 Good morning and welcome to the 17th meeting of the Health, Social Care and Sport Committee in 2023. I've received apologies from Paul Sweeney and from Emma Harper MSP and we're joined remotely by James Dornan MSP. Agenda item 1 is business and private. This is for the committee to decide whether to take item 3 in private. Are members agreed? Thank you very much. Agenda item 2 is follow-up scrutiny of the complex mesh surgical service. For this morning's session, I welcome Jenny Minto, minister for public health and women's health and Greg Chalmers, head of the chief medical officer's policy division from the Scottish government. We are going to move straight into questions. Minister, there are plans to create a single patient leaflet available to women at the point of referral to the service. Why is that leaflet not already being designed, given the length of time that the service has been in operation? How will the leaflet clearly explain the various elements of their whole referral and treatment journey, whether they opt for surgery in service or NHS England or with a private provider? First of all, I'd like to thank the convener and the committee for inviting me along and also recognising the quite traumatic experiences that women have experienced as a result of the transvaginal mesh surgery. I think that what's really clear is when we have started setting up the surgery system for women who have been impacted, that we wanted to design the processes with those women in mind and ensure that we did the right thing for them. There has been a lot of discussion and surveys done with women impacted to find out how they feel that the service should be operating. I think that taking that learning on board has been incredibly important. There is some advice on the NHS-informed website, but I think that bringing out pamphlet literature to support women is incredibly important. We have listened to the women to ensure that that contains the right information, whether it's the pathways for the referral system within the Greater Glasgow and Clyde service or whether it's the independent service. I'm pleased that we have listened to the women and are able to provide them with the information that they have specifically highlighted as needing. In terms of that leaflet, can you give us some timescales around when that will be available to women? I'm afraid that I can't, but Greg Thomas may be. Just to say, convener, you're quite right as Dr Mailer has confirmed in his note to you, which I saw just this morning. We have been developing a patient information leaflet. We don't have a date specifically when it will be available, but we will seek to confirm that with the GCC after today. As you no doubt know, when women attend the service, they are provided with a range of information specifically about their surgery, but also about the range of other conditions that a patient might be relevant to a patient, as well as receiving a telephone call beforehand from a psychologist. I'm sure that the GCC would say that if there were a valid point about continuing to improve that information. However, it is one part of a number of things that GCC have done, including, of course, keeping on improving the website. Thank you Minister for joining us. Minister, when did the bill get passed? The bill was passed in 2021-22. Between the time that it took to come into force and all the planning that went into it, and now, why is there not a clear pathway for women to get referred into the service? Why is there confusion? My understanding is that there is a clear pathway. I was on the NHS informed website and saw it this morning. I have a copy of it here, which is described as the complex meth surgical service pathway, which I would be very happy to submit after this evidence session to the committee. We heard from a number of people and we're hearing that there's direct referrals from GPs. We're hearing that it's a secondary care referral pathway, so if people who are coming to us aren't being absolutely explicit, how do we expect other people to know what the pathway is and the way to follow it? Thank you for that question. If I recall the evidence that you received two weeks ago indicated that the pathway was clearly laid out, that there was an electronic referral to the GCC complex mesh surgical service, and that was the clear pathway that has been introduced. However, I think that Greg Chalmers would like to come in. Yeah, yeah, just on the matter of the act. Now, I suppose that it's important in this discussion of course to try not to conflate the two things, a number of things that are going on. The mesh removal act 2022, which was, I think, gained royal assent in January or a slightly later from recollection, that's about the reimbursement of already entered into private expenditure for women that have got, went for mesh removal surgery generally in the United States but also in Bristol, so that's a separate process from the commissioning of independent surgery through the NHS now and obviously from the NHS service in Greater Glasgow and Clyde. After the 2022 act was passed, as the committee may well know, we published the administrative scheme that underpins the 2022 act and there is an information leaflet available through NSS, who administered the scheme on our behalf. So that's separate from the data of royal assent. But when you are thinking of a reimbursement scheme and we are talking about pathways for women who have suffered and are struggling, these all go hand in hand. The thought of what to do with the women who are struggling in pain unable to get the help they require is something that I was under the impression that the government was looking at during the bill and the act that was passed. So that's why the question was framed in that manner and so my final question on the referral pathway, can you tell me, is it possible for a GP to directly refer into this pathway? So my understanding is that the GP refers to their local health board which then refer to the complex mesh surgical service, which was managed by NSS and Greater Glasgow and Clyde. Thank you. I'm going to move now to Tess White. He's got questions on this theme and Tess is joining us remotely. Thank you, convener. Two questions, if I may minister. The first question is, we've heard that one mesh injured woman has debilitating pain and she's been waiting for 82 weeks for an urgent referral. So what guidance is being given to health boards to manage women with mass infections? Tess White, for her question. It is clear that what NSS have been doing is sending out information to health boards and each health board has got a person, an individual who has been tasked with the responsibility for ensuring that that health board area understands the complex mesh service. I'm sorry, and Greg Trammer's would like to add to that. If I could just say at this point, we hope to be joined this morning by our clinical advisor Dr Terry O'Kelly. Unfortunately, he was taken rather ill last week, so I should apologise if there's explicitly clinical things that we're at this morning that we're not able to answer or if that happens, we'll take that away, but hopefully we'll be able to be as helpful as possible. To come to Ms White's question, we are aware of, as you'd imagine in the government, we do become aware of particular cases from time to time, and I think we are aware of the situation to which the member refers. It is the case that the individual that the member is referring to has been contacted by their health board, and they are following up as a matter of urgency and have arranged for a telephone appointment to take place with the consultant. Obviously, that period of time of wait will be profoundly distressing and difficult for the individual involved. That would not be disputed—of course it would not be disputed—by the Government. In general, GGC, in the specialist mesh centre, is taking steps to reduce the waiting times from a position that I think all involved acknowledges does not require improvement. However, as the situation has developed and the service has been improved progressively, we are now in a situation in which, as Dr Lamont and Dr Maylor said on 2 May, we are closer to the point where the gap between referral for surgery at the centre and the surgery taking place is getting closer and closer to 12 weeks, which is still a significant wait for the person involved, but, hopefully, marks a degree of improvement over the time since the service was established. Ms White, we missed the beginning of that question. I appreciate that you accept that H2 weeks are not acceptable, but what guidance is being given to health boards to manage women with mesh complications? In response to that, I would refer back to my earlier answer with regard to the responsible officers within each of the health boards, which there is direct contact with from NSS and the complex mesh surgical service. That was my first question, minister. My second question is, when we had the meeting, the committee had the meeting on 2 May, there was significant confusion about the referral pathway, so this is one thing that I would like to clear up today, if I may. What work is being done to ensure that the health boards follow the same referral pathways when mesh is identified as a factor? Thank you, Tess White, for that question, which was along the same lines as your colleague Dr Gilhannys. I have referenced the complex mesh surgical service pathway, which I have offered to send to the group. I was aware of the evidence that you received on 2 May. However, I felt that it was clarified in that session that it is required that it is an electronic referral from the health board to the service, and I think that that was made clear by Dr Mather. The complex mesh surgical service pathway will be sent to the committee, so you have sight of that. Thank you, convener. I just want to be clear on some of the points that you made. From parliamentary questions, we know that from outpatient appointments, the medium waiting time between referral and appointment at the complex mesh surgical service in Glasgow is 236 days, and the longest waiting time is 448 days. I just want some clarity from the minister on exactly how you have been approaching that with the health board. It is absolutely unacceptable, and, as members have indicated, that is a long-standing commitment to women. So what discussion have you had with the health board and what reassurances do you have for those women that we can get those appointment times closer? I agree. Waiting times of that length must be incredibly difficult for the women waiting for the referral and waiting for the discussions to find out what is their best pathway, the best course of action that they can be offered, and what is a very debilitating and pretty awful situation to find them in. My officials are in regular correspondence and meetings with the health boards and NSS to ensure that everyone is across the pathways, understands the need to ensure that this is done with the patient at the centre of it, which I think is the way that we would hope to achieve any improvement in waiting lists. As Greg Chalmers has indicated earlier, the whole system has been improved having listened to those who are waiting to try and improve their experiences while they are waiting, so we have introduced a waiting plan as well. In my role with women's health, I am looking to see how that can be connected into the women's health plan as well. I suppose that people will want to hear very practical things like, will there be any extra clinic times, will there be any extra resources, will there be any extra nurses to give out that kind of advice? I know that you might not be able to answer that just now, but it would be helpful for the committee to know those kinds of things for women. I think that the member makes a very reasonable point about the range of points at which patients will be interested to see how the service is developing. As members know, the service has developed quite significantly in the period since it was established in 2020. It has got a wider range, as Dr O'Kelly and Dr Maylis were saying a week before last. Psychologists, physiotherapists, as well as the clinical and nursing staff. In terms of the direct question, we in the Government have a relationship directly through National Service Scotland, who commissioned the service. They do that commissioning through a service-level agreement, which was originally for two years and will be renewed shortly. It is through that instrument that the Government will seek to work in co-operatively with GCC, continue to seek improvements in all the issues of waiting. I think that it is reasonable to say that improvement has taken place in terms of waiting times, but clearly there is still more to do. That is something that the minister and we as her team will be seeking to do together with NSS. If it is helpful to the committee, we can provide that service-level agreement when it is renewed, because that will hopefully be useful to see the types of measures, metrics and plans that GCC has in place, some of which they explained to you a couple of weeks ago, to continue that improvement. Just saying what you were speaking about there, Greg, you were saying that systems have developed quite significantly since 2020, and I certainly agree with that. However, women are still finding that things are confusing, misleading and inadequate. They have certainly described it as in the past there, and it is not the one-stop shop that they really expected that to be. Is there a place for the National Service to devise national guidance on managing those symptoms locally, particularly while women are waiting for a long pace for appointments? I think that Stephanie Callaghan brings to the table a really important idea. For any women approaching any healthcare, a one-stop shop helps, because we have incredibly full lives. If we can get all the information in one place, that is helpful. I think that we have great learning from other areas in the women's health plan, and it is very important that we have fantastic information from the women that have been through the centre and to make decisions as to whether they go for surgery to reverse, or whether they decide on choosing the more conservative, less surgical ways forward. To enable women to make the best informed choices with regard to that, we have a responsibility to make that as clear, open and helpful to them so that they can make the best decisions. As I said earlier, with the women's health plan, we need to look at that. Greg and I have had some conversations about how we integrate that as well. Briefly, in terms of both an integrated service at GGC, but also joining up the different parts of the healthcare system, which the committee talked about on 2 May, I think that what we have tried to do with GGC, with NSS, with the accountable officers is to see how that chain of information and guidance is working as best as it can. For example, on the committee's previous session, Dr Kelly mentioned that we were in the final stages of putting together a using an existing package of training for GPs. Conscious of the number of things that GPs will have to look at, but hopefully that will be of use in increasing awareness. We have alluded a number of times this morning already to the accountable officers. I emphasise that that group is not just an email distribution list. It is a place where the accountable officers come together regularly, share experiences, of course, and share thoughts about how to communicate with their primary care networks and other people. Hopefully, what we are seeking to do is to join up national with boards and primary care networks with GPs, trying to disseminate the best possible information to share it around so that GPs, when meeting a patient with relevant symptoms, is attuned to what they are likely to say. Hopefully, the websites that we have put in place, the information leaflets that we have put in place, are all good and positive. However, we come to this issue in a spirit of knowing that we have made some improvements and that there are still steps to be taken. I appreciate that the website has been updated recently as well. A number of things have shown improvement. I hope that that will be pushed and that it will continue to move at pace. Just to ask a slightly different question there as well, I am interested in data capture. I am not quite sure if there is a definitive record of how many women are affected by transvaginal mesh and if there is a comprehensive system in place for data capture and if that is spread right across the way if it is being effectively collated. I will hand that over to Greg, because he has been involved in this for much longer than I have. However, if I may, on your last point, talking about, as Greg indicated, the GP training, I think that when Dr O' Kelly was with you two weeks ago, he also talked about work that is happening with NHS England as well. There is a four nations approach to this, and so there has been a lot of work done to try and connect NHS Scotland's support for the GP training with that that it is available in England. I think that that is really positive for women as well, because it is looking at how we can get the best resources to support women and the GPs able to support their patients. I know that some of my colleagues have some big questions in GP's litter on there. I will try to get as brief as possible. On the matter of information, there are two things in our minds here. In terms of the performance of the service, the specialist service, the number of referrals, the number of surgeries and waiting times. I hope that that information, as the minister has already alluded to, is already available and will continue to be available and will be addressed in the service level agreement in terms of the expectations that I mentioned earlier to Ms Mocken. On the matter of the future, we have a number of health boards developing a pelvic floor registry with information about relevant procedures that are undertaken in health boards and the types of devices that are used. That is one of the ways in which the Government has been trying to respond positively to the Cumbul's report and its recommendations. We have been working with the other three countries in the UK on the development of clinical outcome registries, and work on that continues. Within NHS Scotland, we have been continuing to develop our scan for safety programme. Dr Kelly will be useful to describe it correctly, but I will try to specify the types of implantables that the implantation will be recorded and linked to patients and clinicians. The circumstances that gave rise to the situation are seeking for the future to put in place systems that will more quickly detect when that is beginning to happen, so that clinicians can respond appropriately. Continuing on the theme of communication and information, I will bring in David Torrance. Thank you, convener. Good morning, minister. Good morning, Mr Chalmers. In evidence to the committee, Dr O'Kelly acknowledged that communication and information could be better improved. Minister, why is the website for national service still working progress, considering that it has been running for a number of years, and why is there no direct hyperlink from NHS website to website for complex mesh surgical services? I refer back to earlier questions. It is important that we get the website right, we get the support for the women who are in this situation right. Currently, the website has got a good amount of information in it. Could it be improved? Yes. I think that there is an argument that a lot of websites could be improved to ensure that people are getting the right information and the right support from them. I think that it is a piece of work that has been continuing in parallel to ensure that the actual experience that women, when they are referred, get the best service as well. The improvement, the moving to the new Victoria hospital and the welcoming and the support and the environment there has been improved. Everything depends on priorities and resources. It is right that some of that priority has gone towards the actual location where women are first given their support in situ. I take on board that the website needs to be improved. We were just talking about the hyperlink yesterday. I would have expected quite a quick win to be able to have that hyperlink into the service. Therefore, as soon as you go on to the NHS inform website or the NSS website, you get directly to the service that you are looking for. Minister, what more work is required to be done for women following the NHS route with communication to their GPs around appointments, surgery, follow-up treatment? Is the standard letter enough or can that be improved? To be fair, a lot of services around that could be improved. That is what we are learning from the women who have experienced the situation. That is why I know that a lot of listening has happened because I appreciate that women did not feel at the start that they were being listened to. Support them even more. Listening has been key. If anyone has experienced surgery, then the best information that they can get is as much information as can be given. Sometimes a simple letter is not enough, which is why there has been an increase or they have introduced phone calls for women after surgery. That is incredibly important because I know that I suffered some surgery and the first 24 hours after surgery, you are really not taking on board what people are saying. I think that ways that can be found to keep the women more informed and their families as well. That is important because that is where their main support will be once they have left the hospital environment. I think that there can be improvements and I hope that that will happen. As we have talked about the accountable officers in the health boards and the additional information to the GPs, we should provide that level of support that women rightly should be expecting. David Torrance was asking you about the website. I believe that he said that the website needs to be improved. I went into Google and put in NHS GCC complex mesh and the hyperlink comes up. It says that it seems that we cannot find what you are looking for. There is nothing. Dr Gilhane, that was exactly part of my comments yesterday because when I did the same thing, so that is something that we have taken away and we will find out why that is the situation. I will move to Evelyn Tweed. My question is about preventative guidance for women and girls. Obviously, stress, urinary and consciousness are a huge issue. I was lucky enough when I had my children that I was giving guidance immediately about pelvic floor exercises, what to do after having a baby, et cetera, but do we need to standardise what information is given to women and girls and should it start in schools and be disseminated across to make sure that everyone knows what to do? I thank Evelyn Tweed for that question. I sadly didn't get the same training as you got. I haven't got children, but I absolutely recognise the conditions and the results of that. In primary school, secondary school and different exercises, I think that that would be a really strong way forward. I know that Emma Harper in the evidence session on 2 May raised that concern as well. Through the women's health group on their websites, they are about to launch, hopefully this summer, some short animations and support to help women understand the importance of doing muscles for their pelvic area. That is a really positive way forward. It reflects the importance of having the women's health plan, which can react and respond positively when there is a specific need that women can see. I would love to see yoga teachers or Pilates teachers coming into school to give women support. That is a good suggestion from Ms Tweed. Is there any sort of programme considered for schools to talk about this to girls from an earlier age before they even think about having children, et cetera? Thank you for that question. Either this week or early next week, I have got a meeting with Natalie Dawn, who is the minister for young people. This will be one of the things that we can talk about at that meeting to see what solutions we might be able to put into place. I am aware, minister, that the women's health champion has been recently appointed. I absolutely appreciate why menopause, heart disease in women and endometriosis have been prioritised within her role and the very important areas that the Scottish Government is working on. I would be keen to hear from yourself about how you see the women's health champion's role within promoting good pelvic health, if I can put it that way, in terms of education that Evelyn Tweed spoke about. I would also be keen to hear about the Government's plans for reviewing the incontinence strategy. I thank the convener for that question. I was very pleased to meet Professor Anna Glaesior very early on after being appointed. Her skills and her personality really embed exactly what women would like to see in their health champion. As you indicated, we have prioritised on menopause and endometriosis. I will have further discussions with the women's health team on how we expand on those. It is important to say that Anna Glaesior is the champion, but I have a group of officers who are working further on the plan. Greg leads the group specifically on that. I think that we have a lot to do. I was saying in a meeting last week that, until we can say health without having to put women's health beforehand, we have got a long way to go. I am confident that Professor Glaesior's leadership and the wealth of groups of women who want to get involved in women's health and who want to increase it to the headlines, I suppose. It can only be welcomed. If I may, the incontinence plan, I am afraid that I have not got any information on it. I think that I will have to undertake to come back to you on that in writing, but we will. My apologies. No, I think that that would be really helpful, given that we obviously want to move to a preventative strategy as opposed to treatment. Given women and girls, the information that they need about looking after their pelvic floor, I think that that is really important for the committee to hear. I am going to move to Stephanie Callaghan. Thanks very much, convener. I couldn't agree more when we were talking about stress during the incontinence. It is something that is often very, very treatable and a lot of women think that they just have to love with it, so I would love to see something like that come along into our schools as well. However, my question is about peer support. I am wondering if the minister would recognise that there is perhaps a need for formal mechanisms to provide peer support. I know that, certainly, there are the Scottish mesh survivors, but a lobby group is not what every woman wants to be involved in. I am wondering if there is a need for that and that is something that is formalised in other countries. Is that something that you will be looking at? Thanks, Stephanie Callaghan, for the question. If I am being honest, it is not something that I have specifically looked at with regard to mesh survivors. However, I have experienced some really positive experiences of groups together, so we indicated earlier, we talked earlier about menopause, and I think that there has been amazing support groups, even since my own football club has created a menopause chat group. I would like to see that happening. I would also suggest that the other way of doing that is through third sector organisations. As an MSP, I have quite regular conversations with the chief officer of Argyllun but Health and Social Care partnership, and it is talking with them about how they are supporting women's health in that health board area and thinking about what connections they can make with the third sector interface or other women's health groups that they can support. I am interested in looking at that, because I have seen great success of self-help groups in other areas. To put it on the record, I am aware that our colleague Emma Harper is not with us today, but she has suggested that the possibility of something like a Maggie's Centre might be a great idea going forward. I will put that on your radar, minister. I am interested in the link with the GPs. It is such an important part, and it must be perhaps the first port of contact. Women have found that quite difficult. For two reasons, of course, we know that GPs are under enormous stress. I would be interested to know what is out there to help GPs in that setting around the transvaginal mesh, but what was brought up to us in our last session is this important point about records and medical records. Why are GPs unable to easily ascertain whether women have had mesh implanted? Do we have an understanding of how we might resolve that issue? Do GPs get good information about symptoms? Some of the women have reported that they have gone with the symptoms of this to their GP and they have been unaware or it has been delayed in getting a diagnosis and a referral. I have read some of the reports from women that really struggled to explain and be listened to by their GPs in the years leading up to 2015, when it was really given front-page billing in media reports. I cannot imagine how frustrating that must have been to the women. I think that the work that has been done in Scotland and the work that this Parliament has done across party has really helped to improve everyone's knowledge of the impact of vaginal mesh on women. I think that, as I indicated earlier, the fact that we have set up this specialist service and specialist services are being set up in NHS England as well and there are also options to go abroad, I think that that is really helpful. I also indicated earlier in a supplementary answer to Stephanie Callaghan about the training that NHS England for GPs has created and the importance of the work that Dr O'Kelley is doing to ensure that Scottish GPs can access. That is absolutely key to getting it right, but I also refer back to the individuals on each of the health boards that are there to support. Greg, can you cover the medical records? Of course, yes. The committee discussed that on the second. I might refer back to what I mentioned earlier, which is the development of the pelvic floor registry, which is being trialled within four health boards, which will allow for the recording of all treatments for pelvic organ prolapse and stress urinary inconstants, as well as mesh removal procedures. I think that that is hopefully, we hope, an important development in this area, because, as the member says, the ability for clinicians, GPs and others under significant pressure on a daily basis, is the ability to access quality information quickly about particular procedures for a patient involving particular NHS settings and particular devices. The ability to get to that information quickly in a way that does not involve sending away for records is a potentially powerful improvement that we can progress in the coming years. We are working on that at the moment with four health boards, and that is part of that wider scan for safety, which is not for me to talk about legacy or anything like that, but what we are trying to do positively through understanding and hopefully improving the situation that has impacted on so many people. We have more and more occasions where more and more NHS staff and GPs and others are able to access information that can be that warning signal in advance. It is for the individual patient but also at the system level so that a number of incidents occurring in a number of places become obvious much more quickly. If we can make that improvement through scan for safety, that will be an important change, an important improvement. I will come back briefly, just because it has been mentioned to us about learning the lessons from this and about having easy-to-access registry systems. In other areas such as hernia mesh devices, whether the Government has considered that we should have that easy access style for those things so that GPs can get information, I do not know that it is just that other people have raised it with us in the past. At the moment, I will confirm this in writing because I think that I am getting into the clinical area where I should be careful. I do not think that it is the case that the pelvic floor registry is touching upon hernia mesh, but I commit to confirming that in writing later. As a practising GP, I can tell you that access to records is shocking. It is not good enough to say that we are going to create a new system and that GPs might be able to access that because I already log into three different systems and it takes forever to go searching for things. How is the new system that you are creating going to be linked in to what already exists in GP records? Let me be straightforward to the member and say that I do not know the operational detail of that, but it is something that is under development and we will be very happy to speak with the health boards involved. As I say, we have four health boards involved in the pilot, and it makes a very important point that, when we develop new systems, the integration with what is already there is clearly a critical success factor. I suppose that what I am doing is agreeing with you. That is clearly something that the pilots will need to reflect on and ideally draw some conclusions on, but it is work in progress and I think that that is an important aspect of it. Just to go back to Carol Mocken's questions about GPs and accessing information, a lot of the times I do not know what surgery a patient in front of me has. A lot of the times that patient does not know the details of the surgery that they have had. You can send me all the information that you want about things that women who have mesh might experience, but if I do not know that this person has had mesh implanted, how am I going to put two and two together? Dr Gilhane, that is a very fair question. In some of the reading that I was doing in preparation for this, I recognise the exact examples that you have given from some of the responses from women and some other articles that I have listened to that women did not know exactly or could not remember exactly what or had not been told exactly what had happened to them. I would hope that, as a very much lay person and someone that goes to a doctor for advice, that their training, their knowledge would allow them to ask the appropriate questions of their patient, which I am sure the vast majority of them do, and then be able to either eliminate or write the next pathway, the next step on that, is perhaps to refer to get a scan to see what has happened. I am only a patient, but that is what I would hope that, if I went to a GP to explain some of the symptoms that I had, as I indicated earlier to Carl Mocken, that the increase in knowledge of this and the support that I believe that health boards have put in to support GPs plus the training will move to allow better diagnosis, but I absolutely get what you say about historically perhaps all that information wasn't captured. Forgive me, you are not just a patient, you are the minister in charge, and I think having a safety mechanism there to ensure that this occurs is very important. As far as GPs being able to co-ordinate patient care, when we have a scenario where a GP would refer into a service and that service then refers into NHS GGC and there's multiple players involved, it's impossible to keep track of where that is. Do you feel a simplified method might be better in these types of circumstances? I know you are absolutely correct. I am the minister, however. I am also a patient and the experience that I was giving you was from my own experiences. I think that that is a strength of a lot of MSPs and a lot of people, everyone sitting around this table, in that we all come to discussions, debates and policy with the experiences that we have. I think that it's important for me to reflect that in answering my questions as you reflect the fact, and I respect very much the fact, that you are a practising GP. Therefore, I take on board absolutely what you've said. Yes, I think that it would be wonderful to have a simple system that allows it all. It allows everything all to be accessible, but I think that we also have to recognise that there are requirements around GDPR, which is very high up on a doctor's list about confidentiality and such. However, the premise of your point, yes, I think that a simplified system would be helpful. GDPR isn't an issue when it comes to referrals? No, no, not at all. No, not at all. No, I was saying with regards to how information is stored and accessible. I am going to move to Gillian Mackay. Thanks, convener, and morning minister. Obviously, the service that we have at the moment is the complex mesh surgical service. On-going, there will be women who will undoubtedly need surgery further into the future. There will be many that will have surgery that will not resolve their symptoms but may remove the mesh. I am interested in how the service evolves as we go through that process, if some of those women receive that surgical intervention. Do you believe that the service will evolve to treat some of the on-going symptoms such as pain? I do not think that it is entirely appropriate for maybe some of those women to end up in generalised pain clinics because of the issues that they face. What do you believe that this next evolution should look like and how long it should be in place? Thank you Gillian Mackay for your question. I think that in the reading that I have done and the way that I have seen the service change over the last couple of years, it has moved to absolutely that holistic service. Early on in this session, I mentioned the fact that it has to be based on the person, on the patient. I strongly believe that the way that we can provide the best support for the women in this situation is by understanding what their needs are. I think that it is about a third of referrals that end up not choosing to go for surgery but looking for the holistic support, whether it is physiotherapy, whether it is pain support, whether it is well-being support as well. If it is currently one-third, that could increase. The service has to be aware of that possibility of increasing that element of the service. I hope that it will evolve—I can see that Greg's nodding here might want to add something. I hope that it will evolve to support women in the way that they feel is most appropriate to their own circumstances. I agree with the minister, as she indicated. The service has evolved and I think that that has been broadly welcome for it to have a wider range of clinical and other colleagues involved. As I mentioned earlier, we will be renewing the service level agreement shortly, and I think that we will want to reflect that evolution. Ms Mackay makes an important observation that the service will continue to evolve. It will be a difficult judgment—a judgment that should be thought about carefully in terms of services that are provided at the specialist centre and services that are provided locally. One of the things that people are referred to quite recently from the islands or the north-east is that it is a long way to go. Of course, there is a balance of pros and cons there. Absolutely. You have preempted my next question wonderfully. Obviously, we would want to see a lot of care for people delivered in the community, but, as she said, there is much of this as a specialist service that has to be delivered in certain places due to that specialism. For women who have maybe had that surgery and have maybe been discharged because of that but feel that they need some wider holistic support, is there thought going on currently about whatever period down the line that is that those women can be referred back quickly and do not have the length of weights that we have seen accessing the service in the first place to be able to get some of this more holistic support that is maybe not necessarily surgical in its first instance in nature? I think that that is a natural follow-on, and I would hope that, given that the service has provided good support for people who are pre-referral and post-referral, there has to be an indication on the patient's records that this has happened so that the GPs and the local health boards, and we also have the official in the local health boards as well, that there is a recognition that additional support may be required. I have had meetings with other groups, with other concerns about the way that their treatment for women's conditions are, and that is something that they have talked about as well. I am not wanting to increase the pressures on the women's health plan, but I think that there is something to think about. They are more holistic across health delivery for women in Scotland to ensure that the aftercare that they get is appropriate to the surgery and the roundabout surgery support that they have had as well. We have a supplementary question from Tess White. Thank you, convener. I am minded of the patient, the woman who had to wait a year and a half for an urgent referral, so just a thought. Sometimes GPs are unable to help women who require the mesh removal, so would it be better off that GPs can refer directly to CMSS, or is there another way to get through the bottleneck that there seems to be? I thank Tess White for that question, and I think that you have to strike the balance, and this was given very clearly in evidence to you on 2 May about the importance of having one route that everybody understands, and that would avoid any confusion or cluttering of the landscape. I think that what I have taken away from the questions that you have asked, Ms White, is that we need to ensure that GPs are absolutely clear as to what the pathway is and look at ways of ensuring that that is the case, perhaps writing directly to the health boards and their officers that are responsible for it. However, to add another pathway in might cause confusion, which might not be the best way of supporting women who are in desperate need of the support. Thank you. I hope that we will monitor it very closely. Thank you. In evidence, the committee heard about the curriculum and framework published by the Royal College of Obstetricians and Gynaecologists for specialist training in mesh complications. I would be keen to hear about the clinicians who have been through that training, and if you are able to give us numbers, are all surgeons involved in mesh removal in Scotland have they been through that training so far? I know that Dr Kelly, when he spoke, talked about credentiality across the four nations. I am not clear how far those discussions have gone, but I know that the surgeons that are operating in Scotland are trained to very high standards. I do not know, Greg, if you have got anything. Probably what we will do is best if we come back to you with an indication of the progress of how the credentiality across the four nations is going and the numbers of those who are trained. Thank you, minister. I think that that would be very helpful. I think that Sandesh Gulhane has a question on this theme too. Absolutely. Just touching on credentialing, what is the Scottish Government's position on credentialing? As we have said earlier, Dr Kelly is not here, and I think that that is an area that I would ask him to answer your question on, because it is specifically a clinician led, but I think that it is a very positive way forward to have a standard, a high standard, that is set, and that is what credentialing will allow us to have across the four nations. Do you envisage credentialing to move into GP? I do not feel that I am qualified to answer that question. Would you write to us with a response? I am sure that we could write to you with that response. With the clinic that has been set up, there is obviously a key member missing. We do not have a specialist within the clinic for your gynaecology. This is causing a bit of angst with a lot of women. That is certainly right to me. I think that we have heard a lot of people talking already about issues when it comes to continents for women. I just very quickly want to say that it is a real shame that women do not come to their GP because there is a lot that we can do, and it is certainly not wasting my time for women to come and see me when they have issues, which is what I think a lot of women feel, very sadly. With the specialist, when do you envisage that we will have somebody in place? I am aware that you asked this question two weeks ago. The response that was given is that there is active recruitment happening at the moment. There are urology specialists in Scotland that are able to support as and when is required. I am afraid that I cannot give you a time frame for that happening, but I have been informed and it has been underlined that that is a key appointment that people are working to progress. I agree with you. I think that women should be able to approach their GPs regularly with whatever concerns they have and get the right support that I know GPs can provide. I might add just for—it is clear that the minister and members are entirely right that there is not a person employed directly in GDC at the moment, but just to emphasise that the service has access to that type of support through another health board in Scotland. The advice is there, understanding that it is not presently in the employ of GDC. My final question, when I was training to be a GP, I was actually at the Royal University of Scotland, and Dr Ross Jameson was one of the trainers that I had in obstetrics gynaecology. I understand that she is no longer within NHS GDC, certainly something that you cannot comment on—it is individual consultants. However, my concern here is when we have consultants moving, when we have staff turning over, when you have such a specialist clinic that is already looking like it is a little bit under strain, what can we do to protect the service? I am not sure that I would categorise it as under strain because, as we have given evidence since you received evidence two weeks ago, it is clear that the service is improving, is listening to women, and in answer to Carol Mocken's questions earlier, waiting times have reduced, and the responses to surveys carried out by NSS are showing that women perceive an improvement in service. The point that you raised is an appropriate one with regard to availability of people to work in that specific area and other specialist areas. That is why I think that we have got to continue to ensure that the NHS in Scotland can get the right access to good people and ensure that we can employ the best people that we can. I would hope that the importance of NHS surgery and support for women is recognised and that we can employ the appropriate consultants and such like. I think that, to look at it from the other perspective, when you look at centralising some or putting care in one specific centre, that gives that a centre of excellence, which Dr Kelly and his evidence said that it is well thought of and well perceived service within the wider United Kingdom. It is important to have that centre where there is all the skills in the one place, as opposed to perhaps having that more spread out across Scotland. I am right in saying that we have got the one centre in Scotland and there is nine in England and that reflects population need. Given that it is seen at such a high standard, we will continue to attract the right people to work there to ensure that women get the right health support that they need. I am aware that we have taken you over a lot of time, but Stephanie Callaghan just has one brief question before we finish the session. Thank you very much, convener, for allowing me in. The minister will be aware that the patient commissioner for Scotland bill is currently making progress through Parliament and that Professor Alison Britton's case of you and transvaginal measures are coming through us well there. I will check that the minister will highlight the need to have learning and work taken forward and improvement work taken forward from transvaginal measures when the patient commissioner for Scotland is appointed. Thank you very much for raising that point, Stephanie. I think that it is a really important piece of legislation that is going through Parliament just now, and you certainly highlighted that in your contribution to the debate last week. As was mentioned in the debate, it will be up to the safety commissioner to decide what areas they will work on once the bill is passed and becomes an act and they are in place. From my perspective, I think that there is a huge amount of learning that we have to get on record and understand from the transvaginal mesh situation, so I wouldn't want to put something on that person's entry straight away, but I think that it should be there. I thank the minister for public health and women's health and Greg Chalmers for the attendance this morning and for their evidence. The committee will look forward to seeing the written responses that the minister and our official have committed to. At our next meeting next week, we will continue our scrutiny of NHS boards, as well as taking further formal evidence as part of our inquiry into female participation in sport and physical activity. That concludes the public part of our meeting today.