 Finlays. Welcome to the 35th meeting of the Health, Social Care and Sport Committee in 2023. I have received no apologies for this meeting. The first item on our agenda is to decide whether to take items 4, 5 and 6 in private. Are members agreed? The second item on our agenda is the first oral evidence session as part of the committee's inquiry into healthcare in remote and rural areas. Today we will be hearing from representatives the Scottish Government and NHS Education for Scotland. For this morning's meeting, I welcome Stephen Lee Ross, Deputy Director of Health, Workforce Planning and Development, Scottish Government, Shabon Mackay, interim Deputy Director of Primary Care Capability, Scottish Government, and Dr Pam Nicoll, Associate Director of Medicine and National Centre for Remote and Rural Health and Care Lead NHS Education for Scotland. We are expecting Professor Emma Watson to join us, Executive Medical Director of NHS Education for Scotland, and Dr Pam Nicoll is joining us remotely, so thank you and welcome. We will move straight to questions. I'm just keen to hear how the work of the Scottish Rural Medicine Collaborative informed the plan for the new centre, and what additional areas will the centre cover. I'll kick off with that. The development of the rural centre is very much the product of lots of discussion around implementation of the 2018 GP contract. I'm responding to the concerns about implementation of the contract in rural areas. A rural working group was set up here by Sir Louis Ritchie to explore that and try to find solutions. It covered a range of issues that are formed by lots of engagement across rural communities, both within the health and social care workforce and users of services. One of the recommendations was the development of the rural centre, which has now been commissioned to take forward. Scoping that centre out, it has built on that original engagement through Sir Louis's work and will continue to engage broadly with a range of rural interests, workforce users, as that work progresses from here. I think that Sir Louis has described it before, hoping that this will be an international example in this space. The centre will very much pick up many of the issues that Sir Louis's broader report looked at around recruitment and retention, education and training, research and evaluation, leadership and good practice. I might hand over to Pam at this point to give a bit more context from Nez's perspective as we move forward on that. We have worked closely over many years within and we are members of the Scottish Rural Medicine Collaborative. We take forward all of the learning and the outputs from their work into the work that we will carry forward and build on now within the national centre. Part of the work of the national centre is to work in a streamlined manner, bringing under one virtual roof all of the work from Scottish Rural Medicine Collaborative. A variety of excellent programmes of work that have been carried out across Scotland to address health and care in remote and rural island areas over many years. As Siobhan has highlighted, that allows us now to work across all four priority areas in a very co-ordinated and streamlined manner, but very much building on the work that has come before and particularly from our work within the Scottish Rural Medicine Collaborative. My registered interests in the registered mental health nurse. When I was reading through the work of the Scottish Rural Medicine Collaborative and the final bulletin to members, I was struck by how medically dominated that was. It talked a lot about GPs. Siobhan referred to GPs here and even the work streams looked to me to be very much focused on doctors and the need for recruitment and retention there. How are you going to ensure that this does not solely focus on medical staff and widen this out to nurses, allied health professionals etc? I'll just kick off and bring Pam back in. Part of the discussion around the 2018 contracts was around some of the challenges for rural areas around the establishment of the multidisciplinary team and the implementation of the contract. That was very much in the scope of the discussions around the rural working report and the rural centre going forward. I know that for the rural centre, those broader professions will be looking at that across the scope of the health and social care workforce. Pam, do you want to add to that? Thank you. We are very much focused on the multidisciplinary workforce here. Our chosen way of working is to focus on the rural team in order that we are as inclusive as possible across community services and primary care services. From an NHS education perspective, we have been working for the past 16 years on remote and rural and island education support and workforce development in that area, and we have taken a multidisciplinary approach to that in all cases to good effect. We find that yesterday's learning from specific professional groups and what we achieve in one professional group, we are very keen to look at where it is possible to transfer that learning across other groups. From the national centre perspective, all of the evidence that we have and all of our success in the past, particularly around remote and rural and island education and training, has been around supporting a multidisciplinary approach, and that is what we will be taking forward very much across the national centre work plan. It would be helpful to see some more detail around that work plan because that certainly was not what I was getting from the reading that I had done preparing for committee. I am now going to move to Emma Harper. Good morning, everybody, and good morning to Pam online. I am interested in issues around how the impact of the national centre for remote and rural healthcare will be delivered. I suppose that I am thinking about the actions impact of the strategy and the plans. We have had previous papers. We have had papers from the remote and rural areas resources initiative. We have had a newer paper in 1912. I remember Jason Leitch talking about Nuka in Alaska, about more community delivered ownership of healthcare rather than being done to the people. I do not mind everybody, I am a nurse. I remember having Professor Leitch talk to us about rural healthcare in the late 90s. I am interested in how will Nes ensure that the work of the centre focuses not only on strategy development but also on actions delivery and impact? I am again in hand over to Pam. Our ambition for the centre and looking at what success looks like is that, through the work of the centre, we see an improvement in the sustainability capability and capacity of rural and island primary care and multi-disciplinarity community-based workforce to increase that capacity across rural and island communities so that we are seeing more people getting that right care at the right point of contact. Pam, do you want to come in a little bit more on that? Thank you for that question because we are very aware of the strong history that we have across Scotland in addressing and identifying our remote rural and island health and care challenges. We are aware that we worked on the excellent policy that was delivering for remote rural health and care and led on the education and training work there. Since then, over the past decades, there have been a range of very helpful programmes of work and initiatives, as you have identified, highlighting both the needs and the challenges of addressing the remote and rural island service delivery and supporting the workforce. In 2008, the Scottish Government supported the establishment of the first permanent team, which was the remote and rural health care education alliance. We have been delivering for the past 16 years education, training and workforce support, but we have been keen to be able to leverage the expertise of partners across Scotland who have expertise in remote and rural research and evaluation within the development of leadership, skills and good practice. We also work a great deal with our international remote and rural partners and we have a great deal of evidence of programmes of work that have been practically implemented in other countries, as well as across parts of Scotland that we want to take forward. The outcome of all that is that our delivery plan is very practically orientated. We are very heavily focused on specific programmes of work that are now bringing all those elements together. For example, before we may have worked on a piece of educational training, but not necessarily being able to back that up with appropriate impact evaluation, practical research into does it work, how is it working, where does it work and for whom, in order to be able to take that across other areas in Scotland, for example, we will now be able to leverage expertise to work across all those areas in very practical programmes of work addressing the priority needs that the centre has been set up to support. I thank you for that question because we are very determined that our work, particularly around recruitment retention, research and evaluation will be incredibly, practically orientated and it will be focused on getting the results out and sharing those with our colleagues within the workforce as quickly as possible. Just to come back on that, about monitoring and evaluating whatever is implemented, so for 16 years we have had a permanent group looking at rural and so how are we monitoring that and then obviously evaluating that is what Pam mentioned, but then also I will just roll in with my final question about how will the centre work with integration joint boards and local authorities to ensure that the work is delivered directly at the point of where it is needed, which is our remote and rural areas for Shetland, Pistran Rar, for instance. I will hand back over to Pam. There is a commitment to evaluate the centre. The centre has funded around £3 million until 2026 and evaluation will take place, I think, after this year 2, to look at the impact that the centre is making and to consider what the future of it is for the initial piece. As a proof of concept, the centre is very much focusing on primary care and Nes might want to speak about what broader scope it would like to have, but we very much see the centre as a hub of support for health boards and health and social care partnerships. Pam might want to come in on how they are linking in with those. While it is focusing on primary care, the work that it is done, doing and will achieve, the aim is that that will be a learning opportunity and replicable in other settings beyond primary care, but I will hand over to Pam now. Thank you, yes, absolutely. Just to follow up on that part, we will be heavily reliant on establishing excellent collaboration with our health board partners, our primary care partners, our local authority partners and a range of other agencies across Scotland in order to deliver on that and to achieve impact. From a Nes perspective, the first part of your question over the past 16 years is reasonable to say that we have become world leaders for Scotland in delivering and designing remote and rural and island education and training and supporting our workforce. To the extent that we have a happy history of requests for visits from other countries to come and understand what we are doing and how we are delivering it, there is still more work to be done. That work has been measured over the past 16 years within Nes through our own governance process reporting to Nes board, for example, and then back to Scottish Government as delivering partners on behalf of Scottish Government for that work. I am very happy to share after the meeting today more information on, if you like, the track record that we are building on and bringing into the national centre, while acknowledging that there is definitely more work to do, but we have a great deal of expertise already in Scotland upon which to build and to take that work forward. We are very much in partnership with people in our communities, with local authority partners and with a range of partnership agencies in order to deliver and have impact. Can I remind those in the room that you do not need to operate your microphones broadcasting in Tiswy? Thank you, convener. My questions to Stephen and Siobhan, please. So, earlier this year I attended a round table with the Royal College of Nursing and it focused on student finance. There was an example from one of the students who had got a placement on the Isle of Skye and she had found accommodation but it had to be registered with the council. Due to housing availability on such a remote location and it being cost prohibitive, she had to withdraw from that placement. My question is, what is the Scottish Government doing to support student nurses who want to train in rural and remote areas? Thank you. I will pick up that to start with. Obviously, for all student nurses across all programmes, the Scottish Government does continue to offer a bursary of £10,000 per annum in addition to support with tuition fee costs. There are additional costs. I do not have the figures to hand but I can enumerate the additional financial support for the committee, if the committee would like in relation to support with additional out-of-pocket expenditure related to placement activity across the country. Obviously, that programme of that combined package of financial support is the most advantageous offered anywhere in the United Kingdom but that is being reviewed in line with the evidence that we are taking as part of the Nursing and Midwifery Task Force, which was commissioned on the back of the 23-24 Agenda for Change pay offer, and that task force is looking expressly at, I suppose, attraction, selection and also I suppose the package and offer of support that is available to nurses in training, as well as to attracting graduates to post across the country but in particular looking as well. I suppose the rural and island infrastructure component that is effecting, I suppose, that poses an additional burden as well. If the RCN wants to follow up with you, Stephen, they can do and share their experiences with you. Yes, of course. The RCN are part of the task force and are a leading voice around that table. Thank you. My second question is, and this is to Dr Pam Nicolle. In the north east, we're seeing a proliferation of 2C GP practices being run by health and social care partnerships because it's so difficult to recruit GPs out of the central belt and we've got the recent example of Breymar. What's the Scottish Government doing to address the GP recruitment crisis in remote and rural areas of Scotland? Thank you. I can answer the part that the National Centre is doing in terms of focus work around this area and then I'll pass it to my Scottish Government colleagues to give an overview of all of the work that's being taken, undertaken by the Scottish Government to improve this situation. As a practical example, we talked a lot about the delivery plan for the national centre, so some of our first priorities for the first 24 months focus very much on a streamlined approach to improving both recruitment and retention and attraction and keeping of our GPs that we have and attracting more into practice, of course. Two key pieces of work that we have begun already, we're working to improve support and training for dispensing practices, which are remote and rural practices for all the staff within there. We know that that's a considerable stress and we know from evidence that some GPs being attracted to these remote and rural practices have concerns around supporting the full dispensing function, so that's an immediate priority for us. We've begun work to develop education, training and support packages around that already. We're also working to introduce for the first time in Scotland community training hubs in our practices and we're very keen to support 2C practices in their suspect, first of all, and if I could just explain a little bit why that will be helpful. There is, again, feedback and evidence around the burden that GPs feel in providing training within their practices and yet we know to attract more GPs. We have to expose GPs during their training and also give positive experiences throughout their career of undertaking practice within more to rural areas to achieve real improvement in recruitment rates. We in Scotland haven't, we've had a large amount of our training, particularly for our medical colleagues, that's been carried out within the acute setting, within hospitals over a long period of time and we're now working hard across Scotland through the national centre to develop a package of support education training programme guidance and protocols that will allow remote and rural practices to become what are termed community training hubs that will then attract more GPs in training into remote and rural practice, more doctors in training will come through remote and rural practices as part of their training without increasing the burden on existing staffing. We intend to do that across the rural practice multidisciplinary team so that will include pharmacists, nursing staff, advanced practitioners as well. That work is already underway and we've specifically chosen practices to be involved in that that are geographically spread across Scotland. Thank you. Just one quick follow-up. How much of a priority is this for you? Is it in your top three priority list? Top priority. Top priority in addressing improving recruitment and retention and supporting our existing staff. Thank you, convener, and thanks to the panel for attending today. Evidence from Infreason Galloway health board has described vacancies as a staggering challenge that is on a par with the financial issues. Can you provide further detail on the extent of the vacancies in rural areas and what can be done to attract people to these roles? I'm happy to pick up that question. So I suppose overall across Scotland we've seen an upward position in vacancy trajectory across the principal job family, so that's nursing, midwifery, medicine, dentistry and the H.P. Over that, since 2019, they've risen precipitously in each job family since 2019, although in the last 12 months what we've seen is a drop in vacancies both in nursing and midwifery and in H.P. roles as well. What we see in terms of the vacancy position overall is that vacancies typically have been on an upward trend in medicine and dentistry for more of our rural and island boards. Borders, Highland, Ocney and Shetland, although for Shetland, Western Isles and Ocney, this sort of fluctuation in numbers is small in nominal terms, and that vacancies in nursing and midwifery and H.P. have been on a downward trajectory for the last 12 months, including both staff in post and advertised vacancies. That's likely to reflect obviously the efforts so that there's been about £80 million of funding provided to recruit international nurses, midwives and AHPs, and that's successfully recruited around 1,250 nurses, midwives and AHPs so far. I suppose it also reflects a shift in the configuration of job families post pandemic. The trends as they stand reflect also the pre-pandemic pattern of them being more of a challenge with medical and dental posts in rural and island settings comparatively speaking as compared with nursing and midwifery, which is the inverse in our urban areas. Thanks for outlining those trajectories, though there are underlying pressures within the domestically-based workforce and certainly have enjoyed recently a table, a round table with the Royal College of Nursing. Students cited examples of wanting to do placements in rural areas and in islands, but not being able to do that because of financial constraints from their student bursary. Is there perhaps more work to be done to support and incentivise rural placements so that there isn't a significant financial cost that could actually be detrimental or a complete disincentive for participating in placements in those locations? Yes, so the attractiveness of placement, particularly in rural and island settings as I was saying earlier, is one of the things that's being considered actively as part of the nursing and midwifery task force. We're aware obviously that there's a financial element to this that's been raised by the RCN and colleagues, and there's obviously also an infrastructure element to this as well, which we've been considering as opposed directly with colleagues in the island boards and looking at the availability of accommodation both for placement activity and peripatetic appointments within those settings. I'm working with colleagues across government to, I suppose, release funding to increase accommodation capacity. So there has been an example quite recently, I think, in NHS Shetland of the board being supported by government to purchase guest house facilities and to repurpose that for the purpose of housing, peripatetic and placement students as well. So we're aware that there's obviously a direct financial component to this as well as a broader infrastructure element and the two need to be considered in tandem. What other efforts are you putting into developing housing capacity? Is it just purchasing existing stock or is there potential to develop more housing around clinical sites? So obviously one of the things that we've done to engage in terms of engaging with colleagues across government who are leading on the rural development plan is pick up the question of key worker housing. So obviously not just housing for, as I say, for placement and peripatetic staff, but how increasing housing availability more generally is part of attracting staff to live and work in the communities in which they serve, both I suppose local domestic recruitment and also our international recruitment efforts. I think the figure off the top of my head but I would have to double check is that the commitment is around £30 million with investment overall in terms of the Scottish Government's broader housing strategy commitments in terms of investment in new housing to support key workers. That is of course across the country. I'd like to ask directly about the 2018 GP contract. Was the Scottish Government told that the GP contract would negatively impact rural and island GP and primary care settings? I'll come in on that. I can't comment specifically on what might or might not have been told to the Government at that time, but I'm aware of concerns that were raised and that work has been on-going since through the work of Sir Lewis's group on-going discussions with the BMA around moving towards phase two commitment to continuing to take account of the needs of rural communities. We've spoken about the centre, which is very much the project of that discussion. We have spoken about all of those things, but my question was very direct. If you didn't know, perhaps Stephen would know if the Government was told back in 2018 that the GP contract would negatively affect rural and island communities. I'm not afraid, I'm not aware of that. Certainly there was a lot of discussion at the time. A declaration of interest, I'm practising NHS GP, but I also sat on the BMA Scottish GPC at the time of the contract. A lot of noise was made by rural GPs that this contract would negatively affect those areas. How long, from the 2018 contract of all the things that you're saying has been put into place, how long the gap was that? My understanding is that the rural working group around very much focused on the implementation of the GP contracts in rural and island areas was established in 2018 and reported in 2020. It made a number of recommendations, as you've rightly mentioned. We have already covered off the national centre, but it will pick up with many of the recommendations in the services report. A number of other recommendations include ensuring that no GP's rural communities or elsewhere lose out, so that the incentives guarantee, if I remember correctly off the top of my head, that's continued. That was about £23 million and has been uplifted since a range of other funding initiatives to support rural communities. There's work around dispensing practices, which is actively on-going and will be picked up by the centre around guidance and training materials for dispensing practices. Work to continue to respond to those concerns has been on-going since 2018 and continues to on-going. As I say, commitment as we approach phase 2 to continue to engage around what that rural dimension looks like. In terms of the establishment of the AMDT, I'm aware that our GP colleagues have been quite clear that if some practice services should only be handed over to the NHS boards at a time when it feels safe, if GP's want to continue delivering some services, we're by no means opposed to that, in terms of implementation of the— Can I pick you up on that? For example, a vaccine delivery system that lots of GP's in the highlands are saying that they would like to take on, but the health board is saying they're not allowed to. Are you saying that they are allowed to deliver the vaccine programme? My understanding is that between the board and the GP's, they can have that conversation and services should only be handed over when it's felt safe and appropriate to do so. On vaccines specifically, I'd be happy to pick up with my GP colleagues to provide more information on that particular question, if that would be helpful. That would be very helpful. Thank you. Tess White asked about numbers, if I can tell you, Stephen. What are the numbers of physicians' associates in primary care in the highlands or in rural settings? I'm not directly aware of the number of physician associates working in GP settings in the highlands and islands. I can say that, overall, we have a comparatively low number of physician associates working across NHS Scotland, both in GP settings and in health board settings, and that number is in the low 2 to 300s overall. But it's a growing number? It's a growing number, but it's growing marginally, nominally, compared with growth in other disciplines. Can I ask what the role of a physician's associate is in primary care? As has been set out, the role of the physician associate in primary care is to support the delivery of primary care services and that that physician associate with appropriate supervision and direction can undertake activities, broad-based activities relating to the delivery of healthcare, providing, of course, that they are appropriately trained and supervised. We've specified, I think it was in a direction letter from 2016, how we expect that to be communicated and enumerated to patients receiving services as well. It's my final question, and I think it's really important about physicians associates. If you look at some material that's coming out, physicians associates are talking about being GPs. There is undifferentiated care being seen by physicians associates who, whilst they certainly have a degree in two years of training, that's not what a very senior nurse would have, for example, who's an advanced nurse practitioner, who's done many years to be at the point where they are seeing someone. So, with the difficulty in recruiting in rural areas, are we in danger of seeing a two-tier health service where people who live in rural or deprived areas are more likely to see a physicians associate than a general practitioner compared to better off areas? So, I can answer that. I don't believe that that would be the case in the context of the trajectory that we're on within the NHS in Scotland and the commitments that have been made by the Scottish Government. So, in connection, I suppose, with general practice, obviously, there is an outline commitment to increase the numbers of GPs by 800 by 2027, and we've seen record increases in undergraduate medical places alongside record increases in GPST training places with a commitment to deliver a further 100 over the next three years. We've also expanded our ScotChem undergraduate programme in medicine. We train comparatively small numbers of physician associates domestically. There is a small programme within Aberdeen University of about 40. As I was saying a moment ago, we have 40 per annum, that is. We have broadly 2 to 300 working across the service, and we've committed to looking at the role of physician associates along with other medical associate professionals over the next couple of years by independently evaluating in line with recommendations that came from a report undertake that we commissioned from us, looking at the role that medical associate professionals can play within and across our health service, and have committed only to pending that evaluation to modest increases in training numbers across the suite of professionals. I met with NHS Frees and Galloway recently and the CEO, Jeff Ace, said that the retention of ScotChem graduates in the Frees and Galloway was excellent. This article here says that there's 55 completed the first four-year graduate entry to medicine programme, which is unique in Scotland. My colleagues in Ireland, as part of the British Irish Parliamentary Assembly, are looking to Scotland to learn about ScotChem so that they can maybe implement it elsewhere. I'm interested in what your findings are regarding ScotChem. Is it successful? Has it proved to be supporting rural recruitment for general practice across either side of the central belt? Obviously, in one sense, it's a little bit early to do the final analysis because we've only had the first group of graduates. What we can see is that, from those 55 graduates, there's been successful retention on two foundation training programmes and we're anticipating a further 40-odd graduates this year. We have expanded the programme in line with our broad expansion of undergraduate medical places. The intake for this year for ScotChem was 70. We are seeing that it is delivering certainly the vast majority of the clinical and preclinical training activity as part of the degree programme in Highland and in Dumfries and Galloway and also on the east coast as well, with indications from the students that they're intending on pursuing a career within medicine in Scotland and remaining in the locality in which they were trained at a higher rate than other groups of undergraduates. Okay, so yeah, that's fine, that was a good enough answer. Thank you. Thank you, convener. Good morning panel. I'd like to ask about palliative care in rural areas. We debated inequality at the end of life in chamber last week, so it will be fresh in members' minds. The most recent Marie Curie evidence to committee, which was around the NCS, highlighted inequity in accessing palliative care in rural areas. My first question would be to ask what role the national centre could have in making sure that our citizens in rural and remote communities know what palliative care is and how to access it? I'll come in and I'll hand over to Pam for some thoughts around that. As we said, the national centre is very much focused on that primary care setting, but I can't speak on lots of detail about palliative care, but that primary care team supporting that person will obviously have a role, and I'm sure that that will be in Nez's sights to thinking about how that primary care team connects with specialist services in the third sector and beyond to provide support for people in rural and island settings, so I'll bring Pam in specifically around palliative care. Yeah, thank you for that. Within the national centre priorities is the need to support our staff to deliver as much care as possible as close to home for the wide range of communities across remote and rural and island areas. A palliative care, in addition to other areas such as provision of high quality mental health support, for example, and also paediatric care, continue to be in our experience from a Nez perspective very high priorities and areas of significant and ongoing need to continually to update staff knowledge and skills with. The national centre will have the ability to understand what these different needs are across different remote and rural and island communities working with the citizens themselves through our stakeholder networks to understand where the gaps exist at the moment, how we can work with our expertise within Nez, we have existing experts within palliative care education and training who work across the multidisciplinary team already, and our job is to understand where the gaps exist across the remote and rural and island workforce now and support addressing those gaps in skills capability and capacity that, in that way, increase in access to good quality skilled support for the citizens that live within Nez communities now and into the future. I am finding this morning's session very focused on staff, which I suppose is understandable in many ways, but I am particularly interested in patients, I suppose. What specifically, Pam Nicolle spoke there about gaps in services, so maybe give some specific examples of gaps that you have identified and how they will be plugged. I suppose that we would all be keen to see that folk we represent in rural communities are afforded the same choices at the end of their life and whether that is to end their life in a hospice or to be at home. Those two things will both have unique challenges depending on whereabouts in Scotland. Someone is based. In terms of addressing the gaps, we work very closely with our remote and rural communities at the moment from an education and training perspective—that has been our history—in understanding the changing needs. Of course, each community has a different range of needs, and each rural team will have a different skill set. What we have developed is an understanding of identifying those specific gaps, both within the community of where we can marry up what is already provided, for example, by some of our excellent hospice work that goes on across the rural areas and working with them to look at delivering educational support and supervisory support for staff in the local areas to feel confident and competent to deliver excellent palliative care, for example, within the local area. In terms of examples, if it is appropriate to step out of palliative care for a moment, such as gaps that we have identified, Scotland has not had a specific training programme to train our growing group of practitioners in rural areas who are working at advanced practice level. That is an area where we expect that workforce to continue to grow and to work alongside the other members of the rural team. We have now developed the first in the UK rural advanced practice programme that means that health boards and primary care practices no longer have to take that on an individual basis. We are currently funding the first cohort of that group of practitioners to go through. Within that will be the priority areas that rural practitioners need to have increased skills and an increased range of skills to deliver that type of care in the local area. I am going to jump in. It is really difficult when you are remote because if you are here I would be trying to catch your eye and not interrupt you. Can you talk to what that would look like for a patient? What difference does that make for a patient, that change in improvement that you have made? Certainly. The change in improvement that we will be measuring the impact on for patients will be, for example, within a specific remote or rural or island setting, where the healthcare practitioner will have an increased range of skills that are increasingly matched to the local community health needs as we go forward. One of the ways that the central department will be using and gathering more data, more understanding and engaging more closely with the local remote and rural and island communities across Scotland in order that we can fulfil that commitment, and then, as we talked about earlier, very practically measuring the impact of that, finding out, asking whether that is making a difference on a regular basis and ensuring that we are delivering a measurable change that has impact for patients. It will be by supporting the service delivery and that will be for us in supporting the workforce capability and capacity to deliver that improved service, but in addition to that, the difference will be in measuring the impact in a very practical and on-going way. I am going to press, if I may, just a little bit one final time. What would that measurable difference be? What sort of thing? Does that mean that somebody does not have to travel to get treatment? Does it mean that they will get treatment quicker? What will it mean for a patient? Where that is possible to have that increased service delivery or if that is the improvements that are required and there are staff within the area that we can support to deliver that care within the local area, then yes, that is one example of what that improvement would look like. I would like to ask about alcohol services because when we had a call for views some of the biggest respondents were about alcohol services, obviously you are aware, as everyone is, about the large number of alcohol deaths that we have here in Scotland. What increases or improvements have been made to alcohol services in rural areas? We probably cannot come in on lots of detail on that, but what I can say is that the Scottish Government continues to be committed to addressing the high levels of alcohol harm in Scotland, working collaboratively with alcohol and drug partnerships across Scotland to understand and help to resolve issues and support them in identifying ways to improve waiting times. There has been increased investment from the national mission on tackling drug-related deaths and it has been used by ADPs across Scotland to support people facing both alcohol and drug use. In 2022-23, £106.8 million was made available to support local and national initiatives overseen by ADPs ensuring that local services... Forgive me, this is specifically about rural areas that I was asking. What is in rural areas to help people with specifically alcohol addiction issues? We do not have material specifically on rural areas, but what is described there will support that rural activity, but we could certainly follow up on that. It would be great if you could let us know what is available and what increases and improvements have been made to alcohol services if you could do that for each year that has come up, including alcohol brief interventions and potential beds that are available for people who want to detox and waiting times, that would be fantastic. I am quite interested in some of the things that we talk about, how we might want to change to a more preventable NHS and how we support that work that we know is quite essential to help people in our populations and communities. In terms of reform in that direction, are rural challenges different? I am particularly interested in the demographic changes of that population, the population and the workforce. Do you have some work looking at how we might be able to make sure that that still happens in a remote and rural areas? I am happy to make a start, I suppose, by taking that question in reverse. What we know in terms of the demographic question that you have just posed is that the demographic challenge is more pronounced in our rural and island communities, because of the twin effects of both ageing and depopulation in those communities. What exacerbates that in the context of that broader community-based and prevention agenda is the total burden of long-term chronic illness that we anticipate we will be managing in terms of demand going forward. There is a set of specific things that we are considering in the context of bringing forward that remote and rural recruitment strategy under the auspices of our national workforce strategy that look at some of the skills mix that is then needed for rural and island working in particular, where you have got lone practitioners and smaller teams and small and multidisciplinary teams of community-based practitioners. It is clear also that there is going to have to be a growing role in terms of matching, if you like, the availability of workforce and service provision with that, I suppose, both national and international demographic challenge that we have with the ageing population across the west in terms of our public health and prevention agenda. That is obviously a key focus of the care and wellbeing portfolio and the proposal to bring forward a further suite of activity to consult on how you sequence that preventative action right from messaging and public knowledge and people being in control of understanding their own health needs, but also dealing with the fact that we know in terms of the burden of disease projections that we will be managing more chronic ill health in the community. I suppose that it speaks to colleagues' questions earlier about the types of skills and areas where we would be focusing on trying to build up the skills mix of staff in rural and island settings. That would be in terms of palliative care, respiratory conditions, long-term conditions associated with obesity, diabetes management and conditions of that nature. The development of the national centre, do you think that that will help with looking at that in that way for remote and island communities? I think that there is absolutely scope for the potential of the centre to reach out once it is being invaded and then picking up that broader, long-term, cross-disciplinary focus that will be needed on preventative health care. Obviously, it is for work streams as things stand and the activity has already been commissioned to deliver and some of that is about increasing recruitment and retention capacity and also diversifying the skills mix. There is a natural synergy there and I suppose that there is a longer-term decision for ministers about how the role of the centre could be broadened. I do not know if you have anything to add. Probably not much more. The CMO published value-based action plan last month on the back of a support delivery of realistic medicine. In that, I talked about every healthcare contact being an opportunity for preventative activities. I will go back to your point about what would the national centre have a role in and around that. Pam might have some reflections on working in that rural and islands context, the importance of those growing MDTs, those growing local primary and community care workforce, ensuring that they have the skills and the confidence and the tools to be able to drive forward that approach of every contact having an opportunity for preventative activity. Pam, do you feel that that is something that the centre will be able to help with? Yes, because it is a really excellent point to meet. We are very focused on addressing our existing priorities, but we are also focused on supporting and training and shaping our practitioners to be fit for the future needs for our population and understanding, at the moment, the demographics for a range of remote rural and island settings, because of course they are all quite different. That is already significantly influencing the way that we are trying to both design education programmes across medicine and healthcare training programmes and recruitment and retention work. If I can give you a little example of what I mean by that, we already have strong evidence to show that from World Health Organization and other rural geographies that the more we recruit from remote rural and island settings across Scotland, the greater the rate of retention of staff will be. Where staff come from a remote rural and island area and have access to training and good quality support, the retention rates go up accordingly, so that is work that we still have to invest in and evaluate across Scotland. If I could say that there are untapped resources there, we know that we are facing a decline in population size across many of our remote rural areas and yet we still have work to do to increase access to ensure that we can recruit as many people as possible into healthcare professions in order to have this capacity to deliver for the needs of the remote rural communities. Work that we are already doing is increasing working with our academic institutions, working with our training establishments to try to develop modern accessible routes into becoming a healthcare practitioner of the future and then influencing the curriculum so that it involves preventative care and an emphasis on preventative care, for example. For island areas, the westerners recently quoted a figure where they have 50 per cent of their school leavers leave the island after school and do not come back or if they come back, they come back very much later in life. There are related areas around education and training, increasing access to qualifying routes and a positive recruitment strategy in place, where we welcome all people to come and work in Scotland and we particularly want to increase the amount of people who live within the remote and rural areas or who have been brought up in their remote and rural areas, who can then be attracted and retained within healthcare careers. That is where you get tied into what we train people to do and who we attract people to become our practitioners of the future and what will begin to have impact around preventative care and providing the type of healthcare that meets the needs of the population now and into the future. Given the changing demographics that we are seeing, how can we continue to move more services towards the community, not only into primary care but into some of our smaller hospitals in these remote and rural locations, which are often much closer to those communities than, for example, Reg Mores to Sutherland? I am happy to pick up that question as a start. I think from a workforce perspective—I suppose I speak predominantly from that perspective—the issue of delivering more care in the community is about how we create the enabling conditions to allow that to happen. I know Pam and colleagues have talked extensively about skills and capacities. Some of that is about professional skills and competence, about loan working, some of it is about professional decision making. Alongside that, what we would put are obviously how we further improve our terms and conditions of service to promote flexibility of that service offering in terms of allowing staff to be better dispersed in community settings. I suppose that another enabling condition that we further two enabling conditions are about how we create the technology or how we invest in the technology and infrastructure to allow staff to work in a more dispersed way but also to be connected in terms of getting support for that collective clinical decision making, being able to use the tools that we know in terms of innovations across the world in medical and other clinical services delivery will allow people to give kind of supported diagnosis and stuff for conditions through advances in AI and other technological innovations, how we progressively investing that and then also how we create the leadership capacity to allow more dispersed network management of staff. I mean obviously there is a service design and a patient safety element to that and we have to be designing services that are delivered in a clinically safe way and for some obviously specialist and acute care that will still require a certain three put of patients within a given service, within a given local for it to be safe, effective and efficient and I suppose that will continue to be the same as well for some advanced planned care treatment as well but I suppose as I was speaking briefly earlier quite a significant focus for us will be on creating those enabling conditions that have just laid out plus also the focus on capacity and skills. Pathways are sometimes opaque to say the least when you live in a when you live in the central belt and go to a major hospital for any of your for any of your outpatient treatment. When there's those extra complexities of distance in some of these smaller hospitals as well it's even more challenging to navigate some of this so what work is going on to ensure that the populations that we're talking about actually have transparent pathways that suit their needs that means that some of these aging populations that we're talking about know where when and how far they have to go for their treatment. Yes and obviously that's a I suppose will continue to be an ongoing challenge as services evolve obviously we have to commit as you as you rightly expect in the broadest sense to continuing to to sign post access to services and to continuing to evolve both I suppose our digital infrastructure and our expectations around health boards and partnerships and even down to practices communicate directly with patients in terms of in terms of their access to and delivery of services and I suppose that as I say that that's something where we're going to have to continue to pay ongoing attention. Great and finally obviously feedback from patients is essential to that ongoing service delivery and an evolution but in some of these communities the doctors and nurses that they're giving feedback on are their neighbours and are much more closely related to the communities than they are in maybe a more a more populous area. Is there active work in going out and seeking some of those views from people so that that feedback can be taken into account in some of these in some of these changes where people might be apprehensive because of that close relationship? Yes and we do recognise that and obviously there are some objective mechanisms for seeking seeking feedback both in terms of people's experience of receiving treatment to anonymous fora like care opinion dot scott and so on but certainly in the context of our ongoing work to develop the rural recruitment and retention strategy under the national workforce strategy we have in addition to doing this sort of standard literature review work done so we've visited so far NHS Western Isles alongside the WHO we've done some some work engagement work with staff and with service users we would continue to undertake some of that outreach work as well through obviously mechanisms we've got ongoing in relation to the nursing and recovery task force also through engaging with service users via our tripartite work structures within the NHS and obviously take cognisance of the fact that there's a number of individual service users of Britain in response to this committee's inquiry that we will now pick up on in terms of the next stage of development of that strategy. That's good, thanks Laverna, Ivan McKee. Thank you convener, good morning panel. When we talk about remote and rural healthcare we often look at that through the lens of for various reasons things aren't as good as we'd like them to be compared in rural areas compared to the rest of the country and how do we improve the standard and of course that's hugely important but I just want to kind of flip that round and look at it through another lens particularly if we're talking about digitisation, remote healthcare, telehealthcare etc because there are clearly opportunities there as well for Scotland to get ahead of the curve in terms of how we deploy those technologies at scale in those communities to drive up health outcomes as a consequence but also positions Scotland as a leading player globally in those technologies so I suppose I'm interested in and I know we've done a lot of that already and there's some great examples of that in Highlands and Islands and elsewhere and I suppose my question is to what extent do you see the national centre focusing on those opportunities as much as it focuses on the many challenges that exist that we've already spoken about this morning? So from a broader sense we've got the digital health and care strategy about homing in on the work of the centre and supporting delivery of primary care services using digital technology to support that was a feature of Sir Lewis' rural working group report back in 2020 and I know that through its four pillars digital will be a theme of the centre's work both in terms of how it connects with that health and social care workforce across rural and island areas but also how it connects with service users to be able to seek their views, training support and other features. I'm very much with that kind of international example in mind. Pam, would you want to elaborate further? I just agree with what you've said it's absolutely an integral part of our work both to be innovative with our community members through the work of the centre in looking at ways that we can harness the skills that we've already got around digital technology both to improve access to services to improve the quality of services. We already have a track record of pioneering, increasing staff and workforce in rural areas confidence and competence in using technology both to uptake their own learning at distance and also training programmes where we are increasingly including digital confidence and competence within the range of skills that our rural practitioners have now and will have in the future. It's very much part of the work of the centre now and into the future. We're very keen through our work to both highlight the fact that often in the rural and island areas there have been leaders in showing others how to use technology really well that we have had and we want to continue that pattern in using all available technologies, artificial intelligence, low tech solutions and high tech solutions to good effect to achieve improved impacts in the way that we deliver services and the way that patients experience that delivery of services. Are there any specific examples where that has been done deployment of technology and digitisation in rural areas in advance of what happened elsewhere in the country or any specific plans where that is in train? Yes, certainly. Again, our experience within this will be in around education and training and using technology so we were early adopters of technology so over 10 years ago we set up our at distance healthcare education networks, which have been running for about 10 to 12 years using available technologies to deliver education around priority areas of need for a whole range of multidisciplinary staff. For example, we also developed in response to meet a technology enhanced learning programme for our learning development staff within the health boards in remote and rural areas. That was again first delivered for remote and rural staff and is now a rolling programme that they take forward themselves, where they then design for their staff within the health remote and rural health boards, education and training in its high quality that makes excellent use of technologies that are available and also the emerging technologies now that are becoming available. Thank you. Any further comments on that? I suppose I would just add that obviously I suppose in two digital technologies that are obviously already in use we see further opportunity for in rural and island communities that would be familiar to the panel, I suppose, namely in terms of video consultation and also connect to me, which is actually focusing on wellbeing and allows I suppose two-way communication with service users in terms of them feeding up feeding in information out with a consultation by a text message or app about their wellbeing and how it's going on and allows them access to a sort of library of services as well. And there's an aspiration to target 80,000 folks for supporting a variety of blood conditions like hypertension through ConnectMe by 2025 and a focus on I suppose rural and island communities in terms of the roll-out of those two programmes. Okay, thank you. Question for Siobhan, if I may. The number of GP practices in rural areas has declined by 7% in the last 10 years, so it's gone from 188 in rural areas to 175. So what is the Scottish Government doing to reverse that decline? Obviously, we've got the nationwide commitment to increase GPs in Scotland by 800 by 2027 and Stevens already mentioned at a national level. We're making good progress on that with record levels at the moment. The number of GPs working in rural practices... Sorry, it's about GP practices, not GPs. Thank you. If you don't have the figure, if you could let us know and then answer the question, because it is a massive concern that GP practices are declining and is that decline going to be reversed? And if it is, what is the Scottish Government doing about it? We'll get back to you specifically on numbers on GP practices. I think that would be very helpful for the committee. I just have one final question specifically for Pam Nicol. We've heard a lot this morning about workforce staff retention, etc. What I haven't heard is where the patient's voice is in the development of the new national centre and how patient voices are going to be heard in the following iterations of the centre and its development. Thank you. Yes, we have talked a lot about our support in improving services through our support for the workforce, which is a large part of the work of the centre. The other part that's a very significant part of the centre is what we term our community accountability, and that will be patients and citizens. We are establishing stakeholder networks. Those will take different shapes and forms, but the intention there is, rather than having sporadic consultations with citizens and with patients, we will establish on-going dialogue, particularly under the four areas that the centre has been set up to support. We will establish networks that will aim to be inclusive and have appropriate representation around the table from a range of different communities north-south, east-west, that will include patient groups and wider groups of citizens. The term that we are very much adopting here is that this is a socially accountable community-accountable model of delivery that we are taking with the national centre. That, by merit, requires us to demonstrate how we are maintaining that dialogue, how we are influenced, how we are guided by the needs and the impact that we are having within the communities and so with patients. It's a very important part of the centre. In addition to having a strategic programme board, early next year we will be establishing a range of stakeholder networks, as we have called them at the moment. It will be completely focused on being inclusive of patient representative groups and of community members, as well as other stakeholders. That answers part of my question in the going forward. Where has the patient's voice been in the development of the proposals and the work programme for the centre? We have taken our lead from the work that the Scottish Government has described that has been in the preparation for the needs around developing the centre in the first place, so it has been a long time in the planning. Throughout all that planning process, we have considered all the information that we have had from a variety of sources and reports, as well as, from anews perspective, our on-going engagement over the past 16 years or so, in communities, in remote and rural island communities up and down Scotland. We have all taken into account in shaping the delivery plan that we have for phase 1 of the national centre. I may not have been clear enough in what I am asking here. Has there been direct consultation with patient groups, patient representatives in remote and rural settings in the development of the work plan for the centre and what its priority should be? I hear what you are saying about what will happen going forward. Has there been currently? We have not had a recent specific series of engagement with patient groups in relation to the national centre itself. That is within our plan to continue that work. We had established a programme of work for that last year but had to put it on hold temporarily while waiting to understand whether funding would be established in 2023 for the national centre. We understand that that is a priority and that is what we will be addressing early next year within the phase 1 delivery plan targets and objectives. I thank the witnesses for their attendance at the committee this morning and will briefly suspend. The third item on our agenda is an evidence session with the independent women's health champion to receive an update on her work since being appointed and the implementation of the Scottish Government's women's health plan. For this morning's session, I welcome to the meeting Professor Anna Glaesor, women's health champion, Greg Chalmers, head of chief medical officers policy division, Scottish Government and Felicity Sung, women's health plan team lead to Scottish Government and we'll move straight to questions and to Sandish Gohani. Thank you, convener, and just to clear my interests as a practicing NHS GP. Professor, it's great to see you. Women's health, I think, is something that we need to talk about more and we need to ensure that over 50 per cent of our population have equality. And with that in mind, why is it, do you think, that we don't seem to have women's health and equality running through our NHS as a way that we would really hope it should be? Do I need to press anything? Well, good morning, everyone. I think it's possibly historical in that the NHS has, classically, over the years been run by men. And I think quite a lot of the conditions we acknowledge in the women's health plan that there are certain conditions which affect women only, which are often conditions which people find it quite difficult to talk about, even doctors sometimes find it quite difficult to talk about. But I think there are other conditions which affect both men and women, but where women are often less well managed than men are clinically. So, as you know, women are less likely to be diagnosed with a heart attack. And even when they have been diagnosed with a heart attack, they're less likely to be on secondary prevention than men. And you have to ask yourself why is that? And I think it's partly historical because I think in the 1950s it was true that it was men who had heart attacks. They smoked, they had manual labour and people haven't moved on from there. So, I think there are a lot of very complex reasons, but we're trying our best through the women's health plan to change the culture and to encourage people to think differently about women's health. And I think we are having some success. I think everybody that I've spoken to and I've spoken to a lot of people in the nine months that I've been in post is extremely enthusiastic about the women's health plan and committed to trying to improve the health of women and girls in Scotland. And so, just on the women's health plan, I was looking at, and there seems to be a very large poverty-related disparity when it comes to breast and cervical screening rates. Why do you think that is and what work is being done? Can we be doing to ensure that we even this up? Yeah, you're right. There is a big difference related to deprivation. I think again the reasons for that are quite complex. We know that women and presumably men as well, but we're talking about the women's health plan. We know that women who live in deprived areas find it more difficult to negotiate the NHS than people who live in non-deprived areas. We know that certainly in the areas in Scotland, I'm sure you're familiar with the deep end practices, the hundred practices which serve the most deprived communities in Scotland. We've talked to the GPs, some of the GPs in those practices, and they tell us that women really have confidence in their GP and are much less confident in going elsewhere. So it's not just a matter of the practicalities of travelling somewhere to get your breast screening, for example. But it's also the issue to do with trust. And so we've been looking at a project which we hope will serve as a pilot for deep end practices where instead of asking women to go somewhere for women's healthcare, we take women's healthcare to the practice. So we're looking at a pilot study where we're taking a women's health specialist or allocating a women's health specialist for one session a week to a handful of deep end practices to work alongside the practice staff, GPs, and practice nurses to improve their skills in providing women's healthcare, to also encourage them to take a more holistic view of women's healthcare to see whether this will serve as a model for all the deep end practices to improve the quality of women's healthcare. But I think also that, as you know, there is people are looking at self-testing for cervical screening. My understanding is that there isn't yet a validated screening test which has gone through the regulatory authorities, but that should be happening fairly soon. And that may improve the uptake of cervical screening, certainly. Thank you. And so I just want to take the opportunity to state how important it is for people to take up their screening offers. It really does save lives and makes a big difference. I'd like to ask you, we've seen in the last few years maternity services in Caithness and Wishaw being downgraded while Dr Gray's and Elgin is still waiting for its consultant-led maternity services to be restored. So two parts to the question. Are you concerned with the management of maternity services in Scotland? And do you feel if this was a men's only issue, it wouldn't have had these issues and been downgraded and had problems? I don't know. I mean, I think that's probably, if I were a rabid feminist, I would immediately jump on that and say, yes, of course, if this was all about men, they'd be being much better treated. I think that's an oversimplification. I think the reality is that if you live in a remote and rural area, there's always going to be problems with providing the level of service that there is in a big city like Edinburgh or Glasgow. So I don't think it's a sexist issue, though in my worst moments I might say that. And I've forgotten what the first part of your question was. Are you concerned? Am I concerned? Yes. I mean, the maternity plan is not part of the women's health plan. The women's health plan doesn't exist in isolation, so there are a lot of people working on the maternity plan, whereas I'm concentrating more on, if you like, the gynaecology side of things. So I keep up to date with what's going on with the other plans and other policy teams in the Scottish Government, but it's not something that I'm concerned with day to day, and I don't think I could speak in a helpful manner to you about that. Okay, thank you very much. Ivan McKee. Okay, thanks very much, and good morning. Thanks for coming in this morning. I just have a few questions around about the plan, and I think it's true to see you came on, came into post a period of time after the plan was pulled together and launched. So to get your sense of whether the plan covers the areas you think it should and its areas of focus are correct, you helpfully unpicked the fact that there are clearly conditions that are female only and others that are shared, and some of the issues that affect that latter category as well. So whether you think that that balance is correct, whether there are approaches in here, and it was quite interesting to read it because I'm reading through some of the stuff around about when we want to play an active role, they want to share decision making, they want access to information, clearly that applies to many as well. Whether you think there's learning from this plan that can be transferred more widely as well, and I've got some other points, but if you could pick up on those first. Yeah, and I'm sure you're right, I mean it is a women's health plan, but men need healthcare as well, and men are often more reluctant to go and see their GP, and that's perhaps another reason why to answer the earlier question about why there are differences in women's health. I think that women go to see their GP with women's health issues, with pregnancy they take their children to the GP, so perhaps when a GP sees a man, he thinks, oh this guy hasn't been to see me for 10 years, so there must be something seriously wrong, whereas when he sees a woman he's maybe already seen her three times this year about something else, and so I'm not saying that that makes people dismissive, but I think there is a tendency to think that if a man goes with something it must be something serious, because they don't go to their GP that often. So I think there are a lot of things that we could learn from the women's health plan that are important for men, and one of the big areas of work for the women's health plan is to improve women's knowledge of all the various women's health issues, and I encourage you as MSPs whenever possible, whenever you're talking to your constituents about health, to encourage them to use NHS inform. The women's health team has done a huge amount of work on the NHS inform platform, and I think it's a great resource for reliable and accurate information, which hopefully allows women, and where it's relevant to men, to take charge of their own health and be better informed about everything that's going on. So yeah, I hope it's a model for when we no longer need a women's health plan, but just a health plan, I hope it serves as a model for that. Yeah, so in terms of that, that core of question about does it focus on the right areas, you're quite comfortable with it? I think it does, you know, it's an ambitious plan, there are 66 actions. It focuses, as I say, more on reproductive health, not on maternity, because there is a maternity health plan, and mental health. There are lots of things which overlap, but it focuses on the things which don't appear in other bits of policy. So yeah, I think it does focus on the right things, and I think we will have learned from this plan when we do the next iteration of the plan so that the next plan is actually even better. It's an interesting comment that women go to the GP more often, therefore they're less likely to be believed. I mean, if anything, you'd have thought that more engagement with the health service would have led to better outcomes, not worse, so it's quite interesting that that's your observation on that. Well, you know, I could ask you when you last went to your GP, and it was probably, you probably don't go very often. You're absolutely correct. You're absolutely correct. So when the GP sees you, the GP will take you very seriously. Yes. No, it's interesting, but it's an interesting observation that more engagement actually leads to perhaps worse outcomes in terms of medical outcomes. The plan is obviously a big focus on inequality, which is great. It's then interesting if you look through health outcomes for a lot of headline issues. Clearly, in many of those women's outcomes are significantly better than men's alcohol and drugs in Covid outcomes. Even on the heart condition and heart deaths, I think I'm right in saying that men's outcomes are still significantly worse than women's in terms of death rates. So how do you approach that in terms of what can be measured? Typically, when we look at an inequality issue, we would say that one group is performing less than others, and the objective is to close the gap. In this situation, clearly there are many of those measures where women are actually performing significantly better than men, life expectancy, et cetera. So how would you measure success of your life in terms of closing that inequality gap in that context? So I think you're right about life expectancy being better in women than in men, but women, of course, live with a lot of unhealthy years of life, and that's where the big differences are when you compare the deprived with the more affluent areas. How do you measure it? How do we measure the success of the plan? Yeah, we've got the plan, we've got your role, how would you look back in a number of years and say, yeah, we've been successful? How would you measure that? I think we need to do better at evaluating initiatives that we've set up. So for example, with this proposal that we have for working with the deep end practices with deprived communities, we are planning to include quite a sophisticated evaluation. So for example, we want to look at if we improve women's healthcare in these general practices, do women get referred less often to specialists? So 51% of Scotland's population is women. All of them, unless they die prematurely, will go through the menopause. I think all general practices should have somebody who is good at dealing with menopause and prescribing standard HRT. If that is done better through various initiatives that we are setting up, then we should see fewer people being referred to the specialist services for the menopause as one example. We're working with national health education for Scotland preparing a package for primary care for GPs and practice nurses to improve their knowledge of menopause and menstrual health. We need to evaluate that and we need to see whether women feel that they're better informed, whether they feel happier with the consultation with the GP and whether eventually, and this is a very long term thing, the statistics change. That's quite a sophisticated measurement that you need to do. Yeah, but do you think the plan is clear enough on what those measurable deliverables are, or is there still work to be done? No, I think there's still work to be done. And I think with the next iteration of the plan, we should do better. Okay, good. Thank you very much. Thank you. Thank you. Can I just pick up on one of the issues that Ivan McKee raises there about what is and isn't in the priorities for the plan? And one of the things to me that seems like quite a glaringly obvious thing is incontinence. Now we know that this is very common in women post childbirth and in later life we've seen a proliferation of adverts and products in the supermarket for women to manage urinary incontinence. Is that something that you think should be in the plan? Is it something that you're considering putting in? Obviously it's very treatable and education and information about pelvic floor exercises is something that would help alleviate that. Yes, and there is a relatively new section in NHS inform that the women's health team has put in on urinary incontinence with information about pelvic floor exercises and so on. So yes, it's not mentioned in detail specifically in the plan. Of course it often comes into discussions about the menopause and the menopause features in a big way in the plan. I wasn't involved in writing this iteration of the plan and we will have discussions with lots of stakeholders to decide what goes into the next women's health plan, but I agree with you. I think we should probably have more on incontinence. I would like to ask about progress towards the priority areas being menopause, endometriosis and PCOS and heart health, perhaps starting on menopause. Okay, so one of the aims of the women's health plan was to have a menopause expert in every health board area and we now have a menopause expert in every health board area with a body system for the island health boards. We have a national clinical network of menopause specialists who meet quarterly and I must say it's a very impressive group and when I first started it was a bit of a talking shop with people kind of generally saying well we experienced this and we experienced that and I now think it's a more formal agenda so that we can say we need a pathway on for example testosterone replacement for women who complain of loss of libido at the time of the menopause, can we working together as a group have a national pathway? So I think we're making progress. So can I ask what, so I'm an MSP in Ayrshire, so what difference does the menopause expert in NHS Ayrshire and Arran make to the the women that I represent who are going through the menopause, what have they done for them? Well I think if the menopause expert is used appropriately then women who don't respond to standard treatment of the menopause so if you went along to your GP with flushes and sweats and you said you would like a trial of HRT I think that's something that the GP would be able to manage. If that doesn't alleviate your menopause symptoms or you have horrible side effects or you're not eligible for HRT because you have contraindications then I think you should be referred to the menopause expert so I think what the women... So the menopause expert is a clinical individual for complex cases? Yes. Okay okay and what about the sort of standard provision for menopause support for? So as I said we're working with the health education for Scotland to provide a module for primary care, for GPs and practice nurses to better inform them about the menopause and I think women themselves are now better informed about the menopause particularly if they refer to the pages on NHS inform which gives them a lot of information about the menopause and the health and social care alliance has done a lot of work on the menopause preparing webinars for women so you know there are a lot of... The menopause has become a very trendy isn't the right word but everybody is now much more aware of the menopause so more women are going to their GP asking could this be the menopause so the GPs are feeling overwhelmed? May I share some reflections from constituents and things? It's not... some of the sort of inequalities and challenges aren't so much around individual women's knowledge about what's happening but about access to support and specifically I guess access to HRT and I know in answer to Sandesh Gohani when he asked about inequality he said you know it's not all about process but and forgive me I hate when politicians do this but I'll give you an example from last year I had to make 25 phone calls to the GP before getting in then get a repeat prescription then go to every single pharmacy within not just the town I live in but the area and I'm lucky because I manage my own diary I can do that I'm thinking about someone who has a job where they're nine to five or they have you know an hour for their lunch I don't think it's it's about women's knowledge some of the challenge I think it's about supply and it's about access to professionals have you sort of touched in you know reached out to women to find out exactly what the issues are from their perspective rather than from the health perspective and that kind of output perspective yes we have done um and so through the alliance we've had meetings with women had quite a lot of meetings actually um with women with various health conditions and and we've met people here in the parliament building with endometriosis with PCOS so we do hear from women and I think all of those problems that you talk about not the availability of the medicines in pharmacy because that's a specific issue for HRT but you know having to make 20 phone 25 phone calls to get an appointment with your GP is something which happens to everybody okay okay so that would that would be that the certain main progress around menopause is the menopause expert the clinical expert in each health board is that the it's that but also working with nez to to improve the to improve the information among primary care okay and how will we know that's worked how will we know that's improved women's lives well I think we should see fewer referrals to expert menopause services because GP should be able to deal with standard HRT okay and are there health boards where the way they're set up is not for it to go through the GP's but to actually go to specific women's clinics is it the same across Scotland no it's not the same across Scotland and so for example in Lothian where where I worked we know that in the Chalmers centre which is a integrated sexual health centre there was a very thriving menopause service to which women could self refer which was great and so we're talking about what in England they're calling women's health hubs but which we call integrated sexual and reproductive health services the problem with that approach is that it does tend to make life better for for women who are able to get to Chalmers who are who who are able to negotiate that sort of thing but also I think that there's a danger that that GP's then say to a woman just get yourself along to the specialist service and so then they stop providing basic menopause care and so I think that's a danger of women's health hubs that you de-skill GP's okay and you said there's a measure of success would be less women referred to specialist menopause like do you think there would be value in measuring the experience of women themselves rather than because a federal to a specialist doesn't necessarily mean a good outcome for for someone no of course and and in all our evaluations that anything that we plan to do yeah we we ask women their experiences we'll so ask the providers their experiences as well as trying to have a quantitative measure yeah okay and the other two ideas endometriosis and heart health is there anything you want to see on the progress of them so I think there's a lot of work gone on in endometriosis there's a lot of research going on in endometriosis particularly in Lothian which is being funded by the Scottish Government for heart health I I have a particular interest in heart health partly because I've never done cardiology and it's always nice nice to learn something new but but also because you know women are more likely to die of a heart attack than they are to die of breast cancer for example there are reproductive health conditions through the women's reproductive life course that put them at increased risk of heart disease and I don't think currently we use those opportunities to try and reduce the risk of heart disease so if I can give you an example of preeclampsia so women with preeclampsia have an increased risk of hypertension and heart disease in later life I think maternity services are very good at looking after women with preeclampsia but as soon as the baby is born the preeclampsia goes away so does the woman and many women don't even get the blood pressure checked at the routine postnatal follow-up if they have a routine postnatal follow-up let alone being made aware that they are at increased risk of hypertension and heart disease in later life so one of the things which I'm looking at during COVID when a woman was admitted with or when a woman was seen in the maternity services with pregnancy induced hypertension or preeclampsia they were given a blood pressure machine and they monitored their own blood pressure and did their own neuroanalysis and that was a very effective way of monitoring women's blood pressure during pregnancy when the baby was born they were supposed to give the blood pressure machine back which about half of them did I would like to reinstate that because although that's kept going in Lothian most health boards have stopped that self-monitoring system I would like to reinstate that but take it further and say keep the blood pressure machine we'll we'll link you into the connect me bp website and you'll get a text message or an email every six months telling you to check your blood pressure and I'm having some discussions with Professor Batticharia in Aberdeen to see if there's a study that we can do where we look at the effectiveness of an intervention like that to reduce the risk of heart disease in later life and there's not just preeclampsia it's PCOS it's premature menopause even recurrent miscarriage where all of these women could be linked into a system to reduce their risk of heart disease in later life and do you think that these that sort of holistic way of looking at things is uniquely missing from women's health or is that a reflection of how our health service operates in general I think our health service has always operated in silos yeah but if we can improve it in women's health then maybe it will spread further than that indeed thank you thank you I've got a couple of brief supplementaries before I come to test white so Emma Harper thanks convener it is just a quick supplementary to pick up on what Ruth Maguire saying about menopause but indeed endometriosis and PCOS as well what work do you do or are you responsible for when it comes to people of women whose English isn't their first language how do we support them into better care and then also third sector for instance but also local authorities I think I counted seven with that I've got a menopause plan out of 32 and is that something that you would be responsible for as supporting local authorities to help raise awareness about menopause for instance with a plan not specifically with health authorities no with sorry with local authorities no but with health boards yes and that we have now a women's health lead in every health board who's supposed to work with the executives in the board to make sure that the actions of the plan are being being included in their work and I think I'm right in saying flicity that NHS inform is available in a number of different languages but I I mean I think there was something on the radio very recently about a problem with interpreters particularly in any an acute situation so there are issues for women whose first language isn't English okay thanks to gohan thank you just again pick up on um Ruth Maguire's point about menopause so see being a a GP I'm lucky enough to go to multiple different practices and my experience and something who doesn't like us giving examples but but my experience is that those areas that I work in where people are from better off areas know about menopause and they come in um having done reading having um thought about it and deciding that this is likely there what's going on and we have a discussion about menopause whether it's appropriate or not and what treatments are appropriate or not um but those from more deprived areas don't come in like that and I haven't seen a huge shift um for women in deprived areas coming in and saying and having more knowledge about menopause so but what what you said earlier is that what we're seeing actually those in because menopause is now more spoken of but that's actually in better off areas compared to deprived areas and if that is the case how are we going to get the message to those women well then I think that's your job as the GP so I think if you see a woman aged 45 to 55 who comes in with insomnia or depression or something like that if she doesn't raise the issue of the menopause then I think it's your job as the GP to say well this could be the menopause and then ask specifically about other menopausal symptoms about her menstrual periods about whether she's having flushes and sweats because you're quite right I think women in deprived areas are less likely to raise these issues and if we look at the prescribing data women in deprived areas are less likely to be prescribed HRT but I think it's the the GP's job or the practice nurse's job to say this could be the menopause um and then open up the conversation from there. Sorry forgive me um a lot of women won't present because they're not aware that this could be menopause and this is something that we could very easily treat but they'd present with other things surely not necessarily I mean so if a woman of 45 comes to you and complains that she's not sleeping well would you discuss with her the possibility that she may be a menopausal because I would potentially but but I suppose that the question is about getting that knowledge into communities um that traditionally don't have that knowledge so that so that they're better informed and they're able to to really champion them their their own yes but I I don't know how you do that how do you how do you make women living in deprived communities better informed about the menopause I mean we had a publicity we're having a we're planning a publicity campaign about the menopause which will take place next year um and we're having meetings to discuss how best to do it there's a meeting this afternoon with the reference group for the clinical reference group for the menopause network to get their advice on on what would you include in a publicity campaign but I don't know how well publicity campaigns affect certain areas of society certain stratas of the population I suspect that you're more likely to be aware of these publicity campaigns if you're in less deprived areas than if you're running around looking after your kids and sorting out your problems with the cost of living um so I don't know what you would do but I think it's the gps job when people do come to see them to raise it as a possibility thank you prism aquire very briefly press my button as well get all flustered um I just I get a little bit concerned when we talk about women in deprived areas being less knowledgeable and my experience as an msp who represents some areas which are very economically deprived is that it's not about women's lack of knowledge or or confidence that it's that it's just simply more challenging to interact with a system if you are an employee rather than self-employed if you're in a low income job or as you said have you know children to look after different um you know demands on your time and I just I would just want to reflect I think you did in your answer to be fair that that would be a kind of quite dangerous lazy assumption for us to make if we're talking about women's health I think that's right like I say I think if you're busy looking after 101 things then maybe you you don't take so much notice of your menopausal symptoms you know that's a glacier um shortly after you came into the post we had a cross party group on endometriosis we remember that so um the women's health plan has committed to reducing waiting times for diagnosing endometriosis from more than eight years to less than 12 months by the end of parliamentary term do you think that's achievable um I hope it's achievable but I know that there are long waiting lists for to make a definitive diagnosis of endometriosis you need to do a diagnostic laparoscopy because you need to see the endometriotic deposits most doctors are reluctant to submit people to a diagnostic laparoscopy because it involves a general anaesthetic um so you have to overcome that but also there is as you know a long waiting list for people with with gynaecological conditions which aren't cancer and whether that situation improves by the end of the parliamentary term I don't know I hope it does and the Scottish Government is putting money into waiting lists initiatives um so the answer is I hope so but we are planning a publicity campaign on endometriosis and I met with the marketing people last week um and this is a publicity campaign for healthcare professionals not for women and they were asking me what would be your single message to the healthcare practitioners and I said I think that listening to women with endometriosis talking about their experience my single message would be one in ten women have endometriosis they would like to know that you're thinking about it as a possible diagnosis and it's the referral so women are saying to me they're just not being referred yeah I think it's the referral but I think it's also I think it's also important to explain to women I'm suggesting this form of treatment because it is valuable in endometriosis I think a lot of women for example feel that they're being fobbed off when gps put them on the pill now I'm a great proponent of the pill I think the pill is a great treatment for things like heavy menstrual periods if you take the pill continuously you don't have periods so you don't have dysmenorrhea but I think gps need to explain to women why they're putting them on the pill so that they don't feel fobbed off and I think if women have symptoms suggestive of the endometriosis then healthcare professionals should tell them that they are considering the diagnosis of endometriosis and that they will refer them if they if their symptoms don't settle on the standard treatments and my follow-up question on endometriosis Professor Glaesius as we know there are an estimated 100 000 women living with endometriosis in Scotland and according to endometriosis UK their view based on their data is the base level of care for that this debilitating condition is currently not being met across scotland so what action would you propose that they take to actually improve the situation for all these women I think we need to work our way through the waiting list so that women wait less less length of time before they're seen by a specialist with an interest in endometriosis and you've talked about heart health being almost the highest priority would you say that endometriosis comes a close second I wouldn't know because I don't think endometriosis is is worse than many other conditions I think we hear a lot about endometriosis because the people with endometriosis have done a very good job of getting their advocacy going and so there is a national endometriosis society that is speaking very well for women with endometriosis but I wouldn't put it just below heart disease I might put breast cancer quite high up ovarian cancer quite high up although I'd just like to say the women who are talking to me and that you shared with you at the cpg debilitating pain breakdown of relationships including marriage not being able to work so having a lobby group is not because of the lobby group it's because of of the huge amount of issues these women are having I know and I agree with that and it's very moving hearing those people talking about their experiences with endometriosis but it's not just women with endometriosis I think there are a lot of conditions which which make women's lives extremely difficult and and we should do better at tackling all of them I think the the difficult thing with endometriosis is that if it's a difficult condition to diagnose without doing surgery and doctors try to avoid doing surgery because it involves a general anaesthetic and that takes time and because there's a long waiting list for for surgical procedures thank you thank you convener carol walking thank you convener good morning I have been really interested in your reflections around working in a different way and attitudes to approaching women's health it's very helpful to hear you talk about that and my question is around funding and I suppose what I'm interested to know is if you have any reflections on how funding is used in terms of supporting women's health whether the plan should have or did have enough funding attached to it or if there's anything that you think we might have to fund to get it right such as the training etc that you're talking about yeah so so of course I would say there isn't enough funding behind the women's health plan I'd be mad not to um so yeah could we have some more money please that would be very nice let me give you an example so long acting reversible mess of contraception IUDs and contraceptive implants if we look at abortion rates they've increased by 19% so that's nearly one in five um between 2021 and 2022 and it's likely that they'll go up more again this year and we know that IUDs and implants are by far the most effective methods of contraception they have failure rates of less than 1% compared with the pill which is 9% condoms which are 18% they're also much more likely to be continued than the other methods because you have to go and see somebody to stop using them so inertia acts in favour of continuation um but we know we're not meeting nearly meeting the demand for long acting reversible mess of contraception um we know that GP many GPs have stopped providing long acting reversal methods particularly IUDs because they're overwhelmed they don't have the capacity to do it it takes three appointments plus the three appointments taken up by the assistant as well so even although the method lasts for at least five years and I would see that as a good investment of time GPs faced with hordes of people coming in to be seen with 101 different conditions don't see it in the same light as I do and we know that sexual and reproductive health services are not meeting the demand so yeah we need more money for long acting reversible mess of contraception okay can I ask then you know how you'd approach in that as the women's health champion with the government if you spoke into them about where the funding might come to or where we might move money about or so what we set up a short life working group to understand why we're not meeting the demand to look at options for how to do things differently so for example in a couple of health boards people have looked at cluster arrangements where one GP who is skilled at inserting IUDs and let's just talk about IUDs one GP who's skilled at inserting IUDs and passionate about doing so provides a service for half a dozen different practices and that works there but all those initiatives that we've looked at have been funded by soft money and they depend on that one individual person so they're not sustainable so we've looked at I've spoken to the the people in St Andrew's house about the GP contract this is probably a very unacceptable thing to say but could we move money from the GPs who aren't doing LARC anymore to sexual health services so that they're providing LARC I've been told that that can't happen so I'm now just finalising a paper saying this is the bottom line health boards have to accept that if they want to reduce unintended pregnancies and abortion rates they should fund LARC and I'm going to tout that round everybody I can think of the CMO the deputy CMO the national clinical director and the minister and try and put pressure on whoever so that boards fund it okay thank you thanks very much NASA be better men interested in you know you talked about trying to train staff so that the approach women's health in the right way do you think there's enough in finance in the system to do that in terms of primary care and GP practices actually I don't think that that is so much an issue of finance I think that's an issue of thinking differently and so if I give you another very brief example so immediate so insertion of an IUD when somebody's just had a baby so the best time if somebody's decided they would like an IUD as a postpartum method of contraception the best time to insert it is immediately after the baby's delivered so baby out placenta out IUD in I think it needs to be the responsibility of the person that's doing the delivery to put in the IUD regardless of the mode of delivery so if it's exultant they should put in a doing a cesarean section they should put in an IUD at the time of cesarean section and they're doing that now in Scotland we've achieved that I think it's true to say that if you're a woman wanting an IUD is an immediate postpartum contraceptive it will be done if you have an elective cesarean section we're not quite so good at doing it immediately after a forceps delivery or a bantu's and we're very bad at doing it after a spontaneous vaginal delivery what we need is for the midwives the college of midwives to put IUD insertion on the curriculum for midwives in training so that's not money that's getting people to think differently about what our responsibilities are for women's health okay and I think you know getting gps to ask questions of women age 45 could this do you have any menopausal symptoms it's getting people to think differently lovely thanks very much we take thank you thank you it this way thank you can I ask please about one in five women will experience perinatal mental health problems and while suicide is tragically the leading cause of maternal death in the first year after a baby's birth would you support perinatal mental health being addressed as a priority in the next women's health plan I think I would need to discuss it with the stakeholders with whom we're going to have discussions because I think personally I think it probably sits better in the maternity plan than in the women's health plan because it's all part of maternity so unless we amalgamate maternity and women's health which I'm not sure would be a good idea so so I'd need to discuss it with whoever we're going to discuss the next iteration of the plan with but I suspect it's better staying in maternity and do you think we need better support and more support for perinatal mental health thank you and too too many women have described to me the dismissive way they've been treated and are being treated by clinicians it's almost as though it's a culture um from the men you know and it goes from menopause to endometriosis we had a few several serious examples in relation to transferdianol mesh scandal and they aren't believed and their mental health is impacted as a result of that so have you seen any of this or are you being told about any of this dismissive culture and if you have is there anything that can be done about well you know I went to the the the group on endometriosis and you hear about it there but I have to say that you only hear from people who are unhappy with the way that they've been treated I only hear from people who are unhappy with the way they've been treated I don't hear from the people who are happy with the way that they've been treated and and that's that's always how it is you hear from a very small very bio sample and I think it colors your view and um I don't think that the majority of doctors are dismissive I think the majority of doctors and nurses and everybody else in the NHS does their absolute utmost to provide a really good service and sometimes individuals are unhappy with the service that they've received sometimes individuals don't hit it off with a healthcare provider but I actually think and and maybe the GP on the committee would agree with me that people do do their best and that people who are very unhappy with their care are very much in the minority I'm sure we're all unhappy with having to phone at half past eight in the morning to try and get an appointment but when we are seen I think the majority of us are happy with the care that we get possibly wasn't listening thank you convener and thanks to the panel for their comments so far I've got particular concern about the decrease in drugs deaths in 2022 because I note that this was far greater in males and there's evidently particular issues with women who use drugs that the rate isn't decreasing at quite the same level do you have any view about why that might be the case and what might be done to I'm not an expert in drug abuse I mean you know I I read the papers but it's it's not something I would have to defer to the people who are working in that area I don't think I can say anything helpful on that I mean you know we we recognise in the in the women's health plan that that women's health everybody's health is intersectional and there are a lot of things going on in people's lives but it that's not my area okay do you have any comments either no I don't think we'd like not to add to Professor Clearser but obviously it goes like I was saying convener if there's any issues that come during the session that you think engage government policy obviously we can provide some clarification in writing if that helps okay Audit Scotland told the public audit committee in September that the mental health transition and recovery plan which prioritised women and girls mental health did not outline timescales for the actions in a review of progress has not been carried out Professor Glaeser is this something that is on your radar as women's health champion and do you support calls for further detail on delivery and evaluation what was the last bit do I support do you support calls for further detail on delivery and evaluation of mental health yeah in general yes I think the women's health plan recognises as I say that that mental health impacts on women's health and that women's health impacts on mental health and we know that that menstrual problems and that menopause affect women's health and through the women's health plan through those specific issues and actions in the women's health plan we're trying to deal with that okay you mentioned that you didn't have a particular locus in drug deaths no do you have a particular locus on alcohol related deaths no I don't okay thank you it doesn't appear in the women's health plan we're moving on to the next theme Mr Sweeney which I believe you've got questions on indeed do indeed um as a former member of the citizens participation and public petitions committee we quite regularly received a number of public petitions that relate to women's health there are petitions at the moment on smear test age fertility treatment and abortion currently being considered by the committee and Professor Glaser what are you doing to ensure that women's concerns about issues like those raised by petitioners through the public petitions committee are being held by the Scottish government the national health service and local government so as you know we're doing a lot of work in abortion smears and infertility isn't in the women's health plan but I know that there's a group that are looking at infertility services um so I think there's a lot going on and I certainly meet quite regularly with the abortion team and I'm very interested in hearing what's going on with the work on late abortions on safe access zones and hopefully at some point on decriminalisation of abortion so I think actually the Scottish government is pretty responsive to those those topics that's helpful um do you have any engagement with those petitions at the moment not specifically with the petitions um but I'm certainly working quite closely particularly with the abortion team because that's something that I have had a lot of experience with and have done a lot of research in in the past and so that and contraception overlap significantly with the with the current women's health plan okay um our last evidence session was on remote and rural healthcare and it's clear that there are inequalities in accessing healthcare in scotland on a geographical basis but also on socioeconomic background um what does the women's health champion do to raise awareness of health inequalities and ultimately reduce them well I think we discuss them in everything we talk about and so for example in our menstrual health network clinical network in our menopause clinical network in with the women's health leads we we wave the women's health plan at them which discusses inequalities and and we talk to them about their awareness of inequalities on women's health and as I've told you at the beginning we have this proposal to do a pilot study in the deep end practices to see if we can do better with having a more holistic approach to women's health and more expertise in women's health um taken to women in those areas of inequalities so I think we are trying hard that's that's helpful um there has recently been a debate in the Scottish Parliament on protecting an award-winning neonatal unit in University Hospital Wishaw and there are concerns about a lack of consultation prior to the decision being made on downgrading unit particularly mothers being separated from their premature babies and what can we do to ensure the voices of local women who have these deep and very emotional concerns and upsetting concerns are consulted on decisions that impact them in a very intense and very visceral way well again I would say that you know I'm not concerned with the day-to-day work of the maternity plan or or issues in neonatal units I mean clearly it is an issue and I'm sure that their voices are being heard but I really can't comment on that okay thank you and Emma Harper thank you convener I think some of the questions have been already covered regarding implementation and evaluation and I'm just looking at the interim progress report from august 2023 which has covers progress obviously yeah so I'm interested in you know where do you see the implementation and then the evaluation as we go forward I know you're doing quarterly blogs and how important is it to communicate the progress because there is a lot going on and I think it's amazing there's so many subjects just looking at the petitions committee and things like that so I'd be interested in how important you think it is to to make sure that progress is communicated so that people know what's being achieved yeah I think you're absolutely right and I think we do need to to make people aware of the progress that's being made and I think we need to make healthcare providers aware too because we hear all the time that people are demoralised and I think demoralisation is a self-fulfilling prophecy so whenever I meet with groups you know I always emphasise the positive and say for example we've got a meeting this afternoon with the menopause team the menopause network reference group so we're going to review what have we achieved in the last year what do we hope to achieve in the next year and I think we need to congratulate them on what we've achieved because we've achieved a lot do you think there's a role for us in as MSPs in our social media connectivity to sometimes social media is not the best platform for communicating things but I think it could be used in a different and more positive way if we have a way to support good communication. I was at an event in Dumfries and Galloway recently where Dr Heather Curry spoke to 100 women in the room about menopause and she is a total champion for communication and understanding what is the menopause all about and de-stigmatising as well so do you think there's a role that we can help in in communicating as well. Yeah I think I think there is and it would be great if you if you said some nice things about how well the women's health plan is going it would also be great if you if you kept reminding people about NHS inform and that whenever they've got a health condition that they want to find out about not to go to Google but to go to NHS inform so they get accurate information so yeah I think it would be really great if if you could be positive about the women's health plan and just okay right happy apologies and and finally a supplementary from Jillian Mackay. I was struck by something you said earlier Professor Glazer about that intersectionality versus the siloed way that the NHS often works and given your priorities are naturally chunked out into three into three large pieces how do you see those working across each other used the the example earlier of women who have PCOS at a higher risk of of heart disease they're also at a higher risk of diabetes and things and quite often once you're diagnosed you're given tablets which have wonderful side effects and are then left without any other any other form of follow-up is that are those crossovers things that are actively being looked at by yourself and the team and how is progress going on some of those areas yes they are and early on soon after I started the team and I went to Aberdeen to meet with Grampian health board and as you know Grampian in Aberdeen they're going to open a new hospital next year the Berde family hospital and speaking then to the non-executive director she said we really want to do things differently so we've been having discussions with them and discussions with the professor of obstetrics and gynaecology there and putting them in touch with chest heart and stroke Scotland so for example I've said to them why don't you in your waiting area of your nice new shiny hospital which sees a lot of women have a women's health information hub where you could check people's blood pressure you could even take blood for cholesterol you could talk to them about osteoprotism all of this could be done with volunteers from chest heart and stroke Scotland it doesn't have to cost the NHS money so yeah I I think it's terribly important that we try and and broaden our horizons and the way we look at health in general but for us women's health in particular that's good thanks community thank you and can I thank professor glisa and the officials that have joined her today for their evidence at our meeting next week we'll be continuing our inquiry into healthcare in remote and rural areas hearing from academics with expertise in rural healthcare and that concludes the public part of our meeting today