 Welcome everyone to the Health, Social Care and Sport Committee's third meeting of 2021. There's been no apologies received where we're all present. Our first item is to decide whether to take item 4 in private, and that's to consider the evidence heard on the cabinet secretary's session 6 priorities. Our members agreed. We are agreed. Our second item today is to take evidence from the cabinet secretary for health social care on his priorities for session 6, and all our witnesses are appearing remotely this morning. I welcome Humza Yousaf MSP, cabinet secretary for health and social care. He is joined by Caroline Lam, director general for health and social care and chief executive for NHS Scotland, Professor Jason Leitch, national clinical director and Donna Bell, director for mental health and social care. Good morning to you all. Good morning, cabinet secretary. I'm going to move to my colleague Paul Cain, who's got the first question for you today. Thank you, convener, and prior to starting, I would just draw members' attention to my reserve interests as a councillor at each run for sure council. This morning, obviously, as we meet, we know that Covid cases have been increasing throughout the summer. We know that there have been a number of very seriously concerning situations across our hospitals, particularly in terms of code black status being reached or almost being reached. I really just want to start this morning by asking the cabinet secretary for his view in terms of the capacity that we have to deal with current surgeon cases and indeed future surgeon cases. We know that there are concerns, for example, over staffing levels and indeed fatigue with staffing. I know that we will come on to those issues later in the agenda, but I think that we are in the pandemic now in terms of capacity and what preparedness we have for the future. Thank you very much. Mr O'Cain, I thank you for the invitation to address the committee today. I am genuinely very sorry that I cannot join you in person. I hope that the committee understands that many of you will know that, after a gentle game of badminton, I seem to have ruptured my Achilles. As Dr Gohani and Emma Harper and others with some clinical experience will tell you, I have to keep my leg elevated for as long as possible. I am really sorry that I cannot be in front of you in person. Before I answer Mr O'Cain's question in some detail about how pleased I am to be in front of the committee, and genuinely, as Cabinet Secretary for Health and Social Care, you will get from me and my team responsiveness, openness and transparency. We will not attempt to stifle or be defensive in the work that we are doing, nor will we try to be anything other than constructive to the work that the committee is doing. Having been a minister for the best part of nine years now, I have always thought that the committee and the Government can work best when we are focused in moving in the same direction together. From my perspective, I am really looking forward to working with the committee and I am sure that it will generate more light than it will heat. In terms of the question, it is absolutely imperative that my immediate focus, as you would imagine from the minute that I was appointed Cabinet Secretary for Health and Social Care, has been the pandemic and the current crisis that we are facing. We are still in the midst of that pandemic and, as Mr O'Cain rightly says, we are facing some real significant challenge. Our job is to work with every single health board right up and down the country to maximise capacity and flex within the system. We have that. We have additional capacity. We base that modelling for capacity on best medium worst-case scenarios, and we ensure that we are able to have as much flex in the system. However, I intend to be frank with you, not just in this session but in any of my appearances. That involves difficult decisions. We are seeing that right up and down the country. Mr O'Cain references some of those difficult decisions that are being made. They usually involve having to take tough decisions around non-urgent elective surgery. For example, we know that a number of health boards now have decided to pause that non-urgent elective surgery. It is one of the pressure valves that we have. We cannot stop people from having heart attacks or having a stroke. Urgent care, of course, we have to attend to, and we will attend to, but that non-urgent care we are able to release that valve where necessary to increase the capacity within our NHS. That does not come without consequences, of course. It does, and no doubt we will talk about backlogs, but, of course, every paused surgery has an impact on the individual that was waiting for that elective procedure. Huge challenges. Frankly, that is why controlling transmission is our top priority, because we do not want to overwhelm an NHS that is already under extremely significant pressure. I thank the cabinet secretary for that answer. I think what he says in terms of recovery and being able to recover services. Whilst we have, for example, in a number of health board areas and a number of hospitals, stopped non-urgent, we have made the decision around cancelling operations and surgeries. I think that there is a concern about how long that will take in terms of recovering the position. We had, for example, Professor Kylian Hyscox in NHS Grampian saying that it could take years to recover the position of being able to get people diagnosed, treated and operations that they require. As I said in my earlier comments, we are either going to come on to talk about workforce pressures, but, given what we know about workforce pressures and the number of people who are considering, for example, leaving the medical profession, whether that is in terms of doctors or the nursing profession, what is the cabinet secretary's view of what could become a perfect storm in terms of staffing levels reducing but also the long period that is required to recover the position where we are able to treat people in as normal as we would expect, and, essentially, in the way that everyone would want to see in Scotland? Can I thank Mr O'Kane again for what I think is a really important question that gets to the very nub of the issue? First, I wanted to say, of course, that NHS staffing is at record levels. We have increased NHS staffing by 5,000 whole-time equivalents over the last year. That is not to say, of course, that there are not significant challenges. There are some areas of an NHS workforce where the vacancy rate is too high and we are going to work to try to reduce that, but he described and used the phrase, a perfect storm. I would agree wholeheartedly with that description. The summer has seen a perfect storm, where, of course, with higher rates of transmission, because, of course, we have eased restrictions and we would expect that to happen, we have had schools returning in the past month as well. Understandably so, our staff are taking annual leave because they are, again, to be quite frank with you, knackered because of the last 18 months, so, understandably so, I want to take some of that annual leave. They are undoubtedly delayed because community transmission is high, so that has an impact on those in the NHS that are having to self-isolate if they test positive or become household contacts. That is a real perfect storm. As our NHS recovers, it is not like the beginning of the pandemic, where what we did was to strip the NHS right back to urgent care, to cancer treatment and so on. What we are doing is recovering the NHS and, therefore, the headroom is a lot smaller than it was at the beginning of the pandemic. There is a lot more that I could say in the NHS recovery plan. It goes into a lot of detail about our plans on how we get to those ambitious targets of increasing capacity by 10 per cent throughout the course of the plan. That involves, of course, the additional recruitment of staff, but, rightly, as Mr O'Kane alludes to, it will also have to require the retention of staff. We have a good record of our pay increase for NHS staff, making them the best paid or continuing to ensure that the best paid in the entire UK is the biggest single-year pay increase for the NHS, which I am proud of. There is more that we can do and more that we will do. I have a couple of questions for you. It is looking at the issue of certification from a clinical point of view. The Covid committee might want to look at it from a different point of view, but that is something that is quite topical. We are proposing to join quite a few other European nations in having certification for vaccination from a clinical point of view and for mitigation of the impacts of Covid. What is the rationale behind that? There has been quite a lot of heat versus light. There is a lot of heat around the civil liberties aspect of it, but there is possibly not enough discussion, I believe, on the rationale from a clinical point of view of why the Government is doing that. I will say a little bit, and maybe Jason Leitcher, national clinical director, will want to come in to add more or just to correct what I am saying, but there are two primary purposes of why we are doing what we are doing. First and foremost, I have been very public about the fact that I know the DfM and the First Minister have expressed similar things. We are not taking the step lightly at all. It is really being done because of the really challenging circumstances that we are facing in terms of the case numbers. Everybody knows that the case numbers yesterday were in around 7,000, so we are facing a really challenging position. I would not have considered that if case numbers were far lower as they were previously at the beginning of the summer, but we are in different circumstances, so our thinking has to evolve. In terms of the clinical rationale, there are two things to say. One, yes, this can hopefully help us to control transmission in particularly high-risk settings. Remember, the certification scheme is limited to high-risk settings, so nightclubs. Again, we can go into the reasons why we think that nightclubs are high-risk settings, but they involve largely a younger age cohort, not exclusively, of course, but largely a younger age cohort. We know that the younger age cohort has lower uptake of the vaccination. We know that some of the behaviours exhibited in a nightclub, for example, close contact behaviours, are more risky in terms of transmission of the virus as well. High-risk settings such as that and the other settings that we have included within any certification scheme, we hope to be able to control transmission. From a public perception point of view, if I was to attend the football at Parkhead, I would feel much safer knowing that everybody around me was double vaccinated, too. That does not mean that they become no-risk settings—nobody is suggesting that—and it just means that we can mitigate some of that risk. However, the second point, which I think is really important, is that they will hopefully incentivise vaccination, particularly among that cohort, where we know uptake is low. It is far too early to say absolutely definitively the causation, but I was looking at the weekend figures. I was looking at Saturday and Sunday's figures of vaccination, and the first doses administered on Saturday that just passed were over 50 per cent higher than the Saturday before. On Sunday, the Sunday that just passed, vaccination figures for first doses were over 70 per cent higher than the Sunday before. Again, it is too early to say absolutely definitively the causation, but if we continue to see that trend, then any rise in vaccination helps us as a society as a whole. I hope that that helps to ask the question. I do not know, convener, if it is appropriate to bring in the national clinical director who we may wish to add. That would be really helpful. I will bring in Professor Leitch. Hi. Good morning, convener. Good morning, everybody. Thank you for having me, and welcome to your convenership. I, like Mr Yousaf, will endeavour to attend and tell the truth when you asked me to do so. It is good to be back. I look forward to when we can all be in the one room. Mr Yousaf has covered it very well. I would, in short, ask you to think of even that room that you are in. I am not suggesting that we should create certificates for that room, but would you feel more comfortable if everybody in that room was double vaccinated or not? Vaccinated crowds are safer. There is not any doubt about that. The difference between alpha safety and delta safety is different. There has been quite a lot of talk in the past few weeks about transmission of the delta variant only being partially reduced by the vaccine, and that is true. It is not as good at that as it was with the previous variants, but it does still reduce transmission. I am in no doubt clinically that a vaccinated crowd is safer than an unvaccinated crowd, and then it is a matter of judgment for politicians to decide what they do with that knowledge. That is the clinical knowledge, and politicians have to decide whether they want to do that in certain pieces of the puzzle—rouds, nightclubs, moving back and forward to the stadia. In fact, it is not that Parkhaired or Ibrox were quite so worried about the outdoor bit, but we are worried about the travel to it or the pubs and houses around it. Getting people to be vaccinated prior to that travel, prior to all of that, is why we think that it is public health sensible. The second point is about incentives, and there are lots of pieces of work all over the world about incentivisation. Some people are giving people 10 quid, some people are giving people travel vouchers, and this is a behavioural science version of that to say that if you want to be able to do that, then incentives are one of the ways to do it. My third and final point is to not forget what that is. It is not a replacement for everything else. It is not mutually exclusive to have another list of mitigation. It is another layer. We are not saying to do this and all the other bits are off. We are saying that we want to do this, but over here is still all the other things about face coverings and distancing where you can and all those things that we have got used to. Emma Harper wanted to come in with a very brief supplementary. It is just a quick question. I am not sure how many European countries or other countries have vaccine certificates or whatever we want to call them, whether they are corona pass or green pass. Are you able to help me to understand how many EU countries have introduced vaccine certificates or equivalent? I do not have all those countries in front of me, but it is not uncommon that a number of European countries have those vaccination certification schemes. I am not to stray into the politics too much, but there are often countries that have Governments that are left of centre, Liberal parties, and often in power as well. I know that there has been some worry about the encroachment into people's civil liberties, as the convener rightly mentioned, but a number of the countries that have brought in certification schemes, I would say that politics is more left of centre. There are a number of countries where this is not an unusual step, but I would also say to Ms Harper what we have seen across the European continent. We have seen other countries far beyond Europe as well, but in the European continent we have seen certification schemes that have incentivised that vaccination. I know from France that the figures as soon as a certification scheme was announced, there was huge spike in people looking to get vaccinated. I am hoping that we see something similar here, too. I would like to go back and pick up on the topic that Mr O'Kane had started off on in that capacity within the NHS. We have seen alarming record lows waiting times over the last three weeks. Just last week, the largest health board, Greater Glasgow and Clyde, which serves my constituents, warned people not to turn up to the department unless it was life-threatening. As we move into the winter period, any waiting times are going to be high, but what is specifically being done in this area to alleviate the problem just now? Annie Wells, for what I think is an excellent question, is again the very heart of what we are planning for and doing at the moment. I would say that these are really difficult decisions, but they are not unique to Scotland. That is no consolation for Annie Wells' constituents or my constituents that are waiting for a procedure or waiting a long time in an A&E department in the Queen Elizabeth, but it is fair to say that those are challenges that are being faced right across the entire UK. Statistics will show that Scotland's A&E, although it is absolutely right, has had extremely challenging performance. It still remains the best performing right across the UK. Again, a little consolation to Annie Wells' constituents or my constituents. What is being done is immediate priorities to get through this crisis. Let us ensure that we can reduce community transmission as best we possibly can. If we do that, we will alleviate the pressure of Covid patients. We have more than 700 Covid patients in our hospitals at the moment. That may seem like a low number, but if we add that on to all the other services that the NHS is providing, that all begins to add up. What else should we do? Today, some guidance should be published by Public Health Scotland that is focused on primary care and GPs, in particular. I hope that guidance will allow more face-to-face consultations to take place at GP surgery at the primary. There is already a patient's face-to-face consultation, but I suspect that Annie Wells, much like myself, has many constituents contacting her to say that they are finding that getting a face-to-face appointment difficult. That can help us at the primary care end. We will invest more in that primary care end. We will invest more in the ambulance service side. Again, I do not need to tell anybody around that committee table just how challenging the situation is with the ambulance service and the demand of the ambulance service. We have just increased our investment in the ambulance service and already seen that pay-off. We had an additional, I think, over 60 recruits to the north and northeast of Scotland for the ambulance service last week. Of course, we are doing what we can in the acute side increasing bed capacity. We have the NHS recovery plan. I have no doubt that we will come on to that, but the back end is also really important when we have increased levels of delayed discharge. What we are doing is working to get rapid units that can make the assessments that are necessary in order to get people back into their communities and to have bridging care plans, even if we can't have a full care plan. Can we have a bridging care plan in place that meets their needs for a period of time and allows us to work closely with the local authority or the health and social care partnership or the IGBs in order to make sure that we have that full care plan available for that individual? I suppose that what I am getting at in short is that the recovery plan, backed by a £1 billion investment, takes a whole systems approach. There is no point us just trying to tackle A and E on its own. We are going to have to tackle the entire system if it is going to have any effect. I think that you have answered all my questions in one there, but I will come back to you later on in the proceedings. I am concerned about recruitment and retention in the NHS recovery plan. You have said that works under way to recruit at least 1,500 additional front-line staff required for the national treatment centres. Are you confident that you will be able to fill those posts? There have been on-going issues with NHS recruitment and we have heard of pharmacists being recruited into GP surgeries, causing workforce challenges in community pharmacies. There is a real risk that, in other places, taking staff from one part of the NHS to move them to another could cause problems and will not solve anything in terms of recruitment. How do you plan to avoid that and ensure that there is capacity across all services? Cabinet Secretary. Again, this is a core element of our NHS recovery plan. We have been up front and honest. We have increased, for example, the number of graduate places for medics, year on year. We have also increased training places for certain parts of the workforce. We are doing all that to increase as best as we possibly can our recruitment, but that is not going to be enough. We have said within the plan that we will look to conduct ethical international recruitment. I really emphasise that word ethical, because what we cannot do is just drain resources from parts of the world that absolutely need it, so our focus is on ethical international recruitment. I have had a good conversation with, for example, the Scottish Academy, which is helping us and no doubt going to be a help in relation to that ethical international recruitment, but it also shows that retention is a hugely important part of what we are looking to do. In my conversations with the BMA, the Royal College of GPs, for example, they have really stressed that retention point. Some of that is in our gift, and of course we are working hard to see what we can do. Some of that is not in our gift, and I have already had letter exchanges and conversations with the Secretary of State, Senator Javid, who I must say I have a good relationship with. I have already mentioned the fact that pension changes made by the UK are having an adverse disincentive for those within the medical professions doctors and GPs in particular. Some of that is in my gift and we will work hard that some of that is not within our gift. Retention is absolutely domestic recruitment, but ethical international recruitment will be part of our plans. Just to follow up on the point about GPs, some GPs have expressed concern about unhelpful messaging, particularly around GPs being closed during the pandemic. What is the Government doing to try and improve communication with the public regarding the pressure GPs are under at the moment and to ensure that everybody knows that they have access to their GP? I will always do everything that I can from a qualms perspective to try to help to alleviate those pressures. Let's be absolutely clear about this. GPs are open. People can get face-to-face appointments, of course they can. A number of people prefer having the video consultation, the near me consultation or indeed the telephone consultation. I, a couple of weeks ago, phoned my own doctor, had a bit of an eczema flare-up, but it was really easy. I did it in between meetings. We had a phone call, I got the ointment that I needed, and it didn't take away from my work day. Many people, like myself, might well prefer that, but there are a number of people who would prefer the face-to-face. GPs are working extraordinarily hard. Everybody in the NHS is. We are GPs at a primary care level at all the thanks in the world for the incredible work that they have done. Any suggestion that they are not seeing people face to face because they do not want to is false. I absolutely reject it, but what I would say is that, of course, there are a number of people and members of the public. I think that particularly our older elderly population that want to see a GP face-to-face and some of the guidance that is published today will make that easier. Just checking with Gillian, you have had some questions about social care. Do you want to ask them now? Yes. Conservatives have been raised by representatives of the social care sector that, while there is an NHS recovery plan, there is not one for social care. With legislation on a national care service coming, services still need a report in the interim period between now and a national care service being established. Does the Scottish Government recognise the need for a social care recovery plan and what plans are in place to ensure that our social care services have the appropriate support as we emerge from the pandemic and before we get national care service legislation enacted? Cabinet Secretary. I agree wholeheartedly with what Gillian Mackay has said. I suppose that I would make the point in which I know that the entire committee knows, but the NHS and social care are so intellect and integrated, so when there is pressure on one part of the system, there is pressure on social care also. Those are really important points to stress. When it comes to social care, I would say again to give as much assurance as I can to Ms Mackay that we are not just waiting for a national care service to be fully operational. That will be the end of the parliamentary term together up and operational. We are taking action now. An example of that, of course, would be the funding of the over 60 million that we provided to ensure that our social care workers are getting at least the real living wage. Of course, we want to see how we can go even further than that in future budgets. I know that that will be an important topic of conversation. We are not waiting around for the national care service. We are also working really hard with the social care sector when it comes to under-occupancy levels, so again you will know the scheme that is in place for payments in and around under-occupancy and has been there throughout the pandemic. We are supporting the social care sector where we possibly can. However, the national care service is hugely important to do that. Unlike the national health service, we cannot set full terms and conditions consistently across the care sector. However, the national care service, which would be accountable to ministers, would be able to have that consistency of approach right across the country. Depending on what the final shape of that national care service is, that can involve a full range of care services, not just adult social care, but many other care services such as child services, so on and so forth, depending on the final shape of that. Again, just to summarise it, we are absolutely not waiting around for the national care service. We are working with national care providers at the moment to do what we can to help to alleviate that pressure. Just off the back of that, before I go to my colleague Sandesh Gohani for his line of questioning, one of the trickier lines that social care providers have got to balance is the protection of their residents and their clients from getting Covid an infection versus the fact that their wellbeing more generally, their psychological wellbeing, allowing visitors and allowing contact with loved ones and also the social aspect of the work. How are we going to support social care providers to be making those judgment calls? I couldn't have articulated the conundrum better myself, because that is the challenge. They are weighing up some incredibly difficult factors. My colleague Kevin Stewart has had a number of meetings with the relatives of those family members in care homes. You can see and get a sense from them just how difficult life has been over the past 18 months. Nobody in the care sector wants to keep relatives away from visiting a loved one at all. We understand the challenges of the past 18 months, so you have to balance that up. What we know is a complex residential setting involving older people, who we know are more susceptible to the most serious and severe effects of Covid. That is why our clinical director at Public Health Scotland or other clinicians keep really close to the social care sector to advise them on a regular basis about what can be done safely. However, I will be honest with you, convener, that the circumstances that we find ourselves in at the moment with high levels of community transmission are having an impact on our care sector. Last count, I saw yesterday more than 120 care homes that have an outbreak of Covid in them. That is not an insignificant number. Therefore, difficult decisions have to be made. However, I can promise you that my colleague Kevin Stewart and I are looking at this on a daily basis to try to ensure that the rights of care home relatives are paramount, while considering the complex safety issues that are involved in care homes. Of course, we have made a commitment to introduce Anne's law in the first year of this parliamentary session. Anne's law has been the ability for a resident to have one close contact. Is that correct? It goes even further than that. Anne's law will give rights that care home relatives can have, according to the staff that are in care homes, for example. We are really expanding on what you have just said, and the final shape of what Anne's law will look like will be up to the consideration of the committee and the Parliament as a whole, but embedding those rights so that they are in statute. Thank you, cabinet secretary. Good morning. I wish you a speedy recovery. Remember, as we get older, we need to do dynamic warming up, unfortunately. Can I just pick you up on something that you said to Julie Mackay a bit earlier about the pension reform? Speaking to the BMA, it said that there were things that the Scottish Government could do, so the Scottish Government would be able to allow consultants to come out of the pension scheme for a little period of time. I seem to have lost a connection. I got you, Dr Gahani, when you spoke to the BMA. I spoke to the BMA and they said that there were things that the Scottish Government could do to help with the pensions issue in Scotland. The Scottish Government was able to allow consultants to come out of the pension scheme for a period of a few months and then go back in, thus negating the problem. That is something that has been done in other places around the UK. Will the cabinet secretary be able to provide me some information as to why we have not done that yet? Cabinet secretary. I am rather happy to look at the issue. In my meeting with the BMA, it raised a number of issues where it thought the Scottish Government could take action. One was that issue that Dr Gahani mentioned. Of course, all those things undoubtedly come at the cost. There are a number of other issues that the BMA and the Royal College of GPs have raised that they think that the Scottish Government could do to help with retention. We are working closely with the BMA, the RC GP, the Scottish Academy and others where we can. We will do that. Where those powers exist elsewhere, we will work constructively with the UK Government. I mentioned my relationship with the secretary of state as a constructive one. He has promised to look at the issue and to come back to me and to return to me on the issue. Where we can take action, of course, we will look to do that. If it involves an additional financial ask, then, of course, that is a decision that we have to weigh up among the other recruitment and retention issues. Before I move on to other lines of questioning, long Covid is something that we are now having to grapple with. Many people seem to be suffering the effects of long Covid. What is the overall strategy that we have going forward to assisting people who are suffering the really complex symptoms of long Covid? That answer will be slightly unhelpful, given what I am about to say. I hope to be able to give a little bit more detail on that next week. We were due to have our debate on the NHS in social care this week, but because of the need to bring forward a parliamentary debate on the certification scheme, we are having that debate next week. I hope to say more about our strategy on long Covid and some of what we are considering doing in that regard, to bolster the local response to the long-term effects of Covid. I hope to be able to say more next week. Currently, we are trying to ensure that the pathways that we have provide care as close to home as possible. That does not rule out the possibility of long Covid clinics. A health board could do that if they wanted tomorrow. However, the model of long Covid clinics does not necessarily work everywhere. In NHS Highland, for example, there may be challenges in having a long Covid clinic in one part of the Highlands. Considering the travel and the distances required could cause some issues and some problems for people who are suffering the long-term effects of Covid in other parts of the Highlands. That model does not always fit. It does not mean that it does not have met. I would reiterate that, if a health board wanted to create a specialist clinic, it could do that. When it comes to current referral, there is a current referral pathway. There is an implementation note with GPs around the long-term effects of Covid. Essentially, using existing services, we are trying to get people the best treatment that they can get in the long-term, as close to their home as possible. What we are trying to do is to understand more about long Covid. That is why we are investing in research to understand more, because our understanding of long Covid and the long-term effects of Covid is evolving day by day. I will go back to Sandesh Gohani, who has some questions about staffing. I would like to ask the cabinet secretary about the 10 per cent increase in key services that is part of the plan. What is the timescale forward delivery of that? It is all in our NHS recovery plan. It should be said that, when it comes to that 10 per cent, that is largely in relation to—well, that 10 per cent increase for outpatient activity will meet by the end of the parliamentary term. By the end of the parliamentary term, inpatient and day-case activity should increase by closer to 20 per cent. You will find that on page 5 of the recovery plan. We also go into detail about how, year on year, we will increase inpatient activity, outpatient activity and diagnostic activity. I am still waiting for the detail, but I know that the UK Government is due to make an announcement today about its own plans. My understanding from what we are hearing so far and what has been communicated in the media is that it will also look to increase capacity by 10 per cent. I am pleased that it has no doubt had a look at our recovery plan and seen that ambition and are going to themselves try to match it. We will, of course, wait for the detail in that regard. What I said to Mr O'Kane earlier on is that we will be realistic. I am ambitious about realistic in terms of the timescales that it will take to clear these backlogs and get our NHS returned back to complete normality. From your answer, we are looking at five years to get to the 10 per cent. My worry is that we continue to fall back as we are trying to achieve this. One of the key aspects that I saw was the redesign of the care pathways. Could you tell me a little bit more about how you plan to redesign the care pathways to achieve the target? Cabinet Secretary? When it comes to outpatient activity, we will be right to focus the parliamentary term at the moment to reach that 10 per cent, but what I would say is that when it came to additional inpatient and day-case activity, we would hope to get there by 2022-23, so hopefully we will get to that 10 per cent a little bit earlier. The significant increases in diagnostics, I think, are really important. What we are doing is when it comes to pathways. I missed part of your question, but was it on particular pathways or was it referral pathways that your reference and forgive me, my connection seems to be timing out a little bit? It was about the redesign of care pathways. The paper says that one of the key aspects would be the redesign of care pathways, so I am just asking for more details about that. For example, when it comes to our cancer pathways, we are already trying our best to get early diagnostics. That is a key part of trying to help to alleviate the pressures on the system. We know that if we can get people that care earlier, particularly when it comes to cancer treatment, they have a better chance of recovery. That means that they are less likely to end up in our hospitals for longer, for example. Our early cancer diagnostic centres are clearly a part of that. The earlier we can get people referred into the system, such as, for example, early cancer diagnostic centres, the better chance we have of alleviating that pressure, the better chance we have of seeing more people through the system. Obviously, we already have some of those early cancer diagnostic centres up and running. Can I also ask about workforce planning? Speaking to the association of anesthetists, there are 2,000 shortages across the country, and only 1,000 are currently being said. Speaking to the Royal College of Nursing, it says that there are 3,000 nursing vacancies. Even with the significant increases that are in the paper that we are going to be seeing, we are still barely going to be achieving parity, let alone looking at increasing the workforce. If we look at the people who are leaving because of Covid, they stayed a bit longer than they are leaving and the natural turnaround. How could we address that? I think that the commission is a really good one. I perhaps touched upon it when I was giving my answer to Ms Mackay. I am not going to pretend to insulting your intelligence and the public's intelligence that I suggested that we are able to meet those ambitious recruitment targets simply by domestic recruitment. We will do that. We will also try to recruit from other parts of the common travel area, but clearly ethical international recruitment will be part of what we are doing. Are we getting the absolute most out of the current staffing cohort that we have? Can we train them to an even higher level? Can we incentivise them to stay for longer? Again, a number of the organisations and stakeholder and member organisations that I suspect Dr Gohani has met and that committee members have met tell me that retention is a key issue here. We are working hard to see how we can retain. Where those powers are at our gift, we have to use them where they are in the gift that other Governments will work constructively with them. Those are common challenges. The challenges that are faced by GPs and consultants, for example, in Scotland will probably be very similar to the issues that are faced in other parts of the UK. Essentially, yes, investing in the pipeline, making sure that there is an increase in training places, graduate places, increase when it comes to recruitment domestically, but also retention and ethical international recruitment are all a part of the mix. I am going to bring in Paul O'Kane. Thank you, convener. I think that we are having a discussion at the moment in terms of our long-term future planning. Indeed, a lot of our work across these next many years will be dominated by workforce planning issues and ensuring that we get that recovery right. I wonder if the cabinet secretary would say something about the particular imminent challenges that we have in terms of winter, because we are about to embark upon a very difficult winter period in the NHS. I note that the national workforce strategy is going to be published in December, but by then we are into those winter pressures. Indeed, a lot of those recommendations will take time to flow through. I think that just in terms of those pressures on staffing for the winter period—and it goes back to not just NHS but also social care in terms of being able to discharge people from hospital more quickly and having care packages in place—I am keen to understand the cabinet secretary's thinking on that. Again, I have to forgive me if I do not answer anything, but I am happy to go back to Mr O'Kane. He is absolutely right that nobody is waiting for a workforce plan at the end of the year to take imminent and immediate action. That is why our staffing levels are the highest they have ever been. We have a record number of people working in NHS in terms of whole-term equivalence. We have 5,000 additional staff—again, WTE—whole-term equivalence working in NHS this year compared to last year. We are investing in staffing right here and right now, and it is important to make that point. We have ambitious plans right across the NHS, so we have time to increase the number of GPs, paramedics, mental health workers and community links workers, and that investment is happening now. We are, of course, increasing paramedics in terms of anaglint service. We are investing right here and right now. We are also undertaking a campaign. That is a slightly lost connection, but I think that it was around social care. What we are doing at the moment is working really hard with the sector to see what we can do to retain the current staff and to do a bit of marketing, a bit of communication, to try to incentivise people into social care, but also those graduates who are studying social care to make sure that they then go on to work in social care and not go off to another profession. We are working with them while they are still in their university courses, while they are still in their courses in college, to try to attract them to stay within social care. I will be very frank and very honest with you. That sight of things in terms of recruitment into social care is probably one of the elements that gives me the most significant concern, because we do not have the same leaders that we would have in the NHS over social care. Just to pick up on what you are saying, cabinet secretary, about cancer pathways and, I suppose, looking at modernising patient pathways approach, we have got the diagnostic centre in Dumfries and Galloway. That is one of the first ones that started in a belief that they are doing really, really well, as far as fast-tracking people that do not have concrete symptoms of cancer. That is something that has been introduced that is working quite well initially, I understand. I am also interested in whether the modernising patient pathways programme is looking at cancer pathways in general. For instance, people in Stranraer and Wigginshire go to Edinburgh for their radiotherapy, which is a longer journey time and travel time when they basically drive past the Beatson, for instance. Is that something that is part of the modernising patient pathways programme, looking at shorter travel time, shorter journey time and maybe having a different overall approach to the whole cancer pathway programme? In short, yes, and the refreshed cancer framework, the framework for effective cancer management, that, forgive me, I am going to double check when we are hoping to publish that, but it hopefully will be in a matter of weeks. That will go into the detail of exactly what Ms Harper is saying, making sure that we have the right treatment at the right time and in the right place for people. We recognise those challenges with that. Even pre-pandemic, there were challenges, let us be honest, about some of the challenges in rural areas in terms of cancer referral and pathway. The refreshed framework in terms of cancer management, the effective cancer management framework, will help to address some of those issues. I am Gillian Mackay. Very briefly, cabinet secretary, other than the measures that you have already laid out about GP recruitment, I wanted to ask specifically about out-of-hours services. The pressure on those who do out-of-hours GP work is particularly acute at the moment, given the pressures elsewhere in the NHS and they are a particularly dedicated workforce. What else can we do to ensure that GP's wellbeing and the want to continue to contribute towards the out-of-hours services can be prioritised, while we recover from Covid, given the pressures in other places that, undoubtedly, mean that more people are accessing out-of-hours than potentially previously were? Cabinet secretary. Yes, again, those are all really important questions, two things. One is that we are looking proactively at the moment on how we incentivise the out-of-hours working, because we know how challenging that is, but we also know how important it is in terms of our recovery. We are looking at what we can do to further incentivise out-of-hours working, but we would have to do that, as Mr Mackay and I would understand and appreciate, working with the trade unions, working with the staff side representatives in order to ensure that they are comfortable with what is being proposed, so that we are still looking to finalise a lot of the detail on that. The important part, which I think that Mr Mackay touches upon and which I am happy to say more, if we get into this in more detail, is wellbeing. It is important for out-of-hours, but it is important for everybody. I, on my very first visit as health secretary, was in Lanarkshire and I was blown away by the testimony that I was hearing from healthcare workers and I actually asked staff more generally. I spoke to, as you would imagine, I spoke to the portal, I spoke to the cleaning staff, I spoke to the doctors and nurses and everybody in between and they were all telling me the same thing. It does not matter what the job was, they were knackered, they were really, really tired because of the last 18 months. That is why I am investing £8 million in their wellbeing. Some of those are very specialist services, but to provide a whole range of services, I will not go into the detail of it right now, just for a brevity, but there is a whole range of services that are available. If we are going to ask our NHS to help us with recovery, which is vital, then we are going to have to make sure that their wellbeing is absolutely paramount. You do not have to press your microphone, Stephanie. It is done for you. Cabinet secretary, we were speaking earlier just a short while ago when I was mentioning cancer. Has there been any kind of exploration of the idea of lung cancer screening? Clearly, it is the most common cancer and, as far as deprivation goes, it is three times more likely for people to suffer from it. I am just wondering if there has been work done around that, or if there is any intention to carry out any work around that. If it is okay, I can probably pass over to the national clinical director, but Ms Callahan is absolutely right. When it comes to our more challenging pathways to cancer, we look at the most common cancers. We know that the largest preventable illness and cause of preventable death is around smoking and cancers associated with smoking, of course, of which lung cancer is one. However, I am happy if it is okay with your indulgence, convener, to pass over to the national clinical director who may be able to say a little bit more about lung cancer specifically. We have a process by which we decide what to screen for, and that is a screening committee. We have a group who looks at the most recent global data. What is the risk benefit of screening and what form of screening it should take? Is it blood test? Is it an x-ray? Is it a mammogram? What is the mechanism by which you would find the cancers? Presently, that data suggests that you should not do routine population-level lung cancer screening for any particular age group. However, if that changes or that committee sees something or the world sees something that would change that, then, of course, they would do it. There are other places where that screening might happen after a GP makes a specific choice based on symptoms, previous employment and age. All those things are available, but population-level screening is quite a rare thing. We only do it for a small number of cancers at any specific time, because the risk has to outweigh the benefit of doing that at a broad population level. To my knowledge, we are not looking at it in any perfect depth, but I will ask that committee to make sure that I have not missed anything, and I will write to you. I will bring in Paul McKean, who also has a cancer-related question while we are on this topic. Thank you, convener. I think that I am just keen to hear something more in terms of the early centres that we have heard alluded to already, and we know the delays that were there in terms of setting those up. I am keen to understand, because I think that there is a real sense that they add so much value in terms of earlier diagnosis, in terms of opening up new pathways for people who perhaps do not have as clear symptoms. I think that there is a sense that we could really utilise them in every health board area, so I would be keen to understand from the cabinet secretary what the plans are to roll out further, and indeed timescales. I can give Osmond writing that was helpful, but our early cancer diagnostic centres, of course, the first of those, are already open, but it is so important that, when it comes to initiatives such as the early cancer diagnostic centres, we do a proper evaluation of those before we decide to roll them out even further. We have procured an external evaluation with an academic institution, and they will then provide that important monitoring. I hope that positive evaluation has been to the early cancer diagnostic centre in Fife in the Victoria hospital. I was really impressed. It was only open for a few weeks, but it had already detected a number of early cancers and a number of patients already. Although it was only a few weeks and those were small in number, no doubt the impact, not just on the NHS, but on those individuals and their families, would be absolutely great. The first two centres need to be done. We need to get the data, we need to analyse what is happening with them. That evaluation will inform, on an on-going basis, the delivery and roll-out of further centres. What I would say to Mr O'Kane is that the early cancer diagnostic centres are one too. I was also at the centre for sustainable delivery, based at the Golden Jubilee. I should say that, if the committee would like to visit the CFST, they would be more than happy, I am sure, to host you. I would really highly recommend it. They are looking at, for example, a variety of innovative technologies, such as a Cologne capsule, for example, that will help with not just the detection of cancer, but the speed and the comfort of the patient by which that can be done. The ECDCs, the early cancer diagnostic centres, are important, but they are one tool and, among the range of tools that we are hoping to deploy in order to help us, particularly in that diagnostic part of the cancer journey. We know when we look at the 62-day target that it is the diagnostic side that is letting us down in terms of not meeting that target. We are going to move on to questions from colleagues on mental health and open up with Evelyn Tweed. For the record, I am also a councillor at Stirling Council. My questions are around the CAMHS service. I have had a lot of anxious constituents in touch. I am the Stirling constituency, but I know generally that there is a problem across Scotland. Can you give us a flavour of how the recovery plan is going to address that issue? I thank Ms Tweed for what is an important question. I suspect that she is not the only MSP. I suspect that one of us receives difficult cases in our inbox and our advice surgeries from desperate family members when it comes to the criticality of the children's mental health. There are a number of things that I will try to say on this, but I will try to keep them brief. I will go into more detail if Ms Tweed or other members want. First and foremost, we are investing in services that I would say are pre-CAMHS. Before people get to that crisis intervention point, we are investing in a number of interventions that we hope can help at much earlier stage so that CAMHS crisis intervention is not needed. That programme of local interventions is again designed to be suitable for whatever that local need is, so it may be different in Stirling than it would be in Selkirk and in other parts of the country. It is really important that we invest in that. Some of that will include, for example, ensuring that we have the appropriate services in place in schools. I will go into the detail on that, but I am happy to expand on what we have done to ensure that we are getting more and more resources into schools. As Ms Tweed will probably know, we had a CAMHS task force. It gave us evaluation of the service, recommendations within the service and she knows that we are investing quite significantly within the CAMHS service. In fact, we have some of that detail within the NHS recovery plan. One of those will be staff recruitment. We intend to provide funding to increase recruitment to CAMHS by 320 additional mental health workers. That increase in the staff cohort will undoubtedly work. I will be honest. The wait for treatment in CAMHS for me is unacceptable. We are not meeting, as we know, that 90 per cent standard. We weren't, I am afraid, meeting pre-pandemic either, and therefore we have invested additional funding specifically to target CAMHS waiting lists, 29.2 million to NHS boards to improve CAMHS, and 4.25 million of that focused directly on those who are currently on the CAMHS waiting list at the moment. There is a lot more that I could say, but for the sake of brevity, I will hand back to Ms Tweed, who I am sure will have some follow-up questions. I also note that nearly a quarter of CAMHS referrals are rejected. Can you tell us what happens to the children and young people whose referrals are rejected? That has been a long-standing issue that has been raised by a number of people in the last parliamentary session, too. That is why we brought forward an independent group to look in detail at the rejected referrals. Audit was done of rejected referrals. A number of recommendations were made. We accepted all of the recommendations of that group in 2018. We have implemented the CAMHS service specification, so that sets out the standards of service that children and young people should expect and families can expect when it comes to CAMHS and we have funded boards to implement that specification. What I would also say is that, within that specification, it is very clear in black and white that there is a very clear expectation that services should be appropriately re-engaged where necessary. As I mentioned already, we have provided additional funding—about £15 million of funding—to local authorities to deliver locally-based mental health interventions and wellbeing support for five to 24-year-olds in their communities. Those services are linked very closely to CAMHS, so that it can ensure signposting. If an individual is rejected and the referral is rejected by CAMHS, they are not just left to their own devices but signposted to one of those local interventions. Ultimately, those are not decisions for ministers to make in terms of referrals, whether they are accepted or not. Those are important clinical decisions, but I hope that no young person would be left without any support whatsoever, given the mental health challenges that they may be facing. Cabinet Secretary, I should probably have said earlier on that I am a councillor at South Lancer Council. I am also a parent to a autistic child as well. I was wondering specifically just as I have followed from everyone's question about parents with children in the autism spectrum disorder. I know that it is certainly looking at the number of kids that have been turned down from CAMHS. You have got parents who have had a really long time for that referral to come through and there is a lot of hope behind that as well. It can be quite devastating for them when their children are then refused CAMHS support. I know that you have spoken about the audit and lots of things have been implemented there, but I am still hearing the same story from parents. I wonder what assurances you can give the children with autistic spectrum disorders and other additional support needs that we will find suitable pathways to support those children. I thank Ms Callaghan for not just the question but for disclosing how it has affected her personally and other families that she may well know that she has a child that has autism. Can I take that one away, if you do not mind? I would be deeply worried if I was to look into the data in detail, if the amount of referrals that were being rejected was just proportionally affecting children who had autism. If that is happening, that gives me a real level of concern and I would have to look at why that is happening. If you do not mind, I will take that one away. What I will do before I pass back to Ms Callaghan of the convener, I do not want to do anything further that Donna Baill, the director for mental health and mental wellbeing, wishes to add to that. I do not have the data in front of me that sets out the split between neurodevelopmental referrals and other referrals, so we can certainly seek that out. We do have a similar service spec for neurodevelopmental conditions that sets out the same expectations that are in place for broader CAMHS referrals, so I am certainly happy to share that with the committee in due course. Thank you, that would be very helpful. We are now going to move on to questions around health inequalities and Paul King. I think that undoubtedly the pandemic has exacerbated health inequalities and I think that we have all seen both quantitative and qualitative data that shows that. I also think that public health has never been perhaps so in focus for people in Scotland and so sharply understood and perhaps in our homes on a daily basis. As we look further ahead in taking the learning from Covid, I am keen to understand from the cabinet secretary what are the key interventions that he sees as we move beyond Covid into recovery. Would he support, for example, the paper that was released yesterday by the British Heart Foundation and nine other charities looking at non-communicable diseases and suggesting that there must be very quick interventions around things like advertising on e-cigarettes, on how we monitor sugar content in foods and on how we plan better for smoking cessation and obesity services. I think that that is just to get the cabinet secretary's thoughts on those. I will try to give a flavour and then if Mr O'Cain wishes to follow up in more detail on a specific point, I am more than happy to do that. First and foremost, we know, of course, that so many of the health inequalities that our constituents up and down the country face is linked to poverty. That is why the role that the Deputy First Minister has in relation to Covid recovery is so important. He is convening weekly meetings between portfolios, across portfolios where cabinet secretaries and ministers are working closely together. We always have, but in a way that I have extra energy and additional focus on ensuring that we are working cross-portfolio, we are not compartmentalising, we are not working in silos, because ultimately what affects my colleague, the cabinet secretary, for education has an impact on my portfolio, which could end up having an impact on the justice portfolio, for example. We all know the interlinkages that exist from a Government perspective. If I can give any assurance to Mr O'Cain, it is that we are working on those issues of health inequalities across Government in a way that has a real determined focus and that is helped by the role that the DFM plays. We also know that the pandemic has not been felt equally. It would be wrong to say, quote unquote, that we are all in it together, although that has some truth to it. There are some people that undoubtedly have been hit harder, far harder by the pandemic, as opposed to somebody like me who, thank goodness, is in a comfortable position in terms of his health, notwithstanding the challenges at the moment, but with his health and, indeed, comfortable in terms of my financial circumstances, too. We are absolutely focused that, when it comes to recovery, we have to ensure that some of those systemic inequalities that exist in the system are weeded out. How will we do that? The women's health plan is one example of how we are looking to do that. There are 66 actions that are looking to address women's health. We know that women's health in some aspects women face greater inequalities when it comes to their health. We are also, for example, looking to publish very shortly our immediate priorities at a priority plan for race equality. That will go into a level of detail of how we intend to work through the inequalities that exist in our minority communities. We know that BAME communities are often hit harder when it comes to health inequalities and particular health inequalities than the white Scottish counterparts. There is a range of actions that we are taking. He also mentions, rightly, some of the important public health interventions from smoking cessation to obesity plans, particularly in amongst children. Again, I will not go into the detail of it right now, but, if Mr O'Kane wishes me to go into detail, I can do it. However, it is safe to say that my concern has been that, throughout the pandemic, some of the good progress that we have made in around smoking cessation, alcohol and the consumption of alcohol and tackling obesity—some of that, I am afraid—we have not been able to make progress during the pandemic because of the immediacy of dealing with Covid. However, I am very, very keen—not just keen—that we are working hard now to make sure that we are getting refocused back on some of those important public health interventions. I am going to bring in Carol Mocken, who has some questions on this theme. Thank you to the cabinet secretary. I was heartened to hear the response around dealing with the root causes, which is very important in this section. I wanted to ask specifically, following Paul's question, just about childhood obesity and approaches, particularly to young people. Would he agree that it is important that we get those things right early on so that we can look at people having long, healthy lives, and that we do make sure that we target those areas of deprivation to ensure that at least we start off with a fair start in life across all the communities? Again, Ms Mocken gets to the very heart of the issue. I am not surprised, given her experience before she was an MSP and the issues that she has raised in the chamber, that her understanding of the issue clearly has a great understanding of the issue. I am extremely focused on ensuring that we weed out some of those inequalities that have existed in the system before. That might sound quite a challenging thing to say in the middle of a global pandemic, but the pandemic, because we have to be mobilised and rebuilt, presents an opportunity to do that in a way that perhaps we might not have had before. In terms of childhood obesity, we have a very ambitious target, but one that is achievable to have childhood obesity by 2030. We have to do that through a range of actions. We have to make healthy food easier to access for people in areas of highest deprivation. I remember very clearly that when I was on the Public Audit Committee before I was a minister 10 years ago, we were going into the heart of Drumchappel and having a session at the health centre. One of the users of the health centre said to me, look, do not you politicians come and lecture me about healthy eating when I have two or three takeaways right beside me that cost half what would cost me to go to the supermarket to get healthy meal? She was right to put that challenge to us. Now, 10 years, we have managed to make some progress and we have seen some of the effects of that progress, but what I am looking to do is we have commissioned research to understand in a lot more detail how health systems can support pregnant women. We want to do that as early as we possibly can, pre-birth, and to focus on children in the early years. How can we put more interventions in place so that they eat well? We have made £650,000 available to NHS boards and community projects to work with families to prevent childhood obesity. We will invest £3 million this financial year to improve young people's weight management services, but, as I mentioned before, we will work constructively with the UK Government where we can, so they have responsibility for, as you know, TV advertising. I welcome very much their commitment to ban junk food advertisements on TV before the 9pm watershed. I want them to go even further. I want to look at online advertising of less healthy food and drink and how to restrict that as well. In fairness to the UK Government, they are keen to work with devolved administrations on shared issues and agendas. Ms Mock, are you content with that? Would you like to follow-up? No, no follow-up questions on this one, thank you. Stephanie, you had some questions on health and the qualities. I wanted to ask about pre-pandemic childhood ACEs, which were possibly the biggest public health issue that was faced in Scotland, and poverty is a strong reinforcing factor around those ACEs. The evidence tells us that that talks extracts results in health problems that go right into adulthood, so heart attacks, strokes, addiction, even increased cancer rates there as well. Clearly, the impact on the NHS of growing ACEs could be absolutely huge. I wonder how you are looking at having health and social care partnerships, local authorities, public health, all of those people knitting together to bring forward policies that support and prevent a lot of that, and therefore down the line are saving people going to the NHS as well with those issues. The work that has been done on adverse childhood experiences on ACEs is something that we pour over as Government ministers, not just as Cabinet Secretary for Health and Social Care, but I know that my ministerial colleagues and cabinet colleagues that we pour over on a regular basis, but it also informs a lot of the interventions and initiatives that we look to bring forward. It does not just have a health impact, and we are obviously focusing understandably on health, but when I was justice secretary and I looked at those people who were in my prisons and looked at those people who were in our care at employment, it was hardly a surprise and deeply disturbing and regrettable that those in our prison system, the number of ACEs that they had far outweathed the average number of ACEs that may be suffered by the average person out with the prison setting in the population. Adverse childhood experiences have massive health impacts, but it also impacts negative impacts and adverse impacts right across society, let alone other Government priorities. If I can give an assurance to Ms Callaghan that we place a considerable weight on the research and evidence, I know that some of the evidence can be quite controversial. Some people have critiqued the average childhood experiences model, but from a Government perspective, we believe in the general principle that if you could intervene as early as you possibly can, pre-birth, hence why some of the initiatives that I have already mentioned, the baby box giving every child a best start in life, but if we can intervene as early as possible, we know that there is a better chance of reading out some of those inequalities that then undoubtedly go on to have the health impacts and other societal impacts that Ms Callaghan rightly mentioned. That's great. That's really, really good to hear. I suppose that one of the things that's really worrying me the most is the fact that sometimes it's like a big jigsaw that doesn't quite fit together properly, and you're trying to hammer pieces into place. It's really about getting those different organisations to really work together as far as developing policies concerned as well, so that it can work as effectively as possible. That would really be where the focus in my question is. If it gives any comfort to Ms Callaghan, we know that we have extremely regular contacts with those that are on the ground. We know that we can set all the national policy in the world, but we know that local delivery partners are key to what we're trying to do. Hence why our investment is usually focused to local delivery partners, whether that is the NHS board level, whether it's IGPs, whether it's health and social care partnerships, whether it's community-based and third sector organisations that are already doing such good work pre-pandemic, let alone the good work that we've done during the pandemic. If there's any comfort to Ms Callaghan, give him absolute assurance that every single Cabinet Secretary Minister works closely and the Deputy First Minister coordinates a lot of this work with our local delivery partners. Just to pick up on what Paul Cain said earlier about the report that came out yesterday about non-communicable disease prevention priorities from the charities and the British Heart Foundation, prevention of ill health is obviously something that we can be focusing on. We took evidence in the last session about £90 million being spent on complications of type 2 diabetes, so if we can prevent those complications in the first place through social prescribing, perhaps that's a way to help to keep people out of hospital, as well as looking at pulmonary rehabilitation. I'm wondering, Cabinet Secretary, are you going to continue to support wider implementation of pulmonary rehab, and what work will be done looking at social prescribing as a way to help to reduce ill health in the first place? Thank you very much. I should apologise. I didn't answer that part of Mr O'Cain's question. It was not done in any way to try to be abusive. I have seen the report by the British Heart Foundation released yesterday and by a number of other charities on non-communicable diseases. Of course, we will take time to look at the recommendations for anything that comes from the British Heart Foundation and many of the charities that were involved in that report will give considerable weight and attention for me. On the broader issues that Emma Harper mentioned, she has a track record of speaking about issues relating to diabetes and recognising her own personal journey in that regard, so I think that there is probably little for me to say other than I agree with her on that. On the broader issues around social prescribing, there was a recommendation, a committee report, on that in the last session. On the 2020 programme, for government, we included a commitment at that time to establish a short-life working group to examine the provision of social prescribing, physical activity and sport. The group's remit will be to identify and communicate social prescribing examples of best practice and co-produce resources for practitioners as well. The establishment of that group was delayed because of the pandemic, and I hope that that is understandable. However, my officials are currently looking, as we speak, at the best way of taking forward that short-life working group, which will also look at the previous committee's report and recommendations into social prescribing. We will be moving on to technology questions from David Torrance, but I want to check with Emma. Do you want to come back in with a supplementary? Just that I forgot to say that everybody is registering that they have an interest, I am still a registered nurse, I better make sure that that is on the record as well. Now we move on to questions around the technology being used during the pandemic and the future for that with David Torrance. Thank you, convener, and good morning, Cabinet Secretary. In session 5 of the Health and Sport Committee reported on the creation of a national digital platform and the problems around data sharing. With a huge increase in the use of technology, which is around before the pandemic, it was about 1,200 a week consultations, and it is now sitting at 1,200 a week consultations. What progress has been made on the use of a single digital platform and on the problems around data sharing? David Torrance for his question. First and foremost, we have seen the effective deployment of technological solutions throughout the pandemic. We have talked a lot—I am sure that we will continue to talk a lot—about the near me video technology that existed and the number of consultations that are now taking place using that digital technological platform is a positive. It shows that people have confidence in it to practitioners and the patients, too. My observations from being a health secretary—I do not know if I can still say that I am new to posts, but relatively new to the posts—we have still got a fair way to go when it comes to the interoperability of our digital systems. He is right to reference the national digital service that was established in 2018, and that is going to deliver, as he rightly says, the national digital platform. We have always been up front, and that is going to take some time. That is obviously established pre-pandemic. The pandemic has undoubtedly delayed some of that work, but effectively, the aim remains the same. The key aim is interoperability, using different information systems, devices and applications to access information, to make sure that we can integrate it in a way that is co-ordinated. It has to work right across organisations, across regions, across NHS boards and across national boundaries to seamlessly transfer that information and to then optimise the interventions for individuals as best we possibly can. A range of actions have taken place and are taking place. I can go into detail on that if Mr Torrance needs to do so. I can write to committee that it is quite lengthy in terms of what we are doing across the various different systems that exist, but we are making progress, but clearly some of that progress has been affected by the pandemic. Cabinet Secretary, you answered earlier about face-to-face consultations with GPs. Is that guarantee there for any individual who wants a face-to-face consultation with any part of the NHS sector? Ultimately, that is the position that we want to get to, but we have to still remind ourselves that we are in the midst of a global pandemic and that important infection prevention control measures are still in place. GPs are seeing patients face-to-face. We want them to increase the number that they are seeing face-to-face, and that should be at the most need. Ultimately, the short answer to Mr Torrance's question is that we want to get to that position. We also know that, from surveys that have been conducted, more than 80 per cent prefer the digital or telephone appointments with a doctor's work. There are lots of different reasons that might not interfere with our day as much, but for those who prefer face-to-face consultation, we want to get to a position where they have the opportunity to do so. We just have to be mindful that we are still in the midst of a global pandemic and that we still have a very highly transmissible virus that we are still contending with. David, can you be happy with that? My final question is, convener. With the use of new technologies and platforms, Cabinet Secretary, what safeguards are put in place to protect patient data? We know how important this is, understandably so, for customers and patients. Everybody in society, whether you have an app on your phone that gets your Uber Eats or whether it is an app that is linked to a public service such as health, the storage and ethical storage of that data and the security of that data is hugely important. One of the first meetings that I had as Cabinet Secretary for Health was with our cybersecurity team, who had an external consultant who was helping us to work through the issues of security within our NHS systems, and they are doing a detailed amount of work. We have a refreshed digital health and care strategy—sorry, forgive me, we are going to publish a refreshed digital health and care strategy, but that will commit to the development of our first ever dedicated data strategy for health and social care. That will include detailed consideration of how to increase our citizens' trust and transparency in data sharing. How do we unlock the value of health and care data? We are doing that in a way that, of course, data can be safeguarded and to throw transparency over how that data will be used. Security is also very important. Cyber security testing has already been carried out for all of our major systems, including near me. We also know that, when it comes to our Covid certification, particularly because it is a very topical issue, we will ensure that we have up-to-date security provision in place, particularly when the app is ready to go live at the end of this month. Just on the point of data, especially going forward with everything that you have set out, who is responsible, who is the cul-de-court guardian for this data and how I will be ensuring that, if it is doctors and GPs, there is security for that? It depends again on what system we are talking about, but we comply with all the regulations and statute. Ultimately, we will be accountable to the information commissioner as an office in relation to how we use that data, and that is exceptionally important. Depending on the system, it will depend on who the data controller is. If it gives Dr Goharry any comfort, there is already regular engagement with the information commissioner's office when it comes to the development and introduction of any new system. I would say that we are already working—our cyber centre of excellence is already working hand in glove with practitioners on the ground when it comes to the development of current systems, but also the current systems that we have. I am sure—I do not need to tell Dr Goharry, of course—that he will be well aware in the other role that he has in primary care, that our practitioners on the ground are usually well aware of their responsibilities in relation to the handling of data. However, if there is anything more that we need to do in that respect, particularly with the development of new systems, I am more than happy to take any suggestions. Thank you. We were scheduled to finish around a bit now, but with everyone's approval, we have still got women's health to cover, which is a very important topic. We should be finishing in about 15 minutes, but I really want to give this an ending—not least declare that I was on the CPG for women's health, which is called for women's health plans, so I am very pleased that that is now in the programme for government. I have a number of people wanting to ask questions on the women's health plan, and I will go first of all to Gillian Mackay. Thank you. I was just looking to find out when we will see an implementation plan for the women's health plan, and will it include specific timescales for things coming forward? If it helps you at all, I am entirely your behest, but I can stay on an extra half hour to have a living, but I know that you have other committee business that you need to get on with, so my time is not constrained. I am happy to stay in front of committee for as long as is necessary. In terms of the women's health plan—I apologise, my daughters managed to drop my crutches—we have within the health plan implementation goals, both in terms of the short, the medium and the long term. The 66 action is set out there. Delivery in the short term means that within one year, medium term, we look at about one to three years timescale, and in the long term, we mean three years or more. We have an implementation board, or we plan to bring forward an implementation board, and that is going to be really key because I think that all of us can recognise that a strategy is only as good as an implementation. Writing the strategy can be the easy part, often, but making sure that we have implementation of that strategy is going to be right to us. We have an implementation board that we will take forward. It will look at key milestones and measures of success, and we hope that the implementation board will meet before the end of this year, and its implementation plan will be finalised by spring 2020 to forgive the interjection. I hope that I give some reassurance to Ms Mackay that, if she needs more information, then, of course, I am happy to provide it in writing. It is lovely to hear that your daughter is cheering on the idea of a woman's health plan. Gillian, do you have any follow-up questions? Cabinet Secretary, I am very interested in the idea of a focus on menopause, health around menopause. One of the recommendations in the women's health plan is having specialist clinics for menopause. I would like to ask for more detail on that. Obviously, the women's health plan has only been out for a couple of weeks, but what provisions are proposed around having those specialist centres for women who have that more complex type of menopause? Cabinet Secretary. Thank you very much, convener. I recognise the role that you have played in relation to the women's health plan. Getting us to this point, I know that you have felt like there has been a bit of a lone voice. I know that you have spoken about this for many, many years, but I am really pleased that it has entered the mainstream consciousness, and that is why our women's health plan is so important. I think that it is really critical that the implementation of the strategy on how the implementation board will ensure that key milestones and successes are made. What we are doing is already working at local health board level, because, again, you can have a strategy at national level. If it is not there at local level, it will not be delivered. I think that the key to this will be the women's health champion. As we have said, every single health board will have that women's health champion in place. It will drive forward that strategic change at a local level. It will promote that women's health plan where it is needed. It will support a network of local women's health experts and leaders. When it comes to a national women's health champion, it will hopefully appoint somebody into that role next year. What we will also do at the moment is to make sure that we have those local structures in place. What will work in one part of the country in terms of a specific menopause clinic might be different to what will work in an urban setting versus a rural setting, for example. We want to leave that largely in terms of what a menopause clinic should look like to local health boards, but we are going to have somebody specified in a health board level to drive that change forward to make sure that it is happening at a local delivery level. Is the idea to reach out to the wider public who might have been through a health care system with regard to menopause and getting public consultation and feeding back what that plan should look like? Ideally, that would be the best way to do it. We know that getting people with lived experience co-designing, not just our policies but our services are so important, and we know from your involvement that the women's health plan had co-design at its heart from women with lived experience. A whole range of aspects—menopause, of course, periods, endometrosis and a number of other aspects of that women's health plan—were informed by women who had lived experience of those conditions. For me, that is ultimately the best way to develop those clinics in terms of menopause, specifically by hearing from those women who suffer some of the more challenging effects of menopause to make sure that the service is built around them. There is no point in building the service and the structure and then fitting people into it. It is much better to hear from the people and devise the system that is built around them. I recently spoke in a debate about women's health, particularly my own journey with endometrosis. It was wonderful to hear from so many women across Scotland that they welcome the Government's plans for how we will take that forward. Can the cabinet secretary give more detail about how we are going to reduce diagnosis times? Women are very interested in that. I thank Ms Tweed for the fact that she has spoken again about her own experiences. I do not take it lightly when people share their own health experiences. It is a difficult thing to do, particularly standing in a parliamentary chamber and doing so. Our women's health plan goes into detail on how we will do that, but what I would say to Ms Tweed is that the best thing that I can do is give her detail of what the implementation board will seek to do, because the implementation of those actions will be different in different local health board areas. One size does not always fit all, so there are different pathways into referrals. We know that the diagnostic side of endometrosis is something that we have to concentrate on. There will be funding available in relation to that and investment accompanying the women's health plan. However, the implementation board will be vital to that. It will ultimately decide what is the best way to implement each of the actions. I can promise you that some of them will be short-term actions, but equally some of them will be more medium to long-term actions as well. I cannot wave a magic wand to help overnight. I know that that is not the expectation, but we will take forward, particularly when it comes to endometrosis, some of those actions at speed, because we know just how much women suffer and how there are still challenges around the diagnostic. I am happy to write in more detail on the implementation of the women's health plan to give more detail to Mr Feed, but particularly if I can do that in a time when we have a little bit more detail around the implementation board. Thank you very much for that. Of course, we will be coming back to the women's health plan in detail as well, but that would be very helpful. Evelyn, do you have any follow-up questions on that, or would you? No, that is me. Thank you. Can I come to Emma Harper, who also has some questions around the plan? Thanks, convener. It could be part of a further response to Evelyn Tweed's question as well. The cervical cancer self-screening research that is happening right now is really, really interesting. I got involved because NHS De Fries and Galloway was taking forward self-sampling in order to capture the 6,000 women who had defaulted on their cervical smear test. I would be interested in an update about how the research is progressing, and are we likely to see a roll-out of self-screening for cervical cancer, particularly in Scotland? I would be interested in hearing an update. I do not have it to hand, but I will get an update on that research and, of course, write to committee. My concern in and around cervical screening has been around some of the issues. My colleague, Marie Todd, updated the Parliament about the end of last year, before summer recess. Of course, she will provide a further update shortly to Parliament, too. My concern is that we do not allow those issues, as absolutely unfortunate and regrettable as they are, not to take away from the importance of women coming forward for cervical screening. We know the effect that the positive impact that a cervical screening programme has had on detecting cervical screening early, being able to treat it early and then having a more positive outcome. I do not want those issues to track the way from the absolute positive benefits of that screening programme. Forgive me, Ms Harper, but I do not have the most up-to-date analysis back from that research, which is still being undertaken. However, when we have an update, I am happy to write to committee. I will, of course, read that to committee members once we have that update. Thank you very much. I have a quick, brief question following Evelyn Tweed's around diagnosis and the amount of time for women to be diagnosed with endometriosis. Also, women speak to me about the fact that it has been a long journey for that, and clinicians acknowledge that they perhaps do not have the expertise. Just to put forward, I am sure that it will be part of the plan, but it is very important that we share expertise across the different clinicians and where necessary training is available on those issues that have been raised by the women themselves. I agree, and I should have said in my response to Ms Tweed's question that one of the actions in the plan is to commission endometriosis research, because Ms Walker is absolutely right that there are a number of people still out of its clinicians and women themselves who want to know more about that condition, understand that condition. Research is there to develop better treatment and management, and we are, hopefully, a cure too. We are commissioning that research, and that is one of the actions that is part of the women's health plan, if that gives any comfort to Ms Mocken. That rounds off the women's health plan, but Annie Wells has a final question for you, cabinet secretary, on health and wellbeing of staff. Thank you very much, convener, and thanks for the opportunity to ask that question. The cabinet secretary rightly started off the session by praising and thanking our front-line NHS and social care staff, which I think that everyone across Scotland would agree with you, but he also mentioned the term that they were knackered. I do not think that that is just a physical health issue, but that is also mental health and wellbeing. I would like to ask the cabinet secretary what was already in place to support pandemic-related mental health and wellbeing issues for our NHS and social care staff, and will staff have protected time to use the wellbeing support that is available? Thank you, Ms Wells, for the question that she is right. It is not just about physical health, it is absolutely about mental health. I remember quite vividly a conversation with quite a senior nurse at a visit to a hospital. She was in the high dependency unit. As somebody who is not a clinician, I had made the wrong assumption that somebody of her seniority and nursing level has seen, unfortunately, a number of people pass away, but because that high dependency unit was overwhelmed at the beginning of the pandemic, there were so many people coming to it, the amount of death that she saw during the beginning of the pandemic was more than she had seen in her entire career. She said that it had a huge mental health impact, and maybe I was taking the obvious, but it is just something that had not registered with me as a non-clinician. It is also a huge mental health impact that is happening entirely with Ms Wells' assessment. What we are doing about it is £8 million going into wellbeing. That includes a range of initiatives. We have the 24-7 national wellbeing helpline, the national wellbeing hub, the coaching for wellbeing and the workforce specialist service. All those resources are being used and used well. We know that the national wellbeing hub has been used over 115,000 times by health and care staff, and we know that the workforce specialist service is being used as well. I am open to that discussion. I am more than happy to take that away with not just health boards but our trade unions and our staff side representatives. I am certainly open-minded to it. It would come with some challenges, given the current pressures that we have all spoken about on the health service. It is key that, if we want to recover our NHS, the staff wellbeing has to be at the heart of it. I know that the additional funding that we gave to support primary care and social care workforce was to secure time for reflection and recovery to meet their identified needs. That funding can also be used for local cover and for backfilling costs. The broader issue of protected time for wellbeing, I am more than happy to look at what more we can do in that regard. Thank you, cabinet secretary. We have come to the end of our questions. I want to thank you for your time this morning and also for Ms Lam, Professor Leitch and Ms Bell's time, too. We will, of course, look forward to seeing you again for more updates on a lot of things that you have mentioned today. Before I let you go, is there anything else that you might want to say to the committee in terms of your priorities going forward? No, thank you, convener. There are a couple of issues that have been touched upon, which you might be following up with other ministerial colleagues. For example, when it comes to the national mission in terms of tackling drugs deaths, that is also a clear priority. For me, Ms Constance, my ministerial colleague, is taking forward that work. However, to give you committee an assurance, I know how important it is to every member of the committee that she and I are working extremely, extremely closely on. If you want me to come back to committee, or Ms Constance, I am sure that she will come to committee to talk about that issue, but I just wanted to give you an assurance from a cabinet secretary perspective that I am working hard on that. I am more than happy to say, convener, that if you want me to come back to committee, even at a particularly short notice, given the nature of the pandemic in which we are dealing with, things can move extremely quickly. I will make myself available to committee whenever is suitable for you. We have Ms Constance coming in next week, so we look forward to asking her particular questions on that. Again, thank you for your time this morning. We will move on to our next item in the agenda. The third item in our agenda is consideration of subordinate legislation, and it is two negative instruments. The first instrument is the national health service, travelling expenses and remission of charges in Scotland, number two amendment regulations 21, and that is SSI 2021 oblique 241. This instrument amends the national health service, travelling expenses and remission of charges in Scotland number two regulations of 2003, SSI 2003 oblique 460, to make free dental care available to people aged between 18 and 25 years. The second instrument is the milk and healthy snacks scheme, Scotland amendment number two regulations 2021, SSI 2021 oblique 274. This instrument amends the milk and healthy snacks scheme, Scotland regulations 2021, SSI 2021 oblique 82. Its aim is to clarify and address technical issues to the operation of the milk and healthy snacks scheme. The Delegated Powers and Law Reform Committee has considered the two instruments, and both instruments were reported under reporting ground J, fully to comply with the 28-day laying period, but that is all that they have mentioned in relation to these negative instruments. No motions to annul have been received in relation to these instruments, so I would ask members if they have any comments to make on either of these instruments. Emma Harper I just wanted to highlight or have a question. The instruments breached because of Covid. Is that right? The laying of the instruments found to be a breach under section 28 number two of interpretation and legislative reform. It is basically because of Covid that the breach was passed. That is correct. It was due to the pandemic. Any other comments or questions? I propose therefore that the committee does not make any recommendations in relation to these negative instruments. Does any member disagree with that? We have full agreement. At our next meeting on 14 September, the committee will hear from the Minister for Drugs Policy, Angela Constance, on her priorities for session 6, but that concludes the public part of our meeting today. Thank you.