 Welcome everyone to the 22nd meeting of the Health, Social Care and Sport Committee in 2022. I've received no apologies for today's meeting. The first item in our agenda is to decide whether to take item 4 in private. Are members agreed? We're agreed, thank you. The second item in our agenda is consideration of three negative instruments. The delegated powers and law reform committees considered these three instruments at the meeting on the 7th of June 2022 and have made no recommendations in relation to them. The first instrument is the novel foods authorisation of smoke flavourings modification of other authorisation Scotland regulations 2022. This instrument implements a decision by the Minister for Public Health, Women's Health and Sport in relation to five novel foods, authorising four new novel foods for placement on the market in Scotland and one extension of use of an already authorised novel food. The instrument also authorises the transfer of authorisation folder for five smoke flavourings. No motions to a null have been received in relation to this instrument. Do any members have any comments in relation to this instrument? No, a proposed therefore, the committee does not make any recommendations in relation to this negative instrument. Does any member disagree with that? Not with an agreement. The second instrument is the national health service optical charges and payments and general ophthalmic services Scotland amendment regulations 2022. The purpose of this instrument is to increase NHS optical voucher values by 2 per cent to support more patients with eye problems being safely managed within the community to enable remote consultations and to deliver other miscellaneous changes. No motions to a null have been received in relation to this instrument. Do any members have any comments they want to make? No, a proposed therefore, the committee does not make any recommendations in relation to this negative instrument. Does any member disagree with that? No, with an agreement. And the third instrument is the national health service vocational training for dentist miscellaneous amendments Scotland regulations 2022. These regulations make amendments to the national health service vocational training for general dental practice Scotland regulations 2004. To A, change the employer of dentists undertaking vocational training from training practices to NHS education for Scotland or NES, and B, continue an exemption from vocational training for dentists holding certain European diplomas. No motions to a null have been received in relation to this instrument. Do any members have any comments in relation to this instrument? Thank you, convener. Yes, notice looking at the vocational training that's here and the fact that it's now going to be NES that pays rather than the individual employers. Does this then mean that they are paying their pensions contributions? I assume it does, but also does it now allow those dentists on vocational training to access NHS benefits, including the cycle to work scheme? Oh, we can write to the minister, we can ask for clarification on that. Any other members get any comments they want to make? Right, I propose that therefore the committee does not make any recommendations in relation to this negative instrument and writes to the minister on the points that Dr Cahane has just raised. Does any member disagree with that? No, we are agreed. Right, so now move on to the substantive item in our agenda, which is agenda item 3 on health inequalities. We're continuing our evidence taking on health inequalities and this follows a series of informal engagement sessions which we undertook on the 20th and 23rd of May 2022 to help to understand people's experience in relation to health inequalities. Very good sessions, very intensive sessions where we have people who have lived experience, and during the session today, this is our opportunity to examine some of the issues that we heard. We're all in different breakout rooms, so we should have a good spread of questions to ask the people in front of us today. We'll be able to dig deeper into some of the things that we heard. We've got four people with us on our panel to answer our questions and to give us some more information. I welcome to the committee Tony Groundwater from Families Outside, who's with us in person. I've also got Richard Mead from Caerers Scotland in person as well. I'm joining us online. We've got Karen Lewis from the Hub, from Dumfries and Galloway, and Sharon Wright from the University of Glasgow. I believe that all four of you have a brief opening statement that you would like to make, so I'll come to Tony first of all. Thank you, convener, and thanks for inviting us along today to highlight some of the inequalities that face those that we support and represent. At Families Outside, we work solely on behalf of children and families affected by imprisonment, and the challenges families face when someone goes to prison are clearly considerable. Worry for the person in prison alone is enough to merit support, let alone the multiple challenges they face for their own health and wellbeing. Imprisonment of a household member is one of 10 adverse childhood experiences known to have long-term implications for health and wellbeing, and the research continues to support the links between imprisonment of a family member and poor physical and mental health for the family, an impact on health even greater than divorce or bereavement. One of the inequalities facing our families is often that they aren't identified or supported to get the help that they need. Greater awareness around the needs of children and families affected by imprisonment across the board is required. Families Outside published in collaboration with partners a framework for the support of families affected by the justice system, which was updated just at the end of last year and can be found on our website. There are just over 8,000 people in prison in Scotland in any given day, and each year around 18,000 people are released from prison. It is estimated that around 27,000 children are affected, but that figure could be much more, as I mentioned earlier, in terms of the challenges that we face and the identification of children and families. By that very fact that someone is imprisoned, it increases the health inequalities for them and their families. We know that health inequalities are widespread amongst our prison population. Almost every problem is overrepresented, including those with problem drug use and mental health problems. Prisons should be viewed as a unique opportunity to address health inequalities. The potential benefits of engaging with people in prison and their families effectively around their health are immense. However, people described to us and we heard through the informal sessions that convener had mentioned, the difficulty in access to basic healthcare in prison, as well as significant problems in continuity of care upon release. In many cases, it has led to serious and traumatic consequences, all of which were felt to be avoidable if treatment and better joined-up approaches had been provided. We have heard instances of medication not being made available for people with existing conditions on arrival in prison, sometimes for a number of weeks. Hospital appointments missed due to shortage of staffing and escorts not available. We heard of someone also missing multiple visits to hospital in relation to a leg injury that resulted in long-term disfigurement and on-going problems. We continually hear about the long waiting times to receive support. We would like to see parity in policy and practice between justice and health agencies and their involvement of families and recognising families as carers with significant and valuable information and support to contribute. The Mental Welfare Commission report on prisons in April this year echoed this point, highlighting that the mental health of prisoners and families could be significantly improved with responsive communication protocols between mental health services prisons and families through which families can report their concerns. We recognise the on-going challenges facing prison and healthcare staff, but what we have heard about the experiences of those we support in their families are unfortunately not isolated incidents or one-off failings in the system or practice. It chines with much of what we can see in terms of the evidence available. From the Royal College of Nursing Scotland reports, prison inspection reports and independent prison monitoring all highlight clear themes around health centres that are not fit for purpose, long waiting lists, challenges around staffing and escort services and barriers in communication and collaboration between prison and healthcare staff. The transfer of healthcare from SPS to the NHS in 2011 was driven by the need to reduce health inequalities for those people in our prisons, but a review of the prison inspection reports into health and wellbeing in April 2021 concluded that, although there is much to admire and transfer in the way health promotions operationalised in Scottish prisons, it is apparent that this is not universal across our prison estate and the rhetoric of health promotion in prisons seems to be ahead of the reality in practice. We want to see health and the healthcare of people in prison and their families at the forefront of the open political debate to reduce health inequalities. People we support often simply ask for compassionate responses, but instead what many get is a feeling of being stigmatised, excluded and that they are guilty of a crime by association. There is an opportunity with joined up approaches between health and justice to reduce health inequalities for many across Scotland and people in prison and their families cannot remain unseen and unheard in this context. I asked Richard Mead to speak on behalf of Cailers Scotland. Good morning. Thank you for having me along today. The idea that informal unpaid caring should be considered a social determinants of health was first raised in the UK in a report for public health England published last year, and there is now a growing weight of UK and international evidence that makes the case for recognising caring as a social determinant of health. The World Health Organization defines social determinants of health as the non-medical factors that influence health outcomes. They are the conditions in which we are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life. A carer can be defined as someone who provides care to ill and disabled family members, friends, partners or neighbours. They are unpaid and they are often themselves family members, friends, partners or people in the community and they are usually described as unpaid or informal carers. The vast majority of the existing research shows that unpaid carers experience poorer quality of life, including mental and physical health outcomes, when compared directly to those who do not provide care. Carers experience higher levels of carer burden, depression, anxiety, distress and stress. They are at greater risk of premature death and experience greater prevalence of disease. That includes greater risk of muscle and bone conditions, heart disease, cognitive deterioration and poor sleep. The Public Health England research suggested that, compared to non-carers, carers were 16 per cent more likely to be living with two or more health conditions, arthritis and high blood pressure being most common. These poor health outcomes are likely to be exacerbated by social isolation, poor support and inadequate information, as well as the financial pressure often faced by carers. The higher the intensity of the caring provided, the poorer the outcomes. The longer a person has been a carer, the greater the impact on their physical health, which deteriorates over time at a greater and faster rate than those not caring. 14 per cent of carers in Scotland currently provide more than 50 hours a week of care. Neglecting their own health is a common practice among carers. Carers are less likely than non-carers to own their own homes, less likely to be employed and more likely to be in poverty. Seven per cent of carers are forced to give up work in Scotland and many more are forced to reduce hours that they work. Supporting the mental and physical health and wellbeing of carers is essential and actually does make a difference. Carers who have access to services have better health outcomes on average than those who do not. However, many carers struggle to access any support or statutory services and many carers go unidentified for support at all. Carers are more likely to be women. 61 per cent of carers are women and they care on average more hours a week than male carers, meaning that unpaid care has a disproportionate impact by gender. The health and equity gap caused by caring has not been closed since the establishment of the Scottish Parliament but is actually growing. The Covid pandemic has exacerbated much of those issues faced by carers and led to many experiencing poorer outcomes. During the pandemic, more people were providing care than ever before. We estimated that around 1.1 million people in Scotland were providing care during the pandemic and the number of people providing care has not returned to pre-pandemic levels. We know that more than 70 per cent of unpaid carers did not get a break or any respite during the pandemic. Many have failed to access services for themselves and those they care for and have struggled to get appointments for their own health concerns, exacerbating their health conditions further. Many are still shielding despite the lifting of protections, worried about the impact of Covid and the failure for local authorities and other services to return to pre-pandemic levels. All this is at the time when the same unpaid carer as a coal is contributing over £11 billion a year to the health and social care system. That health and social care system would quite simply collapse without unpaid carers. The growing level of unmet need for carers is likely to continue as more and more people need care and there is a greater reliance on unpaid carers to meet the increasing gap in the provision of statutory services for ill and disabled people. The emerging evidence shows that the difference in health outcomes between carers and non-carers when accounting for all other factors means that you are at greater risk of ill health by being a carer and that is why caring must be considered a social determinant of health. That should be reflected in all national and local public health policy and strategies designed to tackle health inequalities. It should be a focus and a priority of Public Health Scotland. There is also a lack of research in unpaid care, its consequences, its complexities and interventions, particularly in Scotland, much of that does exist comes from other parts of the UK or is international. A substantial research programme is definitely needed to better understand the complex nature of unpaid care and the adverse consequences that care can bring. Such a programme should look also to test new models of care and support for carers reflecting that understanding of that complexity. We would love to see a research centre for carers established in Scotland. There also needs to be increased investment in those existing interventions to support carers, particularly breaks for caring and financial support to ensure that carers do not fall into poverty and those that are in poverty can be lifted out of it. For example, we would love to see another doubling of carers allowance supplement this December to help carers when their energy bills are likely to be at their highest and Christmas is on the horizon. The failed systematic support for carers has created a public health crisis. I would urge this committee to reflect on this in its conclusions to this inquiry and, above all, recognise and state that this Parliament sees caring as a social determinant of health and a public health priority for urgent action. Many thanks for inviting me today. The hub is a community anchor organisation in Dumfries and Galloway and we deliver a range of social justice projects and services, one of which is the regional rent deposit guarantee scheme, which is what I am here to do a presentation about today. The rent deposit guarantee scheme assists people on low incomes, in housing need, access to the private rented sector. We deal mainly with quite small-scale landlords in Dumfries and Galloway. It is not a business model for them. It is one or two properties. They have jobs. Often many of them have only had a work-based pension recently, so it is often a pension asset for the future. That is the majority of people that we deal with. We can first say, as a given, that in terms of health and wellbeing and any kind of social justice, one of the basic needs in life is that you have a home, that you feel secure in, that you feel that you can put routes down, that you feel that you can build a life. Another great determinant is that you have self-agency. You can make active decisions and you have options about your life. We all agree that those are important building blocks of having good mental health and wellbeing. We need to challenge the assumption that everyone who faces homelessness or is homeless has complex needs or a chaotic lifestyle—certainly many households do—and there are support mechanisms, particularly perhaps the housing first model, where there is multi-agency approach, which works for them. However, in our estimation of the people that we work with in Dumfries and Galloway on the rent deposit guarantee scheme, it is quite simply poverty. They are poor. We are one of the lowest-wage economies in Scotland, and we have a lot of people who are in work poor, who are under-employed and possibly on minimum wage rates. We need to accept that and accept that we—not accept it, we need to challenge it, but I accept that this is happening—that people are in housing need due to poverty. No other complex needs are involved. Rather than doing a lot of statistics on the people that we have supported, I thought that I would present just a couple of case studies that demonstrate the inequalities that people experience in health determinants and just in how the system works if you are poor on a low income and having to live in the private rented sector. I thought that I would give an example. We are working with somebody called Sue at the moment. She is 30, unemployed, and she is in a private rented flat that she has obtained through the rent deposit guarantee scheme because we have provided the deposit bond to the private sector landlord and a short-term rent and advance loan, so that she is able to access a home to live in. Her rent is £395 a calendar month. The local housing allowance that is part of universal credit, we in Dumfries and Galloway have the lowest shared room rate local housing allowance in Scotland. Basically, she will be getting around £260 in her universal credit towards her rent of £395 a calendar month. She can replicate that for anybody under 35 who is on basic universal credit and has no other added benefits throughout Scotland. The local housing allowance shared room rate is throughout Scotland and, obviously, it is assessed on a local authority level about what that is set at. She is going to make up a shortfall out of her personal universal credit of £76 a week. She has got to find £135.70 a month to maintain her home. I put it to you that the level of stress and anxiety about those kind of issues really absolutely affect people's mental health or wellbeing and undermine their capacity to build a life. They are constantly worrying about this all the time. What kind of current supports are available to help people like Sue in the private rented sector? If Sue had been lucky and had a social housing dependency, on average, rents for a one-bedroom flat are around £325 to £330 a calendar month. All her rent would have been met. That stress and anxiety is moved from that person to similar levels of poverty that is removed from them, but not from those who are in the private rented sector. What current support can Sue get? She can, and we have done, apply for discretionary housing payment. That will top up that shortfall, but here is the issue. The clue is in the title, it is discretionary. It is not a given. The maximum that she can get is 12 months, usually it is six months. How can anybody relieve that stress and anxiety, knowing that there is some kind of temporary support and help to help them to maintain their home? Discretionary housing payment is just a sticking plaster. We really need to accept that and look at another solution, which I will come on to in a minute as one of my suggestions. The other thing that I wanted to flag up, and credit to the Scottish Government on this one, that there was the tenant support grant that was issued to local authorities. That was a small-term, short-term support grant to assist people who had got into rental areas during the Covid pandemic, and it was for them and their landlords to apply to the local authority to get. Again, that would remove a lot of stress from somebody if that help was going to be available. Again, I can only talk about Dumfries and Galloway, but we have 352 applications to this funding in Dumfries and Galloway. How many were from the private rented sector? 55, of which only 13 were successful. I will just say that again, so only 13 tenants in the private rented sector accessed this fund. 84 per cent of it was taken by social housing landlords. We asked the question of the landlords that we worked with. Why wasn't there more of an uptake of it? They came back to us and were saying that it was the bureaucracy and the hoot that she had to go through to access the fund and the lack of the detailed information that they needed about their tenants and their tenants' lifestyle and income, which she needed to put in a collaborative application. We cannot say that there is a causation here, but I think that there is a correlation here. Social housing has paid full-time staff and they have housing officers. They know an awful lot of detailed information about their tenants, so it is hardly surprising that they can get a pathway through the hoots that are there to access those funds. I will come on to a possible solution for that. We were asked to think of what we would think of as solutions to those issues. First of all, I urge the Scottish Government to use its powers that it now has to create its own welfare benefits and to look at a permanent benefit that negates the shared room rate. It makes up that shortfall for people in the private rented sector. The new deal for tenants strategy that has recently just finished its consultation thankfully has a very detailed section affordability. It looks like one of the recommendations for the first time that we will get a comprehensive, deep analysis of affordability in Scotland in the private rented sector and the potential of a rent cap. The rent cap potential is based on the affordability—not a broad brushstroke but on a housing market breakdown—and the affordability on the rent and of income. Does that tell those two things that I suggested about a new benefit? The other side of the equation is to—this may be a bit more challenging—to revisit the old tenant initiative schemes that used to be around and are now no longer in place, that would assist those people who are in permanent jobs, who may be modest incomes, who have got a credit reference, who would like to move into the owner-occupied sector, releasing very quickly a social housing for people who need it, maybe that needs to be revisited, those incentives used to pay people's deposit and their legal costs of buying. We also need to look at incentivising landlords in the private rented sector, particularly low-scale ones. As I said, it is not an income generation for them, but maybe there is something about supporting them so that they have better access to the schemes that come out and increase the uptake of those. My final point is that we cannot wait for 2040 and yet again another laudable target of more social housing. We have the same target for 2020, which was never reached. We need to be creative and solution-focused now. Otherwise, inequalities and the impacts on people's mental health and wellbeing in secure housing are a social justice issue that will just continue. Even worse, by not acknowledging that, we are accepting that. In fact, some of the support mechanisms that we introduced are colluding and facilitating with the short-term schemes of support that this continues. I do not think that any of us in a fair and just society should accept that that is normal. My final opening statement is from Sharon Wright from the University of Glasgow. My main point is that poverty drives health inequalities. In order to tackle health inequalities, we must tackle poverty. We need to be honest about the fact that death rates in the poorest communities are increasing now, so health inequalities are definitely worsening. What is the problem? In my field, my research is about the lived experiences of people who claim social security benefits. My research shows that people are experiencing a lot of poverty and hardship, even destitution, while claiming social security benefits. The source of the problem is that the UK system that should be protecting people from poverty and preventing poverty is not operating effectively because of more than a decade of cuts and reforms. What those have done is operate as a large-scale disincentive strategy, so people who should be claiming support are being put off from claiming the support that they need. For example, disabled people and people with mental health problems should be getting adequate incomes, but they are not. People who have medical evidence for ill health are not able to claim benefits like universal credit on the basis of ill health, and they are treated as if they are really fit for work, when they are not. Several reports and a lot of research show that universal credit, rather than alleviating poverty, is driving poverty. That is because universal credit is not generous enough in the rate that it is paid at. It does not give people the money that they need to cover their basic survival needs. Because of quite frequent deductions, about half of all universal credit recipients have deductions made to the amount of benefit that they get. To begin with, it is an inadequate amount, and then it is cut down further because of deductions. Those deductions are for things like rent arrears and to repay the five-week wait. Also, repaying previous tax credits, for example, to HMRC. A lot of money that is coming in is going straight out to repay existing debts. The situation is that unprecedented cuts to UK social security for more than a decade are combined with welfare conditionality to push people towards work, even when that is not realistic for them. Behind that is the world's harshest sanctions regime. That contributes to stigma, hardship, people needing to use food banks. In the worst extreme, our research shows that people rely on survival crime or survival sex, worsening domestic abuse and worsening physical and mental health because of the hardship. Recent research that we did in Glasgow showed that people claiming universal credit still have an enormous fear of sanctions, even though the statistical likelihood of being sanctioned is now less than it was in previous years. The system that is meant to protect people is not functioning properly, and that also has detrimental impacts on those that Richard mentioned were unpaid carers. Those two actions that are required—just two small actions—cut to the value of UK benefits needs to be reversed. One of the biggest impacts is from the benefits freeze that went on for several years and brought inadequate incomes even lower so that people who are claiming benefits, including those in work, had fallen incomes relative to the rising cost of living. What could be done about that is that the Scottish Parliament could lobby Westminster to increase the rate of universal credit. The second major issue with social security is conditionality. That is very damaging because it also applies to the partners of claimants who may be carers and it also applies to those who are claiming universal credit in work, so people who are in low-paid work and in part-time work. That includes a set of older women who have received less attention. For example, women in their 60s would have expected to be in retirement. There is a lot that can be done to improve the system. The Scottish Parliament's own powers could be used to increase the carers allowance supplement and to increase child payment. What is needed in the long term is a major programme of reform to build support for progressive taxation. It was clear in the Scottish Spending Review that there is just not enough money for the enormous void between the support that is needed and the support that is available. Thank you very much to all of you for those comprehensive statements. It is so comprehensive in fact that you have probably answered what I was going to lead off with. Your main asks in policy areas—I want to quote our predecessor committee, in fact a predecessor from the fourth Parliament—did an enquiry into health inequalities in 2015. One of the things that they said in the report is that health inequalities would not be reduced without action to reduce inequalities in every other policy area and across every portfolio. Of course, what we have just heard from Dr Wright is that it is not just the portfolios of the Scottish Government but the portfolios of the UK Government as well have an impact on the health and inequalities. I was going to lead off and ask all of you for your main ask, but you have given us a suite of asks and touched on quite a lot of those portfolio areas. I am going to dig into some of what Tony talked about, because I was in the breakout room with some of the people that you support. I have my notes from that session. I have to say that, after listening to people you support and yourself, I was really quite taken aback by some of the things that those families have been put through. One of the things that struck me is that you led off by talking about the health inequalities that the family members suffer and you talked about the adverse childhood experiences. Every single person in that breakout room was concentrating on the health and inequalities of their loved ones who were in prison. That was their main focus, not themselves, not the impact that it had on their family, although that was evident just in listening to them. However, their main complaint was that the worry and anxiety that they had for the people with partners, siblings, friends who were in prison or custody were not getting access to their rights to healthcare. You can see that that was having an effect on their own mental health. You mentioned in your statement that there should be parity between the justice system and the healthcare system. I want to talk about that change that there was in terms of the SPS being responsible for the healthcare of their prisoners and the change that there was for the NHS was responsible. One of the things that we heard was that the families were saying that when they had concerns about the health or people getting access to medication for long-term conditions, the SPS was saying that that is the NHS that is letting us down there. The NHS was saying that we cannot get access to that person because of the people running the prison. They did not know who it was that was responsible. Can you give us a bit more information? Obviously, you deal with those things every day. One of the main calls—you are rightly stating that, convener—in relation to the basic right to health from what we hear in terms of the people we support is not happening across our Scottish prisons. One of the key things—if you take what happened in 2011 in the transfer, as an example—is that we embedded a culture where there is a prison regime already operating and we took healthcare into that regime, which created many practical barriers and many cultural barriers to making that effective. In the 2017 Health and Sport Committee report, it stated practical things around a need for improved IT systems in relation to prescribing, for example. Those practical elements create massive barriers for people to be able to get access to, for example, medication just early and that continuity of care when they go back out into the community. Those practical things are in terms of how both systems operate. We do not think that they have been fully thought through and fully implemented to the greatest degree. The prison regime in healthcare creates massive barriers and we would like to see much more joined up strategies to improve health outcomes for people in prison and their families. The other thing that was mentioned was the training of prison officers in identifying when somebody really did need healthcare as well. Could you give us a little more information on those who give us some examples of where that has fallen down? Absolutely. One of the prevailing things that we hear about a lot is the stigma and discrimination. People are coming forward to try to access much needed help and support but not being able to either be taken seriously or to be forwarded on in terms of the specialist care that they might need. The basic right to health is not being met. The escort service, for example, people needing to go to hospital for specialist care and then being told at the last minute that they were not able to make a hospital appointment because that service is not available just to the structural challenges that are faced in terms of staffing. We know that staffing in terms of recruitment and retention of healthcare staff within prisons remains an on-going problem. There are some structural challenges on the ground that mean that people are not getting access to the right care and support. Just to continue with that, we work with a family member who unfortunately lost somebody in prison due to death. Part of the fatal accident inquiry highlighted a clear recommendation around staff training so that people working within prisons were prepared for some of the circumstances that they might be faced with. Also, there are very simple things in terms of the administering of medical equipment, the logging of medical equipment within prisons and people being able to be trained appropriately to be able to operate the much-needed medical equipment should an emergency occur. Unfortunately, in that instance, it led to a death in custody. Just before I hand over to my colleague, I will bring it to the other side to the families, notwithstanding the considerable anxiety that they have about their loved ones in prison and the impacts. I am quite near to prison HMP Grampian, my constituency, and I have visited there. They have a family centre that provides a lot of support to the families who are not run by the SPS, which is voluntary led. Is that the case across Scotland? It strikes me that that is an opportunity. You mentioned that prison, in that time of prison, is an opportunity to get help to those families. The one that I have visited seems to be a way of getting a lot of care and wraparound support to those families when they come to visit their family members. Is that the case across Scotland? Do they all have family centres or is it very patchy? There are 12 visitor centres across Scotland that are attached to each of the prisons. That is an opportunity for family members who are visiting someone in prison. They can prepare for a visit. Children and young people can find out a bit more information about what a visit may look like. That is an opportunity for health promotion and to tackle some of the health inequalities that we know and face in many of the families that we support. There is still work to be done in relation to the relationships between families and the SPS. The communication and the involvement of families remains often a barrier. We know that families can get involved in top-to-me strategy groups and ICMs—integrated case management—to support the family members. However, that remains an on-going challenge. There are many barriers in terms of how some of those meetings are made at the last minute, so family members travelling a long way cannot get involved. We would like to see an increase in terms of the digital aspect of that as well, but many of our families experience digital exclusion as well. There is an opportunity, but we do not feel that it has joined up with the prisons enough to fully exploit that opportunity. It was just about the statement that you made about wanting an IT system for prescribing. As a GP, I see people who come out of prison because they need healthcare when they come out. I do not know what diagnosis has been made in prison. You spoke in your opening statement about mental health issues. A lot of that comes to the fore in prison, where they are in a situation where they are viewed and seen and the mental health is diagnosed. I do not know what the diagnosis is. I do not know what drugs they have been prescribed, so they come to me asking for drugs that, ordinarily, I do not prescribe because it is a specialist that prescribes them. We are in a situation where it is completely unsatisfactory for the patient, but also for me because I simply do not know what to do. We want an IT system that works, that talks to each other, we want digital prescribing, but my question is what are your wants and asks to make the process of a prisoner coming out of prison accessing healthcare better for not only the patient but also for the healthcare professional, and invariably they are the same thing? The point that you make is a really important one in terms of—I mentioned in my opening statement about continuity of care. We know that, often, people are most at risk as soon as they leave prison because often some of those wraparound supports are lost. We would like to see much more widespread involvement around the throughcare approach. We know that, in some areas, that has been very successful. Someone having that support at the gate to be able to support someone to access much needed supports. Some of our other speakers today have highlighted the importance of housing, so we know that there are barriers in terms of someone being able to register with a GP or being able to get the much needed medication that they need upon return to the community if they simply do not have an address. The joined-up approaches need to happen to make sure that people get access to some of those much-needed health supports, particularly which we know is a very risky time when upon leaving prison. Thank you very much, convener, and good morning to the panel. Thank you for your presentations, which were indeed very informative. All the evidence that we have heard in informal sessions was useful and insightful. I came to talk a wee bit about culture within our public services and the culture of house service delivery that takes place. In one of the evidence given by the group from the hub in Dumfries and Galloway, someone who was contributing said that there are judgmental and uncompassionate public services and describe them as punitive rather than supportive. Obviously, we could see direct links to some of what Dr Sharon Wright was talking about within the social security system more widely, but I wonder if that is also some people's experience of the variety of other public services that exist, whether that be in NHS, whether that be from local authorities in terms of provision of housing. That is quite stark when people are describing the network of support that we would all want to see there to help people perhaps doing the opposite and feeling judgmental. I am just keen to understand how we begin to shift that culture. We have had undertakings in terms of what the Scottish Government is trying to do through Social Security Scotland. I think that we have undertakings in our local government sphere, but I am keen to understand perhaps what more can we do to have a culture shift away from that sort of experience, essentially. Given that it came from the hub, I do not know if we want to start with Karen on that. Just unmute Karen's microphone. In our experience of people who are navigating their way through statutory services, it is a very mixed bag. Some services are very person-centred and have an ability to be flexible and go a bit beyond what is required. If the computer says no, it is coming up with, well, let me sign, post you, let me set up an appointment with someone that may be able to help you. Other experiences that people get, certainly, approaching homelessness services is very mixed. It is a cultural thing as well. I wonder sometimes whether it is not making an excuse for it, but sometimes when you work at the coal face and you are dealing with a very inflexible system that you have to deliver, maybe you internally close down a wee bit because you are protecting your own self, because you know what you are saying is not what the person wants to hear. It is a very difficult conversation to have. I think that there is something about empathy, boundaries, about wanting to assist people. That is a personal value base. Maybe some people have to switch that side of their personal life off to even cope with the crisis that they are dealing with every single day of their working life with people in need. Unless you are working in that field, you would not know what that is like. Certainly, I think that some of the homeless presentations, the loopholes that you have to go through, the kind of lack of forward sending people on where they might be help, is where there is a disconnect. It goes back to what other people have said about continuity of care. It is almost like continuity. If you have come to me, I have a responsibility to give you an exit to somewhere that may be able to help you, rather than just saying that we cannot. Would anyone else like to come in? I guess that whole issue of the no wrong door, I think that one of the people said in submissions that it takes a lot for somebody to go and ask for help in the first place. If we are wherever they go and ask for help, should be a gateway to that help. Richard, I see you nodding. I think that, on that particular, lots of unpaid carers go unrecognised and unidentified, and do not get the support that they need as a result. That recognition can come in two parts. Firstly, carers themselves do not necessarily see themselves as carers. They might just see themselves as a wife, a husband, a father and a son, so do not realise that they are a carer and do not realise that they themselves will be entitled to help and support. Equally, we find that a lot in statutory services carers will go unidentified by practitioners who potentially could identify them. However, that is in primary care, in social care services. The carer often is the person that they do not see. They will just focus on the person that is receiving help and support and the carers' needs will go unmet. That recognition is hugely important for carers, and that in terms of a culture shift in public services, I think absolutely that carers need to be seen, valued and recognised and treated as partners in care and decision making. They have a great deal of expertise and understanding, not only of the things that are surrounding them, but of the person that they are looking after. Often, for them, they feel frustrated because they feel isolated from decision making and isolated from the practices that are put in place to support the person that they are caring for, and they do not feel empowered to be part of that decision making process. That is something that we would like to see, a recognition and value of carers and the role that they play, and a real focus on identifying carers. I think that that issue of the culture of service delivery is incredibly important, so thank you for raising that. The trouble is in Scotland that a lot of the systems that are certainly in relation to social security and a lot of housing-related issues are controlled by Westminster, so the system is punitive. When Karen was talking about housing insecurity within universal credit, it is the universal credit system that is creating something that is very cruel and punitive when people are trying to access housing and do not have enough money. A lot of people that I have spoken to about claiming benefits have been very scared of losing their home. There is other research from a colleague of mine, Ian Hardy, at University of Glasgow that shows a statistical correlation between universal credit and housing insecurity. It is that UK system that is operating throughout Scotland that is creating something that is cruel. The people on the ground of support workers who are trying to help people have to deliver some very unwelcome news, and they have to have that interaction that is based on a system that is very unfair. That takes its toll on emotional labour from the front-line workers. One of my recent studies, we spoke to work coaches at job centres in Glasgow, and they found that incredibly difficult, sometimes having to tell people, for example, EU migrant workers when they were not eligible for access in universal credit. They found it really painful and really upsetting to have to have that conversation with people, similarly with a lot of people with mental health problems and physical health problems, when they still had to the system required them to look for work, even though their medical records are getting medication, for example, for really severe mental health problems, but the system still requires them to look for work full-time. That is another dimension of the cruelty of the system that the front-line workers are stuck in that position, caught in the middle between a system that is not right and people's immediate needs. We need to be honest about the Scottish system. The Scottish social security system has deliberately taken a different alternative approach to offer dignity, fairness and respect, but we also need to acknowledge that the carers allowance supplement was set at the level of jobseekers allowance. In that sense, it mimics the UK system. It is anchored in the UK system, and that does not offer people enough money to meet their basic needs. In our Scottish benefit payments, we could make a different choice and we could choose to make sure that those are tied to minimum-income standards that ensure that people have enough money to live on. Do you want to pick up on any of that? Perhaps just briefly. In both answers, we have alluded to the challenges that exist for people that are multiple and diverse. I am keen to understand if people feel that front-line workers who are supporting people have enough training in understanding mental health issues. I think particularly trying to identify and try as someone. Again, coming back to that no-wrong door approach and trying to take a holistic view of a person and meet them where they are when they interact with services. We have done some of that, but I am not sure that we have done quite enough. I am keen to get people sensitive. We need to do more on how we might do that across the piece. The first point that I wanted to make was around in order to create an effective culture. We must ensure that it is resourced appropriately so that some of the other points that were made around severe pressures on the ground. To pick up on Paul's point about training, the national prison care network is developing some training for induction for healthcare staff who work in prisons to better equip them. For me, it strikes me that the most important part of any induction or training to feed into the culture that we want to see has to really involve those experiences and those lived experiences of people and the impacts of the systems and the policies that we create. What is the impact that that has on people individually? Any training that we create must have that flavour, but any more inquiries and any more. We must continue to work with people with experience, not only to highlight some of the issues, but also to help us to develop some of the solutions. The final point around culture is about the right to health and ensuring that we make a shift in terms of all our minds around people who have a right to health. It is not a nice to have, so we need to continue to keep that right-spaced approach at the forefront of our minds. I think that it is absolutely right that there is a huge need for more mental health training, but when we interviewed work coaches at job centres, they felt frustrated. The general support for them is mindfulness or meditation, but if you have to tell someone who is disabled or has really bad mental health problems that they are not eligible for benefits or that they have to repay money that they do not have or that they have to go to a food bank because they have not got enough money, it is like a little bit of mindfulness that does not really help you. You are going to feel really awful about that, and that is driving mental health problems amongst front-line workers as well as driving mental health problems amongst claimants. The big issues need to be resolved at the systemic level to stop the social security system creating and worsening mental health problems as well as encouraging better training for front-line workers. Those people who are working at job centres have some mental health training, but not very much. It could definitely be better, but during Covid, we have also seen that mental health has worsened for workers as well as for people who are out of work. The mental health challenge is enormous and it is something that needs a lot of attention. I want to make two quick points. Like other people who may be here today, I work in the third sector. One of the things that I would say is that if we are looking at practical solutions in terms of cultural shift and in terms of wider training, there should be something when statutory agencies are involved that they see the third sector as meaningful partners. There will often be a talk about partnership working, but that is not cascading training to third sector organisations that deliver activities that progress objectives of the statutory agencies. There are often seen more of a transactional group sector that is just going to carry out some activities. They are not involved in planning, they do not offer the training potential either. That is my first point. My second point would be that it is really important that every time I look at a policy paper or an operational plan that is going to put a policy into action, say from the health board or from the local authority, there are always impact assessments at the end of those. Maybe we should look at asking for requiring that, as part of the impact assessment, there is something about mental health and wellbeing, there is something about rurality, there is something about poverty as part of that overall impact assessment so that there is no policy or operationalised policy that has got unintended consequences of those who have to live their lives. Emma, you have some questions for our guests. Thanks, convener. Good morning, everybody, and good morning to Sharon and Karen online as well. Probably a lot of questions have been answered already, but I was struck by Sharon's statement about poverty as a cause of health inequality and that universal credit does not work. The £20 uplift was removed, which was provided during Covid, and that is 80 quid a month for people, but you are using really strong language such as punitive, cruel, unfair, and even that is kind of demoralising, I am sure, for lots of people to hear. That was just a comment, but I would be welcome any further thoughts about what we need to do to change that, such as minimum income guarantee, universal basic income and what we need to do to progress that, as we have witnessed in other countries. My other question is for Karen just about locally. I visited the hub a couple of weeks ago and I witnessed for myself the work that is being done in the hub, and I think that Karen, you should be commended, and you certainly helped my knowledge, but the detail of the barriers for people applying for whatever support they can get, I would appreciate a further expansion on that. I think that your microphone is live. You are absolutely right, universal credit is a major issue, so a £20 uplift would be extremely welcome. It is important that that would also apply to the legacy benefits, because one of the hard things for the £20 uplift, when it did happen, was beneficial to those who were claiming universal credit, but for those who were on other benefits such as employment support allowance or job seekers allowance who had not moved over yet, it felt very unfair that they could not have the uplift. Obviously, it was a terrible decision to remove it. It still was problematic in some respects, because during the Covid pandemic, when the uplift was in place, some people did not get the full benefit of it. If you give a £20 uplift, people will have £20 more in their pocket, but because there are so many deductions to universal credit, what happened was that, for some of those people, they were paying out some of that money to repay old debts, such as rent arrears or repayment to DWP. DWP has aggressive debt management strategies that sometimes require people to repay large sums within a very short period of time or to have regular deduction all the time, which leaves people with very little money to live on. In the long term, the minimum income guarantee that the Scottish Parliament is currently looking at is promising, but it depends on a number of different scenarios. The minimum income guarantee could be most effective if the Scottish Parliament gets increased powers over social security. That is most likely if there was a vote for independence, but that is not guaranteed. If the minimum income guarantee was operating only with current powers or only with a partially increased set of powers over social security, it could be quite limited. It could be that the minimum income guarantee would operate alongside the universal credit system. I have two concerns of that. First of all, it might take a long time to get going, so maybe four years at least, maybe more. The second concern is that it might have to operate alongside major parts of the existing system such as universal credit. I urge you not to wait with your recommendations but to just press ahead and ask for increases straight away, because people are really struggling. A lot of people have very low incomes, and you can see that that is so much worse now than a decade ago before we had universal credit, before we had the benefits freeze, before we had the five-week wait and all those deductions. The minimum income guarantee is hopeful for the future, but I do not think that we can wait for that to take action, because what is going to happen while we are waiting is that health inequalities are going to worsen. Literally, people in poorer communities will be dying while we are waiting for that to come in. Please do not delay with increases for income. Can I just pick up on something? The Scottish Government seems to be prioritising families with children and getting money to families with children with the doubling of the child payment. Obviously, that is going to miss out a lot of people as well, so there are other interventions. Do you think that prioritisation is probably right at this time? It is really hard to say that some people deserve money more than other people. I can see that it definitely will help with meeting the child poverty target. It is a really good intervention to give more money to children. I am definitely supportive of increasing the child payment. It could easily double that it would be a really good use of resources, but, like you say, that is really difficult for people who do not have children, because at least if the child payment comes in, the household has more money. However, if there are no children in the household, they are just left out of that transfer. That is an issue for households where there are not any children. That increased likelihood of poverty and that deepening of poverty. As time goes on, it gets worse and worse. With universal credit, because that is for people in work as well, it is replacing working tax credit. It is like there is no escape. Those people who are most disadvantaged are, for example, a double disadvantage. If you are disadvantaged in the labour market, for example, if you are a woman or a black or minority ethnic group, if you are disabled, there are employment penalties that mean that you are less likely to be in a well-paid job, you are less likely to progress in work, you are more likely to have low pay, you are more likely to be working part-time and you are more likely to have to claim in work universal credit, which will then trap you into that poverty. It is a genuinely tricky issue, but going forward, it is projected that 70 per cent of working universal credit claimants will be women. Within universal credit, the emphasis is on full-time work of 35 hours per week, and that is really difficult for many women who have caring responsibilities, either for children or for other adults, and women who also have health problems themselves and are disabled. It is really difficult to find an easy solution, but I am certainly supportive of an increased child payment. Thank you. I bring in Karen, and then I will come to other colleagues. Yes, the question that Emma posited was about barriers faced by people, but I would firstly just endorse a bit what Sharon said, that the child payment will help those families with children, obviously, but the people that we deal with, many of them, do not have children or older people. We have people who we deal with on the rent deposit guarantee scheme who are in mid-life and have no dependent children, so it does not help them. The barriers that we have found that affect people claiming support and help while they are in the private rented sector. If we take that tenant support grant that I referred to, where there were so few private sector tenants who accessed it, you had to demonstrate that you had to prove that there was a rent debt. That meant that the landlord had to show that they did not have payments from the tenant. The tenant had to agree with that and explain why they had not paid their rent. A lot of those tenants might have been getting some help towards the rent, not full housing allowance. They might have been working getting some and had not paid it over. The chances of them thinking that they had a positive relationship with their landlord were frightened of collaborating to claim that. That was one issue, but they then had to look like they had been a pre-plainment plan agreed between the landlord and the tenant. Difficult to prove that you have that, you have had that, you have developed that. Those are the kind of things that put off private sector landlords applying for it, or being eligible for it, and tenants as well. Housing associations have already got all that paperwork. They have a kind of debt management process. They have already got these things ready to go into claim. That was one barrier. In terms of barriers faced by people just trying to access all the kinds of help, we mentioned universal credit. You could have somebody 30 years old working 32 hours a week, because I said that a lot of people in D&G are underemployed. If they are earning the minimum wage, they would not qualify for universal credit. If your take-home pay is around about £1,100 a month, you will not get any help whatsoever, not even council tax benefit, apart from the 25 per cent discount. If you have took off your rent of £475 and your cost to travel to and from work, you have probably got £470 a month to live on, and that is somebody in work that cannot get help from anywhere else. The differential is going to grow with that, unless that person manages to work the way out of poverty, get a better paid job or work more hours, they are always going to be in chronic poverty. The other thing that I wanted to mention is that a lot of people—I think that the least sight of this—when you are struggling on very low-income in poverty with all the impacts that we have talked about on health, your worldview shrinks to getting through that day. Your capacity diminishes to actually chase to get through the gateways, to get through the barriers, to have the evidence to provide. Often, people just give up, the system grinds them down. Sometimes we have the support there, but the processes that people have to go through to access it mitigate against the very people who are vulnerable and who have got a lot of other stress factors going on in their life to even cope with waiting on the—an example that I tried to ring up the benefits section yesterday for someone. I was on the phone 55 minutes before it then cut off because the office had closed. I was trying from just before five to four to five o'clock. Now, that is me as a worker using my work phone. I am paid to do that time, but if I was somebody under stress, I would just give up. It would just be defeating. I think that we have to realise that we need to look at simplifying access to things and having decently funded support services that assist people to navigate the way through those things. Without that, that is why there is undertake on support and benefits. That is why it seems to be the people with the highest capacity who maybe get them than others. That feels inequality within a group of people who already are facing inequality. There are different layers of it, which I just do not think in a social justice sense is acceptable. I just wanted to pick up the issue of unpaid carers. A report by the Joseph Rowntey Foundation published this year found that unpaid carers are more likely to be in poverty than non-carers. The greater the number of hours that a carer works, the more likely they are to be in poverty. We published a report earlier this year to look at carers and the cost of living crisis. Overwhelmingly, carers are facing greater increases in everything from energy bills and reduced income. Obviously, we welcome the carers allowance supplement, but even with the carers allowance supplement, that is simply not enough to meet all the challenges. Carers allowance, as we know, as soon as you are working as a carer, as soon as you hit £132, you lose any entitlement to that. If you have a pensionable age and receive pension, you will also not get carers allowance. Carers allowance in Scotland only reaches about 90,000 carers, so lots of carers really struggle. We need to do a lot more through Scotland's social security system and, hopefully, through the carers assistance consultation, there is a chance to do that. Although I have some doubts, we need to do much more to address what is carer poverty. I know that the Scottish Government has a child poverty strategy. We would very much be in favour of a carer poverty strategy, too, to try to address some of the unique conditions that carers face and the poverty that they face and how we might address that through the powers that we have in the Scottish Parliament. Obviously, the increase in utility bills, particularly from heat and electricity, will really be affecting people with care and responsibilities disproportionately. Massively disproportionately. I can give you some really good examples of people. Often, if you are caring for somebody who has medical equipment in the house that might need to be on 24-7, you simply cannot turn that off. How are you going to be able to then meet those costs? We have seen examples of carers facing bills in the tens of thousands a month because of costs. That is extreme, but that is not uncommon that carers are facing or families with people with disabilities and carers are facing huge challenges to heat their homes, to keep their homes running on such very limited financial resources. I am so curious that the allowance comes in, but it is completely swallowed up by an increase in fuel bills. It does not even touch the sides. Emma, you have a very short supplementary question, and I must move on to other members who are starting to come in with asks. Sure. It is a very short question for Karen. The rent deposit guarantee scheme, is it only a Dumfries and Galloway hub thing, or is there other third sector D&G hub equivalents that have it as well in Scotland? There are rent deposit guarantee schemes across Scotland. The majority of them are statutorily run. There are about two or three nearest ones in Ayrshire that run it, but each of them run in different ways. For instance, our scheme is not allowed through our funding agreement to cover renteries. We are saying in Dumfries and Galloway putting all the risk on the landlord who has a social conscience who will take the rent deposit instead of a cash deposit, and they are going to run the risk of the renteries that they would normally have been able to keep a deposit for. They run in throughout Scotland. They are funded in different ways, not centrally funded. We are supported by Crisis, who supports the rent deposit schemes in Scotland. They are funded to do that. They have not any more, but we still do it. I do not know off the top of my head, but I can let you know how many there are. We will extend the session for another 15 minutes. We have got until 11.30, but there is an awful lot of people who want to ask questions, so I wonder if you can direct them to individuals. I mean that we will get through everyone. David, do you have a question or two? Thank you, convener. Good morning, witnesses. The first sector is very successful in reaching families, individuals and communities, and in many cases far better in government agencies. How has the Covid pandemic affected the first sector? I am talking about volunteers here, because they rely heavily on it. I just know two of the organisations that have been involved and they just haven't returned on the same numbers. Maybe Richard first. In terms of unpaid carers, what I can tell you about Covid is that for many unpaid carers, Covid simply is not over. Many are still acting as if we were during the lockdown. They are shielding, they are deeply concerned about Covid coming into their household, but they get it themselves, which means that they can no longer provide care potentially to the person that they are looking after, or worse, to the person that they are looking after. If that person is clinically vulnerable, there is a risk of severe outcomes and they have deep concerns about that. For many unpaid carers and people that we work with, they are acting as if they are continuing to shield and feel a bit isolated from society's return to normal, as protections have been lifted. We have definitely seen a lot less interaction from people that we might have seen prior to the pandemic. That might be appropriate to what is happening in the hub. Yes, there has definitely been an impact on volunteering. I think that people over Covid internalised that kind of isolation. I think that that is going to be a transition for people to feel that they can come back and volunteer again. I think that a lot of the changes that we have brought in during Covid, in how we are delivered and how we engage with volunteers, I think that it may be part of the role that, again, some people are learning a new role, but there has definitely been an impact. It will come back, but it will take time. It needs to be recognised that, because an awful lot of statutory agencies rely on the third sector and volunteering to deliver activities and services. There needs to be a recognition that that is a challenge. Many third sector organisations do not have funding to employ a volunteer development post, and we have revisited all that to maintain our volunteering and to provide additional support that they may need during the transition period. Many people are represented in poverty, but they are in work. The question is to Sharon. What do we need to do to change employment law, because a lot of them are on zero on our contracts and things like that are forcing them into poverty, and they are stuck because they cannot then go on to benefits? I think that that is a really tricky question. The living wage definitely does help in promoting the living wage or even requiring the living wage would be helpful. On changing employment law, that is tricky because of limitations in Scottish jurisdiction. Zero hours contracts are problematic, so people who are on universal credit can be required to take zero hours contract jobs that do not offer any particular hours but tie people into a contract in terms of getting rid of it. I am not exactly sure how you would do it, but I do like the intention. Can I come to Tess? There is a Scottish Government target for 250 link workers in surgeries, so go to Tony first, but people coming out of prisons are integrating into the community and they need healthcare. Do you think that having the link workers in the surgeries would help? Yes, absolutely. The key point for me, and I mentioned it earlier, is around the through-care elements, so engaging with someone whilst they are in prison and setting up some of those key services and supports that they may need. So long as the continuity is maintained and the relationship that we know is really, really important for that consistency to happen in a community, so long as that is going on, we would be really supportive of that, but I think that that is the key element, is that the relationship started and maintained while someone is in prison. Richard, the link workers in surgeries? Everybody in health and social care settings should have a duty to try and identify carers, and link workers are an important part of that. GP's themselves, it could be practice nurses, it could be the staff that are working reception desks, carers often come in and accompany the person they are looking after, but might sit in the waiting room and nobody speaks to them, nobody identifies them, nobody actually, they could be caring and they could be identified at that point. So I think that absolutely health and social care staff should have a duty to identify carers and link workers could definitely be part of that. Great, so a message could be to speed up the recruitment of those 250 link workers. Can I ask another question, which is a general question to the panel? So the pandemic has exacerbated systemic health inequalities. In your own areas, have each of you identified one example of good practice, even if it is a small example, that could be widened across Scotland? So if we start with Richard. To be honest, I think that there are lots of little things that perhaps have made some improvements and I think actually some of the digital stuff that we've seen, so the ability for people to access digital services, but the problem that of course is digital exclusion. I talked about obviously a lot of families are still continuing to shield and worried about coming back out into society. Sorry, that's like a bigger issue. Is there one tiny small example of best practice that you've identified that could be? Digital, whether it's using hybrid for work, whether it's support with appointments for GPs or the digital benefits that we've discovered during the pandemic can definitely play a role. Okay, thank you. I'm Tony. I think it relates to both your points there, but I think one of the key things for me is around the whole family approach and Scottish Government are committing to that and part of the promise and part of the drug and alcohol framework. I think in terms of link workers and also in terms of good practice, some wraparound support where the whole family is involved, I think is a key element and could be important as part of the link work that you mentioned earlier. We'll go to our colleagues online and maybe we'll get a response to Tess's questions there for coming to Sharon first of all. Yeah, so my current research is about how migrant essential workers have been affected by Covid and one thing that would be really useful there is for link workers to be specifically dedicated for migrant communities. There's research from North America that they call it community navigators and the idea is that the link worker would be someone from the community who helps to guide people towards health services so it's culturally sensitive and appropriate using the target language and specifically to put migrants in touch with the health services that they need. Thank you and I'll come to Karen though. Yeah, during Covid a single access point model was piloted in an area of Gunfriese and Galloway and that was where it was that single point of contact and from there you were diverted to an appropriate agency. I think there's a kernel of a good idea in that. I think it would facilitate that no wrong door idea. However, it's operated by computer algorithms so unless you're in the loop and your service is included in that single access point the person would never get referred to you but I think there's something that could really work and be quite innovative there. Fund is not being passed a pillar to post and I mean to tell the story yet again. At that point of contact it's sent to the right organisation straight off whatever sector that should be. So I think the single access point but to include a much wider sort of framework for who's on it. Thank you very much. Can I move on to another colleague now Sandesh, do you have a question? Thank you convener. It's a bit on Tessa's question but what I want to focus on is sort of the inverse care law where those who need help probably the most have the least access to it and we can see that Tony. We can see that with the lack of prison medics. We can see it in areas or poverty that have the least number of GPs available or dentists available for those people to access health. So my question is more focused upon healthcare and what we have done, anything good that's happened that we can see and point to and say look that that's a good scheme and how we can scale that up and allow people to have more access to healthcare. One of the things that comes to my mind when you were talking is around some of the effective initiatives that happened in prison. So the role that the Covid vaccine within prisons was a positive initiative and it was good take up and where it fell down was when people returned to the communities. So that through care element and that community links and whatever is required is important. The bloodborne virus screening within prisons again was another positive initiative that we've seen work well within the prison establishment in terms of healthcare. What strikes me is that often the third sector is playing a massive role in terms of supporting people with their health and reducing health inequalities. It relates to a point that Karen made earlier that perhaps we need to be thinking a lot more about strategically about the role that the third sector can play in partnership with different healthcare initiatives in order to have more positive outcomes for people involved. What we've seen is existing issues really being highlighted by Covid and we're seeing quite clearly some of the real big fault lines that we have throughout Scotland. What do you think would be our number one priority to tackle in view of what Covid has shown us and how would we actually be able to go about doing that? When in particular are you looking for someone that Richard will come in? For us, for unpaid carers, we needed to see a return to the pre-pandemic level of support and services in the community. I think that more than 70 per cent of unpaid carers have yet to have a respite or a break as a result of the pandemic. A lot of that comes down to that because day care services and other social care services are simply not back to the level that they were pre-pandemic. Not that they were particularly sufficient at that point, but equally now, as a result, carers are struggling and they've just not been able to have a break. That needs to be a priority. Looking at things such as self-directed support and how flexibilities promised during the pandemic were implemented in certain parts, but not others, and some of those flexibilities could be implemented nationwide and could really support carers about how they spend a budget if they're eligible for getting one and being able to use that flexibly to get things like a break and to get support. That, for us, would be a real priority. We need to focus on getting services back to pre-pandemic levels so that not only do people need to get the support that they need, but it will allow carers to get breaks. Thanks. I've got two number one priorities. The number one priority is adequate income to tackle poverty. That's the best way to tackle health inequalities. However, the number one health priority is mental health because we've seen the evidence on the worsening of mental health during the pandemic. It's a huge increase in mental health problems. How to go about doing that, I'm not so sure, but it's a huge problem and mental health definitely needs to be tackled. In my current project on the impacts of Covid on minority ethnic groups, we found in our survey that it was people working in health and social care who had the worst mental health and people who were working in essential goods. It might make sense to do a bit more research into who is worse affected in terms of mental health and to target support specifically to those sectors, so to people working in health and social care and people working in essential goods. There was also an above-average increase in mental health problems among those working in education, but we think that that was mainly a gender effect that it was because that sector was dominated by women rather than the sector effect sort of separately. My first question is to Dr Wright. You spoke earlier on about lobbying Westminster 10 Christchurch universal credit rates, and certainly that's not something that I disagree with, but what I'm just wondering about as well is the fundamental design flaws that we actually see in that system as well, so the conditionality, I can't say it properly now, conditionality for employed and unemployed people. The long waiting periods initially, at least five weeks when people are going without money and the severity of the sanctions that we have, which compared to the rest of the world are incredibly severe, so I was just wondering if you could comment on that. You're absolutely right that those are major problems with universal credit, so the conditionality is very problematic. One of the problematic issues is that people are very scared of sanctions even if they're not very likely to be sanctioned and that fear runs really deep, so because the housing payment is in part of universal credit, people are really worried that if they miss an appointment just by five minutes, if they're late for their appointment, they might end up losing their home. You would think that that's an irrational fear, but it's actually a rational fear because that's how the system is designed that these things are interconnected and people are really scared of losing them. What's happened in recent years is that DWP have eased up on sanctioning, so the system is still extremely harsh by historic standards and in comparison to other countries, but what they've done internally is that they have stopped applying sanctions as frequently as they did at the height of sanctioning, which was 2013-2014, but the whole system, apart from that, got rid of the longest sanction, which was for three years, but all the other sanctions are still in place. It would definitely be extremely welcome if you were able to lobby DWP to reduce the length of sanctions further and to protect people from being sanctioned. It's quite easy to trigger a sanction. The five-week wait room continues to be problematic, but there's no evidence that there's any reason to design the system in that way. The rationale that DWP put forward is that universal credit is paid in arrears, so that's why there's a five-week wait, but they could just make a different policy design decision to pay people up front and then deal with it later if they weren't eligible for it for any reason. The five-week wait definitely should be changed because that is highly problematic. The research that I did in 2019-20 for Joseph Rowntree Foundation in Glasgow showed that about half the people we interviewed applied for an advanced payment and half didn't. Those who didn't have the advance really struggled during those five weeks. They found it extremely difficult to have money to eat. They had to rely on friends and family to get by with their basic survival. Those who took the payment then had stored up trouble for later because they had to repay it, which meant that they didn't have enough money later. The other side of conditionality is not just being sanctioned or the fear of sanction. It's that continual pressure to work, which is especially difficult for people with long-term health conditions, people who are disabled, including many, many claimants who have mental health problems. A lot of people didn't realise about universal credit when it was first released, because it was designed to treat people with mental health problems as if they didn't have mental health problems. In our Glasgow research, we found that people were waiting as much as a year for a work capability assessment. They would claim universal credit and be subject to full conditionalities. They would be expected to look for a job or multiple jobs for 35 hours a week. They could, in theory, discuss with their work coach a reduction in conditionality, but many people felt that they weren't able to do that. They felt this in power. Even those who request it are not guaranteed to get a reduction. The pressure to look for work is intense. The fear of doing the slightest thing wrong and not having any money to survive also pushed people away from the system. People who are eligible for universal credit do not necessarily claim it or people might choose to stop claiming it because they are so put off by that intense pressure. In my big research project about welfare conditionality, we spoke to people who had chosen to, instead of claiming that they had chosen to live in a car, for example, with their children, rather than to claim universal credit. The incentive strategy is really powerful and urgently needs to be addressed to ensure that people get the support that they are entitled to. My current research with migrant essential workers showed that EU migrants were very unwilling to access universal credit, and some of those who tried were not able to access it because it is very difficult for people in that circumstance to claim. It is working imperfectly. There are a lot of design flaws, but for those who are claiming it, it would still be extremely helpful to reinstate that to when you pound up Lyft. I wonder how we put wellbeing at the centre of the approaches to all the different issues that we are hearing about around the table today. Perhaps there is a place for wellbeing plans for individuals that they have power and control over, where they are looking at their own needs and prioritising their needs, and then using that as their access to different services across the board. I will ask a supplementary question in the completely new area, Stephanie, given that we have 20 minutes left. If we could get a couple of our panellists to respond to that briefly before I move on to questions from Gillian Mackay. I can be very brief. Under the Careers Scotland Act, every carer should be entitled to be run, adult carer support plan or a young carer statement. Those should be, in part, wellbeing plans. They should be about identifying carer needs, having conversations about what they might need to support them in their caring role, signposting them for information and support, and if it is likely that they will be eligible for further statutory support, then making sure that they get a carer's assessment. I apologise to you. You wanted to respond to something that I think that was off the back of what Sandesh was asking about, your top asks. Can I bring you back in before I move on to Gillian Mackay? Yes, thank you for that. Although my response figures with other things followed, we saw during Covid that there was a flexibility around support. Obviously, we had the £20 uplift of universal credit. Addictions were halted and there were other schemes, which shows that we can do things quickly when we need to do them. My one ask is that none of those things should be short-term. We have seen the fall-out with taking the £20 universal credit uplift back off. That feeds into what I talked about and what Dr Wright and Sharon talked about. It builds in insecurity, anxiety and levels of stress in people who at least need to be under those conditions because they are never quite sure if the rug is going to be pulled from under the feet. I would say that my one ask would be that whatever is developed and delivered to address poverty, as much as we are able, within the confines of what funding we have available and what the legal framework is, we need to make sure that it is not short-term. We need to make sure that we are not building up an expectation that that is going to be there forever and that it is pulled away from people or that people plan their lives on the basis of A and then suddenly from nowhere they are on B. A lot of people we all presumably work with, certainly from the panel, are people who have not got assets, they have not got savings that can help them through a period that lots of us who have been in work maybe have got that. They have not got access to credit. Lots of them have not got families that they can rely on. That is a fundamental issue for me that whatever we do needs to have longevity with it and we are not getting people in the cycle of being back to square one constantly because you can imagine how that erodes self-confidence, it erodes capacity and it erodes people's health. I am talking about people effectively being in a precipice that the whole time has been plunged in. Thank you for that description. Gillianne Somerville Thanks convener and apologies again for being late. There was an additional meeting of bureau that I had to attend. I think for time I'll stick my two questions together if that's okay. So my good morning panel sorry. To what extent are health and care services taking a trauma informed approach and what improvements need to be made? The second question sort of links to that. We've heard this morning about interactions between income and poverty. In other sessions we've heard about how disability, sexual orientation gender identity asylum status, justice experience being a carer and many other factors interact to present cumulative barriers. To what extent in each of your areas are health and care services equipped to take an intersectional person-centred approach and could I maybe just start with Tony? Thank you. At the minute there is prisons needs assessments undertaken so where the last prisoner needs assessment was done in 2007 and we urgently await the most up-to-date one, which I understand is currently under way looking into the physical mental health needs of prisoners but also in terms of substance use. We urgently await that so that we can design person-centred trauma informed services within prisons so we welcome that as a key opportunity going forward and we would urge that any findings to that is clearly linked to anything that we think about in terms of health inequalities and the wider health and justice portfolio of which there are many opportunities to join some of that up with the prison needs assessment stuff. I think that your point about intersectionality is really important. I mean carers are more likely to be women, they are more likely to be in poverty, they are less likely to be in work and more likely to be older. All of that combines to really contribute to the poorer health comes up they face when compared to non-carers and I think actually what we really need to take is a real systematic approach to how to be addressed that because you can't just fix one bit of it and then the rest will fall into place you need to look at the whole system and that includes everything from the health and social care system to transport to the environment to access to services, digital exclusion I mentioned all of those things we need a really a public health approach when we're talking about how we tackle the needs of unpaid carers and and I don't see the possibility of that on the horizon at the moment and I really hope that as a consequence of this inquiry is that some of these issues are addressed and that pressure is put on government and others to take that sort of systematic public health approach to some of these issues that we're talking about. I'll come to Karen next. I'm always speaking regarding people who come through the rent deposit scheme who as I said earlier often it's just poverty I say just they're in poverty if you haven't got other complex needs so they've maybe not got other agency involvement so I would say that I see very limited evidence of health and care taking a trauma approach I think a lot of people go through services certainly the people I talk to who are not assessed on how this is affecting how your current situation and your experiential experiences have had a traumatic impact on your health. I'm not aware that that's asked I'm not aware that that's investigated and I think that that is something that trauma is there within the person services can assist a person but we're not actually really digging down and finding out from a trauma approach on these things certainly not in housing that I've observed. I'll come to Sharon last. In social security there doesn't appear to be a trauma informed approach and rather than taking into account intersectionality or a person-centred approach the system the UK based system seems to be driving trauma and reinforcing disadvantages and structural inequalities so it would be a fantastic improvement if trauma was taken into account and if people were treated in a genuinely person-centred way the DWP suggests that people's back to work plans people's climate commitments are individually tailored but all that means in practice according to the people who we've spoken to is that people will maybe have a reduction in the number of hours that they're expected to look for work or an adjustment in their conditionality it's not genuinely person-centred in relation to anything to do with health or social care and worse than that it actually directly invalidates physical and mental health problems because the system is taking too long to assess people's health and is disregarding medical evidence people's medication the opinion of specialists and GPs doesn't inform the way that they're treated in terms of being pushed towards work well at all until they have a work capability assessment and many people are not eligible even after a work capability assessment because particularly for mental health they can't score enough points for that to make any difference to what's expected of them so that it would be a fantastic improvement if it could start to okay thank you much join carol thanks convener so many of the points been well made today i'm in a lot my questions have been answered but i'm particularly interested obviously i take the points about lobbying and making sure we get the system change across the UK that is so desperately needed meantime in Scotland obviously we have responsibility here in the Scottish Parliament so i'm interested to know what we can do in Scotland so i'm hearing some of the things as we can maximise and use the benefits that are available to us here we can look at system change here and i'd be interested to know from the panel particularly around carers that we want people to know that they are entitled to these benefits to these systems to healthcare how do you think we best do that in Scotland with the powers that we have here well i think you're right and i think i've already mentioned that the carers allowance supplement although welcome could definitely be higher there is a cost of living crisis at the moment Scottish government showed precedent during the pandemic where they doubled carers allowance supplement on at least two occasions i think we certainly would like to see that again this winter to support cost of living which we know energy bills are going to go up again but obviously there's also the carers assistance consultation at the moment and Scotland has a really good opportunity to include to create a far better far fairer and much more supportive carers benefit and we would really urge them to consider how to doing that in terms of making sure that people are aware of what they're entitled to that's huge and as i mentioned before lots of carers don't recognise themselves as carers or aren't identified we've done research that suggests it can take carers up to two years to realise that they are actually in a caring role all in that time they may well be getting support whether it's social security support or whether it's support from social care services around short breaks and respite so actually more we must do more to try and raise a visibility of unpaid care and caring roles and we must do more across all of our health and social care systems to proactively identify carers approach them and support them to actually realise the support that they're entitled to and should be getting to help them in their caring role. Yeah, I just wondered it from yourself if there was things you thought about how we make sure that the system understands that people are entitled to that healthcare. Yeah, following on from much of what Richard's already highlighted, we know that the majority of people that we support at families outside are women and often are supporting them, a son or a partner within prisons so I think more could be done in terms of the wraparound support within prisons and the justice arena to ensure that carers are identified and get access to their appropriate supports. That's lovely, thank you. Thank you. Can I come to you, Evelyn? You have some questions. Thanks, convener. Good morning, panel. In evidence, we heard a lot from people who were worried about the cost of living crisis, how they were going to pay their bills, heating or eating generally. Obviously, a lot of people have got their heating off just now, but they're worried about winter. Do you think that Rishi Sunak's cost of living payments will help and are people still in for a difficult winter? I would like to put that to Dr Wright, please. Yes, the cost of living payment will help people, but I don't think it will help people enough. The shortfall is so great and some people have enormous debts, a history of debts that have built up over time. The amount of money that people are getting through benefits and the extent of in-work poverty for those who are on low wages or working part-time means that there is an enormous gap between the amount of money that people need and the amount of money that people are getting. It will help, but I don't think that it will help enough. If I could just come back to that last question about what we can do in Scotland, I definitely support the proposal to increase the carers allowance supplement to double it again. A couple of ways that we can maximise take-up would be via targeted adverts. Actually, Facebook can be quite effective in that. They've got a targeted adverts function that could be used particularly to target carers, to target women in the particular demographic groups that we're most concerned about. Also, radio adverts could be a good way to get to women who are of the demographic that would need the carers allowance supplement. I just want to pick up on a quick point. There's a robust evidence suggesting that the financial impacts on the family when someone goes to prison are currently involved in a piece of research at the minute, looking into more up-to-date evidence on that in terms of the financial impact. We know often that when someone goes to prison, often that person is the sole breadwinner for the family. One of the most important things that our families want to do is to keep connected with the person in prison. The increase in costs of living and transport costs make that increasingly difficult. There is a help with prison visits that people can access. It means tested and it does sit with the UK Government, so that presents considerable challenges. We have one family member in work poverty where they can't access that benefit. However, because they are employed, it doesn't take into account how far, for example, the family member may live from any given prison, so it increases social isolation and all the other things that we know impact that thereafter. That could impact on the breakdown of a family relationship, which should be particularly difficult when somebody is coming back into the community. Do you want to come back in? In terms of the chancellor's announcements, some carers will receive some of that support, whether there are mean-tested benefits or pensions, but we know that we still haven't quite worked to have the exact number, but a number of those carers will not get any additional support beyond what the rest of the population will get. That gap is exactly why we think that carers allow and supplement should be doubled again this winter to make sure that carers particularly don't get disproportionately impacted again by the cost of living crisis. That came back to that earlier comment that we made about the disproportionate effect of the increase in the cost of living, particularly in fuel. Sandesh wants to come in. There was something that I wanted to pick up on that Dr Wright said at the very start. I have written it down here. I just want a little bit more information, and I have heard it right. He said that people have been put off from claiming, and there are disincentives to claiming. We have heard that throughout this morning. People are treated as if they were fit for work perhaps when they have mental health problems. They might turn to survival crime or survival sex, I think that you said there, so they are pushed into—could you expand on that, please? I have heard that right. Yeah, you did hear that right. I know that it's really upsetting actually. This was a finding from a big research project that it did between 2013 and 2019 called welfare conditionality, and we looked at the impact of sanctions. What we found was that it was a combination of things. It was what was happening with the sanction system. It was also to do with household benefit cap, the two-child limit, the freezing of the value of benefits. All those things combined to put people in extremely difficult financial situations, much worse than would have been the case pre-2010. We interviewed people who had turned to extreme measures because they had no other alternative. It was only a very small minority of the 481 people that we spoke to, but some people were forced to turn to survival crime in a couple of situations, survival sex. That was because they had no money and no way of getting any money that they went to those extreme measures to try to get by. It's very, very distressing that people are doing things like that in times that shouldn't be happening. Okay, thank you for clarifying that. I guess with things like the cost of living crisis that we might see more of that as people are plunged deeper into poverty. Sandesh, do you have a question before we wrap up? Yes, thank you. I just wanted to pick up on the question about the financial impact of going to prison. When you get released from prison, does that mean that the job that you can get is of a much lower pay? Does it also mean that you're going to really struggle to get any job whatsoever? Yes, I think we all, and it's well noted that the struggles that many people with previous convictions have in terms of trying to reintegrate back into society and also be able to gain meaningful employment again. Yes, I would agree that that's an added barrier, but also just to pick up on the point that I made earlier about meaningful relationships, access to care, all of that will ultimately have an impact on health. I want to thank all four of you for the time that you spent, but I also extend that thanks to the many people who you brought to speak to us a couple of weeks ago, some of whom are in the gallery today and it's nice to see you and hopefully we'll be able to meet you after this meeting. Our next meeting on 21 June, the committee will continue taking evidence as part of our inquiry into health and the qualities, but that does conclude the public part of our meeting today. Thank you all.