? There are a number of things. Again, we need to listen to the voices of lived experience in terms of how we shape services for the future. I will refer back to the latin woman. There were mixed opinions on various parts of service delivery, but one of the things that all the folks who expressed an opinion said was that, during the pandemic period, the Grampian resilience hub was absolutely fantastic in responding to the needs of those women. We need to take the learning from the Grampian resilience hub and see whether we can replicate that across the board. There was something that went on there that obviously worked for those women. If it works for them, it is likely to work for others. That kind of service can be the same in a remote, rural and island area as in an urban area, because, in the main, it is communication by telephone or by video call. That kind of thing is something that we need to look at in more depth. I will be honest with you, convener, that the nuggets of information and the nuggets of good practice would not be picking up if we were not going out and talking to the voices of lived experience, which I want to continue to do. Maybe he will want to add a little bit more on that, convener. Just in terms of what support is available in the meantime, as the minister said, we are trying to invest in a range of services here. Whilst we are talking more about specialist assessment and treatment, we are also looking at what support can be provided by the third sector. We have touched on universal services, but we are offering training to health visitors to midwives around perinatal mental health to give them that confidence to also be able to offer that support as well, to be able to assess properly to understand the issues, and we are getting some very positive feedback on that, too. Universal services have a key role to play in that, too. Stephanie, can I bring in Emma Harper, who has a specific question on this? Thank you, convener. It is just a supplementary when we are talking about access. The minister will be well aware of coming from the north-east rural area. My thoughts are also with the north-west and the south of Scotland. Are we monitoring the women who are accessing from rural areas and then tracking the care and the pathways that are associated with that? It is just to highlight the challenges for rural areas, too. I am a tunzer from the north-east rather than a country boy, but I well understand the difficulties that there often are in accessing services in rural and island communities, as I point out. We have to adapt to service delivery. The words are often the best places to know their area, too. However, we want to make sure that, in terms of the shaping of those services, women and families are listening to about their needs. I pointed out that the Grampian resilience hub is possibly being a solution that could be replicated elsewhere, which I think would work as well in Dumfries and Galloway, as it would in rural Aberdeenshire. As the committee and certainly colleagues who have heard me before in the previous role, I am a great believer in the exporting of best practice. Where we find best practice, we will be spreading that far and wide. I know that Hugh and his team on the board have been doing that anyway, but we will continue to do that. As I said earlier, we will continue to look for those nuggets and information from service users about what works for them and try to replicate that across the board. In every other area, we will look at the best practice. Some of that will need to be adapted for certain parts of the country in terms of delivery. We will look at best practice and try to ensure that the voices of lived experience and what their opinion of services is to help shape them. In terms of that data and monitoring, I assume that many of you are referring to admissions to mother and baby units. We have a keen eye on that. We have some recent data on which boards are admitting to mother and baby units. Women are not being admitted to mother and baby units, so they are being admitted to adult non-MBU settings. One of our key things to do next year is to interrogate that data further to understand what are the reasons behind that. We are hopeful that we are going to get permission to look through the managed clinical network to be able to do that, so that we understand better the choices that are available to them. Another key priority for us next year will be to push on with regional aspects, as you will appreciate sometimes where the remote and rural areas where birth rates are low. The need for a dedicated team is not as such there. There will be a much more dispersed model. We are very keen that the regional links are made. Certainly in the north of Scotland that is happening now, with Grampian, Highland and the Islands, we will begin to come together to discuss that. Just on top of that, we have had a priority for near me during the pandemic, which has worked very well for those who, obviously, are at suits. Third sector funding. Finally, for remote and rural, we set up the mother and baby unit family fund, which gives funding for family and loved ones to be able to travel and stay when the mother is admitted to an MBU. We appreciate that that is not the answer to everything, but it has certainly been helping, and we are getting good feedback from that. Is the minister much to come back in? Yes, since mother and baby units have been mentioned, it is important to expand on some of our thoughts about that. Delivering effective services recommended that the number of MBU beds in Scotland should be increased, and that that could be achieved through either expansion of the existing units or through the creation of a new third MBU unit in the north of Scotland. The delivery of effective services also recommended that an options appraisal should be undertaken to determine the most appropriate way forward to increase the number of beds in Scotland, and that work is currently under way. A number of options are being considered, including the creation of a third mother and baby unit in the north or the expansion of one or both of the existing units in Glasgow and Livingston. We have to look at a number of issues here, including equity of access, cost and safety and the sustainability of the service, and all that needs to be considered as part of that options appraisal. My intention is that we will hold a public consultation hopefully early in 2022, which will help to inform that options appraisal and help to inform the decision making process. We will seek to engage as many stakeholders, particularly those folk with lived experience, to engage with as many of those folks as we possibly can. As she is rightly pointed out, at the moment, with the two existing units, recognising that folk from further fields, from Livingston and Glasgow, often have a fair bit to travel, we have to place the mother and baby unit family fund to help with travel expenses for families. Again, hopefully, in the early part of next year, we can move further forward on that front in terms of consulting folk about the future of mother and baby units. I move on to the issue of Covid-19 and the restrictions around that. Sandesh Gohani has questions. We know that mental health across the United Kingdom deteriorated over the pandemic, especially during the lockdown, and we know that the perinatal mental health has been difficult for all our women in Scotland, even before the pandemic, from stigma to not having a dedicated mother and baby ward that they were able to go to. My questions are going to focus on women who have ethnic backgrounds. What impact did Covid-19 have on ethnic backgrounds, and what learning have we done to prevent that from happening again with further restrictions possibly on the horizon? I think that we will probably go to Kevin Stewart first, and if Meretod wants to come in on the anti-natal care aspect of things, I can bring her in afterwards, if that is okay, minister. In terms of the pandemic period and perinatal, feedback from the third sector highlighted the difficulties that there were in navigating service delivery in a safe way during what has been very turbulent times. To support the third sector, we funded additional support focused specifically on wellbeing issues. Again, there is learning that we have had during the pandemic period, which I think that we can utilise during future periods. The Grampian resilience has been the prime example for all that. In terms of the impacts on perinatal mental health support for ethnic minority women during the pandemic period, I do not have anything specific in terms of information here today. We can have a look and see what information we hold and get back to the committee in that regard. I will pass on to Marie for some of the other issues that Dr Gohan raised. The pandemic shone a light on pre-existing health inequalities, but it also exacerbated them. We have seen that in maternity care as well. Unfortunately, even in this day and age, the strongest predictor of the worst outcomes during pregnancy is your level of wealth. People from areas where deprivation is high are more likely to have poorer outcomes. We also see health inequalities along—precisely, as Dr Gilhane says, along Black and Minority ethnic lines. Outcomes from maternity and pregnancy are often poorer for women from Black and Minority ethnic backgrounds. It is a difficult issue because in Scotland numbers are relatively small and outcomes are generally good, so largely outcomes are good from pregnancy in Scotland. The numbers are quite small where things go wrong. It is a challenging area to study, but this is somewhere where we work very closely with our neighbours in the other UK nations. I will bring Kirsty in to explain some of the work that is going on in England that we are benefiting from in terms of looking more closely at how we can meet the needs of Black and Minority ethnic populations during pregnancy. As the minister has highlighted, we know from a variety of different reports and data and evidence that outcomes for women from deprived backgrounds and outcomes for women and babies from Black and Minority ethnic backgrounds can be poorer. We are also expecting to see—and we are already seeing—that that has been exacerbated by Covid because we know that women from Black and Minority ethnic backgrounds are more likely to catch Covid and to have severe symptoms from Covid. That applies to pregnant women in that category as well. As the minister has highlighted, in Scotland our 14 health boards contribute to a number of UK-wide audits, including the Embrace audit, which is mothers and babies reducing risk through audit and confidential inquiry. We participate in the audit as part of a four-country approach. We are also part of the perinatal mortality review tool development process and the national neonatal audit programme and the national maternal and perinatal audit. A combination of all of those audits has really helped to shine a light on some of the disparities in outcomes for women from Black and Minority ethnic backgrounds and for women from deprived backgrounds. The most recent NPA report, which was published back in early November, made a number of recommendations for health boards to take forward in relation to improving services and attempting to reduce some of those outcome inequalities. We are going to be working very closely with health boards in the early parts of 2022 and as soon as health boards have the capacity to work with us on those things. As the minister has highlighted previously, at the moment, things are particularly difficult in relation to the latest challenges that have been presented by Covid, but as soon as health boards have the capacity to work with us, we are looking to work with them to look at how we can implement some of the findings of the latest NPA report. The findings are very practical and pragmatic and it is really helpful to have them set out in a report attached to the evidence so that we can clearly make the links between the interventions that health boards can make and the outcomes for those women. The minister for mental health would like to come in and then Huw Masters. I'll let Huw come in, convener, and Huw may cover what I was going to say. Okay, Huw. Thank you very much. Briefly, two points really. One on learning from the pandemic. I think that it's been clear, the evidence is gathering pace, that the impact on young families has been particularly acute. We're beginning to see evidence that it's the sort of whether our children are not at two years, perhaps where the parents report most difficulties. During the pandemic, we've worked with the managed clinical network to advise statutory services in terms of provision and maintaining that. The third sector developed a directory of services, 99 of them, that continue to operate and see families in the pandemic. That's been really important. Again, I pay tribute to the work that they've done during this time and continue to do that. We have an equality subgroup as part of the programme board that is currently looking, and has identified ethnicity and cultural issues as something that we need to further develop, and we'll be doing that in the near future. I just wanted to highlight some third sector funding that we have awarded to an organisation. I'm at Berthgan companions based in Glasgow who do a lot of work in the perinatal period with women and families, where English is not the first language. They recently won the NHS Scotland award for diversity award ceremony. We're looking to spread their learning from that project to across other areas. The important thing to say is that, as we've heard, black women are twice as likely to die during pregnancy, and ethnic minorities are also less likely to get the Covid vaccine, so they are at greater risk. Those things combined are certainly our cause for concern, but specifically on perinatal mental health, stigma is a big problem that can occur, especially in ethnic groups. I'm keen to hear that we will be able to take forward the learnings from the NMPA report and put that into effect. I appreciate that it's not large numbers, but that really matters. We need to get ethnicity right. We've had a period where we've had some stability. Why have things not been put in place, as far as the question is to Kirsty? When you say capacity, when is it that you expect to be able to start helping people of ethnic minorities? I don't think that nothing has happened in health boards, so the report that came out in November follows on from previous reports that I've highlighted exactly as you identified the disparity in outcomes for women from black and minority ethnic communities. We have done quite a wide range of awareness-raising style events with members of the clinical community across Scotland and making sure that the information that is in those reports is known about at a local level and that care can be adjusted. At the beginning of the pandemic, when in particular some of the emerging concerns arose around the worsened outcomes for women from black and minority ethnic background in pregnancy, the chief midwifery officer at the time wrote to all health boards outlining some measures that they could take at that point in time to try and mitigate against some of the effects of the Covid pandemic, including a reduced threshold for extending care and for testing, and a range of other things, including focusing where possible on giving these women as much continuity of care as is possible at that time, recognising some of the challenges that have faced the NHS in relation to staffing over recent months associated with the pandemic. So there has been stuff that has happened. There is definitely more that needs to be done, there's no doubt about that, there is a lot more that can be done, and that's why we intend to work with boards in the early, in the new year to start to instigate this, and we will start that work as soon as we can, and all that is holding us back at the moment is essentially monitoring where this current wave of Covid is going. As members of the committee will know, maternity services remain as an essential service throughout the pandemic, and have done, and those babies are in the pipeline of maternity and neonatal care needs to continue. Boards have continued to do that through the challenging times that we've had, but we are very careful about not adding to the burden on them at time when they are under such pressure, so we do want to move forward with this as quickly as possible. Thank you very much, convener. I should say to the committee that we have just engaged a second participation officer specifically to link with minority ethnic communities and other equality groups as part of our work in listening to the voices of lived experience. I think that he already mentioned resources that we've given to the AMMA women's group. We also have the experts by experience group who are working with Amina Women Muslim Support Centre to understand their challenges better. Also, in terms of our small grants funding, we have funded multicultural family base for peer support. I should also say to the committee that the equality impact assessments that we have done have highlighted issues around stigma for BAME groups, but that stigma exists across all communities in that area. We have a huge amount of work to do across the board to ensure that we de-stigmatise perinatal mental health. That is going to take a lot of work. We all need to work together to ensure that there is a greater understanding of the needs of women's and families in that area. That is why I am grateful to the committee for carrying out the inquiry, because your findings will add to the information that we already have, and we need to act accordingly there. You have a situation whereby some women feel so stigmatised that they cannot even go into a bookshop to buy a book about the information around how they are feeling. That is one of the things about the small grants funds and the work of Latin women and others who are recognising those kind of things and ensuring that folks have easy access to those things. For all of us, we should be working together to de-stigmatise all of us, whether that be in the BAME community or communities across the board. I know that Emma Harper wants to lead on stigma later on in the session. Mary Todd wants to come in, but I will throw in another question. One of the things that came up from the women that we spoke to was that the Covid-19 restrictions meant that their partners could not be there in a lot of their appointments, but they could not have anti-natal classes and that that added additional pressure in terms of their pregnancy experience and it could impact on their mental health. Some of the women were really quite emotional hearing the impact of not having their partner there, particularly because they were receiving not great news. As you said, we are not out of the pandemic yet. What assessments were made on the importance of having partners involved and anti-natal classes? The first thing that I wanted to do, if you will indulge me for a moment, was to pick up on Sandesh Gullhane's point that there was low levels, perhaps, of uptake of vaccination amongst pregnant women from black and minority ethnic backgrounds. It is an opportunity for me to emphasise just how important vaccination against Covid-19 is during pregnancy. I think that it is perfectly understandable that there was some hesitancy and concern in accepting a new product when it first came on the market over a year ago, but it has been used. Vaccinations against Covid-19 have now been used worldwide in millions and millions of pregnant women and the evidence is very solidly that the benefits outweigh the risk. One of the ways that we are approaching that is to increase vaccination in that population, who, particularly for Delta, appeared to be more susceptible than the rest of the population. One of the ways that we are approaching that is holding specialist vaccine clinics in maternity services. You will see, for example, Greater Glasgow and Clyde have been holding vaccine clinics for pregnant women and those will naturally, because of the catchment area, target black and minority ethnic communities. I cannot let the opportunity pass without emphasising just how important it is for a pregnant woman to get vaccinated and to be fully vaccinated during pregnancy. They have every opportunity to talk to health professionals and to talk to the vaccinator if they have any concerns at all, but the evidence is very solidly behind vaccination during pregnancy now. On your broader question, I suppose that I will start at the beginning and go back to March 2020 last year. At the start of the pandemic, every service in the NHS pivoted a digital response. Face-to-face visiting was reduced. Those were the days before we had a vaccine and things were very dangerous. Much of the way that we managed to get through the early pandemic was by pausing almost anything and everything. However, family nurses and health visitors worked really closely with local partners in designing perinatal and infant mental health pathways, making sure that the community could continue to be looked after. Recognising the importance of support for new parents and babies at the time of national emergency, very few of those individuals were redeployed. If you think back to March 2020, people were being redeployed from pediatrics, for example, into Covid wards, not largely our health visitors, not largely our family nurses, because we know how important it is to support women and families at these times. The importance of prioritising visits for new babies was emphasised. The guidance was adapted throughout the pandemic where possible. There was an emphasis on returning to face-to-face visiting, but that has not been possible at every stage of the pandemic. We have seen amazing adoption of digital options such as NHS near me for anti-natal checks, blood pressure monitoring and things like that. Support was continued, but it was not always continued face-to-face. In terms of the importance of having partners at significant appointments during the anti-natal period and at the birth and postnatally, we have always recognised that and we have always tried to enable that to happen. There have been challenges in individual maternity units where there was insufficient space in the actual room for social distancing. We had to leave flexibility for health boards where the risk assessment was that there could not be extra people in the room, but largely we have all absolutely throughout the pandemic we have recognised just how important it is for women and their partners to go through those experiences together and to be able to support each other during anti-natal appointments and birth and the postnatal period. I want to talk a bit about workforce, as the convener said. One of the biggest things that struck me is that evidence from the Royal College of Nursing suggests that the biggest difference that we can make to improving that is around staff vacancies and workforce. Mental health is one of the areas where there are significant problems with workforce. I know that the Government is trying to address that, but it is quite important that we understand in that context just what the Government is doing around workforce planning for specialist perinatal mental health services. Have they done anything around workforce planning? One of the key things that we hear from the nursing organisations is about retention of the really good, well-trained staff. I wonder if you had any feedback on that. Thank you, convener. Workforce and sustainability have been at the very centre of all the programme board delivery plans. Last year, the workforce sustainability group was established to explore the issue across all sectors of the perinatal and infant mental health services. NHS education for Scotland has been expanding training places on commissioned programmes, as well as ensuring that additional perinatal and infant mental health training is provided across a range of professions. That will result in our investments in 51 additional psychological practitioners by the end of 2021-22. There is a huge amount of work going on, not just in terms of training and getting folk in, but also training others to recognise exactly what is required. As the committee well knows, across mental health services, I have said that we will look at a new workforce strategy for mental health in the first half of this Parliament. However, in this area, we are well on the way and we can see that in terms of the recruits that we are managing to get in. The minister is looking for training across the board. Can I have a bit of clarity on the 51 practitioners? That is an additional practitioner across all services. Those psychological practitioners will cover a range of services, but it is extremely important that we get it right in this area as others. Having kept a very close eye on recruitment, we are doing well. We also have to make sure that we retain those folks as we move forward and that we need to grow for the future. I have a supplementary question on the workforce. I know that there are education online learning programmes. RCGP has a perinatal mental health toolkit, and, as I am still accessing the two RAS learning modules myself, as a vaccinator, I check the perinatal mental health modules. There are seven specific modules just with a quick search, and one is looking at stigma. How do we track those modules? How do we track the uptake? Who has taken them up? Is it midwives? Is it psychologists? Is it GPs? I think that those modules are fabulous. How do we encourage our healthcare professionals to take up the e-learning modules and how do we monitor that? I do not have at my fingertips who are accessing all those modules, but we can get back to the committee around the information that we hold. I notice that Hugh has put an R in the box so that he can come in with some of the more detailed information that he has in his head that is not in front of me at the moment. We have worked with NHS Education Scotland, as I said to Ms Mawkin earlier, to embed perinatal mental health within undergraduate education to increase the numbers of psychology trainees at a postgraduate level and to roll out that suite of materials that has been mentioned to make them accessible to all professionals across Scotland to further develop expertise at all levels across specialist and universal services. Importantly, we have committed to investment in perinatal and infant mental health services beyond the life of the programme board, so that will allow boards to recruit the required staff on permanent contracts and support recruitment and retention of staff and the development of centres of expertise. That great expertise is grand, brilliant, but we also want others to be able to access the kind of educational materials that Ms Mawkin has talked about. We have done that in terms of details of who is accessing. If Hugh does not have the answer, we will write to the committee. I do not have the exact numbers, but as the minister has said, we will get back to you with that. Nes does have those exact numbers in terms of the number of people who have access to the number that has been completed. We can get that exact breakdown. I am glad that Ms Harper is accessing those materials. I have done so myself, too. They are very well evaluated. We see constant evaluations from Nes on that. Whilst they are aimed at the enhanced or specialist training end for the workforce, we feel that it is really important, given the sudden surge in numbers of people who are going to work in perinatal, that you will appreciate. A number of staff clearly have those skills in place, but for some it is a matter of developing them. That makes the post attractive and hopefully makes it somewhere that they want to continue to work. Those practitioners and others in universal services can also access specific modules. You have mentioned that the stigma module is an introduction to perinatal, too. We know that that is also being accessed, too. In general, what we are finding, as the minister has said, with recruitment is an attractive area to work. It is still difficult in some places, and there are challenges. On the whole, the teams are reaching their staff complement. We should not forget that the third sector is here, too, and the issues that they have around sustainability and making sure that their staffing is what it should be. We will come back to you with that precise data. Convener, some very clever person has managed to get to me on the stigma module alone, and 700 practitioners treated that module. Thank you for that. I will bring in, very quickly, Sue Webber has a quick supplementary question on workforce, before we move on to questions from Gillian Mackay, too. I am curious, because NHS Lothian, in some of the information that we have, says that the Government needs to invest further beyond the recommendations. We have heard a lot about training in the staff, etc. I am just looking to get some assurance that there will be a continuous reassessment of the workforce, what is needed and the level of investment that will be needed. They talk candidly about the need to consider increased staffing, complement to ensure that education training, clinical supervision and support are embedded as part of practice and held in the same parity as direct clinical care. It is all about making sure that self-development and improvement are included in their working time. I was just wondering whether the minister, Mr Stewart, might be best suited for that. We are continuing to monitor that, not only myself, but also the programme board. I know that there are always calls for additional resources. That is the way of the world. What I am keen to see in all boards is that the resources that have already been allocated for this work are to be utilised and used. It is that point that we would then look at to see whether other resourcing is required. The key element for me at this moment is to make sure that those treatments are taken place, that that money is spent and that the services that are being delivered are being shaped by the voices of lived experience. After looking at the report cards that I talked about earlier, we can look at what else we need to do in what places. However, I would ask all health boards to ensure that they are utilising the resources that they have already been given, the max, in the first instance. We move on to questions about joined-up care from Gillian Mackay. What role do universal services play in the prevention of perinatal mental health problems? How can these be strengthened or services better signposted? I would like to put that to Minister Marie Todd first. It will come as no surprise that universal services play a key role in prevention and in early detection of perinatal mental health problems from preconception onwards. Public health messaging about awareness of mental health, positive health behaviours and health relationships has a significant impact on later emotional wellbeing. All of the team, so midwives, health visitors, family nurse practitioners, all play a crucial role in identifying and preventing perinatal mental health problems. That is why we have invested in the next perinatal and infant mental health curricular framework. We have just been discussing a whole suite of multidisciplinary training options to support universal and specialist staff to develop their knowledge and skills and to feel confident to address mental health and wellbeing issues with the women that they work with. All mental health staff—I believe that we may want to discuss this further with Kevin Stewart, but I think that all mental health staff are able to access those modules as well, particularly those working in specialist areas with relevance. If we look at the universal services, perinatal mental health is a fundamental part of the core curriculum. We are trying hard to make sure that wherever you work and wherever your specialty is, perinatal mental health is an important part of your training and your continuing professional development as you go through the course of your working life. Very much. At universal services are the key to all of that and ensuring that folks are able to access the services that they need. Obviously, delivery is often different in various parts of the country, but ensuring that we get that right for every woman, for every family is absolutely essential as we move forward. Joined up care and holistic approaches are key for supporting women and their families during the perinatal period. We are taking specific actions to improve that joined up services for women and families with complex needs such as substance use. You have Marie and myself here today, obviously, with intertwined work. We work very closely with Angela Constance and, obviously, the substance use issue is a very important one, and somebody mentioned it earlier. Across government approach, in partnership with the managed clinical network, with the third sector as well, and as I cannot emphasise enough, those folks will live to experience to get that right. We are looking to hold a stakeholder event in the very near future, designed to discuss ways to improve the quality and consistency of support and services for women and families. Thank you. When Kevin MacDonald mentioned the delivery of services in different parts of the country, I wanted to say that the delivery of universal services has looked a bit different during the pandemic. We have seen anti-natal classes move to online delivery. We have also seen breastfeeding support groups move largely to closed Facebook groups and social media, and we have seen social media and virtual opportunities to connect mums and babies, largely but often families. We have seen outdoor meet-ups, for example, and we have seen walk-and-talk groups in the country. While that has happened because of necessity, because it is safer outdoors than indoors, and small numbers are safer than large numbers, I, for one, as a public health minister, think about the general health of the population and the challenges that we have around getting people active, the challenges that we have around maintaining healthy weight, particularly during this phase of life and how important it is for women to be a healthy weight during pregnancy and subsequent pregnancies. I hope that that continues, so that opportunity to meet up outdoors and walk together to socialise through exercise is probably a very valuable step forward. I will look forward to the day when it is not the only option. Probably following on from that, what action can be taken to ensure that women and their families receive joined-up care? Obviously, that will look quite different just now, probably compared to what our ideal would be after the pandemic. I will probably come back to Mary Todd on that one, first, please. Joined-up care and a holistic approach to supporting women and families, I think that you have heard that throughout the evidence that we have given this morning, it is a really important cornerstone of care in the perinatal period. We are taking specific actions to improve joined-up services for women and families with complex needs, such as substance use, and we have talked about that. We have made an investment prior to the pandemic. We have made a significant investment to increase health visiting. We have increased the health visiting workforce by almost 50 per cent to build capacity and to provide more support to those individuals who need it. That is a significant difference in approach in Scotland compared to the other UK nations. That is because we have recognised just the incredibly valuable role that our health visiting teams provide to new families and we have invested in it and supported them with their role. Can I come in on that? There was something specifically that was mentioned from the women that we spoke to and people who put in written evidence. That is about the support for infant feeding. When that support was not there—again, it comes back to the consistency of the approach throughout the country—some places that particularly breastfeeding support was not there or they felt that midwives did not have the time to give them the breastfeeding support, led to the added to postpartum depression issues. What can we do to make sure that women feel supported? Will crucial feeding your baby keep on coming up as being an issue? Thank you, convener. It is a really important point. I will probably bring in Carline Wilson to give some more evidence on that. I will give you some of my initial thoughts, though, as well. It is a really important thing. I am consistently pre-pandemic. For a long period of time, we have had far too many women who have given up breastfeeding, not because they wanted to or because they chose to, but because they were not given appropriate support in the early days. That is an issue that we have been working on for a very long time. In actual fact, I hear you that some women feel that they were not supported well. The reality is that the outcomes are that, during the pandemic, breastfeeding rates went up. The most recent infant feeding statistics—it is very complex, is not it, to unpick why that happened? We are still trying hard to understand why that happened. However, the infant feeding statistics show that almost two thirds of babies born in the financial year 2021 were being breastfed at least some time after their birth. That is up 1 per cent from the previous year. More than half of those babies were being breastfed during their first health visitor visit, which is at 10 to 14 days. 38 per cent were being exclusively breastfed. That is increases of 2 per cent and 1 per cent respectively from the previous year. The proportion of babies being breastfed at 68 weeks of age is now at the highest rate since records began. It is still too low, so it is at 45 per cent, of which 32 per cent were being exclusively breastfed. That is again an increase of 1 per cent over the previous year. I would not dream of dismissing those women's experiences. The data show on a population level that we managed to get something right during the pandemic year in terms of breastfeeding support. Whether that is because fathers were often at home, whether that is because there was more support provided virtually in people's own homes rather than having to go out and ask for help, I am not sure that we will unpick the details of that. Of course, all of that improvement comes on a background of real commitment to breastfeeding in Scotland over decades. Carling may have set the scene on this better than I can, but Scotland was the very first of the UK nations to achieve 100 per cent unicef UK baby-friendly accreditation, which is a really important landmark in terms of improving breastfeeding rates. You will be aware that there are massive cultural influences on women and families in whether they choose to breastfeed or not, and whether they are able to or supported to breastfeed. The unicef baby-friendly programme gave us very strong evidence-based practice in order to improve the rates of breastfeeding in Scotland. I will hand over to Carling now. I will bring in Carling and I will need to move on to Evelyn Tweed's questions. Thank you, convener. I am just checking. Can you hear me? Sorry. We can, yes. Just adding to what Ms Todd set out there, we recognise the importance of that very early opportunity to breastfeed. It is very important that all women get into skin care and get an opportunity to have that very special time of their baby immediately after birth. We have set ourselves a stretch aim in Scotland to try to reduce the drop-off rates of breastfeeding at different stages. We measure that at six to eight weeks, but we look predominantly at what happens in the very early hours and days following birth. That links into the maternal care that they receive. We are well on our way to reducing that drop-off. Across the whole of the country, the number of women, as Ms Todd said, who initiate breastfeeding and who are supported to breastfeed for longer is absolutely increasing. That is due to the increased financial investment, but we are also trying to understand more about what the support infrastructure should be around women and to provide them with the resources that they need to continue to breastfeed for as long as they wish to. Looking at that very early stage, it is really important. The points that are made about not dismissing the individual women's experiences, but we know that there has been a lot more contact with our breastfeeding helpline, with some of our virtual support, and we know that infant feeding teams were largely protected as well as an essential service during the pandemic, and that is what we remain committed to doing, because we know the importance of that tiered level of support from peer support up to specialist support to support women on their breastfeeding journey. That is the first couple of days that was highlighted to us as being a particular issue. Kevin Stewart, you want to come back in before I move on? I will be very brief, convener, because Ms Mackay's question about universality and accessing services is the committee well knows that we have ambition to ensure that we set high quality standards across the board in mental health services. I have talked about what we have already done with CAMHS, what we are doing now with psychological therapies. Here in Perinatal, we are proposing to bring forward a service specification, which will be absolutely vital in ensuring consistency of care and promoting those joined up care pathways across Scotland. In so doing, we will also look at national and local conversations with the third sector and those with lived experience to ensure that we get those specifications right, and we will adapt them accordingly. That, again, is a vital piece of work that we will carry out to ensure consistency of care across the board. Thanks, convener. Good morning, panel. It was great to hear Kevin Stewart's opening remarks on the focus that the Scottish Government has on Perinatal mental health services. However, the third sector advised that funding is often short-term and fragile. How would you respond to that, minister? What I would say to Ms Tweed is that today we have invested £1.8 million in third sector services in Perinatal and infant mental health portfolio. We have publicly committed to investing up to £1 million per annum in third sector provision. A key part of our on-going third sector work has been to invest in the sector, as well as providing funding to specific organisations. I know myself from conversations that I had last week that none of that is easy and that third sector organisations would prefer it if we could provide multi-year funding. I wish that were the case, too, but the UK Treasury will not give us multi-year funding, and that is where it creates difficulties. We have given as much comfort as we can to third sector organisations. I value the work that they are doing, and we will continue to work with them to provide the resources and services that women and families need across the country. Can I bring in a few masters? Just very briefly, I appreciate the time. I will very quickly tell you what the minister said. The programme board always had third sector. In fact, the first funding that was awarded from the programme board was from the third sector, so we very much don't see them as a separate section or a separate issue for discussion. As you see, it has come up all repeatedly today. We are both exploring how funding may continue beyond the life of the programme board, and that is something that we will focus on next year. More importantly, we also work with a partner organisation, Inspiring Scotland, to manage the fund, but they do not just manage the accounting. They work with the third sector organisations in terms of how to make their funds last as such and also to those organisations that are not very versed in it about applying for further funding. Inspiring Scotland has done a great job in working with the third sector to try to make them as sustainable as they can be. Evelin. As we look forward to giving the demands on the NHS, how does the Scottish Government see the relationship between the third sector, perinatal mental health services and the NHS developing in the future? Kevin Stewart, please. That is an extremely important question. What we require here, without doubt, in order to get that right for women and families across Scotland, is for complete co-operation and collaboration and a lot of communication between NHS boards, the third sector and the voices of lived experience. That is the best way of ensuring that we do all that we can for women, their babies and their families. I have to say that, in terms of some of the third sector work that I am aware of, it is crucial. In terms of the developing of services at board level, third sector and the voices of lived experience should be at the very heart of that work in order that we get that right. That is a very important question from Ms Tweed. What I am saying is communication, collaboration and co-operation, and then we will get it right for people. We move on to final questions from Emma Harper. Thanks, convener. I know that the minister mentioned stigma in the opening comments and also took a question from Sandesh Gulhane about stigma, so I will not belabor it, but I know that the Government is doing a lot of work to address concerns and raise awareness with the public around perinatal mental health. I am reading some of the issues here, tackling stigma and fears around perinatal mental health, including concerns that mothers might have their children taken away from them, is one of the issues that is being addressed. There are 12 action items in the perinatal mental health plan. I would like to elaborate a wee bit on specific actions that are being taken to tackle stigma. I know that a common theme and the evidence that you have had was a concern from mothers that seeking help with perinatal mental health services could result in the loss of their child. On tackling that kind of stigma, it is extremely important that we get that right. The forthcoming raising awareness speech practice guide will aim to highlight mechanisms to tackle that kind of stigma at multiple levels. We recognise that we cannot remove stigma by adopting one single approach and that, to be effective, stigma reduction needs to be tackled on multiple levels. Therefore, we must look at what works for different families, members of different communities, within the public and within different groups of professionals. The modules that Ms Harper has talked about earlier on perinatal mental health contains a specific module for practitioners focused on stigma to help inform professionals across Scotland to help to ensure a consistent and empathic approach that I should have avoided is adopted. Every baby box in Scotland includes a leaflet on perinatal mental health. The leaflet is currently being updated to include the latest information on where to seek help. We are currently working with CNE to explore ways to actively promote role model and highlight good practice around stigma reduction and raising awareness across perinatal and infant mental health. In addition, in February 2021, we ran a national campaign aimed at increasing awareness and reducing stigma around infant mental health, called Wellbeing for We Once. Without doubt, convener, that is an area that we need to do much more work in. It is an area where we need to co-operate together to ensure that we reduce stigma. We must do all that we can for women, babies and their families in the sphere. We need to get the general public to recognise that this scenario will go through what could happen to anyone and that we as a society need to do all that we can to help women, babies and their families to get through difficult periods and hopefully reach a brighter future. That is a good note to end on. I thank both ministers and all their officials, as well as the many people who got in touch with the inquiry to tell us of their experiences. We will suspend the meeting before we come back at 10.45. The third item today is consideration of the Transvaginal Mesh Removal Cost Reimbursed in Scotland Bill at stage 2. To make everyone aware, we have a substitute member, Mary McNair, who is substituting for David Torrance, who gives his apologies. I welcome the cabinet secretary for health and social care to the meeting. Before we start, I will explain the procedure briefly for everyone who is watching us. There will be one debate on each group of amendments. I will call the member who lodged the first amendment in that group to speak to and move that amendment and to speak to all the other amendments in the group. I will then call any other members who have lodged amendments in that group. Members who have not lodged amendments in the group but who wish to speak should make a request to speak by typing R in the blue jeans chat function at that appropriate point, and please only speak when I call your name. If he has not already spoken in the group, I will then invite the cabinet secretary to contribute to the debate. The debate in the group will be concluded by me inviting the member who moved the first amendment in the group to wind up. Following the debate on each group, I will check whether the member who moved the first amendment in the group wishes to press it to a vote or withdraw it. If they wish to press ahead, I will put the question on whether that amendment is agreed to. Any member who still wishes the amendment to be put to a vote if the original member does not want to press it will put an N in the chat box at that stage. If that happens, we will then proceed to a vote on the amendment itself. If a member wishes to withdraw their amendment after it has been moved, they must seek the agreement of other members to do so. If any member presents present objects, the committee immediately moves to a vote on that amendment. If any member does not want to move the amendment when called, they should say not moved. Please note that any other member present may move such an amendment. If no one moves the amendment, I will immediately call the next amendment on the marshaled list. Only committee members are permitted to vote. Voting will take place electronically using the blue jeans online chat function, as convener, I will provide instructions on how and when to vote, and those will also be relayed via the chat box. If any member has requested a vote on an amendment by placing an N in the chat function when asked if that amendment is agreed to, we will then proceed to a vote on the amendment itself. First, we will record votes for the amendment. Any member who wishes to vote for the amendment should then place a Y in the chat box when prompted to do so. Secondly, we will record votes against the amendment. Any member who wishes to vote against the amendment should then press an N in the chat box when prompted to do so. Thirdly, we will record abstentions on the amendment. Any member who wishes to abstain on an amendment should then place an A in the chat box when prompted to do so. To enable the clerks to record votes accurately, please do not use the chat box for any other reason during votes. If you need to communicate with myself or the clerks for any reason during this time, use our private messaging group that we have set up. Once voting has been completed, the clerks will check the result and they will pass that result for me to read out. Once I have read the result of the vote, should you consider that your vote has been incorrectly recorded, please let me know as soon as possible and I will pause to provide time for that. The committee is required to indicate formally that it is considered and agreed each section of the bill, so I will put a question on whether each section is agreed to at the appropriate point. I now begin stage 2 proceedings. I call amendment 1, in the name of cabinet secretary, group with amendments 2 and 5. I call on cabinet secretary to move amendment 1 and speak to all the amendments in the group, cabinet secretary. We cannot hear the cabinet secretary, so I am just going to allow a little bit of crackling, but that is about it. Can you hear me now at all? I am not sure what is happening with my headphones. Forgive me, convener, but if there are problems, of course, I will log back in and perhaps without the headset, but I will not touch the setup that I have here now and hopefully you will be able to hear me fine. Thank you, convener. I hope that you and all committee members are doing well this morning. Section 1, 3 of the bill currently defines qualifying mesh removal surgery, as surgery for a person who is ordinarily resident in Scotland at the time, the surgery was arranged. Concerns were raised during the evidence session at stage 1 that the criteria was too narrow in scope. It was felt that the eligibility criteria should be widened to allow those who were not ordinarily resident in Scotland at the time, they arranged mesh removal surgery but had been at the time of the insertion of the mesh. I gave an undertaking during my appearance before committee on 2 November to consider that point further. In response to stage 1 report, the Government agreed that the resident's eligibility criteria was too narrow to bring forward an amendment. Therefore, the amendments before you today will extend the eligibility criteria to include those who were not ordinarily resident in Scotland at the time of arranging the mesh removal surgery but who were ordinarily resident in Scotland when the mesh was inserted. I hope that those amendments will be welcomed by committee and I move amendment 1 in my name. In respect to amendment 5, the bill is intended to allow reimbursement of those who have themselves arranged and paid for mesh removal surgery. Where mesh removal surgery is arranged by a health board, it is provided free of charge. A health board would not normally arrange surgery for a patient who was not ordinarily resident in Scotland. For those reasons, the Government cannot give its support to amendment 5, but, as always, I would be keen to continue to liaise and engage with Ms Mocken in her explanation of the amendments that she has tabled. We can, of course, revisit the issue if it is required to come to stage 3. Thank you, cabinet secretary. I now call on Carol Mocken to speak to amendment 5 and the other amendments in the group. Thank you, convener, and thank you to the minister for his movement of the amendments. In moving amendment 5 and speaking to all the amendments in the group, I want to be clear that I am very happy with the spirit of this bill and the very collaborative nature of the Parliament in moving this forward and through each stage to ensure that the women involved are reimbursed at the earliest possible timeframe. My amendment 5 is to ensure the broadest scope for the qualifying residence element of the bill. As the minister has stated, the committee has always agreed that this is the correct approach. Amendment 5 ensures that, if there are any women who have had mesh implant removal undertaken by the NHS but are not ordinarily resident in Scotland, they would be included in the eligibility criteria to allow them to seek expenses. The committee did, towards the end of our discussions, touch on this and the right of all women adversely affected by trans vaginal mesh surgery who had any surgery in Scotland. Therefore, in the interest of clarifying the bill and making sure that parts of it are not unclear for those affected, I move amendment 5. Thank you. I am not saying any other members that wish to speak on this, cabinet secretary. Would you like to wind up and press or withdraw amendment 1? I have lost you again, so if anybody wants to put that wire, you should go. Will you pause to allow the cabinet secretary to log in and log back on? Hello, can you hear me now? Are you able to hear me okay? Yes, we can hear you. We'll leave the headphones to the side, I think. We'll go without it. But if you hear my daughter in the background having a tan from then on, my apologies in advance. That's just life during Covid. I'm used to it by now. Sorry about that, convener. That's okay. Right broadcasting, just let me know when you want me cued. Okay, we're ready to go. Thank you. So we've got cabinet secretary back. I believe that you're not, you don't wish to sum up. I'm happy, convener, to wave right other than to say that I'm happy to speak to Ms Mawkin off-table if her amendment doesn't pass to see if we can give any further reassurance in relation to stage 3. Thank you. So the question then is that amendment 1 be agreed to. Are we all agreed? Now I just remind you that if you're not agreed to put an N in the chat box and then we'll go to the division. Just give you a couple more seconds because it is looking like we are all agreed. We're agreed. Amendment 1 is agreed to. I call amendment 2 in the name of the cabinet secretary already debated with amendment 1. If I can get the cabinet secretary to move amendment 2 formally. Moves, convener. Thank you. The question then is that amendment 2 be agreed to. Are we all agreed? I'll give you a few seconds. Amendment 2 is agreed to. I call amendment 5 in the name of Carol Mawkin, which was already debated with amendment 1. Carol Mawkin, can I ask you to move or not move amendment 5? The question then is that amendment 5 be agreed to. Are we all agreed? We're not agreed, so we will go to a division. We'll use the chat box, please. All those voting in favour of amendment 5, please type a Y in the chat function now. Thank you. All those voting against amendment 5, please type N in the chat function now. Thank you. Anyone wishing to abstain, please type A in the chat function now. The clerks are just finalising the vote. You just give me a second or two. Here the votes for amendment 5 were 2 and against 8, and there were no abstentions, the amendment is not agreed to. I call amendment 4 in the name of Jackie Baillie, and that is grouped with amendment 3. I'll point out that amendment 4 pre-empts amendment 3. Therefore, if amendment 4 is agreed to, I cannot call amendment 3. I will ask Jackie Baillie to move amendment 4 and speak to all amendments in the group. Jackie Baillie. Thank you very much, convener, and I'm grateful to you and the committee for the opportunity to move amendment 4 and speak to both amendment 4 and 3 in my name. Those obviously flow from the committee's evidence session prior to stage 1 of the bill. Policy intention behind the amendment is fairly straightforward. It extends the eligibility period for women who have arranged surgery for mesh removal. The original cut-off date, members will recall, that was suggested by the Government was 12 July 2021, and the committee was clear that to capture as many women as possible, we needed to be as generous and flexible with eligibility criteria as possible. We didn't want any unnecessary barriers in the way of women accessing reimbursement. The cabinet secretary said at the time that he would give the matter further consideration, so here I am with two amendments. Amendment 4 and amendment 3 have the same effect but are two different ways of achieving the desired outcome. It is very much for the committee to decide which it would prefer. Amendment 4 puts on the face of the bill that the qualifying date is for any removal surgery to have been arranged before royal assent and not specified in the scheme. Amendment 3 stipulates that the date will be specified in the scheme, but it can be no earlier than the date of royal assent for the bill. Ultimately, the difference is whether you want it on the face of the bill or you want it in the scheme. I will move amendment 4 at this point in time. Thank you, Ms Bailey. I am not saying any other members who wish to speak on those amendments, so I will go to the cabinet secretary. Thank you so much, convener, and thank you to Jackie Bailey for bringing those amendments forward, for moving them and also thank her for being the only one who is clearly in the festive spirit with her backdrop. I am grateful genuinely for Jackie Bailey for bringing those amendments forward. As well as other committee members, Jackie Bailey pressed the Government to consider whether or not the cut-off date of 12 July was when I announced publicly the completion of the first stage of procuring an NHS referral route to private removal surgery. Was that the right date to have in place? I thought that committee members are also, most importantly, the women affected to you to get evidence from as a committee. I thought that their arguments were very persuasive indeed, and I have always said, ultimately, for this bill, not just to meet its primary purpose, but to seek to try to bring some justice to the women involved, then the voices of those women must be central to any of our deliberations on the front. I also absolutely appreciate that there has been a delay since the initial announcement in July, and it has taken some time for contracts to be completed. That is not because of any application of goodwill of the parties involved or far from it. They have been engaging very well and helpfully in negotiations, but it is no doubt that those are complex contract negotiations. I fully accept that, having met a number of women involved, the delay in completing those contracts has undoubtedly caused anxiety for women who have suffered far too long. The Government does not want those women penalised for the fact that contract negotiations continue to make progress, but, of course, they are taking their time to work through the intricacies of those contracts. I will confirm now that the Government wishes to add its support to amendment 3, brought forward by Jackie Baillie. In confirming our support, we hope, too, that there is a consensus in the committee and, more widely, that the scheme should not be open-ended. There should, after the cut-off date passes, be that all the options put in place by the NHS, including referral to private providers, which should offer women the support and the choices that they need. We need to have a date that is not open-ended, but I think that the committee would probably agree with that. The Government considers that it is reasonable now to be an extension to the cut-off date for the scheme to include time since July to around the time of royal assent. I did take notice of amendment 4, and Jackie Baillie thought so well. I think that amendment 3 is better because it retains some element of flexibility, given those particularly uncertain times. I think that it would be sensible to keep open the option of adjusting the cut-off time if there was some unanticipated development. As I said, good progress is being made with the two private providers in terms of contracts. We are confident that surgery in the independent sector will be available from early next year. I am closing. I thank Jackie Baillie for tabling amendment 3. I confirm again that the Government will support it, and I hope with that support that it allows Ms Baillie to withdraw amendment 4. I will ask Jackie Baillie to wind up and to press a withdrawal amendment 4 with Baillie. Thank you very much, convener. There is an important lesson in politics as in life, which is to quit whilst you are ahead. I thank the cabinet secretary for his support on that basis, convener. I am content to withdraw amendment 4 and press amendment 3. I call amendment 3, in the name of Jackie Baillie. I have already debated with amendment 4, and I ask Jackie Baillie to move or not to move amendment 3, Ms Baillie. The question is whether amendment 3 would be agreed to. Are we all agreed? I do not use the chat box and put an end. It appears that we are agreed, so amendment 3 is agreed to. I now call amendment 6, in the name of Carol Mocken, which is grouped with amendments 7, 8 and 9. I call on Carol Mocken to move amendment 6 and to speak more amendments in the group, Carol. Thank you again, convener. In moving amendment 6, 7 and 8 and 9, I clarify again that my amendments aim to be helpful in ensuring the spirit of the bill in the discussion of the committee and that it is captured in the final bill. Amendment 6 and 7 seek to add wording that will give clarity at this part of the bill. The committee did seek to ensure eligibility for someone in current costs and supporting someone to have treatment, and that is covered in my amendment 6 and 7. That would allow that to happen. Amendment 8 is to extend the bill to cover those who may have begun the process and had costs, but unfortunately the process has halted due to travel restrictions or surgery restrictions in relation to coronavirus. Amendment 9 is a simple amendment, just laying out the meaning for coronavirus for the state of the bill if passed. I move amendment 6, 7, 8 and 9 and seek the support of the committee in what is quite straightforward amendments. I am not seeing any other members wishing to speak on that. Can I come to the cabinet secretary? Thank you, convener. I echo what Ms Malkin has said about how the passage of this bill has been collaborative and constructive. Although I will be resisting Carol Malkin's amendments, I want to make an offer to her that if they do not pass, I will be more than happy to work with her between stage 2 and stage 3 to see if we can give some effect to some of the concerns that she may have. I am grateful for her explanation of the intention behind her amendments 6 and 7, and I want to assure her that the bill, as drafted, do cater for the circumstances that I believe she has in mind. In section 14A of the bill, it states that qualifying costs are, I quote, as charged to or in respect of the person who underwent surgery. The words, in respect of, therefore, already allow for expenditure by someone other than the patient to be taken account of and reimbursed. If a person who is not the patient has directly paid part of the cost of surgery, the evidence of that expenditure can be submitted and, of course, can be considered for reimbursement as part of the claim by the person involved by the patient. As I noted in the Parliament on 24 November, we expect that applicants may well want to claim reimbursement of costs and then pay back any money available to them or spent on their behalf by family members or friends. The draft scheme that has been provided to the committee includes some important details on that point. paragraph 17 of the draft scheme clarifies that money received from public fundraising campaigns must be declared in the application and may be deducted, but costs that have been met directly by another person may be included in an application and it will be for the receipt of any reimbursement to distribute that money that they receive. For example, if a sibling paid for surgery on behalf of the patient, that expense could be included in the patient's application and, of course, once the patient receives the reimbursement, she could then repay her sibling. I should also say that I do have a worry that Ms Malkin's amendment could lead to people who are only slightly connected to the patient making an application for reimbursement in relation to the patient's surgery. I appreciate that that will not have been the intention but, in general, it would make sense for applications to be made for or on behalf of the patient and their supporter and then allow any private monies to be repaid. I hope that that clarification is helpful to Ms Malkin and I hope, therefore, that she will be content to withdraw amendment 6 and not to move amendment 7. In relation to amendments 8 and 9, again, I am also grateful for the explanation. I do, of course, appreciate the plans of patients who are hoping to arrange mass surgery. They may well have been disrupted, particularly in the times that we live in. My officials are aware of a number of cases, as committee members will load out B2, but the Government is not aware of any circumstances where travel has been actively curtailed in the way envisaged by the amendment. That said, we consider that there is more than sufficient flexibility to deal with individual circumstances in the draft scheme. As a result of the decisions of foreign governments, it is made impossible to expect that carriers will either refund at the costs or offer an offer. Broadcasting, we may have to suspend briefly because we have lost the cabinet secretary. If we could suspend briefly while we just check the connection for the cabinet secretary and get him back in. We appear to have resolved our technical difficulties. I will check that we have got the cabinet secretary back with us before I move on. Hi, convener. We do. I think that we heard your summing up there. I am going to ask how Mocken, if she would like to wind up and press or withdraw amendment 6. Hi, thank you, convener, and thank you to the cabinet secretary. I appreciate the discussion around the amendments and accept that there is time at stage 3 or before stage 3 to discuss them again and make sure that we get it right for people. I will withdraw amendment 6. Do you want me to go on, convener? No, I will prompt you with the other amendments. You are withdrawing amendment 6. I will then call amendment 7 in the name of Carol Mocken to already debate with amendment 6 and ask Carol if she would like to move or not move amendment 7. I will now call amendment 8 in the name of Carol Mocken to already debate with amendment 6 and ask Ms Mocken to move or not move amendment 8. The question is whether amendment 8 be agreed to or we all agreed or not agreed. Therefore, we have a division. If we just stand by and again use the chat box, if I can ask all those in favour of amendment 8 to type Y in the chat function now. Thank you. All those voting against amendment 8 please type N in the chat function now. All those wishing to abstain in amendment 8 please type A in the chat function now. The clerks will now finalise the vote. At the results of the vote on amendment 8, we have four members, four and six against and no abstentions. The amendment is not agreed to. We move on to amendment 9 in the name of Carol Mocken. I already debated with amendment 6 and asked Ms Mocken to move or not move amendment 9. The question is whether section 1 be agreed to or we all agreed. We are agreed on section 1. The next question is whether section 2 to 5 be agreed to or we all agreed. We are agreed. The last question is whether the long title be agreed to or we all agreed.