 Welcome everyone to the 20th meeting of the Health, Social Care and Sport Committee in 2022. I've received no apologies for today's meeting and our first item today is to invite Tess White to declare any interests relevant to the committee's remit tests. I declare I've got no interests. Thank you very much and welcome to the committee. We want to say a thank you to Sue Webber who's departed the committee for her work during her time here with us. Our second item on our agenda is to decide whether to take items item five and the next meeting, which will be the 7th of June, is to be in private. We agree to both those things. And our third item today is two formal evidence sessions as part of our inquiry into health inequalities. These sessions will focus on the impact of the pandemic specifically and then good practice examples from the pandemic. I welcome, first of all, our first panel joining us in person. We have Bill Scott, the chair of the Poverty and Inequality Commission, and online we have Dr Emma Jackson, the Scottish Migrant Ethnic Health Research Strategy Group. We've got Ed Pibus, the policy and parliamentary office for the child poverty action group in Scotland, and we've got Claire Sweeney, the director of place and wellbeing for Public Health Scotland. So good morning to you all, both online and in person. Just a reminder, I'm sure that you've already been brief, but those of you online, if there's anything that you want to add your comment to, but you haven't been directly asked by a member, just put an R in the chat box function and the clerks will let me know that you want to come in. I want to go around all of you first of all, just to ask that obvious first question of you, about where the pandemic has had the most impact and to which groups in our society have been disproportionately affected by the pandemic in terms of health inequalities. I'll go around each of you in turn, just to get your overall assessment on that, and that will be a good springboard for us to ask some more specific questions off the back of that. Can I come to Dr Jackson first? Good morning, and thank you for this opportunity to speak. I work with communities that are adversely racialised and experience racism, and the pandemic clearly highlighted the disparity between those who are racialised and those who aren't. The key issue from that perspective was that, for Black minority ethnic people, the pandemic hugely highlighted the systemic racism that is operating in society. The moment of realisation more publicly, more generally, was a key moment in society to understand how the processes and lives that we live and the ways that we all operate within society have been creating the health inequalities that were evidenced through the pandemic. Before I move on to the next panelist, Dr Jackson, how did that manifest itself, would you say, for the people that you work with? It wasn't just for the people that I work with, but more generally, from the first incidences when the pandemic first hit, there were disproportionate deaths, the rate of staff in NHS, staff health workforce, the very clear disproportionate morbidity and mortality for those who are from minority ethnic backgrounds throughout the UK and many other jurisdictions. That was the evidence for all to see. Thank you, and can I go to Ed Pipers now? Hi, and I also like to echo thanks for being invited to give evidence today. I guess to look at the impact of the pandemic, I have to go back and look at the causes of health inequalities. We know that it is pretty clearly established that health inequalities come about because of poverty, because of wealth and income inequalities. The best way of addressing health inequalities is by addressing poverty, treating poverty as a public health crisis, as a way to deal with these health inequalities. What we have seen in the pandemic is an increase in poverty. Low-income households were far more affected by the negative impact on their finances compared to higher-income households, so it exacerbated income inequality, which has an effect of exacerbating health inequalities. In our submission, we highlighted some of the figures on that, which shows that 36 per cent of low-income households had to increase their expenditure during the pandemic, and we can many understand why that is. We have less access to cheaper shops, for example, where 40 per cent of the people with highest income decreased their costs. The pandemic has over-emphasised the inequalities that are already there and the wealth inequalities that are knock-on to health inequalities. We know that racialised minority ethnic communities are also far more likely to be in poverty. Most of our statistics information comes from child poverty, but the same applies across the board. We know that they are more likely to be in poverty, which again has a huge impact on their health inequalities. We also know that low-income households find it harder to access health services, whether that is by less services available in areas of higher deprivation, or by the hidden costs of accessing services. The hidden costs of pregnancy report looked at some of those, the costs of transport when services are centralised, the costs of parking when you are attending, the costs of not going to help upon them because you cannot afford to take time off work, etc. All of those are exacerbating health inequalities, and all of those have been exacerbated by the pandemic. As the first witness was saying, it has put a focus on the spotlights on the inequalities that already exist. A pandemic has highlighted those more generally. Good morning, convener. Good morning, committee. Many thanks for the opportunity to be part of the session today. I am just going to confirm what the other speakers have highlighted. We know that the pandemic had highlighted and accentuated those long-term inequalities that were already in place across Scotland, particularly the groups that we would be concerned about are vulnerable children, young people, particular problems around those folk who live in poverty, as the previous speaker said. Beyond that, the pandemic has made it difficult to address inequalities because of the pause in various services and reduced capacity to pick up some of the issues that are pre-existent challenges, climate change, etc., drug debts, and mental health-related problems. Importantly, it has caused more problems with the root causes of inequality across Scotland, particularly the economic situation that people are facing. It has widened existing inequalities, and we know that when we look at things such as disability-adjusted life years, which are an overall measure of the health of the population, the gaps around the time lost to ill health has increased. We have figures around premature mortality rates, and we know that there are particular challenges there. That has widened in the time during the pandemic. There are significant issues around children that I would probably want to highlight in addition to the messages from the other speakers, thank you. I want to pick up on one thing that you said and highlight it. People with disabilities, particularly in those lockdown periods, those early periods in the pandemic, people who rely on having services come into their households or rely on services out there to help them to get through their day and their week, and parents with disabled children. There are particular issues there early on, right there? That is right. We have been concerned about access to services during the length of the pandemic, and those groups that we might also call marginalised in some way have absolutely, all of the research shows, been adversely affected during the pandemic. Can I come finally on this very open first question to Bill Scott? The pandemic, I think, as Glasgow Disability Alliance described it, supercharged existing inequalities. In the decade before the pandemic, improvement in health in the UK had slowed dramatically, and health inequalities increased. Health for the poorest people and life expectancy for the poorest people got worse. The gap between the most affluent and the poorest households life expectancy dropped in the poorest households, and the pandemic has added to that. The gap between the poorest areas in Glasgow and the most affluent areas is over 17 years for a man, 17 years less life expectancy on average. On top of poverty, you have already alluded to race and disability, and gender is also a factor in the health inequalities that we have experienced during the pandemic. Women are more likely to be poor, disabled people are more likely to be poor, black and minority ethnic councils are all more likely to be poor, but the caring responsibilities that were thrust on to women have also caused significant mental health issues in the population as well. In terms of deaths, as has already been alluded to, if you were from a black and minority ethnic community, you were significantly more likely to die from Covid. Similarly, if you were from a poorer household, but for particular groups of disabled people, the risk was enormous. Analysis by the Office for National Statistics shows that of all Covid deaths, 58 per cent were among disabled people when they made up about one in five of the population. You can understand that the risk was way, way higher for those households. Within certain impairment groups, the risk was even higher. Learning disabled people were five times more likely to be hospitalised due to Covid and eight times more likely to die than a member of the general population. As you can see, there are intersectional issues. A disabled woman, for example, would be a greater risk, as would a woman from a black and minority ethnic household. As I said, Glasgow Disability Alliance described the situation exceptionally well in saying that existing inequalities were supercharged, and that is the legacy that the pandemic has left us with. Tess, do you want to ask a question? Thank you, convener. For Claire, if I may, I have two questions. This is the first, convener. The Scottish Government's women's health plan seeks to address health inequalities experienced by women. It says in the report that it has not specifically investigated the impact of Covid-19. The question for Claire first, but maybe the panel would like to answer this as well. Does the panel believe that the plan is still workable and deliverable with that caveat? Is it still workable? Bearing in mind, it has not addressed the health inequalities experienced by women. We believe that the plan is still workable. There is much more to do to fully understand the impact. The previous speaker has mentioned some of the impact that we know. There has been a disproportionate effect on women throughout the pandemic. It can again reinforce some of those underlying existing inequalities that were already there. Without doubt, there is more work to be done to fully understand the impact of it. We believe that the plan is workable. We are involved in a range of work relating to women and child health and broader issues to do with reducing the inequality gap. We chair the national group around ACEs to look at a trauma-informed approach across Scotland, bringing together a lot of different stakeholders who are involved in working with women and children and the wider community to start to get those practical changes that can make a difference. We also work closely with the Scottish Government and many other colleagues to implement a programme of work around gender-based violence, particularly so that we are very happy to share more details on that with the committee, if that would be useful. There are indirect harms of the pandemic on women. It has impacted on existing health inequalities. For example, negative effects on the mental health of women and horrendous backlogs of life-saving screening. What is the panel's view on the mid- to long-term health implications on women's health inequalities? Women in general, but also women from different ethnic, cultural and socio-economic backgrounds. Bill, first of all, if anyone else wants to come in, you can use the chat box and let me know if you want to come in. I will come to Bill first. Absolutely, as you said. The longitudinal studies that were conducted during the pandemic show that in the first wave, women were more than twice as likely to suffer stress, anxiety and depression as a consequence of the lockdown. That increased again in the second wave and second lockdown. That requires more study, as Claire Sweeney has alluded to. It is thought that the additional caring duties that women had, the increased levels of domestic violence and that many women were working on the front line in healthcare, etc. Disproportionally, nursing is a female profession. Therefore, they had these impacts. The problem has always been that mental health has always been about a Cinderella service within the NHS that has never really had the resources dedicated to it that it requires. Mental health is now, well, probably, because I have not seen the most up-to-date statistics, but it is the fastest growing impairment group among disabled people. 39 per cent of those claiming disability benefits have mental health issues. That is just behind those women's mobility issues, which is 40 per cent. You can understand what the pandemic itself has increased the numbers and proportion that have mental health issues. In dealing with the aftermath of the pandemic, much more resources will have to be dedicated to dealing with the mental health impacts of the pandemic. One of the things that has been talked about is that unemployment has fallen significantly. At the same time, economic inactivity has actually grown during the pandemic and in its aftermath. There are one million fewer people in the workforce because they have stopped seeking work. A lot of those people are women who have either had mental health impacts that they cannot cope with work anymore or have had increases in the amount of social care and childcare that they are providing, which means that they are unable to look for work. There is going to be a lot of work that needs to be done to address the backlog of mental health issues, particularly among women. Again, the intersectional issues are all there. If you are a disabled woman, you are much more likely to be socially isolated, which will increase the risk of mental health issues. Similarly, there will be a lot of work that needs to be done to address that. I look to Dr Jackson. When you spoke, you said that systemic racism was operating. I would like to know more about systemic racism operating in Scotland. We are all aware of the problems that the pandemic highlighted for people from black and ethnic minorities in jobs that were more front-facing, but the word systemic racism really took me. I would like to explore a bit more of what you meant by that. When I was asked to come to this committee, I asked what I was going to explain to a committee who understands this terminology and how it operates. What happened in the pandemic was that the systems that we operate within and live within the economy, the jobs that we have, the housing that we have and the health that we have are impacted by racialised inequality. When the pandemic materialised, our views of how all the inequality that happens in society around those who are adversely racialised became seen within the pandemic. In Scotland, when we first—it was the real height of the pandemic when it first hit—we were four times more likely, if you were from a black and minority north ethnic background, to be at risk of dying. We did not really know why that was happening. In Scotland, we were not able to present the data in a way that our data was not able to tell us enough about that. We looked to the sage group in England, who were then realising that their data was able to show us who had the most impact and, subsequently, we were working out why that was. That is the cause of the effect of systemic racism in society operating on our health. The second thing that we saw most clearly in the pandemic was the understanding of what—not just systemic racism—how living within systemic racism impacts on your health. We had global scholars and experts explaining and re-looking at their evidence and their systems to share and understand how we even report about health inequalities and how we understand what health inequalities are and the effect of racism on your health. That is not just about access to services or the sort of mojito, but the effect of living a life where you experience racism impacts on your health. Many people have been arguing for that for generations, but that understanding seemed to be realised and accepted because of the way that the pandemic moved and operated within society. We could see that it was those who were unable to stay at home. We are in front of delivering people whose jobs, lives and housing and all the situations that create come from inequality were impacting on the life chances of people who were experiencing systemic racism. That is broadly what systemic racism is, so it is not about how our systems operate. When I became co-chair, the Scottish Government set out an expert group on Covid and ethnicity. That became a vehicle in Scotland for us to start to look at the evidence that was being created globally as well as in Scotland and nationally around how those systems operate, how they are created and how we are operating within them and what are the mechanisms that we need to put in place in order to begin to address this systemically? A couple of other people want to come in, whether it is on Sandesh's question or the previous question from Tess Edd. Do you want to come in? I am not sure which particular question you want to come in on. I was wanting to respond to Tess's question, but I guess I would echo what Dr Jackson said. In looking at poverty, we know that systemic racism means that certain communities are more likely to be in poverty because, for example, when I research on childcare, I find it hard to access childcare, for example, which has a knock-on impact of being unable to work. It has an impact on poverty and has an impact on health inequality, so there are many layers in which systemic racism works. On Tess's question about women's health, all of this is dealing with the symptoms of health inequality. Even people who are on par have health problems, but there needs to be a clear answer. The gender poverty needs to be looked at if we are going to tackle the health inequalities that women face. It is a basis to make that point. I will bring in Claire Sweeney before we move on to questions specifically on children and young people. Claire Sweeney Thank you, convener. I absolutely agree with Amos' points about systemic racism and the teaching, the things that we have learnt through the pandemic, which have been profound. We have been doing some work with Emma to help to progress this. I did just want to let the committee know about some of the work that has gone on in this area during the pandemic, so some of the health and equality impact assessment work that we have carried out around vaccines, for example. Public Health Scotland led that work, and what it taught us was quite clearly that people from different ethnic minority groups and people living in deprived areas were experiencing a range of barriers to coming forward to access the healthcare system. What it did was give us some very clear recommendations to the Scottish Government and the rest of the system about what needed to be put in place. I also just wanted to mention that beyond the data, and that is true, there is more to do to make sure that the data we collect is good and we have work under way on that. We have found it really important to work with communities directly, particularly through organisations like Minority Ethnic Health Inclusion Service to tailor services and to learn alongside communities, rather than trying to put in place services that we hope are as good as they possibly can be. I think that one of the strong messages coming out of Covid across a range of different areas needs to be that we need to work more closely with local communities to get that change to happen, so things are appropriate and tailored, and that people feel that they have a real engagement and involvement in how services are planned going forward. Can I come to David Torrance's questions on children and young people in particular? Thank you, convener, and good morning to panel members. The pandemic has been extremely disruptive to children and young people at a time in their life where they expect stability. What are the long-term impacts of the pandemic likely to be in relation to children and young people, particularly those with health inequalities? I guess that our area of expertise is about poverty, so there has been disruption to health services and disruption to education services for children and the impacts of those. I do not feel that we have the expertise to talk about that, but we do know. As I have already stressed when we are talking about health inequalities here and what we are talking about is health inequalities that are caused by poverty, that is absolutely clear. As I have already stressed, the pandemic has hit no-income households harder than high-income households and has increased that inequality that people face. We are also living in a situation of rising child poverty, when in fortune of living in poverty. We know that any period of time when a child is living in poverty has an adverse impact on their long-term health prospects. The fact that the pandemic has increased poverty and increased inequality shows that that will have an adverse impact on people's children's long-term health going forward. I guess that there has been some changes. For example, the temporary increased universal credit is expected to mean a slight drop in poverty net rates for the year that it was in place. We do not have statistics for that year yet for Scotland. I think that the data that was collected was not enough to bring a child poverty figure for Scotland. However, the other key thing that we have in Scotland is the investment in the Scottish child payment. What that has started to do is to change the trajectory of child poverty in Scotland. If all of the planned interventions take place during the next year, we will start to see child poverty falling in Scotland and move away from the trajectory for the rest of the UK, which is welcome. It is not really an impact for the pandemic as such, but the Scottish child payment has come in at a good time to help to reverse the direction of travel on child poverty in Scotland. Having said that, there is still much more to be done on that, but one in four families are living in poverty. That needs to be addressed if we are to make sure that everything that we address for helping inequalities that people face. In Public Health Scotland, we have been publishing a series of reports that are focused on exactly this issue. I am happy to share all of those details with the committee. It is called the Covid Early Years Resilience and Impact Study, and it was something that we were doing throughout the pandemic to track the impact on children and young people. We absolutely know that it mirrors much of what has been said before. Those children living in poverty were disproportionately experiencing the worst of the pandemic. It is clear that those families that were struggling in terms of income before the pandemic were most hardly affected. We also know from our data that those children who had any long-term conditions or were disabled experienced more substantial impacts from the pandemic. It is particularly worth drawing to the committee's attention that our data shows that the impact on P1 children in Scotland at risk of overweight or obesity increased across all deprivation quintiles, so it affected everybody. All children were affected. We know that inequalities relating to that measure were also increasing during that time. We also know that the impact on education for more disadvantaged children was more significant. Again, we have good data that we can share with the committee around that. Essentially, the time that children lost in terms of education was much more significant. The attainment gap was much more significant for those children who were living in poverty. I apologise. We have done some work around education and learning lockdown surveys as part of a cost to the school day project, which we did look at some of that stuff as well. That is why I better highlight that. Some of the kind of things that that found was, for example, low-income households did not have connectivity and did not have access to IT. We were not able to learn remotely as easily, despite not having free school meals. How low-income workers might have discussed key workers and how to return to work and the lack of childcare, for example. Some of those things are being addressed, and we welcome the promise of connectivity for all children. Even without a pandemic, children can connect, but it may have exacerbated the issue. Again, the cash support that was made during holidays as opposed to vouchers for children to help them with the pandemic. There is stuff that can be done, but I can forward that report on to the committee about highlights of the impact that it had on low-income households disproportionately. As Claire said, that has an impact on the attainment gap. Again, the attainment gap is all about poverty. You need to look at the way to deal with your attainment gap, but the poverty-related attainment gap is to deal with poverty. I hope that that deals with your attainment gap. I probably know the answer to the question that I want to put on the record. If we were to focus on the inequalities of the health and wellbeing of children and young people caused by the pandemic and take into account the capacity of the system, where should we focus first to try to get the best results? Is that directed at Ed? Ed, yes. We need to focus on child poverty. The immediate way of tackling child poverty is investment in social security and cash payments to low-income households. We have shown that that works, and that is the best way of investing in long-term health inequalities by ensuring that families have adequate incomes. Many of the investments in tackling child poverty also tackle wider poverty in society, so we are not just talking about children. Beyond social security payments, it is for things such as tackling barriers to work, making sure that work is well paid, tackling childcare and access to childcare. The cost of childcare is a barrier for people working, and the lack of available childcare is a barrier for people working. To come back to Dr Jackson's point, it is tackling barriers to work, particularly, for example, for certain minority communities. It is more than just about paying a living wage, it is actively understanding barriers in all of our different sectors and making sure that we can overcome them. It is the same as Bill's point about people with disabilities barriers for them working. Those coincide with the priority groups in the child poverty delivery plan that the Scottish Government has identified as the priority groups to lift out of poverty, as well as lone parents, larger families and young families. It is doing all that work. The child poverty delivery plan starts to build on some of that. The next thing to do is to make sure that the detail is put in to make it happen. I cannot stress enough that the immediate way of lifting families that poverty is giving them more money is that the long-term changes to the employment and labour markets of childcare to education can happen and that can allow people to lift out of poverty in other ways. That will probably surprise you at that response. For Public Health Scotland, what we want to emphasise is why we have talked this morning about a lot of the challenges that we are facing in Scotland. The big message that I want to get across is that we can do a lot about this. There are lots of levers, there are lots of opportunities in Scotland to address this. This is by no means something that is intractable that we cannot address. We can address this. Public Health Scotland was introduced in 2020 as the new national public health agency for Scotland, as the committee knows. I was focused from the get go has been about impact and making a difference. I absolutely agree with Ed's point about the biggest thing now and probably always will be about fiscal levers and the legislative underpinnings in Scotland that give good public health no doubt about it. It also has to be seen in the context of what else we can do in Scotland, so it is not an either or. That is absolutely the biggest thing that can be done. There are reams of public health evidence that say that for sure there is. But if we just focus on that, it lets everybody else off the hook, there is a lot in Scotland that we can be doing. Local action we know will mitigate some of the effects of those underlying causes of poverty and inequality, but if we look at the spend on public bodies, for example, in Scotland, it is enormous. The amount of millions of pounds that are spent by the public sector in Scotland every year, there is huge opportunity to use that money to give effect. We have seen many of those things in place in Scotland already, so a couple of the things that it would be worth drawing to the committee's attention is the national performance framework, a really good thing in Scotland and community planning partnerships. The underpinnings of how we address this are arguably already there in Scotland. The things that need to be done, nor to strengthen that, and currently very much the topic of debate across Scotland, is about tightening accountability around that. For example, we hold public bodies to account for financial targets, for access targets, but we do not hold public leaders to account as strongly for reducing inequality, so that is something really clear and tangible that could be done. We would like to see budgets and spend across Scotland more closely aligned to impact, so it exactly speaks to that point about reducing inequality, particularly child poverty. The messages around public health interventions that make the difference are very clear. They are clear internationally. It is about early years, it is about access to education and training, it is about having good and fair work, it is about having a good standard of living, an affordable standard of living, and it is about having healthy communities in place so that people have access to green space, good transport, et cetera. I absolutely think that there is a lot of agreement on what can be done, it is about how we mobilise the rest of the system to start to realise that, and that is absolutely within our gift to do in Scotland. I have a couple of other members who want to come in on this particular issue. Carol, and then I will come to Tess. I absolutely believe that tackling poverty and putting money into the pockets of communities that need it is really important, so I agree with a lot of what people have said so far. I am interested to know about services and service provision, and anecdotally I have heard that perhaps in some of our more deprived communities it has taken a bit longer for services to open up, and that we know that there are staffing problems around and that perhaps it is more difficult to attract health staff and support staff workers into those communities. I just wondered if there is any evidence of that or if that has been looked at. The second thing that I am interested in and perhaps clear could respond is that we know that if we tackle health inequalities, it helps everybody in our society. Therefore, the amount of money that we are spending, do we look to ensure that that is being directed to those groups of individuals who need it most? I would be interested to know how we measure that. We do know that, prior to the pandemic, and probably reinforced by the pandemic, the inverse care law applied. The inverse care law is that resources are not where they are most needed. There are more GPs and more health services available in affluent areas of Scotland than there are in poorer communities. That has an impact right away on identifying existing health problems. People get shorter consultations because there is more pressure on the GPs that operate in deprived communities. That means that they are less likely to diagnose conditions that, if they are caught early, can be treated and get successful outcomes and extend lives. The inverse care law was there before, and I am absolutely certain that some of the shortages that we are experiencing among health and social care staff are making that situation worse. It also has to be said that the return to normality has been more evident for some than others. Proportionally disabled people are still self-shielding. They are not on any list for priority booster jabs on earth. My ex-boss at Inclusion Scotland, Dr Sally Witsha, has been isolating at home now for two years and four months. She is not eligible for a booster jab, but she is at extremely high risk. As I said, there is that for me isolation. A lot of GPs are still providing appointments, mainly by telephone or over the internet. It is useful in many ways, but anybody involved in diagnosis will tell you that physical presences can be identified. A layperson would not notice, but a doctor will colour the whites of your eyes. That is missing. We must remember that the most deprived part of the poorest sections of our society are the least likely to have internet access, least likely to be able to afford to make lengthy phone calls to the doctor. Online services are good in many ways, but they exclude particularly disabled people. About one in three disabled people do not have internet access. We have to think through how we deliver services to those who are not digitally included at the moment. As I said, we have learned valuable lessons in that we can do some of that work online, but, again, coming back to learning disabled people, for example, we know that they need longer consultations because it often takes time for them to understand what a doctor is looking for by way of response to questions. I am glad to see that there will be annual health checks for learning disabled people provided by the Scottish Government. It is long needed because, even before the pandemic, they were twice as likely to die from preventable causes as non-learning disabled people. There is definitely a lot there about where our services are, which services need to be bolstered because we know that the disproportionate impact has been on poorer communities, disabled people, black and minority ethnic people and all likely 11 poorer communities. We need to begin to restructure our services so that they address where the need is. As I pointed out, that is in the local communities. We need to really make sure that we have the resources in place to deal with the inequalities that have been not just created but magnified by the pandemic. We will have to move up pace a little bit. A lot of you are asking for supplementary questions. I have a lot of things to cover. If I do not take you in a supplementary, you will probably get back in later, so roll them into one. One of the most important things that we have touched on already is the idea of intersectionality. People are complicated. Where we have an intersection of different issues coming together, we need to be put in the person at the centre. We need to be treating people as people, putting them at the heart of everything. We also need to be working really closely with them to design out the discrimination that is built into services, often entirely unintentionally. We need to be co-designing services with people so that they are easily accessible. They are built around the person. That notion has been around for a long time but it is getting an increase in traction in Scotland, which is really good to hear. That could be things like where services are located. It could be some of the follow-up arrangements and just recognising how difficult some people's lives are to access some of the services that they need. There is a lot of work to be done in that area. We have introduced in Public Health Scotland a new approach to hospital system modelling to work closely with public sector providers to work through the implications of essentially getting systems back up on their feet post-Covid. Again, I am very happy to share that with the committee. I want to briefly mention one of the other things that we have not touched on. I am sure that it will come up, but the impact of the cost of living crisis on all of the things that we have talked about so far is absolutely significant and is of great concern to the public health community and all beyond. Again, I am happy to talk in a little bit more detail about that, but I am conscious of the time. Tess, a quick question from you. There must move on to questions from Gillian Mackay. Very quick, thank you. The pandemic has had severe impact on the mental health of children and young people. The target, as we know, is 90 per cent for people to receive CAMHS treatment within 18 weeks. My question for Claire is, is the funding sufficient to enable children to have CAMHS treatment? Thank you. The targets that are in place around mental health for children particularly, we have been doing a lot of work on. Again, I am very happy to share that with the committee. I will make sure that we do that. The underlying issue here is that the real challenge in what we know we need to do across Scotland, which is to shift the focus from the acute end of dealing with the consequences of poverty, inequality and health issues and making that big radical shift to a more preventative approach. So, whilst there is no doubt that there is a demand for crisis services, for very highly specialist medical mental health professionals, there is an awful lot more that can be done in community settings. We are working very closely with schools and head teachers to think about how we support schools in their work with children around their mental health. I think that it is not one answer to that issue. I think that what we are very good at counting at the moment is that acute end. We need to get a lot sharper about understanding the impact that can be had at a more community-based and local level on preventing those issues before they get to a crisis situation and before we have those increased wait times for access to those specialist services. Gillian Mackay, do you have questions? Does the panel have a view on universal basic income or minimum income guarantee as an effective method of tackling health inequalities? Let's go to Bill first. I have to say that the commission has not examined either, and therefore I am expressing a personal opinion. The minimum income guarantee is probably the easier to achieve, and therefore the one that stands the greatest chance of having benefits for those in low-income households. It is an idea that goes back to Adam Smith, that the essentials of life actually include your ability to participate in public life, and if you are not able to do that without a sense of shame, you will lose self-worth. It damages your mental and physical health. We have already said that race discrimination damages people's health, mental and physical, so does poverty. As Claire has already said, the cost of living crisis that we are currently facing is going to damage children's health and young people's health. The minimum income guarantee has the capacity to raise living standards at the poorest households to a level where they are able to participate fully in society, and that really is the essence. It is not just the bare essentials, it is not just being able to heat your home and eat. It is actually to be able to participate without a sense of shame. At the moment, we are damaging more young lives than we think we are, because normally we talk about poverty as affecting one in four children. My colleague Professor Morag Trainor has looked at that, and by the time a child is halfway through primary school, more than half of Scottish children will have experienced poverty, more than half, not one in four, more than half because people and households move in and out of poverty. If you have that floor at the minimum income guarantee, that stops happening, and that impact on the healthy children, dietary health, apart from everything else, but also being able to participate without a sense of shame. That is really, really important to children, and the cost of living crisis is going to make significantly worse for a larger proportion of households. Unless we address it properly, we will be living with the consequences of the impact on physical and mental health for another generation. The short answer to your question, Julian, is yes. Poverty causes health inequalities, both universal basic income and minimum income guarantee help to resolve poverty, so it should reduce health inequalities. The devil is in the detail what can be achieved and what do we mean by universal basic income and minimum income guarantee. Here is not the place to get into details of that, but I say it on the minimum income guarantee, one of the working groups on that, and we are looking at the issues. The main point about this is that you can have a system that should provide everyone with a certain level of income, but many people are still excluded. For example, we know that take-up rates of means-sisted benefits can be relatively low, maybe only 70 per cent of children who are eligible get the Scottish child payment. As well as having the social security systems in place, we need to make sure that we are addressing those barriers so that people are accessing them. There is an interstitial approach that we need to talk about. As I am sure, Dr Jackson would say that there are barriers for people playing, so it is no good to have a universal social security system if there are barriers to people accessing it. It also has to be addressed. However, yes, it is essential that increased people's income decreases health inequalities. Clare Swede, what is the coming in? I do not think that I can really better much what Ed said there. It is really simple, but it is complicated at the same time, and it is about increasing income. That is a good thing in terms of reducing health inequalities, no doubt about it. I want to mention that we have been doing quite a lot of work in Scotland around destitution. As Ed mentioned, people who do not have recourse to public funds, so there is some work that the committee will be interested in, I am sure, and I can send on details of that. I just wanted again to emphasise the impact of the cost of living crisis. If we were worried before about households that were experiencing fuel or food poverty, there is no doubt that they are at increased risk, but also at increased risk is what we would probably return the newly vulnerable. People who have been accru in debts that might have been able just to manage before or have seen their incomes or savings reduced or their employment circumstances becoming more fragile in part because of the impact of the pandemic. There is no doubt that increases in the cost of living will have an impact on health outcomes and it will be a negative impact. There is no doubt about that. We have got information that I can again share out with the session today about the impact of COVID on the economy, and then when you look at the impact of some of the other broader issues around the economy, it is far worse, it is far much more significant. I am happy to share those with the committee afterwards, but we would still be worried about all those groups that we have already talked about in this context. Women's health, children's health, emotional and cognitive development, winter mortality etc. All of the usual things that we would be concerned about, all of those things are at risk of being heightened because of the financial circumstances that people will find themselves in. Gillian, have you got another question? If you can direct it to someone, that would be great. We will do. I will try anyway. We touched earlier on services and intersectionality as well, and everyone on the panel has very different expertise in different areas. Given the increasing cost of living, and I will direct it straight to clear, what would you point to as one of the biggest interventions that we could make in terms of health interventions and poverty specifically? That is hard, but it would absolutely come back to that point about money in people's pockets. There is nothing that will have a better impact than that, but I would also, if I am allowed to supplementary, say that some of the drivers that I talked about around better use of the national performance framework, better use of the CPPs, more accountability in the system, all of those things are essential in getting the whole system to remobilise around these issues. It is not enough to treat it as a single issue, so money in people's pockets and anything that we can do to get that cross-governmental, cross-sectoral approach all focused on reducing health inequalities, that is something that we would absolutely call for from a public health perspective. Specifically, things that we can positively do will come up later in the session of some other colleagues. Can I come to Paul O'Kane first of all? Thank you, convener. I suppose that I am keen to understand more about our policy interventions that we can make in Scotland in a devolved context. We have had quite a lot of evidence and we have had quite a lot of discussion in committee about what happens at a reserved level and what happens at a devolved level, but I am keen to get a sense of what policy makers can do in the devolved context to make a difference. I will maybe start with Edd, if that is possible, because I know that Edd's organisation, CPag, has been close to the work around the child payment, so I am just keen to get your sense out of how we can go further. I guess that, in the short term, as Glair said, it is getting cash in people's pockets and that has increased investment in Scottish child payment. There are also many other things, for example, the two-child limit, the policy of universal credit, but unless you have conceived a child in coercive circumstances, you cannot get assistance from more than two children. The Scottish Government could try to mitigate that in Scotland and have a huge impact on some low-income households. We have a big support of universal provision as well. Universal provision will be speaking there and its increases uptake rates, as I have already talked about. It is no good having a system of people untaking up so that there can be universal support for people. One of the key areas that we have been looking at is childcare, which has knock-on impacts from both allowing people to enter employment but also reducing costs, if you can reduce the cost of childcare. Things like that can be looked at. In the longer term, it is around better-paid work, increasing and reducing barriers to work. We know at the moment that entering work is not a way of getting out of poverty. People who are even getting paid a living wage—two pounds working full-time on the living wage—are barely able to rise above the poverty level and only get anywhere near meeting minimum income standard with the support of the social security system. There needs to be stuff looked at for that. I guess that there are calls on further investment in the social security system from the Westminster Government, but there is stuff that the Scottish Government can do in the meantime. Most of my work is focused on policy engagement. Although it is a year-on-year system, childcare is for a much wider systemic issue. I am not sure whether it is quite come across about how serious the issue is about understanding our systems. We have operated our health research bodies, the key health professionals and our policy systems. They have not had an understanding of how racism operates within those systems. I know that we have had, for example, from Glasgow Centre for Population Health, Michael Kelly from Population Health, but all those organisations need support to understand how their systemic processes are not managing to incorporate perspective out how inequity is produced for those who are racialised. Your question about how policy can be supported with it is by bringing in those expertise. We do not have an NHS of the race observatory like they do in the rest of the UK. We are so limited in Scotland with our process to support the kind of decision making that policy makers need to evidence and understanding that they need to understand to be able to make good policy decisions. We are, and I will talk about it later, about what the Scottish Government has decided to put in place to support that process. However, the key issue is that our existing systems are operating with limited understanding of how the policy processes adversely affect and her risk of creating and re-creating the inequity that, essentially, as Clare senior said, they are attempting to address. I want to bring in Clare just now. Thanks, convener. Just to concur with Irma's point, the best advice I had from Irma when we were working together was to listen and to learn from those communities most affected, to then think about how we work together to make things better. I think that advice has really struck me and stuck with me. You asked about the policy context in Scotland, so I have mentioned the national performance framework and the CPPs, but a couple of other things to draw to the committee's attention. That will, thankfully, inject a bit of hope into some of the conversations that we have had today. The focus on a wellbeing economy in Scotland is really getting some traction now, which is absolutely to be welcomed. Government commitment to consult on a wellbeing and sustainable development bill is good and to publish a wellbeing economy monitor. Those are good things. We are involved from a public health Scotland perspective and will continue to support that work. There is a very exciting opportunity in Scotland around learning from the work that has happened in Wales, particularly around the Future Generations Act and the Future Generations Commissioners. That is the mechanism to start to get health inequalities at the top of everybody's agenda. We think that that is a really exciting proposition that absolutely can lead to demonstrable change across the system. We know that children born in our poorest communities in Scotland will die around a decade earlier than a child born in our wealthiest communities, so the differences are unfair and they can actively be addressed. The Future Generations Commissioner idea will have a focus on preventing and protecting the wellbeing of future generations and start to look at addressing and putting in place those building blocks that are needed to reduce health inequalities across Scotland. There is much merit in that approach. Beyond that, we would advocate to implement really good public health advice and principles, so thinking much deeper and harder about prevention, planning in a much longer-term way, linking funding to outcomes and collaboration across the whole system. That is something that Public Health Scotland and the directors of public health and the wider public health community in Scotland are strong advocates for. We have two questions on building on the momentum that may or may not be there. Just to say what the convener said earlier about rolling questions in, so I am going to just roll a question that I had earlier to Claire. One of the things that you said earlier was that you want to work with communities to improve. One of the things that I have found is, for example, information leaflets in Greater Glasgow and Clyde health boards. We have information leaflets in Urdu, Arabic, Romanian, Polish and Chinese, but nothing in Hindi for what is essentially a large community in Glasgow. I was wondering what we can do to try to stop this type of thing from happening and be more inclusive. Thank you. There has been a lot of progress during the pandemic in engaging with particular communities and making sure that the advice and support is tailored and is accessible. There is more to do, no doubt about it, there is more to do. My answer to that would be that we do that through engaging with those communities really closely. We do that through listening to feedback about areas where there is a demand and we have not responded to it. I think that that goes not just for Public Health Scotland but across the wider system. There are things that we can do absolutely, but for us we have a really important role in helping to mobilise the rest of the Public Health Services and beyond in Scotland. I will take that away as a particular action on the back of the session today. Thank you for drawing that to my attention. I was not aware of that before you mentioned it. I think that it is really important in this conversation to know that in a Covid expert group in the city in the pandemic put in a series of recommendations, all were accepted by government. It will come right to your question, but the key issue for the sorts of decisions that are being made is that we need a body not just with listening to communities but who has power to influence the decision makers. It is not just about going out and saying that it is enabling. One of the key recommendations was for the development of oversight observatory and repository for Scotland about how it makes policy decisions such as those about what and to have the experts with communities but experts who understand how systemic processes discriminate against people from minority ethnic groups. That is something that I am leading on with Ms McHelvie. Ms McHelvie is leading on that with me and Telet Jakub, and we are developing that infrastructure. That is something that will be launched next year, but we are hoping to have ministerial workshops for people to engage and to understand the importance. It does not come as a surprise, but it is helpful because it is exactly the sort of policy-focused infrastructure that Scotland needs in order to stop making decisions that have not considered the systemic processes that impact on it. Dr Jackson, I would like to stay with you please. I am keen to ask you for some specific examples of systemic racism, and following on from that, are there examples of good practice, local work, that we could push forward as bigger Scotland-wide policies? I think that one of the clear examples for me, and Claire Sweeney knows about this, is the vaccine management tool, recording of ethnicity. Here we had a pandemic that was affecting black and minority ethnic people, which is hugely disproportionate to anyone else. The evidence was coming out, and we had an opportunity. The agreement was made to record ethnicity, which is the only mechanism that we have. We record ethnicity in order to demonstrate where the inequality happens. That is the only reason that we record ethnicity. Our data was inadequate at the time of when the pandemic hit. When we were going towards making the vaccine management tool, a decision was taken to not record ethnicity at that point, and that was made by the Government at that point. However, the impact of that here, we had a brand new whole population data set. We could have had all of our society being recorded at the point of vaccination. It was a unique moment. A decision was taken to not implement that. That was, even though other jurisdictions were doing that, because it was felt at the time, and there was a lot of pressure and everything. Subsequently, a decision had been reversed. It took a year, it took more, but that process to me. I understand the reasons why people made that decision, but the impact on our system is generational. We are now recording ethnicity, but it came in much later. That, to me, is an example. I hope that you can see why those are processes that we create. If we had people who had understood the significance of the moment in discussing it, arguing with it or strategising about it, we would not have made that decision or required the huge efforts to reverse that. That, to me, is a recent example. I am not talking about the face-to-face. That is an interpersonal reason. This is about systemic processes that make decisions because they do not necessarily understand the impact that they will have. Dr Jackson, what can we do in just what you said to improve that systemic understanding? We agreed that we are moving forward with Government to create a national oversight observatory and repository. All the evidence about what has existed in Scotland, who knows where to go to look for that information? It is not there in our GCPH or research institute years ago, but it was dismantled. Scottish Government agreed to set up the observatory. I am working with colleagues, we have an advisory group. That is going to be implemented in launch in March, May 2023. Supporting that, understanding what that means for all members to understand why that is a tool for them, that this is something that is supportive. It is modelling from the promise. It is using the similar kind of model of the care experience and how we need to rethink the systems, the systemic processes and how they impact on the decision making. It is not intended, but, if you do not understand that perspective, you will make decisions that do not create equity. That would be my key infrastructure for people to support that. Thank you. Can we move on to examples of good practice, Evelyn Tweed? I was interested in what Clare was saying about the cost of living crisis and the negative impact that it is having on health outcomes. Clare, in your opinion, can the Scottish Government mitigate everything that is happening with the cost of living crisis? Will the Scottish Government's targets be affected and how are we tracking what is happening? Back to a previous contribution about how we address the challenge of poverty in Scotland. It is multifaceted. There are various approaches, but the most important is about using all of the fiscal leaders that we have in place. Some of that does sit at a UK level, but some of that does sit at a Scottish level. We are tracking ourselves with lots of other agencies the impact of the cost of living crisis on the population through a raft of different measures. Some things spring to mind around measures about fair work, employment and the consequences of it in terms of people's health. For example, things like access to food banks, issues to do with the impact on education. It is multifaceted and we are tracking it across a lot of different measures across Scotland, not just ourselves but with a range of different agencies. There are lots that can be done in Scotland, harnessing the power of that public spend that is available in Scotland. We have seen some really good examples of that. I think that there has been mention already of child poverty payments, etc., but there is no doubt about it that some of that is at a UK level and a Scottish Government level. I would also say that it is at a regional level in Scotland and we have been working really hard with a lot of public agencies in Scotland to make sure that they spend in a way that helps to have a positive impact on inequality. For example, some of the city region deals and the plans across Scotland, when decisions are about to be made about how a resource is invested or how money is used, we are working with partners to make sure that public health measures and public health evidence is being used to inform those decisions. That is something that has not happened as well as it could have done to date and that is something that our PHS is absolutely pushing. When we are making decisions about how resources are used, how are we thinking about the good public health evidence that we have about what works, how are we thinking about the consequences that that will have on a population's health and we are seeing a lot of progress around that? Obviously, that is something that the commission has oversight on and tries to hold government to account on. On the modelling that we have seen that the Scottish Government has done, we may well still hit the interim poverty target. However, the problem is that we are going to miss the other targets and they are all equally important. Relative poverty does not take into account costs other than housing costs so that the rise in energy prices and the rising food prices, poorer standard living for many households, will not be reflected in the relative poverty figures. In fact, perversely, if there is a drop in average income, relative poverty can actually go down, which seems unimaginable, but that is one of the problems with it. However, in terms of absolute poverty, we expect that to rise and the combination of low income and material deprivation that we expect to rise. To give you examples, the Food Foundation carried out a survey in January before the energy price rise hit. At that time, one in five households were saying that they were already facing a heat or heat dilemma, and one million adults went without food in that week in January. One million adults in the UK, so that is about 100,000 probably in Scotland. On all that, the destitution that Claire talked about earlier, from what we have seen, we think that destitution rose by about 50 per cent during the pandemic, and that means probably about 75,000 children went without food on a day during the last year. If that is the case, we need to focus in on what we can do, but I do not think that we can fully mitigate the cost of living impacts in Scotland. Control over means test benefits, which is the most effective way of delivering support to low-income families, is, for the vast majority of those benefits that are held at the UK Government level. The package of measures that was announced last week are extremely welcome, but most of them are one-off measures. What we really need to see is rises in benefits, inline reinflation, baked in to the benefits, so that people know that they will not just be this year that they will get help, but they will get help in future years. We can do a lot in Scotland. We can certainly address employability issues, barriers to employment, and we need to do that by speaking to the people who experience those barriers, the people who have lived experience. They know what the barriers are, they know what stops them getting into work, but we also need to make sure that, as Claire said, every public pound spent, as far as possible, should be spent on reducing poverty and inequality. If we can do that through procurement, through encouraging employers to pay the real living wage rather than through expanding childcare provision, we will allow more women to work more hours. I have already said that women are more likely to be living in poverty and more likely to suffer from some of the health inequalities at Sarah. There is a lot that we can do. We can do everything at this level, and we just have to accept that. I worry that the cost of living in crisis is going to impact quite severely on health inequalities in Scotland. I am supposed to pick up Bill about the living wage issue. Jerry McCartney last week responded to a question that I asked about the living wage. He said that we needed to remember the difference between living wage and minimum wage. I am thinking about the Scottish Government mitigating things such as encouraging employers to implement a living wage, but would there be an opportunity to say that we continue to ask for devolution of employment law, for instance, or for further benefits, so that we have better fiscal control, so that public funding can be delivered in the way that the Scottish Government can choose? I can only say that the inability of the Scottish Government to set the real living wage for all employees obviously prevents that happening in every sector of employment. Those additional powers would obviously be welcome and help to get the real living wage throughout the vast majority of employers. However, there are things that we can do. The Scottish Government has now said that, for every procurement contract, those involved in that will have to pay the real living wage to all their employees who are involved in the contract. That is one way of driving adoption of the real living wage among employers in Scotland, because they know that, to get a Scottish Government contract, they will have to pay the real living wage to their workers. More employment law coming to Scotland would assist in the adoption of the real living wage, but we can do things in the here and now to try and drive wedges up. Once you come in on this, Emma, broadcasting can unmute your microphone, will be fine. Thank you. Thank you very much. I'll briefly just give an echo what Bill said about procurement, but also, I was listening to the session last week, and I think the point was made, but I think Highlands NHS and Highlands council are all becoming living wage employers, which is real living wage employers, which is very far, but it's still much more that can be done. They can also be addressing, as I mentioned, probably barriers to employment, that certain groups, for priority groups who are in proud poverty, people who have disabilities have certain minority ethnic groups. Loan parents, they can be addressing those barriers, so being a living wage employer is not enough. There's still a lot that the public sector in Scotland can do in becoming these anchor institutions that drive this change, can drive change in society. Even where there isn't the powers held in Scotland, there can be changes made. That's a policy decision. Again, it's looking at an organisation's policy, policies through that lens of tackling child poverty, tackling health inequalities and tackling those barriers to employment that people face. It also allows flexible working, for example, things like that, but it allows people to work within their caring responsibilities as well. Yes, we're lobbying the UK Government to increase the minimum wage. If that powers out with the Scottish Government, we'd be lobbying the Scottish Government to increase the minimum wage, but at the moment, the Scottish Government doesn't have that power, so there is more that can be done to address barriers to employment within Scotland as well. Can I bring in Claire? You just very briefly convened just to add to Ed's point. I guess what you're hearing is the level of concern that we all have about the cost of living crisis is really driving these issues right up the agenda, which has to be a really good thing. As we said right at the start of the session today, none of this is new, it's just bigger. We're not seeing necessarily new issues emerging, we're just seeing the ones that were already there becoming so much more of a concern. I really do get a sense from working with partners across the system that there was a real recognition that the way to crack that is to use all the levers, all of them, that we have both in Scotland and to emphasise that need at the UK level as well. Again, not quite hope, but a real sense of what's going on within the system across Scotland. It's something that unites everybody at the moment. I have time for a quick supplementary before I move on to colleagues. Just a quick supplementary about a rent deposit guarantee scheme that I heard about that's been utilised for supporting people who are going into private tendencies with private landlords. In social housing you just get your accommodation, that's it, but in private accommodation there has to be a rental deposit. I'm wondering if you have a wider understanding of whether the rent deposit guarantee scheme is something that will help wider in Scotland, because right now I only understand that it's—well, I only have knowledge of it working in Dumfries and Galloway. I don't know if anyone has any comment on that or knows anything about that. Claire? Yeah, thank you. If I could just come in on that one, so two points. One is, I can't speak to that particular scheme, but in the list of groups that we would be concerned about, private renters would absolutely be on that group. We've got statistics that show that that group are particularly at risk, so that's one point to make. The second connected point I would make is that the example that we've described is one of the issues that, as Public Health Scotland, we're trying to tackle, which is where there's a good example, where we know that something makes a difference, how do we make sure that everybody is doing that, rather than quite a pilot project approach, something short-term that is switched on in one area and the learning is not spread to everywhere else. That housing example, I can think of lots of other examples where something really great has been happening and it's not spread more widely across Scotland, so we're using our power to convene us as strongly as we possibly can to get those examples mainstreamed. Thank you. Finally, the question is the priorities for recovery. We basically have been talking about this, I suppose, all morning, but some specific questions from Paul Cain and then Stephanie Callaghan. I think that the last two years of Covid-19 have dominated so much of everything that we've, you know, every part of our lives, but particularly in terms of our actions on health and equality. I'm keen, firstly, to get a sense of people's views of the recovery plan and essentially what should be prioritised in the Covid-19 recovery plan in terms of tackling health inequalities. I appreciate that. That's a big question. Oh dear, it is a big question. Nick, a short answer. The things that we need to prioritise put simply it's about prevention, prevention and maximising income. We need to make sure that services are up on their feet and we have a range of work on the stocks to help with that, for example, our cancer services. A lot of work that Public Health Scotland is doing with stakeholders across Scotland to make sure that cancer services and a range of other services get up on their feet, but increasingly what we need to do is shift the focus away from the treatment of the consequences of the underlying causes of inequality and shift that focus to a preventive approach. In my perspective, the importance of this moment in the recovery is to understand the system that we have been operating within and intentionally has been creating and recreating racialised inequality. From my perspective, the Covid recovery plan has to reflect an understanding of how that operates and for them to build that knowledge into what the plan is purporting to do. I guess that getting cash to low income households to reduce poverty won't be a surprise. Again, it's that whole system approach that people have said. Help inequality needs to be addressed across the system, and so does child poverty and so do inequalities, particularly racial inequalities. Beats can all be done together. We have child poverty delivery plan across Scotland, local child poverty delivery plans in local authorities and the community planning partnerships. All of those lenses have to be applied to all of those decisions to make the system work and solve all those problems. In a way, it's not difficult. We know what we need to do. It's just that it all needs to work together, but the whole system needs to work together to lift households out of poverty, break down barriers and that will deal with these helping inequalities. Very quickly, I don't think that recovery from Covid and economic recovery can be divorced from one another. We've heard that health inequalities are not divorced from the other inequalities in society, such as race, gender and disability. Therefore, the priority should be in addressing where we know those inequalities exist. How do we reduce that? Over 50 per cent of disabled people working age are not in work. We need to increase the proportion of disabled people in work. Women are more likely to be low paid and there's a gender pay gap. We need to reduce the gender pay gap if we're going to address women's inequality within the health as well. It's the same with race. Systemic approaches are definitely needed, but we need to see quite radical reform of our economic system. The first thing that I talked about was almost the explosion in mental health issues as a driver of increased disabling conditions that exist in our society. The growth in mental health issues has been over the past 10 years, and it's got worse in the last three or four. What is driving that is insecure employment, zero hours contracts, a benefit system that penalises people through sanctions and deprives them of the income that they need to get by in society without feeling shame. We can address some of those issues in Scotland. Some of them have to be addressed at the UK level at the moment, but unless we address them, health inequalities are going to continue to increase, not decrease. We know where the inequalities exist. We now need to devote the resources to reducing those inequalities and to say that health inequalities and other economic inequalities are not separate. They coexist. A couple of questions, but first I just wanted to say to Dr Jackson as well that I'm really, really interested in the development of the national oversight of the arbitrary repository for Scotland. It would be great to hear a bit more about that coming time next year when we've got some more information on that. Two questions that I've got here, first of all for Claire. Claire, you were talking about linking spending to outcomes and you were talking about the importance of community planning partnerships. Are there specific people who should be on community planning partnerships? Are there people that are missing? Are there other links that they should be making? I know that there's quite a variation across different local authorities, for example, about who sits in those partnerships. I'm wondering whether, as a way of sight, you mentioned measuring the link between spending and outcomes. Is that sometimes something that gets in the way when things are difficult to measure? That actually means that the focus doesn't go on them the same way? Thanks. In terms of the community planning partnerships, the infrastructure has been there for quite a long time. I think that there is something that needs to be revisited around the powers that they have to address some of the issues that you mentioned about the decisions that they're able to make, the people who are sitting around the table, and holding to account. That becomes the most important thing. It's not something that's really hard. It is absolutely complicated and really hard to do. It's really hard to measure, but that can't be an excuse. It's the right thing to do, and the system in Scotland has been built almost around that mechanism for making that difference, so we need to make it work. I think that it's really important that there's a strong public health voice around that table. This is a personal view, but I do think that when we talk about health inequalities and when we talk about public health, often there's an assumption that that's health's problem, but all of the underlying causes sit elsewhere within the system, so it's far more about housing, economy, jobs, employment. There is an absolute need to make sure that the CPP function across Scotland is strong, that it's got power, that it's got teeth, that budgets are aligned to outcomes, which we know is hard to do, but there is a focus around that and the national performance framework and the intention of the national performance framework gives you the underpinnings to do that, so I'm positive that that can happen, that can be strengthened. One of the things that we've not touched on to the, and just to briefly mention so it gets a little bit of airtime, is about the challenges around this, so we've almost kind of made it seem a little bit more simplistic than it is. If I looked at Public Health Scotland as an organisation in and of its own, we're relatively small, we know that we're not going to fix the problems around health inequality in Scotland by ourselves. We were introduced to help leverage the change across the system, so by doing that we can really have that bigger impact and we can get the system to use all of its assets to target reducing inequalities, so there is more we can do, but I think the key message I'd like to get across is that it's complicated and it's interrelated and it's very hard to see what is due to one organisation or another organisation's input, so that's why working as partners and being really clear about the measures and being really clear about what we're trying to achieve is absolutely essential. One of the things we've prioritised in Public Health Scotland is building what we've called purposeful partnerships, so not partnering with people because it feels like the right thing to do or we've got shared interests, having really clear action plans with partners to say, right, okay, we've got something that we can work on together, for example ourselves in Police Scotland or Food Standards Scotland, how do we make sure that we're being really innovative and focusing on those small number of big things that we can put money and resource against and start to kind of turn the tide, so I hope that answers, it's a really, it's a complex problem, but we've done so much in Scotland to get us to the right place. Now there's just that extra bit around giving it a bit more teeth, weight and accountability to make that next step. Emma wants to come in on this, but I was going to actually ask a final question of Emma because we had a number of informal sessions with a wide range of people and this issue of no recourse to public funds came up time and again probably the most disenfranchised group of people and it probably disproportionately may obviously affecting a lot of migrant individuals or people seeking to get some kind of status within the UK with regards to decisions made from the home office. How do we ensure that the voices of those people who have the voices of are not often heard in decision making, but they're probably most disproportionately affected in terms of health and equality and inequality in general? How do groups like yours help facilitate them getting round a table so that we have a group of people who have no recourse to public funds and as a result I probably suffer some of the greatest health inequalities in Scotland? In 2014, I was giving evidence in the previous committee and was talking about that issue then. How to bring people who haven't got voice or power into the decision making for is part of the point of the observatory because what happens particularly for the issues that I'm talking about is that people make decisions about people who generally aren't there in the room or their perspectives are not represented. We have this implementation gap. In 2014, we made good recommendations but the implementation of the issues that have been recommended are not the accountability mechanisms behind that. The observatory and repository is in fact an oversight structure to support us to have systems that are more accountable. In that space, that is going to be with experts who understand participatory methods, how to bring in lived experience that is not just co-opting people to come and ratify things but proper power sharing approaches to support our policy making infrastructure for government. Those sorts of mechanisms—I would say that the promise is a precursor to what we are proposing—are the sorts of mechanisms that we need to ensure that the decisions that are made and the levers that can be used, bearing in mind the differences over immigration rules and who is able to access what we need mechanisms that understand what levers we can use in Scotland and to have the confidence to implement those in ways that would support those who are most marginalised. To be clever about how our system can operate in that way, there is an implementation gap and infrastructure to address those implementations. There have been good recommendations made about that specific issue that you raised but, following on about implementation of that, it is hard to know where that went. I probably threw a curveball at you there. You wanted to come in on something specific that Stephanie asked? It was following up with Claire Sweeney about the implementation gap and the processes that we need. We have run out of time. We have gone over time but Ed wants to come in and we must have a break and get our next panel in. Ed? I think that Emma is really coming in. I know that we have caused public funds limited what the Scottish Government can do but they can find innovative ways to get money to these households. We have got a call minimum. It is caused to provide local policies with funding to fund through certain payments for unconsistent public funds. However, more broadly, in the social security system, where things have been developed, we have mirrored some of the rules for the UK system that they do not need to do. For example, the past presence test, which does not impact people—we know, of course, public funds—but it does impact people arriving in the UK. The past presence test has been mirrored within the Scottish disability and carers benefits and there is no reason for the Scottish Government to need to do that. Not doing it sends that message out but, in Scotland, it is a different thing. It is also pushing the UK Government to remove Scottish support from a list of public funds. They know that the Scottish support should not be on the public funds. We should be able to support anyone that we feel that we need to in Scotland. Stephanie, I am just getting the notice that you wanted to ask Bill a specific question and we must round off. If you can make it quick, please. Just very briefly, I am really interested in the fact that Bill mentioned shame and guilt and the ability to participate in public life and the huge impact on mental health, which is going to be massive for our recovery there. I remember back in January, Mary Glasgow had spoken as well about the universal cut, where it was withdrawn and being brutal and unfair. The huge impact on children and families is not just practically and financially but emotionally, too. In fact, that sent a message about society's views of the needs and how it created shame and guilt. I am wondering as well notwithstanding all the measures that we bring in to address poverty itself, because the media often does not help with that perception, too. Are there other things that we can do to influence that and to help everyone to feel respected and valued and remove that shame and guilt that people find really isolating and that really impacts their mental health so badly? Thanks. The universal protection is one of the ways that we can sometimes address some of those shame issues. Free school meals for all children removes any stigma associated with the receipt of free school meals by poorer children, children from poorer households. The NHS is free at the point that it needs. Again, that should remove any shame or stigma involved in being from a poorer household. There are certain things that are better delivered universally. Support for families with children is one of them. The Scottish child payment is there for families on lower incomes, but there is still child benefit, which has not risen now in value for years. Society acknowledges that we pay child benefit as an investment in the next generation, which we expect to look after us in our old age. The universal provision is one definite way that we can address some of the issues around shame and stigma and advocate on its behalf in regards to school meals. Everybody should be able to expect a certain minimum standard of income coming into the household that allows them to participate through it. Once we achieve that, we open up possibilities because many households cannot take up the opportunities that are there, not just because of the shame or stigma but because the barriers to low income. We cannot afford public transport, we cannot afford childcare, so free childcare for more families helps poorer families disproportionately. Thank you very much. I want to thank all our panellists this morning. We have run significantly over time, but it has absolutely been worth it. We are going to take a 10-minute pause just now before we bring our next panel in. Welcome back. This next session will focus on some examples of initiatives to tackle health inequalities that started either or before the pandemic. I think that we have heard from the last session that nothing really started during the pandemic—it just got bigger. In this session, our witnesses have prepared short verbal presentations as we take these in order. They will be followed by around table discussions. Once you are listening to the presentations, you might want to ask our panellists for more detail. I welcome to the committee Joe Batty, the Employee and Diversity Manager of South Lanarkshire Council, Danny Boyle, joining us in person. He is the Beamers Scotland Senior Parliamentary and Policy Officer and the National Coordinator of the EMNRN, or has that got a snap here? Emma Fife, the Senior Manager of Development for Clack-Manager Council and Dr Gillian Purden, Head of Nutrition and Science and Policy for the Food Standards of Scotland. Welcome to all three of you around line and Danny's in person. I will take you in order in which I introduced you. I come to Joe Batty first of all. Thank you very much and thanks for the opportunity to come along today and share with you some of the things that we are doing in South Lanarkshire to support people with health conditions and other circumstances that make finding sustainable employment difficult. I am a great believer that work can make a huge difference to people. I hope to be able to show by some examples what that difference is. First of all, a little bit of context. Clearly, there has been some volatility in the labour market during Covid and some of that continues. A little bit exacerbated at the moment, I would say, with the cost of living concerns, compounding precarious employment and some of the pressures around about pay. Labour market data also indicates that there are more people doing part-time work, especially women, and there are more people who are economically inactive in our working age population. We also see that there is an increased number of job-ready candidates available to fill jobs. They could be school leavers, college leavers, university course leavers, or potentially people who have recently been made redundant. That means that, for those with barriers such as health conditions and who are not ready to work or need significant support from employability services before taking up work, that that gap is bigger and that is something that we need to address. I work for a large local authority and I think that there is a responsibility on our large public sector employers and anchor institutions to lead by example. In our employability support services to local residents in South Lanarkshire, over 2000 in the last year, we have provided employability support and the vast majority of them have multiple barriers to employment. We work closely with our partners through the local employability partnership to ensure that our services meet local needs, are targeted at those who need it most and are focused on people and place. You can have services that are bespoke and person-centred and reflect the needs of the individual, but place is something that we are increasingly seeing as an area of where we can work in very localised environments to make a big difference. Funding helps a lot, especially when it can be used flexibly to meet needs. For example, anticipating high levels of youth unemployment during Covid, both UK and Scottish Government funding, the form of kickstart and the youth guarantee programme, targeted funding for employability at those aged 16 to 24 years of age. Now you can see that youth unemployment rates are lower in South Lanarkshire, it is actually lower than pre-pandemic, we are at 3.6 per cent at the moment for 16 to 24 year olds, and that is the lowest rate since February 2018. The funding does help, it is still over 1,000 young people who require support. Looking forward, as well as addressing those young people, we need to look at those who are over the age of 25 and those with health concerns. As well as those who are seeking work, I think that we should be spending some time looking at more support for those experiencing in-work poverty. That is a real issue for women and for those who are working part-time. I think that you heard that earlier in your session. One of the programmes that we offer is to address that, and that is for upskilling, and that is aimed at employees who are in work but maybe have low or no-skill levels and in receipt of low incomes. We aim to improve their job prospects by offering them support so that they can progress through training, qualifications and skills development. Our measure of success is that those individuals will then get better work opportunities such as real living wage, better hours and better conditions. Last year, we supported just under 170 people in work. The majority of them were women to enhance their skills. Where we intervened, the level of training or qualification did not need to be a huge undertaking. It could be quite simple, but it made a big difference, increased people's confidence and, most important, gave them something that they could point to that said, I can take on more hours, I can take on more responsibility and therefore get an increase in salary. Looking at parents, for example, who are seeking employment, we have a making-at-work programme that is funded through parental employment support funding. This is particularly aimed at parents with health conditions or disabilities. We aim to assist parents to realise their potential and overcome barriers in order to progress further into education, training or employment. Often, it is very easy because of those participants' lived experience and low levels of confidence and self-esteem not to apply for the job because they are worried about being rejected or that they do not have the skills or experience that are required. Since November, we have engaged with 76 parents with a range of health conditions and disabilities. In that group, more than 60 per cent had mental ill health conditions. 12 of us have moved into employment so far with the remainder undertaking skills development, confidence building and training before moving on in that journey into work. It takes a little longer with this client group, and often we have found that full-time work is not the answer. Part-time work might be a better solution for their particular conditions, or for their circumstances. I have some examples of people that we have worked with recently. N was in a violent relationship and left that with suffering from extreme anxiety and had to relocate to get their life back on track. They were also a single parent, but they had no skills and no qualifications in order to get a job. With our support on a four-week intensive training course that focused on personal development and entry-level qualifications, N managed to get an interview and then a part-time job in social care, where they feel that they are valued, they are making a contribution and it fits with their other commitments to childcare. That suits that particular individual. The transformation of that individual just through work is wonderful to see. I can turn a little bit to disability specifically, as a large public sector organisation that we are concerned with our mainstreaming equality reports. Part of that is reporting on the disability employment gap. The additional funding that has been made available for employability support has enabled us to put in place more support for those with disabilities, and that is very welcome. Though, during Covid and towards the end of the pandemic, we used a mixture of funding to create opportunities and 11 per cent of those recruited within the council have disabilities and now have bespoke supports ranging from access to work to British Sign Language support and physical adaptations, such as ergonomic chairs and dedicated parking, for example. That helps with our aspiration of reducing the disability gap, and those employability supports, more importantly, have allowed participants to fulfil their potential and become financially independent. That is something that puts a big smile on their face. We had an example of a young man who had a range of difficulties, both physical and mental ill health, and who had no skills or opportunities and just wanted, in his words, to get a foothold in the door. With some support with the health issues, but also mainly with interview preparation and confidence building, using the funding that the young man was able to take up an opportunity, again part-time, in February of this year. It was very sheltered initially for six weeks that it was shadowing until the young man managed to build his confidence. He is now, again, transformed by work, financially independent and performing very capably and independently in this role. We have also used council and Scottish Government funding to create modern apprenticeship opportunities within the council's workforce for care-experienced local people. That is part of our responsibility as a corporate parent, and again we recognise that it may take a little longer for them to settle and adapt to work. We believe that it is worthwhile for those who have been so disadvantaged in their early years. There are many more examples that I could give, but in summary I think that employment is a clear way out of poverty, is a route to financial independence and potentially good or better mental and physical health. Employability enables us to use funding to target those most in need of a bit of help, whatever form that might take. Employability services do not exist in isolation and they should not if they are to make the greatest impact on individuals and families. We try to lead by example as a large employer in the area. We are anchor institutions in our localities and we embrace and promote both fair work, the living wage and new ways of working. Working from home actually opens up employment opportunities for some people with disabilities or health concerns. I think that with a bit of lateral thinking and joining up services should ensure that no one is left behind, that our funding should be flexible enough to support the ambition rather than getting tied up in bureaucratic knots. The current discussions that are around multi-year funding are going a long way to enable that flexibility, which in turn will allow us individuals. The aspirations that are being expressed around the new child poverty and employability funding are very welcome and reflect the need for joining up services to support individuals. Child care, as I am sure you have heard, is very often a barrier to employment either because of cost or availability, especially in the rural areas, with the increase in nursery and early years provisioned health parents with work to. I mentioned at the beginning of the presentation that we also need to support those who are in work and on low pay. The living wage campaign in the South Lanarkshire area has reached over 100 employers signed up to living wage. We continue to bank that drum and encourage wherever we can. I have seen the pride and relief on individuals' faces when they receive their first pay in the bank. Financial independence is a huge confidence booster and a great equaliser. I am sure that that is within your territory. On that note, I will end, but I am happy to answer any questions when it is appropriate. Thank you very much, Gill. I move on next to Danny Boyle from BEAMUS. Thank you very much. Good morning, everybody. My name is Danny Boyle. I am the parliamentary senior parliamentary and policy officer for BEAMUS Scotland and have also been co-ordinating the ethnic minority national resilience network. Given that we are here to talk about the vaccination information fund that we set up, we thought that it was important in recognition of the general positive outcomes of the vaccination campaign to be able to be here in person to speak to you. It feels quite poignant to be able to do that and that is because of the overarching huge success of the vaccination campaign. I think that it would be helpful for members if I had just explained very briefly who BEAMUS is, what the ethnic minority national resilience network was and what it continues to be and some of the practical measures that we took to enhance health, particularly via the prism of the vaccination fund and the vaccination campaign. BEAMUS is a national race equality democratic membership organisation. We were set up when the Parliament reconvened in 1999 because there was a recognition that there would have to be a mechanism, a body for the voices of diverse ethnic minority communities to engage with parliamentarians and policy issues that affected them. We are strategic intermediary partners with the Scottish Government's race equality unit and our core funding is received via them. It might be helpful for members to understand then how BEAMUS approached the subject of race because that characterises how the ethnic minority national resilience network was then set up and the broad scope of community issues we were able to respond to. As an equalities and human rights organisation, we recognise that minority ethnic communities are recognised under the human rights race provisions of colour, nationality, ethnic or national origin, and that takes in a significant percentage of the Scottish population. Those provisions are contained within article 1 of the international convention on the elimination of all forms of racial discrimination and also within the equality act. In the provision of a vaccination campaign, for example, a national and local government are bound by those provisions of recognition, which are supposed to give us a very intricate understanding of the different health experiences and other policy experiences of people who fall under those categories. We work with multigenerational ethnic minority communities, Pakistani, Indian, various African communities, Jewish, Irish, Polish, others. Newer migrant communities from Eastern Europe, Roma, Slovakia and Hungary, and those designated by the UK immigration system as refugees or asylum seekers, such as Syrian, Afghan and a multitude of other communities. We can see there that it is quite a complex set of people and circumstances. Some are maybe four or five generations living in Scotland and others have arrived significantly earlier. So, BEMIS is an organisation. What do we do? We raise awareness and support our membership, our colleagues' Parliament, networks to challenge and respond to issues that affect them. We support ethnic minority communities to develop their own democratic representative organisations so that they can engage in policy areas and issues that affect them directly. I speak on their own behalf. We administer cultural integration programmes in Scotland so that those really diverse communities feel that they are part of Scotland, part of our civic society, provide equalities and human rights analysis of policy and public service provision. Of course, we have facilitated and organised and direct response to the pandemic, the ethnic minority national resilience network. Where did that come from and how did it characterise our response to the pandemic and how did it characterise the work that we were able to do quite rapidly in response to the vaccination campaign? I think that we were the same as probably most people around the table are listening, both as individual citizens and as professionals. January 2020, we were loosely aware of a virus emanating from China that may have some significant impacts, but our senses really peaked when we began to see the huge issues that were occurring within Italy. Part of our responsibility as an organisation, as BEMIS and the multitude of international communities that we work with is to be aware of things that happen on a geopolitical sphere because it can have community cohesion and hate crime challenges in Scotland. We saw the impacts in Italy where disproportionately affected people in poverty, disproportionately affected elderly people and we know from the years of working with minority ethnic communities in Scotland that that would likely translate into disproportionate and different and quite significant challenges for them with regards to the impact of the pandemic. So, March 2020, we engaged across our membership and networks to develop that intelligence and that eventually became the ethnic minority national resilience network, which is a coalition of 106 organisations and experts across Scotland who have self-identified under those provisions of race, covering colour, nationality, ethnic and national origin, so Pakistani, African Black, Jewish, Polish, Irish and many others, and they have been proactively engaging with the work that we have been doing. What we saw at the start of the pandemic with the full lockdown is the significant impacts for people, particularly those who have designated no recourse to public funds, so they were not able to access furlough and they were not able to access universal credit. So we had people in precarious employment who all of a sudden extremely quickly found that they had no access to money whatsoever. This has significant mental health challenges as well as physical health if you can not feed people. At that particular point, we set up a fund where people could receive referrals from trusted partners from the third sector or public sector and be able to provide some form of financial support to those people at that particular time. We were very much having to respond very, very quickly. In addition, we saw a significant increase in mental health needs for diverse ethnic minority communities. We picked up a challenge that should have been a current where the NHS had been trying really, really hard, obviously, to respond to those problems, but there becomes a problem when you are trying to translate from a murrow tongue into English. There are not always direct translations. Arabic, for example, is a much more metaphorically rich and diverse language than English, so those immediate translations do not always work. We set up a multi-lingual mental health service free to access with the BACP—I think that is the correct designation—registered mental health professionals so that that could happen in various different languages and that continues to be on-going. The network had a number of three key overarching strategic priorities. It was about intelligence and signposting, responding and providing, and ensuring an inclusive and receptive approach. We met once a month or even more often in the first months of the pandemic, depending on what situations were arising. Scottish Government officials and Cabinet secretaries and health officials were routine attendees at those events. What I would then like to focus on directly is the vaccine information fund and the implementation of the general vaccination programme. What I was attempting to do there was give you a very quick overview of the work that had been developed, which placed us as an organisation in the network in a really advantageous strategic position to be that intermediary partner to engage people and prepare them to participate within a vaccination campaign. Hopefully, members will have had the opportunity to read our submission on the vaccine information fund and the timeline and that the annexes in terms of the meeting notes of the meetings that we had with Scottish Government officials at that particular time, but, obviously, on 8 December, we had the first vaccine administered. On 9 December, the resilience network met with senior Scottish Government vaccination officials, Julie Hoey, and a couple of others. Sorry, I apologise for their names, escapement at the moment. Scottish Government were always very proactive in terms of coming and attending meetings and being there to participate in the discussions. There was a really positive attitude at that particular time, looking forward to the impact of the vaccines. Obviously, then, we received a bit of the hammer blows that everybody else did with the introduction of the Kent variant, and then, in January 2021, Scotland went back into a full lockdown. The resilience network had to move quite rapidly at that point, because you will all remember that there was a very clear recognition that we were in a race vaccination against spread, and we had to ensure that the communities that we were working with had access to the information that was required to increase informed consent, because we knew from other experiences during the pandemic that not everybody accesses information and services in the same way, and that was very much the case with the multitude of communities that we were working with and supporting. Early February, we cast another wide net in terms of developing intelligence very specifically on the vaccine and potential barriers to accessing it. That was to our resilience network members and others, and we developed that information over the month of February. Some of the challenges that were coming up in those discussions, some people's perceptions of the vaccination campaign, so that vaccines, the actual vaccines themselves, had not been tested on a diverse enough population, and that they were tested on different vaccines on different racial groups—black and white people. There were different vaccines for black and white people. If I go for the vaccine, I might be deported. That came through very strongly. People who have had an incredibly negative interaction with the Home Office and are designated no recourse to public funds—all of those experiences—built a picture of their engagement with the state. People were approaching vaccination with trepidation and a real trepidation that, if they access that particular method of support, it might have significant repercussions for them. Some of those were generic, so I think that the whole population was interested in what the ingredients of the vaccine were and how they were developed. Finally, the pressure of the pandemic and the lockdown and the increased mental health challenges and the expansion of the destitution had an impact on people engaging with services. If you wake up in the morning and your first concern is, you know, how am I going to feed my children? Other things that maybe all of us take for granted are not so obvious to people in those sets of circumstances. We knew that we had a professional and civic obligation to intervene, and we submitted our findings to the Scottish Government and proposed the actions of response were the actions that were suggested by our membership that trusted local partners should be used to help share information, community members and positions of respect, and that events such as Q&As online with health professionals with translation support about vaccination would help deliver capacity in terms of people accessing it. Not everyone accesses written information, so some people visuals and other things were better, and some of the translations were using overcomplicated language. There are a number of other ones outlined there, but I think that you get the general flavour of what we are saying instead if you want any further ones. When we went to our colleagues in the race equality unit, we outlined that we thought there would be barriers and that those were some of the solutions. They were moved pretty rapidly to provide us with funding in order to take that forward. All in all, over the full duration of the campaign, we received a first tranche of £50,000 from the Scottish Government and then a further payment of £40,000, £90,000 all in to try and change the dial in terms of uptake within ethnic minority communities. The summary is outlined there. I am not going to go through every single bullet point of it, because it is there and you can read it yourself and pick up things if you have any specific questions. However, it is suffice to say that during that part of the campaign from March until September, there were 45 community organisations funded. They are all listed there. What we can see then from Public Health Scotland's data is that the uptake of first and second vaccinations lifted quite considerably. In the first of May, for what was classified, the racial classification of white, the uptake was 64 per cent, but that was in comparison to Asian at 39 per cent, African at 34 per cent, Caribbean or Black at 37 per cent, so quite big disparities. By the time we got to late August, the Asian figure had climbed from 39 per cent to 76 per cent uptake, African from 34 per cent to 66 per cent, Caribbean or Black from 37 per cent to 66 per cent. There was a significant amount of work being done by the NHS, Public Health Scotland and agencies such as ourselves to change that dial. In that initial aspect of it, we began to see some quite significant impacts and some positive impacts on that. One of the biggest challenges that we faced with the vaccination campaign is that we did not collect ethnicity data at the point of vaccination. When that did occur, we saw some stuff in the press that there was some malicious reason for doing so, but certainly from our perspective, supporting our members and our members who have been calling for this for a long time, we really needed that ethnicity data from the start so that we had real-time data intelligence and newware to channel resources. What we had to do was to cast a very wide net and hope for the best. There were some significant gains and some significant positive impacts that came from it. As we moved through the inclusive vaccinations campaign, we were coming up and our community intelligence was continually returning. There would remain stubborn challenges in African, Caribbean and Black communities to vaccination uptake. In response to that, we set up a subgroup of the resilience network, the African, Caribbean and Black inclusive vaccinations group, which continues to be chaired by Margaret Lance from Women in Action and Dr Charmaine Blaise from the Unison Black Workers Committee. That is all on-going at the moment. It is a real-time group that has worked diligently to respond to vaccine challenges in those demographics, but I have also commissioned research into what the vaccine experience has been for those ethnic groups between first dose, second dose and third dose. As you all know yourself, the vaccination campaign has changed rapidly at different times, and keeping on top of that has been a real challenge. The gains that we saw at the first dose from March until May, we do not have the same indications that that has been maintained into second and then particularly into third doses. There may be a number of reasons with regard to that, not least the general success of the vaccination campaign and our ability to move further out of lockdown. That research will be on-going at the moment since it is nearing its end, and it will be published in August and launched alongside the Scottish Government's own research by Ipsos Moray into the vaccine experience of those communities. The Cabinet Secretary for Health and Sport will do that in conjunction with it. There is a lot in there. We look forward to discussing it more with colleagues, but I think that the big takeaways that we have made are a number of recommendations, which should be legacy recommendations for public bodies, but just to recognise that without the strategic interference of ethnic minority communities themselves who really led the charge at a grassroots level in terms of increasing informed consent, the vaccination campaign for those groups would not have been as successful, so we would like to acknowledge that here today and look forward to further discussion with colleagues. Thank you very much, Danny. I move on to Emma Fife. Good morning. Thanks for the opportunity to present today. I am Emma Fife, and I am senior manager for development at the Clitmanager Council. I have prepared a set of nine slides that you should have before you, and I will refer to those as I go throughout my presentation. Turning to the first title slide, what is a wellbeing economy? For anyone who might be less familiar with concept, a wellbeing economy is about ensuring our society thrives across economic, social and environmental dimensions, so it is putting people and planet at the heart of our economic system. Through the wellbeing economy project, we are working in partnership with the Scottish Government at Clitmanager to develop and test a framework for delivering a wellbeing economy across our area. I move on to the second slide in my pack. This sets out the six-stage framework that we are applying for the project, which is building on the five key outcomes of the inclusive growth framework. Those are productivity, population, participation, people and place. The wellbeing economy framework also takes into account a wider set of environmental considerations and indicators around the circular economy, biodiversity, natural capital and land use. The framework helps us to look at all leavers in the system that could help to deliver wellbeing economy outcomes and to focus on those outcomes rather than specific interventions or policy areas. Most importantly, the work is about moving beyond the data and evidence to understand priority areas for action and identifying the tools and leavers that we have to deliver change. I move on to my third slide. The wellbeing economy story in Clitmanager. I understand how the area compared against neighbouring local authorities and the Scottish average performance on a variety of wellbeing economy indicators was benchmarked over a period of time. From the data analysis, we identified seven key themes covering the range of areas that you can see on that slide. As part of that process, we mapped those themes against the national performance framework, against Scottish Government priorities and Clitman ensures on local outcome improvement plan and child poverty action plan to ensure that alignment with local and national priorities. I move on to my fourth slide. Understanding what drives performance. In the second stage of the wellbeing economy project, we took each of the themes that we identified and focused on understanding what was driving the outcomes in those areas. That was followed by a programme of extensive stakeholder engagement to help us to test the evidence base and fill any gaps in our understanding. We also incorporated evidence from a local business survey to better understand Covid impacts and wellbeing economy priorities for businesses in the local area. Moving on to slide 5, the Cypher systems mapping exercise. This kind of systems mapping exercise was used to better understand the links and strength of links between different aspects of our local system. In partnership with the Cypher research consortium, we hosted three interactive online workshops, with 54 participants from Clitmanager Council, the Scottish Government and other key public and third sector organisations. Cypher workshops were based on the seven key themes that were identified in the initial stages of the wellbeing economy project. That allowed participants to explore causes, effects and dependencies within the local system. The evidence gathered was then used to produce a systems map showing the relationships between key components of the local wellbeing economy in Clitmanager. Moving on to slide 6, it shows an example. With the help of the Cypher team, we are using the systems maps to strengthen our understanding and to recognise where factors driving outcomes are impacting across multiple themes. The slide shows an example of the key factors identified by participants in the workshops that are directly influencing and driving outcomes around the quality of jobs in Clitmanager. Slide 7 shows the Cypher quality of jobs influence. The Cypher systems mapping has also helped us to identify where the driving factors are impacting across multiple areas in the system. Here, we can see the potential impact of focusing interventions on improving the quality of jobs, ensuring that individuals have access to jobs with fair pay, fair and flexible contracts and opportunities to progress and directly impact on poverty, mental health and financial security across the local area. Moving on to slide 8, priority areas for intervention. Following the completion of the systems mapping workshops, all of our data analysis and systems mapping evidence were combined to identify a list of about 30 key factors driving wellbeing economy outcomes in Clitmanager. To help us to identify the most important priorities for delivering transformational change in the local area, we worked with the Scottish Government to carry out a prioritisation exercise. The 30 driving factors that we identified were prioritised using two dimensions, impact, which looks at the impact that something is having on wellbeing economy and how strong the evidence base is, and deliverability. That is where we bring in stakeholder preferences and how important something is to them, as well as considering how challenging change would be from a time and funding perspective. Those seven areas emerged as key for delivering wellbeing outcomes in Clitmanager, because there was strong evidence to suggest that interventions in those areas would have a high impact, as well as being considered deliverable by local partners. Moving on to slide 9, I would give some case studies about implementation that we have been undertaking. The kind of in-depth understanding of our local system will help us to ensure that investment and policy interventions are targeted where they will be most impactful in helping us to deliver our wellbeing economy objectives. One of the practical ways that we can achieve our wellbeing economy vision for Clitmanager is through our community wealth building action plan, which was developed in partnership with the Centre for Local Economic Strategies. That has been reinforced through formal commitment to community wealth building for both the council and our community planning partnership, the Clitmanager Alliance, with the inception of Clitmanager's wellbeing economy anchor partnership. We also have a number of community wealth buildings case studies. We have an ALWA hub, which is ALWA's main time in Clitmanager. That is where the council used direct derelict council-owned public toilets. They are being converted into a high-quality active travel heritage and community hub. That was used by the Scottish Government's town centre funding. Community shares are being sold to raise funds and to ensure that the community has a stake in this valuable community resource. We have also got the integration of community wealth building into the starting and Clitmanager city region deal, for example through the approved full business case for Scotland's international environment centre. We also have the Clitmanager good employment charter. That is a pledge that our businesses and agencies can take that commits to a range of fair work practices. We have progressive procurements, so we are funding a new procurement officer post to get better at using our local supply chain wherever we possibly can. The Clitmanager Alliance, which is our community planning partnership, has also agreed to the creation of a wellbeing economy local outcome improvement plan to ensure that work happening across the council is aligned and contributing to our wellbeing economy vision. We intend to use the themes that we have identified through the wellbeing economy work as a basis for stakeholder events that will be held in support of that local outcome improvement plan development. We also have an ALWA transformation zones approach, so that is a place-based whole systems approach to transforming our largest town. It is being led by the council with assistance from the Scottish Futures Trust. It is in its very early stages, but it recognises that transformational change is needed across Clitmanager as a whole and specifically within ALWA. We recognise such a wide range of people in place focused work taking place in the town and that perhaps not everyone is aware of what the other is doing and whether there is any overlaps or gaps. We are aware that there is also potentially significant levels of funding coming into the town through our city region deal and other government funding. The transformation zone approach aims to bring together all of that activity and investment that is focused on the town and to make sure that it is co-ordinated with overall aim being to improve community life and economic resilience. Clitmanager has also been selected for a full support package for the shaping places for wellbeing programme, which is being led by Public Health Scotland and Improvement Service. That focuses in on ALWA to our largest town and will support us in looking at what impact place has on people's wellbeing, specifically health and equalities. That aims to achieve a set of place and wellbeing outcomes based around the national performance framework, including things such as active travel, natural spaces, air work, quality housing, feeling safe and influencing control. The thought process being if those outcomes are achieved, our people should really be able to thrive. The last example that I have is the family wellbeing partnership. The aim of that is to improve the wellbeing and capabilities of families and young people in Clitmanager. It is working with families to support what matters to them. The council is working in partnership with Columba 1400, and it is funded by the Scottish Government's social innovation partnership. Clitmanager's family wellbeing partnership works to empower young people, their families and our staff in the council, giving them voice and agency. It includes a focus on what needs to change within the existing system, shifting values and behaviours of the people who are designing and delivering and receiving support within Clitmanager communities since 2018, and supporting us to roll out values-based leadership across the whole system. A critical foundation of the family wellbeing partnership is shared values, attitudes and behaviours, which are focused on finding different solutions to what matters most to our communities. Columba 1400 has worked with young people, families and Clitmanager Council front-line staff, senior leaders, community partners, elected members and senior managers of the Clitmanager Alliance, and that work is still outgoing. That concludes my presentation today. Thank you for listening and I am happy to take any questions when appropriate. Our final presentation is from Dr Gillian Purden from the Food Sands for Scotland. Thank you for the opportunity to present evidence in relation to inequalities on behalf of Food Standards Scotland. Just by a little bit of context, our remit covers all aspects of the food chain that can impact public health, with a name to protect consumers from food safety risks and to promote healthy eating. We know that a key determinant of health and wellbeing is diet, and we know that there is considerable and long-standing health inequalities associated with that. Food Standards Scotland also has a statutory objective to improve the extent to which members of the public have diets that are conducive to good health. To achieve that objective, we support Scottish Government by providing advice and evidence on actions that will support consumers to have healthier diets through their focus on prevention rather than treating the impact of poor diet over the life course. We consider that at a national level. It complements a lot of the local activity that we have just been hearing about, and we explore policy options at both levels to improve diet and related health inequalities across the population. To help inform our recommendations, we have been monitoring the Scottish diet and purchasing behaviours of people living in Scotland, and we have been tracking that for a number of years. We have a quick overview of diet and diet-related inequalities in Scotland. Our evidence shows that we are really a long way from achieving our Scottish dietary goals, and they represent the direction of travel and the extent of change that is required within diet to reduce the burden of diet obesity and diet-related disease in Scotland. Our current diet is too low in fruit and vegetables and fibre and too high in saturated fat and sugar, and it is not really a problem reserved to any particular group. Diet poor diet exists across the whole population. However, we know that those living in the most deprived areas tend to have the least healthy and the most energy-dense diets. Our poor diet has big implications for our long-term health. The association between diet and health outcomes such as heart disease, type 2 diabetes and certain cancers is well established, but the pandemic, as we heard earlier, has brought into sharp focus the adverse health consequences that can arise from those living with overweight or obesity. The strong links between deprivation diets and health outcomes exist, so those living in the most deprived areas are most likely to be living with overweight and obesity compared to those in the least deprived areas, and that has accentuated since the pandemic. I will talk a little bit about some of the approaches to tackle those dietary inequalities. It will be no surprise that this is a really complex problem and that it has no single solution. Although public information and education have a role to play, the food environment directly influences our purchases and consumption choices. The food environment currently exploits biological, physiological, social and economic vulnerabilities, and it really heavily incentivises and promotes over-consumption of unhealthy foods. The evidence base indicates that addressing the systemic issues within the food system are most likely to have the greatest and most equitable impact on diet, sustainability and ultimately on health improvement. However, the changes are not quick fixes, they are long term and it is going to be a long time before the benefits are realised. However, they offer the potential to reduce rather than widen inequalities because they require really little conscious effort by individuals to help to change dietary patterns of the population as a whole. I will give you some examples of what has been done so far and things that are currently in train. The really positive example is the Scottish Government's flagship policy around school food. That has undergone significant transformation since the nutritional requirements for food and drink in schools came into force back in 2009. It was revised subsequently in 2020 following advice from ourselves and a technical working group around changes to sugar and fibre. Those regulations have really been instrumental about bringing in positive change in schools, but we recognise there is still much more to do beyond schools and with the food environment more broadly. The planning and design of our food environment can provide opportunities to improve dietary health, for example, including looking at the proliferation of things such as fast food outlets. They are particularly of concern in our most deprived neighbourhoods and are trying to improve access to healthy, affordable and culturally appropriate food. We recommend that those issues are included in the review of the national planning framework for which was recently out for consultation. However, progress towards improving out-of-home food environment has generally been really slow, in part due to the pandemic but also due to the difficulties that many food businesses now face as a consequence of the pandemic. However, we are progressing a number of commitments that have been outlined in the recently published Scottish Government out-of-home action plan to support healthier choices for everyone in Scotland. That includes progressing consideration of mandatory calorie labelling at the point of choice, developing an eating out eating out framework to support food businesses to improve healthy food and drink offering and development of a code of practice for children's menus. All of those should help to increase the availability of healthier options. It is important that those options, for example, legislation to put calories on menus captures businesses that are more prevalent in the deprived areas so as not to exacerbate existing dietary inequality. We also welcome Scottish Government's plans to consult and propose proposals to restrict the promotion of high-fat salt sugar foods. That should make it easier for consumers to choose healthier options when they are out shopping in supermarkets. It is a critical piece of improving our food environment because we know from our data that promotions are currently skewed towards less healthy foods, and that legislation will help to rebalance in favour of healthier options. The promotions, contrary to what has been in the press, also tend to stimulate us to purchase more than we might have intended in the first place. Tattling wider inequalities, looking beyond the food environment, structurally inequalities that we have touched on this morning and the discussions around income, access to education, fairly paid work, childcare, purchase of shops and healthy food, go poverty, housing, all impacting on an individual and a family's ability to make healthier food and drink choices, and that can ultimately impact on their health. We know from the discussions that the pandemic has exacerbated many of those underlying inequalities, so addressing some of those is potentially outwith our default competence, but there is still a lot that we can do within Scotland. Food and security is a significant concern for many households in Scotland. Again, that is something that has intensified as a result of the pandemic. Data from the 2020 Scottish Health Service found that about 8 per cent of adults were worried that they would run out of food due to a lack of money, and 4 per cent reported to having eaten less than they should. We know that food price is a major determinant of food choice, as price rises disproportionately affecting the lower income groups. Analysis conducted by the Food Foundation demonstrates that healthier foods are almost three times more expensive than less healthy foods for equivalent numbers of calories. An evidence from our own tracking survey demonstrates that cost remains a key perceived barrier to health eating in Scotland, and 45 per cent of adults are stating that health eating is just too expensive. We also found that, back in July 2021, around a quarter of people said that they had been worried about fording food in the past year and 14 per cent having skipped meals as a result. The findings are really hugely concerning, and I am likely to intensify, given the on-going cost of living crisis that we have been touched on during the discussions, so actions to reduce poverty can therefore impact on dietary intake and dietary-related health in our most deprived communities, which would be very much welcomed. Just to round up ahead of the broader discussion, those health inequalities persistence in Scotland across a range of outcomes, but one of the starkest indicators is the difference in overweight and obesity rates between the most and least deprived communities. That has a huge impact on overall health, quality of life and, ultimately, on economic productivity. The pandemic has produced disproportionate impacts for the number of groups that we have heard this morning and inequalities in household income and wealth, and that is all likely to increase. We need to address the causes of those differences in order to start to narrow them. We might ask ourselves why do those living in more affluent areas tend to have better diets? The food system is undoubtedly a factor that highlights the importance of focusing efforts to increase access to affordable healthy food across the board. Income is a key influence on impacting our purchases, as less healthy choices are cheaper and often highly processed. For the population to restart to meet its dietary goals, a focus on prevention of problems rather than tackling the symptoms of unhealthy diets that are required, which resonates with a lot of the discussion earlier this morning. We must retain our current focus on the food environment, which represents a more equitable way of improving diets. We are well beyond the point that the answer is simply for individuals to choose to eat less and exercise more. The problems really are systemic. We need to focus efforts on ensuring that everyone has access to sufficient resources. That can go beyond income but also spanning housing, education and environmental factors, such as green space. The impacts of those broader societal factors must be addressed in order for Scotland as a whole to be a more equitable and healthier nation. What is clear is that the adverse health consequences of continuing on our current trajectory are really not tenable in the longer term. I am happy to take any questions on any of those points. I thank all four of you for your comprehensive presentations. We have about 15 minutes left, but you have been listening to all those presentations. Have you got any questions that you want to ask? Sandesh, please direct your question to whoever has peaked your interest. My question is to Dr Perdan. I would like to know your opinion, although you mentioned it in your presentation, but I would like to know your opinion about putting calories on to menus. You have articulated, and I think that we can all see clear benefits to doing this, but I have been contacted by a number of constituents who have eating disorders, and they are scared that this labelling will lead them back down the route of anorexia or an anxiety, and I would like to know what your thoughts on how to balance this. You make a really good point, and we are very much aware of that. It is a very serious issue for many people, and as has been touched on, the pandemic really has accentuated mental health problems across the board. We are very much aware of that. In terms of the rationale for putting calories on menus, it is beyond the information for consumers. What that does is it gives the establishment information about what they are providing, which is not always known, and the ability to… What tends to happen is that they might change their menus slightly reformulate so that the menus become healthier as a result. That is something that happens as part of the process, but the information is then there for the consumer, so that they tend to order less calories. We know that putting calories on menus tends to result in less calories purchased, but we also know that that can have a detrimental effect on those with eating disorders. What we need to do is to look at what we can potentially do to mitigate against that. Given that policy has been implemented south, there is the option for establishments to have menus without calories, but we need to look at all the broader range of options to see what may or may not be possible. It is a really off concern, but at the moment we are consulting and we will take on board the feedback and look at what we do as a result of those considerations. On the back of that, that was one of my concerns and then learning more about it. As part of the eating out framework, there will be an option for out-of-home menus to have no calories on menus for people who have concerns. I am sure that my question is about whether the eating disorder charity Beat has had concerns about that. I know that the Scottish Government is working with the charity closely, so I am sure that that will inform the evidence as we move forward on that. That is just a reiteration of a question. Beat is one of the charities that is involved in developing the whole process. We have been leading closely with Beat throughout and they have voiced their concerns. We are taking that very seriously to see what could potentially be done to mitigate against it. It is, as we said, accentuated given the impact of the pandemic. However, when we look at the data and we are collecting a lot of data on what people purchase, we do not have a lot of information from the supermarkets. Obviously, the nutrition information is readily available out of home, but we have a lot less information. From our knowledge of what is available and what is purchased, it is very difficult. The same menu item could have vastly different calories. The consumer perspective and our perspective on knowing what is available out there is very difficult without that information. However, we have been leading with Beat and we will continue to do so throughout. I have a question for Dany, for Ryan Cattle. Dany, you mentioned at the end of your presentation that there are legacy recommendations, and it strikes me in listening to you talking about the vaccination campaign that you undertook along with partners. There might be areas in which, in terms of preventative healthcare, that some of the lessons that have been learned from your vaccination programme might be taken over to encourage more people from particular ethnic groups who are not accessing screening in the numbers that they could be. Is there anything that is following on in those legacy recommendations that you think could be applied to other health interventions? Yes, I will be as brief as I can given the time, but the fundamentals of what we learned during the vaccine information campaign, both in terms of the way data was or was not there in order to inform real-time policy, and 51 self-identified ethnic groups participated within the vaccine information fund. The last ethnicity data that we have from the 2011 census is out of date, and we have the 2022 census at the moment, which is a good time to reframe how we aggregate and disaggregate ethnicity data, because Scotland is significantly more diverse now than it has been at any point in the past. The recommendations that we have made with regard to that would cover all the different aspects of health provision, as health ethnicity data must be gathered and disaggregated as a core responsibility and function to inform policy and decision making. The example that we saw within the vaccine information fund was the racial classifications of white, Asian, black, African and other. They are not sufficient to inform a strategic health response, because when we got the disaggregated data on the white block, it showed that the biggest lack of uptake within a specific ethnic group was Polish. Now, if we hadn't went in and drilled into that and suggested recommendations to respond to it, that might be a continual problem, and that's obviously reflected in the screening issue that you picked upon. The vaccine information fund was a rapid stop-gap measure that's not sustainable for Bemis, or the third sector, or the grassroots communities to continue to carry that burden, although they did very well and that should be recognised. The basic principle here is that, as Scotland's ethnic diversity increases our health services, we need to evolve to respond to that ethnic diversity across all different various provisions. That's really having a really strong grasp on what we're talking about when we're talking about ethnicity and race equality and creating public services that are capable of understanding and responding to the demographics of Scotland in 2022 and moving forward. That really needs disaggregation of ethnicity data, not aggregation of racial classifications that don't give you a direct or clear analysis or information on what's actually occurring. If we have a specific area where there's a lack of uptake or participation within an ethnic group, we're in a position to direct resources to change that. Following up on that, you had a really interesting looking at the list of partner groups that you deployed to speak to their own communities. I know that that was a one-off fund with regard to the vaccination, but is that maybe an opportunity to say to the Scottish Government that we've now got these partner groups that did this healthcare intervention? What way else can we maybe put some funding into their hands so that they can do additional healthcare interventions? To a certain extent. The tension here is duty bearers and rights holders. All of those groups listed are rights holders and deserve a health service in other policy areas that are able to respond to their needs. It's the duty bearers responsibility. Legal obligation under the terms of the international convention outlined as well as the provision of public services within the equality act based upon the definition of race, which is colour, nationality, ethno and national origin. That's where the duty and responsibility lies. These community organisations and other citizens can help inform what that looks like, how it's shaped, but it's not for them to receive funding to provide public services. There's quite a distinction here. They do deserve funding and capacity support to be able to act as active citizens and work with the multitude of agencies and duty bearers that exist in Scotland, but it's not for them to carry the burden. We've made—maybe I can provide this in writing to the committee because we're sort of maybe heading into a different area, but we were members of the expert reference group on Covid and ethnicity. The reality is, in terms of the allocation of our national budget directly to equalities and human rights, and within that, the protected characteristic of race is absolutely minuscule. It doesn't even register 0.01 per cent of our national outlay. Even groups such as BEMIS and other compassionate organisations, similarly, we're not duty bearers either. We develop intelligence, we engage with Government, we can inform policy and we strive to do that, but the actual complete rebuilding of public services to respond to people's diverse needs has to be built, and it has to be a structural change in terms of how we develop a multitude of public services to respond to a change in demographic. That's coming across very clear. Carol? Hi, thanks. I'm very interested in 20-minute neighbourhoods, but particularly interested in how we ensure that if we build these, there are affordable wellbeing neighbourhoods for people, so how affordable is green space and leisure activity? How do we have co-operatives perhaps that provide affordable food? To do that, we need to work more across departments. I just wondered if you felt that that was developing in your area. I also wondered whether Dr Pyrton felt that there was enough cross-department working in terms of that notion around food. Is it affordable? Is it in the right place? Do the planning departments make sure that they take on board those things? If you could? He wants to go to Ms Fivie first. I then come to it. I was just interested at a local level how we felt it worked then at that national level. Let's hear from Clackmannshire first of all and then we'll come to Gillian Perdon for the second part of your question. Thank you. We're definitely interested in 20-minute neighbourhoods as well and having a whole system approach to everything that we're doing. I think that's what we're aiming for with our transformation zones approach. You know there's a huge amount of activity going on right across the system in terms of housing with our third sector partners, a different range of activity. We all went to communicate, try and establish those relationships so that we can all work together on a consistent basis, just to make sure that a whole systems approach is taking place. I think that we've got really good partnerships with our third sector who are very active in the area with our housing associations as well to make sure that housing is going in the right place for the right client group. We're definitely taking forward by Clackmannshire that kind of whole systems approach. I'll come to Gillian Perdon. Yeah, just maybe to follow on from that, we're very much supporting the whole systems approach to improvements. I think that the question was around is the cross-team mental working well enough? I think that it's much improved but I think that there's still more that could be done. I think there are opportunities to link in. I think that the planning framework is a good example of where perhaps health and wellbeing could be elevated in terms of the agenda there. I think that it is very difficult for a local authority, for example, to refuse planning permission for a fast-food outlet, for example, even when there's a proliferation in that local area. I think that there's more that could be done and we very much support that whole systems approach. I think that we are linking far better now and working with partners, for example, with Public Health Scotland but also with Scottish Government to support each other and not just Scottish Government health but working across the other departments from climate right through to food and drink. I think that bringing all those together and having that role of influencing across those different departments can be really powerful and it can mean that we can weave in some of those considerations, whether they are sustainability considerations but they also touch on diet across the piece. I very much think that it is improving but there's probably more that we could do. My question is for Jill Batty on employability. I'd like to ask about neurodiversity because there are specific barriers for that and a lot of anxiety and mental health issues as well are prevalent in that group there, too. Quite often the interview process itself for jobs screens out neurodiverse people that I contact the social communication skills that are looked for. I'm wondering how that's been monitored, what is the evidence that it's actually saying and what steps have been taken to address that gap? Thanks very much. Interestingly, 11 per cent of young people who had been recruited to the council opportunities during Covid, there were a number of those young people who had neurodiverse disorders, sometimes on their own but sometimes in addition to other physical disabilities as well. What we found was that the additional supports that we were able to put in because of the additional funding were very helpful. We have also learned that we need to prepare staff and colleagues about how to work more closely with people with neurodiverse disorders and that has been an on-going discussion that we've had with our colleagues in HR. Again, it's something where we've seen the benefits of having the opportunity to spend a little longer with people with those conditions and also ensuring that their individual needs are met as opposed to sometimes stereotypical assumptions that can be made by colleagues and others. That's something that we've had direct experience of as a result of the additional funding that we've been able to put in place, which gives additional opportunities. That's been a good thing, I would say. In terms of monitoring, it's a constant challenge because divulging disability is voluntary and we often find that people are still worried about telling their employer or other large organisations about disability. That is a challenge and one that we encourage through our employee networks and through our trade unions to reassure people that we ask for that information only to be supportive and to ensure that services go forward to meet their needs. It's an on-going area of work. It's just a quick question for Dany about vaccine hesitancy. As a vaccinator myself, when I was working as a nurse during the roll-out, we did have a number of people who talked about fertility issues and worried about fetal development. It was our social care workers who came from Poland predominantly. I'd be interested to hear about how we're going to support people in the future to understand that the vaccine is safe and tackle fake news and things like that in the future, because I'm sure we'll be rolling out vaccines in the upcoming months to continue. Straight answer is that it's really complicated. There's no silver bullet solution. The Polish issue was a legacy issue of the swine flu pandemic. There were cases that the Polish community told us in terms of our engagement with them. There was a strong narrative internally within Poland about one of the side effects being narcolepsy with regards to the vaccination around that. That was recognised in academic studies and has some prominence as a narrative within the community. People are accessing information from their home countries as well. Some home countries have quite different interpretations of vaccination from a religious or a cultural standpoint, which then filters into communities here or makes them more susceptible to being victims to fake news and information. The reality of the challenge of fake news around all aspects of the vaccination, the content process side effects long-term consequences, continues to be quite disruptive across a number of ethnic groups because that's what our community partners feed back to us. People who are part of the community are what's at group or part of a Q&A discussion. The challenge for us and for Parliament and Government is that we don't see this information until it's already become embedded within society or within particular demographics. That was part of our intention of the Vaccine Information Fund to equip and empower communities with resources and additional sources of access to information to try and push back against some of this stuff. The fake news challenge is going to be an issue that affects a whole swath of policy areas and will define one of the biggest issues that we'll face as a society for the coming five to ten years. Every single issue that we come up against, be it the vaccination fund or the multitude of others, there is a host of alternative non-credible information that takes a grip in multiple different ways that we've found hard to unpick. While we don't have any absolute confirmation or data on this from our perspective, if you're a malicious actor somewhere else and you want to sow tension or community cohesion issues within a particular society and demographic, the vaccination fund or the vaccination issue was low hanging through because if you can start putting out information that ethnic group A is not supporting it as much as ethnic group B, then that can create some tension on the ground within different communities and portray and contain a narrative within it that some people aren't showing the commitment to society that others are. It's an on-going challenge that will need to be resourced to respond to it. If there's something like the Vaccine Information Fund that has to be continually deployed, then that's fine. The Polish community has done a significant amount of work on it. It likes a phoenix, so it would be worth asking them for written information or if you have a further evidence session to speak to them directly on Polish-specific issues. But certainly from the African Caribbean and Black community, we have that on-going research at the moment, which we're really trying to delve into things about experiences of vaccination. Yes, but how people are getting information in that will be launched in August and it will be an open launch, so committee members are more than welcome to attend and listen and participate and will share the report in due course, because it's highly likely that in autumn there may well be another round of vaccinations and vaccinations just more broadly. Are we comparing how New Zealand handled the pandemic and America, for instance, because in New Zealand there's a high level of social solidarity when tackling whether it's vaccine uptake, whether it's looking at diversity, whether it's health inequalities. In the USA, for instance, there are some challenges because healthcare isn't available to everybody. So are we able to look at that kind of comparison and see how other people handled not only just vaccine uptake but also just issues around diversity? International comparisons are always helpful to benchmark and see where progress has been made or where we can learn. BMIS is an organisation. We don't have the capacity to do that. It may be within the committee's interest for that to be one of your core recommendations to the Scottish Government to do a comparative analysis of the vaccination campaigns between the UK and other countries. Our focus was entirely domestic because we knew some of the issues that were occurring. The survey that we did in February 2021, that stuff isn't rigorous academic based qualitative or quantitative research or what it may be, we need to move swiftly and move fast because we're picking up information at a grassroots level which we don't have to benefit a time to leave lying. Everything that we were concerned about at that point came to pass and has continued. So our focus was purely domestic and getting information to people in a multitude of different ways because it was important. It was life for deaths. I'm going to come to Stephanie in a second but I do have a question ahead of that. Stephanie is going to have to be our last question because I want to run up. It's to Jill Batty and it was really interesting hearing about what you're doing in South Lanarkshire to facilitate people with disability getting into employment. I'm just wondering when you've got a success to raise, yours definitely sounds. One of the things that we hear in Parliament is that there's good practice happening in X but it's not happening in Y part of the country. Is there any mechanism for people like yourself who've worked and done this programme to be sharing this kind of good practice and to be talking to your colleagues and all the other local authority areas who maybe don't have programmes in place like this who maybe could be learning from what you do so that they can actually start programmes themselves which encourage and facilitate more people with disabilities into employment? Thanks for your question. There is a network of employability leads across Scotland which meets fortnightly currently where you take the opportunity of sharing good practice and often it's not about individual stories, it is about the broader issues, sometimes the challenges around data and funding but that would be a natural home for that kind of sharing of good practice. We also take the opportunity to share locally with our local employability partners some of the good news stories that we call them because often partners have had a role in that person's journey at some point and I think that that is a good opportunity for everybody to feel that their contribution has made a difference and that will encourage people to do it again. I would definitely welcome more opportunities to share that kind of good news because it not only helps partners to get involved but it also helps the perception of people with disabilities that they can do it and that there is help there for them to overcome barriers. Very often barriers can be significant but often they can be quite small and it just takes a little helping hand to get over that line. My question is for Danny. Evidence is heard from a patient who requested access to their medical records and what they found was that many of the health professionals that they've been in touch with had all recorded under different ethnic backgrounds so rather than asking directly that they had made a decision on it themselves. Is that an issue that you're aware of? Is it something that's quite common? Obviously it's implications for the data that we have and there were also assumptions made around our diet for example as well because of a ethnicity that weren't correct and I'm just wondering how much of a role that plays in it and how it's been looked at. The collation and use of ethnicity data to inform public policy has been a considerable challenge for a long time in Scotland and remains an on-going challenge because if we were to take 32 local authorities for example our experience has been there may be 32 different interpretations of what we're talking about when we're talking about race and ethnicity and that's again reflected in a multitude of public bodies and so on and so forth. There's no uniformed approach to understanding race and ethnicity and that creates the discrepancies that you're talking about in terms of the collation of information and data. At Beamis, as I said in my opening remarks to the committee, that this shouldn't be overcomplicated. The reason it shouldn't be overcomplicated is because we have the census codes. The census codes aren't perfect but they're good enough to give us much more intricate information. The problem is that when we get those census codes and we get the information, which comes from them, we as a policy at moment seems to be across many duty bearers, is to aggregate that into racial classifications so into black, white, Asian, other. Black, white, Asian, other, these aren't ethnicities, these are racial classifications so the actual ethnic discrepancies and diversity exists within those classifications. Again, one of our recommendations to the expert reference group in Covid and ethnicity and to the Scottish Government consistently is that there should be a policy of disaggregation of this information so that people can see it. In terms of the personal relationships between doctors and nurses and police officers and other core public servants to people of different ethnic groups, I think that we will be quite honest that there's still a nervousness around about discussing race and ethnicity within our society. That shouldn't need to be the case. It's a very simple question to ask somebody and to have the census codes to help guide that. What's your ethnic group? This is done, again, changing public perceptions and structural issues. It's done because we want to create public services that are capable of responding to an increasingly diverse population. There is no malicious intent in collecting ethnicity data in order to inform informed public services. We would encourage local authorities and other duty bearers just to have the confidence to ask these questions and core public services just to have the confidence to ask these questions and be equipped with that basic information about why we're collecting ethnicity data and why it's so important. Stephanie, we couldn't hear you. Could you start again because your microphone wasn't muted when you first speaking? Oh, my apologies. Sorry. It was just really specifically, Danny, that this is about the national health service in a series of different health professionals and consultants. How much of an issue is this? Do we have any idea of that? Or is there any kind of—are we looking at that? Thanks. It's a massive issue. I would imagine going by our experiences that the different parts of the public health system and when different professionals are engaging with individual members of the community—I think you said the GP and a consultant and an occupational therapist, for example—may all have different ways of recording ethnicity data, which is problematic, but professionals and their own personal experiences may be more confident and competent than other people in terms of having the confidence to ask the question and then be able to have a basic interaction and discussion around it because there is a nervousness for public health officials to have those sorts of conversations with citizens and that's reflected within other core public services. Thank you very much. I want to thank our four panellists for the time this morning and for their presentations and we could have spent a lot more time asking you lots of questions but unfortunately we have to round it up. That's that panel session finished. We have one more item on our agenda that we need to look at and that is our consideration of a negative instrument. That instrument is the Food and Feed Safety Fukushima Restrictions Scotland Revocations Regulations 2022 and this instrument will revoke retained commission implementing regulations EU 2016 oblique 6 imposing special conditions governing the import of feed and food originated originating or consigned from Japan following the accident at the Fukushima nuclear power station and these regulations also revoke declaration OFFC 2019 S003 which was made in terms of regulation 35 of the official feed and food control Scotland's regulations 2009 and which also imposed controls on the import of certain food and feed from Japan as a result of the Fukushima nuclear accident. So the Delegated Powers and Law Reform Committee have considered this instrument at their meeting on 24 May and they made no recommendations and no motions to null have been received in relation to this instrument. Do any members have any comments they want to make in relation to Sandesh? Thank you convener. Whilst I will be in favour of this, I would say that I have a concern as to why these levels were set in the first place at a hundred becquarels per kilogram. If this has a negligible impact then should that not have been set higher in the first place? Your comments are on the record and they are recorded. Any other comments in relation to this? I propose therefore that the committee does not make any recommendations in relation to this negative instrument. Does any member disagree with this? No, we are all agreed. At our next meeting on 7 June, as I have said, the committee will consider our draft report on our inquiry into alternative pathways to primary care and that will be in private session and that concludes the public part of our meeting today. Thank you all.