 Welcome to the 36th meeting of the Health, Social Care and Sport Committee in 2023. I have received apologies for this meeting from Tess White. The first item on our agenda is to decide whether to take items 4, 5, 6 and private. Are members agreed? The second item on our agenda is a second oral evidence session as part of the committee's inquiry into healthcare in remote and rural areas. Today, we will be hearing from academics with expertise in rural health and wellbeing, nursing, geriatric care, delivery of rural healthcare and wider issues in remote and rural healthcare. For this morning's session, I welcome to the meeting Dr Stephen MacKinn, senior clinical lecturer, University of Aberdeen and honorary consultant Jerry Attrition at NHS Highland, Dr Rebecca McLean, research fellow division of rural health and wellbeing, University of Highland and Islands and Professor Aneta Smith, Professor Emerita, University of the Highlands and Islands. We will move straight to questions and to Carol Mawkin. Good morning to the panel. It's really great to have you here. My first question really is quite general, and it's just to ask the panel whether we have a tendency to develop healthcare policy in an urban-led way. If that is the case, could you give us any indication as to why that causes a problem for us in terms of healthcare in more remote and rural areas? I agree. I completely agree. I think that we do have a tendency to develop healthcare for urban areas. I think that there are a number of reasons for that, largely because when we're developing healthcare interventions, it's usually done by clinical academics who are based in universities and, with the exception of me, are working in big urban hospitals. There's a tendency to forget that you have to deliver healthcare differently in a rural hospital. I'm a Jerry Attrition of my subspecialty stroke and we're struggling to deliver thrombolite, thrombectomies in rural areas because when that service was developed and the evidence was developed, it was all developed in big urban centres. Just thinking of the basics of how I practice in case-ness and I'm there with thrombectomies in Dundee, how am I going to get and you have to do it in six hours? How do we even select the right patients to go to Dundee and when? We're really operating in almost an evidence free zone. In terms of solutions, I have a clinical academic who works in a rural area. I try and personally just stay involved and get involved in trials and I often am the one that puts my hand up and says that's not going to work in a rural area for various proposals but it does contribute to inequality because it's like we're a different planet. Sometimes you feel the evidence is for a different planet. Thank you, sorry, somebody's unmuting me there. I don't know whether Dr Mackinn or Professor Smith would have anything to add to that at all. I completely agree with Dr Mackinn and I would say that every part of the patient's journey from diagnosis to treatment to accessibility to treatment is affected by the context in which the patient is situated and even within a rural area, whether it's remote, rural or island, even that context differs as well. While some patients are living rurally, their access to hospital care can be quite efficient for others who are living a distance from that hospital in the same rural area, the experience can be quite different. While there are differences between urban and rural contexts, there are also differences within remote, rural and island contexts. In terms of policy making and decisions around healthcare, that is why it's absolutely vital that clinicians that are delivering care and also patients that are receiving care in those areas are part of that decision making and modelling for what's going to happen. I think that Dr Mackinn has indicated that she will come in. Hello, sorry, it's Dr McLean. I think that I just wanted to agree with both the other members of the panel and to just say that our research in rural health at UHI has really identified the key issues that are needed within this work to support rural health and rural healthcare. Their work is still needed to design and embed models of service delivery that overcome the disadvantages of geographical distance, like Professor Smith was saying, about the issues of transport and transportation and access and availability. We still haven't yet overcome the challenges of recruitment and retention of rural workforce with particularly shortages of people choosing to enter rural general practice. There is still work to be done to integrate digital technology into rural healthcare delivery to ensure that it's acceptable to patients and healthcare providers. Thank you for that. Apologies for my senior name. I would be interested to know just a wee bit about the research community, because it was touched on a wee bit. Is there things that we can do in terms of making sure that research is happening in rural areas, or is it about being connected in with research as it happens, but making sure that rural areas are involved in that? I'm happy to come back on that. I think that it's a bit of both. There are issues with rural research being included in large-scale studies and projects that are funded, but the funding to conduct rural research and going into rural areas and travelling these distances to meet with the communities and engage with communities, which we have found in our research, is so important that the communities and the people that are involved in this decision making are involved both care providers and the patients and community members themselves. That is actually quite costly to go and conduct this research. I think that it's about supporting those costs. Unfortunately, that sometimes can be higher than those in urban centres when we're looking at researching and travelling these distances to speak to people in dispersed geographical areas in Scotland. That makes sense. Does anybody else want to add to that? I don't have any more general questions if somebody wants to come in or move on. Yeah, I'll come in if that's okay, thank you. I think that any decisions that are made around clinical practice need to be based on good evidence and I don't think anyone would argue with that. Dr McLean was saying that it's important that we have the ability to conduct remote and rural research and the resources to do that so that we get to the heart of what communities want. We also need to take account of existing research. There's a vast body of research around remote and rural practice. There's a lot of international research that we should take notice of. There's a lot of innovative solutions that others have used that they could also consider as well. It's looking at the existing research base that is there, but also, as Dr McLean said, ensuring that decisions are made where we are able to access local communities in terms of furthering that evidence base and what is best for them. Thank you. Thanks very much. Can I just ask a supplementary to Professor Smith there? You mentioned that there is international research and I'm thinking of other countries that have very remote communities, Australia, Canada. Are we using the research that's been done there for their rural and remote communities or are we overlooking some of that? I don't think we use it as well as we could. I'm not sure the context when we're looking at remote and rural international research can be quite different. Sometimes we've got more in common, for example, with our Scandinavian countries than perhaps some of the other remote and rural areas, but there are excellent models that we could learn from. As an example, I'm thinking about the extensive work that's been done in Northern Ontario with their medical school and the ability to recruit local people to train as doctors so that they remain and work and live in the areas that they trained in Northern Ontario. That's one example, but there are plenty of examples of innovative solutions to workforce and healthcare delivery that they could really learn from. Good morning to witnesses. You've touched on that earlier with one of your answers, but how important should community engagement and co-production play in the development of rural health services and what are the types of benefits of this? I'll go to Dr McLean first, please. We have seen in our research in rural health at UHI that it's extremely important. Its co-design is so important for the development of rural health care services with community members and local health care professionals being involved in this. It's important to understand their viewpoints and for them to have an opinion and be involved in the design of services that people find acceptable and affordable. We've found from projects being here project, which we designed primary care models in several Highland communities that this was really important. We've also found from the literature review that the ethos of this sort of engagement is as important as the particular methods used. This sort of engagement needs to be done in a way that ensures that the community feels supported and listened to and that they have ownership and appropriate representation so that this design of healthcare is not being done to them but it's being done with them and working with them and that's been highlighted across all our different types of research that we do in rural health. Any other witnesses like to comment? No. Can I ask then of the examples that are in place, how could we strengthen them and what good examples are there out there that we could share across the rest of Scotland? I think as well as engagement with the local community through research as Dr McLean has just outlined that there are also very good structures in place within communities where we can make sure that communities are actively involved in planning. For example, through using local planning groups which are quite active throughout some remote and rural communities and it's also absolutely vital to include the third sector in that engagement as well as they are very much partners in care delivery. So when we're looking at community engagement we're looking at it in its broadest sense both through formal, informal and research opportunities. Any other witnesses? Dr McLean, are you looking to come in there? Only to agree with what the other witnesses have said is that without community engagement the services, if you're designing a new service without community engagement there will be yet another. It's unlikely to be valued and it's unlikely to meet the needs of the community. There's numerous examples of well-designed services with community engagement and poorly designed services where it's north and pundits, leading the central part. Thank you, convener. I wondered if I could ask a brief supplementary to Professor Smith. As a board member at NHS L and the Shear I just wondered if you would have a specific example. I think it's good to hear about the principles but if there's a specific example from the western aisles that would add a bit of colour to our discussion that would be helpful. I'm just thinking about the re-engagement of local planning groups. Post Covid the local planning groups are just starting to really, not all of them but some of them, starting to re-engage. So I think probably Dr Mack is going to come in with an example. Thank you. I'm sure that have been many examples in Highland in your health board but in Highland there's been two examples I can think of in case there's one where it's gone well and one where it could have gone better. The local maternity service in case there's general, which is a two and a half hour drive from Inverness, was downgraded to a midwife-led unit about 2016, largely because of concerns about safety of immediate safety of babies. But there was not a lot of consultation with the community about the fact that it was felt by NHS Highland that it couldn't provide a safe consultant-led service and there's still a lot of resentment within the community and with justifiable reason because the experiences of mothers and babies is driving two and a half hours as in Labour. I've never had a baby but I suspect that would not be an easy thing to do. It's difficult because there's a degree of urgency there if there's patient safety issues but we could have engaged more with explaining to the community what the difficulties were and looking at the different options. We've recently redesigned services for older people with a lot more community engagement and it's gone much better and the proposed model of service of a community hub for intermediate care is being valued I believe as a valuable service people want to engage with and even though we're moving services from the acute hospital to the community it's not been seen as bed closure, it's seen as opening a new service which it is even though we are reducing the acute hospital beds by two. I suspect involving the community in the dilemma of why we can't, the problem with the existing service would have been helpful for the first example. I'm aware of the first example and I think it is slightly different when we're talking about safety concerns so if we can move to the other one where you've said there's been good practice, you said there's been engagement with the community, what did that look like, who did the health board speak to, how did they do it? They, it's been a long process and it started before I joined in 2019 but there were a series of, we've got the local health action team which is a pressure group which we really do engage with. There were a series of events that designed the service really at the very early stages before the appointment of contractors or consultants when we designed a specification where there was representatives from almost every local community group we could think of. It felt like there was almost everyone there, certainly the local health pressure group, the voluntary groups, the local council and care agencies but also charity and third sector groups and it felt like everyone had a voice there and we did, we really, the service was designed from a very basic level at those events, what do we want from a service but also where should things be delivered, what would good look like and that was before it was about two years before we even appointed an architect or had a term of specification for the service, didn't feel tokenistic at all. Dr Mackinn, can I, sorry to interrupt, can I just ask, had the decision to move the services to a community-based setting already been taken and this was about designing what they looked like or was it the public's input that led to it which way round was it? It was, I'm not, I will be honest and say this happened two years, three years before I joined the health board, the initial decision. Shortly after the maternity service there was a top-down decision to move services to a community-based setting that didn't and there were protests in the street I think as a result of that so they stopped that and then looked at doing service redesign. As part of that they did have a presentation about the unsustainability of the current service model and why it was something that they didn't feel could be sustained but actually during the consultation there were far better models of service that we were delivering services in hospital that could be delivered in people's homes and actually when you put it to people no one wanted to be in hospital when they could have been at home so I think the mutual feeling that actually it could be better but no I don't think the initial planned move services to a community setting was made in a top-down way, there's no consultation and this was a reaction to that. Thank you, that's helpful. Can I just ask a brief supplementary on that so you spoke there Dr Makin about co-production, about community engagement and redesign of services and this might not be specifically a question for yourself it might be for other panel members but what's the difference between redesigning services that we in a remote and rural setting compared to an urban setting? I will be honest and say I've never designed a service in an urban setting, I suspect it's easier in a remote and rural setting because you can almost get everyone, you can't almost get everyone in one room but it's a bit more of a connected community and I think it was easier to identify the people that needed to be invited so I suspect that the more connected community it's easier to identify them but I'd be very interested in hearing the rest of the panel's views. Dr McLean, do you want to come in? Hi yes I think it's that issue of touched on earlier with taking an urban model and trying to put it into a rural area and the difference in getting people who live in more remote rural areas understandings and experiences of healthcare and accessing healthcare can be very very different to those in urban settings so that might be the difference between the urban and rural divide within that so that the difference in getting people to engage is to understand what works for them and not necessarily taking a model from urban areas and putting it into rural area and thinking that will work and understanding why that is so we've done some work particularly with mental health issues highlighting that really rural residents are concerned about what they perceive as a lack of mental health services and we used community engagement methods and a consensus building exercise on rural mental health needs in the western aisles and in the black aisle and residents themselves recognise a need for preventative and police based integrated NHS and third sector mental health services that would work for them in their local area and also in their geographic area how they will get to access these services and so that's an important aspect of service design when we're looking at the difference between rural and urban and a lot of it is to do with the geographical distances and what's the availability of services which is the difference between the urban and urban settings you maybe got much more availability and also if somebody doesn't want to go to one particular place there's another choice for them to go to whereas in more remote rural areas that isn't always the case and there's one service that's accessible if that in some cases. Thank you. I'm going to move on now to Ruth Maguire. Thank you convener. Actually Dr McLean I'd like to hear a bit more about the work you did on mental health services. One of the themes raised in response to the committee's views was very much around mental health and addiction services and people spoke about their concerns as you say about lack of availability. I think issues around waiting lists and access were raised in a number of submissions. They also spoke about health inequalities and deprivation, I mean things that are actually common across the country I suppose and I think your points there about the services that people are looking for in rural areas I think people in urban areas would very much also appreciate preventative community based work. You spoke about the model you used when engaging with the community. Did you do consensus building or exercise or can you speak a bit more to that so we can understand what happened? Yes so I have to say this actually was by colleague who couldn't be here today who conducted this research so I can't really speak to the full detail but it's a consensus building so it's called a Delphi modified Delphi method which basically you use a consensus you use some statements that people disagree with and agree with and then you keep going around and going around and see what people agree with the most so you get consensus that way. You can also have people rank what their priorities are and then you keep going around a circular mode with all different community members to find out whether there's consensus in that and that we find that that's been with community members has been a really effective way to understand both healthcare providers but also patients in community groups views because sometimes they can differ about what their priorities are so patient priorities can differ very much to what healthcare providers priorities are priorities are and then both being in groups and seeing that and visualising what each one's opinions are can actually really help to build consensus in these areas. Oh that makes sense. It does make sense it does absolutely and did you say that work was done in the Black Isle and the Western Isles? So and how did the health board respond to that work? Was there any change in the services to the citizens living there? That I couldn't tell you yet it's fairly recent work so I'm not sure of any changes being made as a result of that work. Okay thank you. Moving on, that some respondents highlighted that a whole system approach to policy action is necessary. Could one of the panel members tell me what a whole system approach is and how that could be used to the benefit of people living in rural areas? I can speak to that and give an example if that's okay and I guess the most pressing example just now we have is around recruitment and retention of healthcare and social care staff throughout the Highlands and Islands and in some places it is more acute than others but it is pretty concerning everywhere and I think maybe it's easier for me just to give an example of the Western Isles as to how that whole systems approach would work. So the difficulties of recruitment are tied up not just in the availability of health and social care professionals but also in the infrastructure that supports people to live and work in the Western Isles. That includes everything from schooling, to wraparound childcare, to transport, to accessibility, cost of living, digital structures, connectivity. All these challenges have been extremely well rehearsed and we know what they are for health boards and for council, they are quite key considerations. So if we are to look at recruiting health and social care staff it's not just the availability of staff, it's how they live, they work and thrive in for example the Western Isles and the structures are there to support that. If they are not, people simply won't come because they can choose to go elsewhere where they have more ready access to services. So in terms of a whole systems approach, that's one example. We can try as hard as possible to recruit staff but if the social structures aren't there to support people to live and work in the islands then staff won't come. That's one example of a whole systems approach. Things cannot be addressed in isolation the whole context has to be considered. I suppose in the highlands that housing will play quite a big part in that as well. Is there any work going on at the moment to address those matters? What work are the health board and the local authority doing? There's been a lot of work done in terms of mapping the population. There's a significant concern as I'm sure many of the committee know about depopulation and the demographic differences for example in the Western Isles are more stark than they are in other remote and rural areas although that is also an issue in other remote and rural areas. It's working, it is not something that the islands for example can address themselves. It needs to be done in partnership with both Scottish and UK Governments. Thank you for your contribution so far. I just wanted to pick up on the service levels issue. The CAMHS target is for 90 per cent of patients to be seen within 18 weeks of referral but this target has never been met nationally. Do the panel have any particular insights in what waiting times are like in rural areas vis-à-vis urban areas in Scotland? I don't have those figures available about the waiting times between CAMHS. I do know their significant waiting times in NHS Highlands for CAMHS for young people and that is an issue that has been repeatedly highlighted by service providers and by young people and their families themselves about the waiting times for CAMHS but I don't have the figures of myself, my head between urban and rural areas. No problem. Dr Mackin, do you have any insights at all that would be helpful? I don't have the figures to hand and I couldn't easily find them by googling what Dr McClain was speaking either. I think you have to look a little bit broader than waiting times in that if there isn't a service available there's not going to be a waiting list for it. I know this sounds stupid but there are many instances where the service that can be offered is just not accessible so people won't be referred for it and if people on an island would have to travel to the mainland to get an operation and they elect not to have it because it's not available because they don't want to travel or the travel isn't accessible then just looking at the waiting times is going to mask that. Sorry to always drag myself back to Cationers but in some rural areas for instance we don't have any care at home services available and most of my patients in those areas because we know there's no care at home it isn't always requested they just choose to get straight into a care home but I've had to kind of start asking my team to just put the care at home request in so we've got a waiting you can see the need for it but yes the service isn't accessible there won't be referral so you won't necessarily see a waiting list. Are you aware of any geographic deserts with regards to CAMHS provision in rural settings in Scotland? As a geriatrician no I'm not because it's not I don't treat children. No that's fair enough there's just might be a general insight. Professor Smith do you have any insights on CAMHS provision in rural settings? No there's nothing I can add that the others haven't already said I don't have access ready access to to the figures although we know that demand does exceed supply. Okay health inequalities have also come up a lot during the consultation process and we know that people from areas of high deprivation of poor health outcomes but are also less likely to accept offers of care and engage with health services. Did the panel have a view on how we reach those people and address health inequalities in rural areas specifically perhaps Professor Smith that coming back to you. Dr Mackin gave a very good example when he talked about community engagement in Caithness so you know you're talking about again you know a whole systems approach where you can encourage community engagement. I think the difficulty is there will always be people that are harder to reach and that are less likely to engage with for example preventative care. So it's coming up with ideas and solutions that will ensure that those that are less accessible or less likely to seek help are supported to do so. I just wondered maybe Dr Mackin have you had any insights on it. Obviously your work with geriatric patients will show a lifetime of the consequences of inequalities. Do you see that quite starkly in rural settings? A little more starkly there but in rural settings I think what is important is when we come up with a new model of service we do a thorough equality impact assessment. I've that again I think examples can help. NHS near me is a great service for video consultations. To use it at home in a rural area you need to have expensive broadband. If you're not on fibre optic broadband personally I'm not I'm talking to you from a non fibre optic broadband house because I pay £50 a month to get mobile broadband. When I try and do a video clinic none of my patients most of my patients can't actually their broadband isn't good enough for a video call so we just end up talking on the phone which kind of negates the whole isn't the same and by moving our service to video we're creating more digit inequality or exacerbating social economic inequalities. Again we're reducing it in other ways for people who can't travel but I don't know if an equality impact assessment would pick that up. Okay thanks very much and Professor McLean. Thank you you've just upgraded me to Professor. Yeah I just wanted to speak a bit to inequalities and just talking a bit about our mixed methods research that we did this year with younger people in the western Isles and the interaction between reproductive and sexual health and wellbeing and mental wellbeing. As really identified that adolescents living in remote rural and island communities require further support and young LGBTQIA plus young people are more likely to express this need so the fines of the study identified that the intersectionality of being LGBT plus and residing in the remote rural context might increase the experience of inequality in health and wellbeing support that's accessible for them and to support mental wellbeing so for example 68% of all young people in this study said that they'd witnessed LGBT plus bullying and this increased to 86% for those who are actually identifying themselves as LGBTQIA plus so fears of judgment and stigma from the local community and a lack of anonymity and availability can inhibit access to health protective behaviours and support. So again this study is looking at health inequity but also identifying the real need for place-based health and wellbeing support for young islanders in particular and the support should be co-produced with these young people living in the local and social context to able to counteract this health inequity that these young people in particular are experiencing. It's really helpful insight, thanks very much. Thanks convener and good morning to the panel. What impact is an ageing population currently having on the healthcare services in remote and rural areas and as we see that ageing population increase how is that likely to continue to affect services and could I go to Dr Makin first please? Obviously the ageing population is having a profound effect on services. Our core patient, our core customer base if we were providing customer services the older person 80% of our inpatients are older and the need for healthcare is those people need healthcare and in terms of the challenges there's a number of them. One of the challenges is that if not just the increase in older people in rural areas it's a decrease in younger people and if there are no if your family are 500 miles away they can't help you when you need help and if there are no jobs for younger people but the older people stay there's no one to look often their family aren't there they more likely to stay in hospital and to delay discharge after a minor illness they've got no family to help them. It's exacerbated I feel by people moving income in retirees who contribute a lot to the community but I'm going to quote a relative of one of my patients who said that you move 600 miles away mum why should I I can't drop everything every time you get sick yeah they if you've moved away from your family and your social network when you're in you often need to stay have more health and social care services to recover and if the incoming retirees have increased the health problems to the point sorry my dog is having yourself shut up please be quiet if you think if the incoming retirees have increased the health prices and then younger people are able to stay in the area who is going to care for them do any of the other panel members want to come in on that at all before I move on yes you know I would like to just mention one more thing you know older people they're the greatest consumers of health and social care and as absolute numbers increase there will be increased pressure on health services and budget allocations don't necessarily take account of patient profile take account of numbers so if your demographics suggest that you have a greater number of older people than the younger people in the population they are going to consume much more of that health and social care budget you know we know about availability of health and social care workers to support older people and the difficulties associated with that in remote and rural areas that Dr Mackinn has alluded to but there's also the fundamentals of how we actually resource that increasing requirement to support older people in health and social care settings thank you in terms of designing services what do we need to do now to address the the ageing population and what current barriers are there to designing services that would meet the needs of older people in remote and rural areas and I'll maybe go back to Dr Mackinn first thank you when it comes to designing services she's a therapy dog in a local care home the biggest barrier I think the maybe's just been acknowledgement it costs more to provide services in rural areas I know that sounds stupid that sound obvious but it's not always reflected in the funding model that if we want to provide services in rural areas it's going to cost a bit more you have to cover the travel times for instance or you come up with a new model where it doesn't work in quite the same way in terms of barriers I actually the obvious barriers are if you set up a community engagement event in a town housebound people from the villages aren't going to be able to come to it that's fairly obvious barrier I think I do potentially think you have to really work with people who know the community and work out how you're going who is going to be the core users and go to them I actually think it's a little easier in rural areas to identify the core people and work out who is going to use this service and make sure they come along and too often community engagement it's the same familiar faces that come to every event and we very much appreciate their contribution but often I find it's the same people at every community engagement event even if whatever service we're discussing and they put a lot of time and effort in and we value their contribution but the main we maybe need to be a bit bit more proactive about this that's great thank you thank you Dr McLean yeah Dr McLean yeah yeah I just wanted to sort of speak to some evaluation that we've recently done in terms of aging well for non-pharmaceutical interventions that are linked to social prescribing dimensions and the social dimensions of health we conducted an evaluation of technology enabled social prescribing for rural older people and this was in Scotland in Ireland and in Northern Ireland and this identified that the format was particularly effective at improving patient reported outcome measures for those with depression chronic pain and chronic kidney disease which may all may both be related to depressive symptoms it did have the least effect for frailty and dementia but in the evaluation 60% of those with depression decreased their level of loneliness before and after the social prescribing and 48% said that their life satisfaction had increased and we've got a full report of that as well if the panel would be interested and this is about the technology enabled social prescribing we're also currently doing on-going work at UHine rural health to evaluate the community link worker social prescribing model in NHS Highland and alongside other variables this works looking at collecting the demographics of the population who's uptaking that social prescribing service and how this translates into more rural and remote settings as well we know it's been positively evaluated more urban settings we're looking to see how this might support the aging population in more remote rural areas so that should hopefully the initial findings expected in July 2024 of that research that's really useful thank you and if those could be sent any of those pieces of work that you've referenced can be sent on to the committee i'm sure we'd all be really grateful to see those as well so thanks convener if there's no one thank you Ivan McKee thanks very much good morning panel i'd like to touch on the area of technology and digital services and we've kind of touched on that slightly already with regards to some comments on the potential for that to exacerbate inequalities but they'd like to focus on his understanding and what role new and emerging technologies can play in supporting in the rural environment and i think that clearly the need for those technologies is probably greater in that environment which i suppose gives the potential for them to be rolled out more rapidly in the remote and rural areas i suppose i'd just like to understand what you see in terms of those technologies happening and what else could be done to further roll them out and i suppose we're talking about digital connectivity but also things like medicine delivery by drones or sensor technology in homes or or any across a wide range of technologies you may be aware are in use i don't know who wants to come in on that first i can make a start i can make a start and i'm just saying this is not necessarily my area of expertise but i mean the role of technology in remote and rural areas is undisputed really and it can certainly be used to enhance services not always replace services and i think that's what's important to remember it does feel like we're on the cusp of a technological revolution in terms of supporting people to live at home and delivery of medical care but we have already mentioned that it's important to get when we talked about a whole systems approach so it's it's good that technology is there it's developing the possibilities about what it can do are exciting but you know the infrastructure broadband speed the network coverage has to be in place first you know so it's it's quite difficult when exciting things are promised but they're not then deliverable because of the reasons that again we know and we've talked a lot about older people living in remote and rural areas as well and we we know they are less likely to use technology and that access will decrease with age i think i'm just going to say something as well that that i've been thinking about for quite a while i think some of the terms that we sometimes use around technology and the possibilities of technology aren't always aren't always seen as the most positive so for example you know we talk about remote medicine now for me as a clinician as an academic the possibilities of remote medicine are exciting and it means that people can get access to expert clinical opinion and not necessarily have to travel but i think the whole concept of remote medicine sometimes seen as a negative i would like to see remote medicine being called accessible medicine so it's turning you know i do want to feel like i'm remote from my clinician i want to feel like i'm accessible to my clinician so i think as well in terms of public perception the terminology that we use to describe the the technology can be reconsidered so it's seen as advantageous rather than accentuating the distance between new and the healthcare professionals thank you that's very helpful and i think that point is well made in thinking about this in a more positive light and seeing in remote and rural communities it being at the forefront of adopting this technology which then rolls out more and more widely i think is perhaps a helpful way to look at it um anyone else want to come in dr mack i'm just wondering if dr mclein wanted to come in hi sorry trouble unmuting there yeah i just wanted to talk to a bit of work that we've done on the with nhs highland on the tech pathfinder project on respiratory pathways using um digital approaches and the root causes that can actually digical digital approaches because we find that can help to tackle or important issues that have been identified so that data needs to be in the right place at the right time for that it's not always successfully shared between different parts of the healthcare system so between primary and secondary care or accessible to patients themselves and patients want to be able to access information online in one digital place they don't want to have to go to different places they want to have one in place where they can access their support but also their their own information and also enhance patient experience can come from more confident informed healthcare staff about using these technologies themselves i think that's really important through digitally enabled formats we did some work on the use of vc consultations that dr mack and had talked about the near me system in remote communities and also just with digital service design and this was in communities in skip with communities in sky and this identified again the importance of cold production with digital service design in remote areas public members really identified and provided insights on how community could use near me at home which otherwise wouldn't have been unknown if we haven't done that piece of work with the community so the patients and public hold unique perspectives when it comes to accessing digital health services and how they can be designed to fit into their communities so for example this piece of work that we did with individuals on sky some people were able to access from home but also some people came to healthcare clinics with a local GP or even sometimes in a more community centre sometimes local public library sometimes in really remote places all these these things are all in one place anyway and to access their online near me appointment rather than doing at home so that someone they had problems with technology they didn't have broadband then they could actually access and sit in a room in this local community place and if they had problems there would be somebody on hand to actually help them with accessing this so that was seen as quite an effective way of using this digital service for community members okay and just just can explain that a wee bit further I think what you're saying I think that's kind of come up earlier in the in the session as well through necessity redesign of service delivery in the remote and rural setting is perhaps more advanced as I say through necessity than it might be elsewhere and I suppose I just like to understand what extent do you feel through technology or or or service redesign remote and rural health boards in areas that are leading the way with technology and processes that then get adopted elsewhere or is that not really part of the consciousness in terms of how things are developing I suppose what I'm saying is that you're always feeling at the back of the cube because you're a remote and rural or other areas where you feel kind of more at the front of the cube because you're developing these technologies and processes in advance of anywhere else I think in some ways would so with that project with new me and sky I felt like we were a bit more in front of the cube in that in that area but I think for other other areas it's a bit of a bit of both really but I think there is really important learning and I think it would be I think there's so much potential for the use of digital technologies or accessible technologies in these areas that that we could lead the way on great thank you doctor marketing did you want to come back in I was going to add that the name example the other thing is I think the answer is in a previous question if a technology is co-produced and implemented well then it's going to be likely to be accessible and one of the reasons I think near me with success is I believe it was very heavily co-produced which is although during COVID people without board bank couldn't access it very often people without now people can go to that local health centre and use a near me room it is more accessible and it was co-produced if something is co-produced probably it's likely to be accessible because the community will raise the issues okay thank you very much thank you thank you so far just want to pick up on a point that was raised briefly by doctor mackin earlier when he discussed the limitations on consultation using digital devices because of the lack of fibre broadband or higher bandwidth broadband you said that potentially worsens health inequalities because of the like less likelihood of people low incomes people to afford the premium broadband service that you described you required and do you feel that there's some intervention required from a healthcare perspective to temporarily make available enhanced broadband services to those people who are experiencing difficulty connecting and would require that sort of face to face more intense digital connections or some mechanism perhaps you think might be useful to provide availability for a high quality satellite broadband service people in particularly rural areas who are finding it challenging is that something that might be useful I think improved role of broadband would be useful for many reasons nonetheless improved access to remote employment which would improve health for many people but within a richest highland people there is the option to access video consultations at your local health centre if you don't have your own broadband I do not know how many people who can't access those then can't access and limited if the technology was there to improve broadband for a shorter period of time for someone who needed a say intense pain this mental health treatment that couldn't be provided remotely but they couldn't go out that you know I don't know then I think that could be useful in some settings I'm thinking particularly you referenced CAMHS um I'm afraid to say this is something I've heard from a friend friend whose child tried to access CAMHS and didn't was that if it's traveling a long distance for group therapy it's difficult if it could if it was being offered remotely and you don't have the broadband you know maybe it's something that could be offered in the short term I don't know how you do that technologically at all and it may be conceptually an idea worth exploring but thanks for that insight that's a helpful insight I know there's been some discussions of good practice so far but one of the things that seems to be a recurring theme is pockets of good practice which don't necessarily get scaled up well across the service do you have any insights as to what barriers there might be institutionally to capturing good practice and then trying to scale it up across a wider territory you know Dr Mac and you've just spoken perhaps maybe any of your colleagues have a thought initially on that but can I always come back to you anyone feel free to chip in if you've got a thought on that I think the main value you've got you can divert pockets of good practice can come across can be developed by a small group of enthusiasm without a lot of funding it's quite hard to then get to then scale it up can be more challenging just because getting the funding the funding environment is difficult and often these pockets of good practice were done by enthusiasts without any specific funding for that work the Dr McLean has just probably not wanted to come in I was just going to say that the pockets of good practice is a lot of them are being conducted by the third sector not NHS so there are a lot of really good third sector organisations who are supporting people's health so sometimes we don't necessarily know about what's going on I think that's one of the things is about knowing what they're doing and finding out maybe through word of mouth or through rural remote communities kind of work like that sometimes and you find it that there's a really good third sector organisation that's really supporting people's health well and has a really good model so it's about actually investigating and understanding how that works and then taking that learning from that and sometimes that can be a bit of a barrier if it's a third sector but it's not an NHS organisation I think also across rural remote areas what I'm thinking of is for young people in particular there are different models within different health boards for what young people can access so there's not always across the board equity at all about what young people can access and some people in certain areas of rural Scotland can access services for the mental wellbeing for the sexual health for instance much more accessible than other young people in other remote rural areas and that seems to be an issue where there's not not a set of guidelines or a set of best practice evidence based practice to support that which I think would be something that should be investigated and looked into or supporting certain sections of the population's health and wellbeing in remote rural areas so the speaking of like I don't know headhunters within the NHS are going around looking for pockets of best practice and opportunities to scale up or I would say maybe some it's not not quite angel investors but you know I mean people who would be going around trying to identify opportunities and how they can be benchmarked and brought into a broader basis within the services that you're saying so possibly but also just you know working with the communities and what what what they find is the most supportive for them but usually third sector organisations are very good at community development and doing that so there when they're doing it well they're normally I've got a very good model so maybe to look at some of that and take the learning from that that's great thanks thank you the committee's heard obviously from from other submissions and from other panels about workforce workforce shortages difficulties recruiting in remote and rural areas so I'm not I'm not going to ask you specifically about recruitment but I suppose I'm keen to hear from yourself as academics about how you would see training opportunities and learning opportunities for staff in remote and rural settings how you would see that as attracting people to stay to come and live and work in those communities don't have professor smith if you want to start off on that one yeah thank you yeah I think workforce training and education is absolutely pivotal to you know as well as the other things that we spoke about to attracting and retaining staff in remote and rural areas um I think there are many many aspects of this um you know there's we need to ensure that health care professionals are not professionally isolated and maintain skills that are very often more general um than me um their urban counterparts um may use as well so we need to ensure that their robust training and education opportunities available it's also important to have clear professional progression opportunities and that's for nurses doctors ahp's but also the unregulated workforce as well so there is opportunity for people to develop because we have to capitalise you know for want of a better word on the population that we have and that are working um in health and social care and it's really important that we provide development opportunities for these staff um so they will stay and work in the areas um where where they are I think locally accessible training is is absolutely vital and I'd like to just illustrate one example if I may um about how we can address both training and education and recruitment opportunities and if we have ensure that students who are in training have access to remote and rural placements so they get a taste of what remote and rural health care is like and if we make these placements as good as they can be and they are supported then there may be an increased likelihood that um we will attract some of these professionals back into remote and rural areas I do think myself that um it is really important to have students access that experience and a taste of remote and rural practice and sometimes we have to be a little bit pragmatic as well because it may be that that experience will mean that a health care professional will come and work in a remote and rural area for two or three years they might not stay there forever um so I think we have to look at how we can maximise the opportunities through education through training through placement opportunities and make these as best as they can be to encourage people to come and work in remote and rural areas and not feel like they're going to work in a backwater and that their professional careers are going to stagnate that it needs to be the opposite that is going to be seen as exciting professionally and with opportunity education and training built in okay thank you anyone else want to add anything to what Professor Smith has said on that subject thank you Dr Macon easy to actually this is an area where new technologies have made a big difference in that it's a lot well I wouldn't be able to come to this committee if it wasn't for remote technology I just couldn't um and it's a lot easier to stand touch it's a lot easier to work remotely and it's a lot easier to not be professionally isolated I never thought I could be a clinical academic and live and work in work I just didn't I do think and I don't think when I my own job came about because I was a clinical academic and I brought a holiday cotton chair and one of the managers from NHS Highland tried to recruit me and actually made an academic job for me which would involve a lot of creative thinking but it does mean not only am I taking the lead on medical students and supervising PhDs I hope that from coming from a teaching hospital and being in touch with research community the students don't feel they're in a backwater they feel they're getting up-to-date training and I know there's a lot of clinical academic the clinical academics aren't the only solution to rural healthcare but if we further embedding clinical academics in rural healthcare if there's more of us and we're willing to come I think it could add a lot and I think it really helped with training just being on a steering committee of a trial if you're not in a teaching hospital just means you can intervene and stop something being developed that's totally unrealistic and also by agreeing to fund research or part fund people's research sessions they're a lot cheaper than paying a local and it means they stay as well I think trying to recruit clinical academic to rural areas they got me here I hope it would get other people too. Thank you Emma. I'm now going to move to Emma Harper. Thanks. It's been really interesting hearing the discussion and the questions from colleagues this morning. I'm interested in how we look at policy development for the government in the future and preparing for this inquiry I've accessed loads of papers and research related to remote and rural healthcare whether it's adults, whether it's children, whether it's maternity there's a 2007 report in front of me from the remote and rural steam group there's been discussions from Lewis Ritchie there's been Derek Freely papers there's been I remember Jason Leitch talking about the Nuka healthcare system in Alaska that was being used to develop rural healthcare in Scotland so that was in 2000 so that we've been talking about rural and how do we deliver healthcare in remote and rural areas we've been talking about it for decades and I'm interested to know and I know it's complicated that's why there's so many policy papers that have been discussed as well so I'm interested in what you think that the Scottish Government must address with current issues facing the delivery of remote and rural care at the moment I know it's quite challenging post Covid but we've learned from actions of from the pandemic when we immediately switched to near me so I'm interested to hear your thoughts about the current government policy and what we need to do as a matter of urgency I'm probably just going to reiterate what's been spoken about before but I think it's important and I absolutely agree that there's been so much work done on remote and rural healthcare I think sometimes we don't learn from what's been done and there are social personal and professional dimensions that affect both healthcare delivery if you're a healthcare provider or if you're a recipient of healthcare and to look at some of the challenges in isolation just doesn't work and I think that's why we do need a whole systems approach needed to address many of the challenges in terms of delivery of healthcare recruitment and retention of staff innovation and development so for example we were just talking about digital health you know we can without having an education element a digital health and making sure that the staff that use digital health solutions are adequately prepared and educated then it won't be as effective as it could be so that whole systems approach based on the needs of the population in the remote and rural areas should be a part of that policy making and I know that is pretty complex but if we pick off ideas and don't look at them as a whole then because we're talking about a social system then many of these solutions that can be absolutely excellent just more work. Can I just pick up on the whole systems approach with Professor Smith it reminded me about some of the challenges that we've experienced with local case work like the bus from Stranraer to Dumfries doesn't have a toilet on it and so people were feeding to me that they were avoiding taking their diuretic on their way to a hospital appointment which they shouldn't be doing and so and actually I need to remind everybody that I'm a registered general nurse and so I've in Dumfries and Galloway which is quite remote and rural in many of the places so a whole systems approach makes me think about like we've asked for a toilet on the bus but the bus company or the regional transport partnership aren't even on the integration joint board or part of the health and social care partnership so that means that this there's obviously part of that system isn't isn't connecting if people are avoiding taking medicine just because you know because their bus journey might be two hours and there isn't availability for a loo so that is that's an example of where I think part of the system isn't working right now. Yeah I agree I think there's a lot of patients not taking diuretics before a hospital appointment. Monskas has taken a long time to get to where they need to to be. I think Dr McLean's going to want them to come in this year. Yeah no I just want to agree with the points made and talk about you know the infrastructure of remote rural areas really needs to be supported for the health care workforce and for patients and communities to be able to act to have access to what they need and that's an absolute dimension of its support and health and wellbeing within these communities the social dimensions of health really really important looking at that and redesign that's not afraid to break the mold and actively involve patients and frontline frontline health care professionals is so important and the digital integration of data so allow data flow between primary and secondary care not just VC appointments but looking at wider systems within that digital healthcare system as well and importance of looking at an underrepresented and marginalised communities within remote rural areas who may be at increased risk of further health inequity because of where they live and remote and ruraly but yes just agreeing with what what professor Smith said as well about the whole systems approach rather than little models of what's going well which is important but we need to have that whole systems approach and infrastructure there in order to be able to deliver good health and social care within these communities. Does the new national centre for remote and rural health care need to have an advocacy role to help address some of the challenges that people might bring to you know issues around their health care whether it is adult children maternity I'm interested in about how do we advocate for patients when when they are feeding into the system so that then the system reacts. As opposed in relation to the national centre there needs to be a patient voice because of the national centre is addressing and finding solutions to health and social care problems in remote and rural areas the patient's voice and the community voice is absolutely central to that and I know that was part of Professor Richie's report the original report when the centre was proposed so you know I think that's absolutely crucial to the centre's success it's not just about the healthcare practitioners it's about the remote and rural communities thank you convener and good morning to the panel just a declaration of interest as a practicing NHS GP I'd like to start by asking about primary care so obviously that's a focus of mine and I'd like to ask the panel especially Dr McLean because you've mentioned it what do you feel that the GP contract that was introduced by the Scottish Government did to rural primary care is it positive or negative? I don't know if I can speak for the whole of rural primary care but I know it's had positive and negative so I know for some of the GP contract it took away some of the specific things that GPs used to do so vaccinations things like that it created local centralised sort of rooms for people to go and get their vaccinations and things like that dressings done, wind care and for urban settings that works quite well because there's lots of healthcare centres for rural and remote areas perhaps it didn't work quite so well that method and that model of care provision so for somebody elderly who maybe lives quite rurally and will go to their GP on the bus that only comes once a week and they would go to get their vaccinations or flu vaccinations maybe get wind dressing things like that making a more centralised location for patients to get that was perhaps not the most useful thing for patient outcomes as they maybe had to now travel to Inverness rather than staying within their local area in order to go and get these vaccinations also for people and patients who maybe had more chaotic lives opportunistic vaccinations of maybe parents with young children forget their babies vaccinations things like that for a trip to their GP in their local area is more accessible than actually going to a specific room designated to go and do this with regards to the community link workers scheme that's being rolled out in Highland as I said earlier on we're evaluating that in the moment so hopefully we'll have more information about that in a later date next year but for my part that's as much as I can tell you that I know about in the GP contract in rural areas I think rural GP contract I'm not a GP I'm a friend with GPs I'm go to the GP cluster meeting I work closely with them I don't think the current rural GP contract's been well received by our local GPs it certainly the vaccinations the lots of vaccinations that I don't think has worked well in in Highland in remote areas and logistically we're hearing of people driving three the three hours to give one vaccination the centralisation just hasn't you can't centralise things when there's a centre is 200 miles away it doesn't work and I'm aware that the local GP rural GPs don't feel the contract's working for them I know the BMA GP committees you know the there are many organisations that can speak for rural GP is better than I can okay well thank you very much and certainly that was an interesting point that you made doctor I mean because I've been told of rural patients who've decided not to get their children's measles vaccinations because they say well it's a three hour round trip and quite frankly we don't see anyone so what's the point which terrifies me that we're not getting measles vaccines done one of the other things about primary care that I've been looking at is the the percentage change in income allocation with the new contract so if you're in the urban belt in general we've seen an increase in the amount of money that you're getting and in more rural areas it doesn't seem that increase has happened so it almost seems as though we're trying to promote general practice and primary care in those urban settings which admittedly 80% of the population live there but we do have a substantial proportion of people 20% who live in those rural areas so what would you propose that we do for primary care to make things better for people who live in rural areas and I'd open up to anyone who would like to answer I think that the stability of GP practices in rural areas is important to consider and I mean my answer is simple I would ask the GPs who are delivering care in these areas about the most effective way to sustain these services Thank you Dr Macintosh, you wanted to come in as well I think my colleague on the local case nurse hub might say the easy win is just let us do the vaccinations again we were doing them cheaper and better than Highland Wars in terms of obviously far more to it than that but I mean certainly coming back at that looking at the amount of money being offered to GPs to do that it seems that those costs are going to be not very much being offered to GPs to do it which makes it very difficult for them to do and you mentioned Highlands and there's been a big report about bullying in the Highland health boards now I'm not going to talk about Western Isles Professor Smith because I haven't heard anything from there but certainly from Highland health boards so with this endemic culture which is what the report found how can we see a better integrated rural health care moving forward if your answer to me about primary care was speaking to those on the ground and getting things done I assume it's very similar in secondary care so with these issues how are we going to move forward Personally I joined NHS Highland very shortly after the report was published and I've noticed a big I think the changes there's been a big effort in the organisation to address the bullying culture to the extent I wouldn't have known I don't recognise the organisation from the report and that said moving forward don't think that I suspect engagement with the GPs through the cluster meetings you know in more of a policy level and in a higher level when I go to our local GP cluster not officially but I do go and it can very often feel like they're being talked down at by the health board or rather than the health board consulting GPs and I think the health board then you're certainly on the vaccination discussions has been well this is what we have to do we don't have any choice about it and we know it's not working so I don't know if that's something it was consulted on just in the central belt and then if we're trying to rule it out and impose it on rural areas in terms of moving forward sorry no so go on I think it's finished so in terms of moving forward I think a lot of the pressure on the health service in hospital in patient care comes from the fact where the default social care provider in a crisis half of my ward at the moment is someone delay I've got 22 beds in my ward 22 and the other ward I think we've got about a third of those people waiting for social care if that's putting pressure on the acute services which is again putting pressure on general practice I don't know how much of a pressure comes on GPs from the lack of social care because they tell me it does but I don't know it's the biggest pressure I if I could make one point is we either need to make a decision about are we providing social care care at home or to everyone or are we going to say to people you can't have it in certain areas in which case should we be open about it and maybe if you're thinking of retiring somewhere should you be able to look up on a map can you get social care in this area and at the moment you can't do that but that's slightly different to your point I appreciate it thank you very much and just my final question if I may you know I want to touch upon the thrombectomy that you spoke about we're still struggling in Glasgow to get thrombectomy so so and that's a very rural sorry urban area and but I want to touch back upon caitnet and the issues that we're having with maternity services the downgrade and things not being upgraded again like you spoke of right at the beginning um I'd like to hear from from yourself dr makin if I may about um you know you said that you're not a woman giving birth that's that's true but you must have patients that you've spoken to that are worried about this and you know what pressures does this put upon people in the area and what solutions could be put in place uh to try to help uh it puts um I'm you're right I'm not a pregnant woman and I'm the only man on the panel I certainly don't want conscious I don't want to be speaking over women um but living in caitnet it does put a lot of stress on people no one I'm also aware of the issues with the form of service and no one wants to go into labour with a healthy pregnancy and a healthy baby doing well and come out and leave hospital without a baby and that was the risk that was the concern that it was not safe um I think I when my you know at the personal level when one of my colleagues was pregnant and he didn't have a car we sort of had a reverse on-call rotor if she went into labour the consultant he wasn't on-call was a driver to Inverness but then we then we found somebody in Inverness she could stay with for a few weeks the delivering a consultant led maternity all bells and whistle safe maternity service in the rural general hospitals so the as you know the five rural general hospitals which have around 40 beds and no pediatrics is always going to be a challenge the island hospitals deliver a little bit more but after extremely high expense I have heard off the record how much Shetland spend on having an obstetrician available and I not going to say but it's eye watering um and then they're not going to have pediatrics so that I don't see there's going if we're going to reintroduce maternity services to the rural generals as informed maternity services do we accept a risk to babies or do we spend a vast amount of money or if we accept that the only way to have safe services is to centralise then women are going to have to be some distance away from their families doing the later stages of their pregnancy and it's very difficult and at the moment there's not a lot of support available for them you know you there isn't although there's accommodation for a short period of time um but do we need to look at supporting women more if they are going to need to spend the last two weeks of their pregnancy in Inverness but at the moment it's all done socially I think the mother I've heard of I've heard of mother's planning when they'll be in too much established labour to be transferred and they just turn up to A&E in labour um and as the as the consultant on call would be resuscitating their baby I'm a geriatrician that terrifies me and I don't really know that but I've heard it on the local facebook group I've heard of women even putting off having children because they don't want to face giving birth if you're a single parent and you're having your second child who's going to look after your first if you have to stay in Inverness for two weeks there isn't really any arrangement for that it's all done remotely it's all done you know and I'm talking on face of networks um and but we've got a choice between do we accept a substandard service that's dangerous that could be dangerous or do we make people uncomfortable and have to travel and I know no one in Highland wants to provide a substandard service and I have to say I work in Cumbia when around the time of the curcup report and the response to NHS Highland to the critic glinston that led to the maternity service has been withdrawn with exemplary no effort to hide it no cover up very open investigation certainly a world away from other areas where maternity issues were not raised and I think my the opinion of a geriatrician is largely irrelevant but I think the way they handle the safety concerns openly is actually something they should be praised for um because I've seen I've been reading the newspapers news online about the maternity service investigation to think that it's not been handled openly and I don't know if women are willing to accept a more dangerous service for convenience and the women who are are probably the ones with socio-economically deprived and can't afford to access the better say for service but I'd be very keen for the women on the path. Thank you to the panel for their additional service to the committee and remaining online for for an additional 15 minutes and we're very grateful for the evidence that you've given us today and we'll now move on to our next item which is consideration of two negative instruments the first instrument is the food Scotland act 2015 compliance notices amendment regulations 2023 the purpose of the instrument is to correct an error in the food scotland act 2015 compliance notices regulations 2023 specifically to substitute an incorrect reference to regulation six brackets two of the novel foods scotland regulations 2017 with a reference to regulation four of those regulations the policy notes states that the correction will allow authorized officers to use compliance notices to deal with breaches of the requirements in the novel food scotland regulations 2017 the delegated power and law reform committee considered the instrument at its meeting on the 21st of November 2023 and made no recommendations in relation to this instrument no motion to anull has been received in relation to this instrument do members have any comments? Ivan McKee thank you convener i don't have any any issue with the substance of the the legislation it's more a comment on process and maybe i'll ask the clerks to go and do some some background work on this i'm interested clearly this issue is arisen because there was an error in the the drafting of the legislation i suppose i've been interested to get a bit more background on who often this happens what process improvements are looked at to reduce the number of times that happens what is the process for finding them how is this one found and i suppose what is the the risk of these kind of errors not being found in legislations already being considered so i'd be grateful if there's any work that the our data the clerks can pull together on that aspect thank you thank you mr mckay i propose that the committee does not make any recommendations in relation to this negative instrument it does any member disagree with this no thank you the second instrument is the feed additives authorisation scotland regulations 2023 the purpose of this instrument is to implement the decision made by the minister for public health and women's health on 13 feet additive applications it authorises the placing on the market and use in scotland of 10 new feed additives renews two authorisations with modifications and renews modifies and authorises a new use for one other additive this instrument also includes a trans transitional provision concerning an existing authorization for one feed additive which is renewed subject to a modification by the instrument the policy note states that the instrument aligns scotland with england and wales and with similar eu legislation for these food additives it also states that the food standard scotland and the food standards agency have concluded that each feed additive as described in the applications are safe for the targeted species users consumers and the environment the delegated powers and law reform committee considered the instrument at its meeting on the 21st of November 2023 and made no recommendations in relation to this instrument no motion to anull has been received in relation to the instrument and do members have any comments no i propose that the committee does not make any recommendations in relation to this negative instrument does any member disagree with this thank you at our next meeting we'll be continuing our inquiry into healthcare in remote and rural areas hearing from a panel of representatives of healthcare professionals operating in remote and rural areas and that concludes the public part for our meeting today