 OK. Good morning and welcome to the 11th meeting in 2015 of the Health and Sport Committee. Apologise to me received from our convener, Duncan McNeill, who can't be with us this morning. I would ask everyone in the room to switch off mobile phones as they can interfere with the sound system, and you will see some of us here using tablet devices. This is instead of hard copies of our papers. Our first item on the agenda today is to take a decision on taking a business private, and I invite the committee to agree the following to take the approach to the smoking prohibition, children and motor vehicles Scotland bill, the draft report on health inequalities in early years, the committee's response to the fertility treatment evidence sessions and future work programmes all in private at future meetings. Can I get the committee's agreement to do that? OK. Thank you very much. We move on to agenda item 2, subordinate legislation, and we have five negative instruments before us today. The first instrument is the National Health Service Pension Scheme Scotland Regulations 2015 SSI 2015 Fawr Slash 94. There has been no motion to anil. The Delegated Powers and Law Reform Committee has drawn the attention of the Parliament to the instrument. The details are in your papers. Can I invite any comments from members? OK. There are no comments from members. Can I ask if the committee has agreed to make no recommendations? OK. That has agreed. Thank you. The second instrument is the National Health Service Pension Scheme Transitional and Consequential Provision of Scotland Regulations 2015 SSI 2015 95. Again, there has been no motion to anil. The Delegated Powers and Law Reform Committee has drawn the attention of the Parliament to the instrument and the details are contained within your papers. Can I invite any comments from members? OK. There have been no comments from members. Is the committee agreed to make no recommendations? OK. That has agreed. Thank you. The third instrument is the National Health Service Superannuation Scheme Miscellaneous Amendment Scotland Regulations 2015 SSI 2015 forward slash 96. Again, there has been no motion to anil. The Delegated Powers and Law Reform Committee has again drawn the attention of the Parliament to the instrument and the details once more are contained within your papers. In this instance, do members have any comments? OK. There have been no comments. Can I ask whether the committee has agreed to make no recommendations? OK. Thank you. That has agreed. The fourth instrument is the Food Scotland Act 2015 Consequential and Transitional Provision Order 2015 SSI 2015 forward slash 100. Once more, there has been no motion to anil. The Delegated Powers and Law Reform Committee has drawn the attention of the Parliament to the instrument and the details again are contained within your papers. Can I invite any comments from members in this instance? OK. There has been no comments from members. Is the committee agreed to make no recommendations? OK. Thank you. That has agreed. We are almost there. The fifth instrument is the National Health Service Clinical Negligence and Other Risks in Demnity Scheme Scotland Amendment Regulations 2015 SSI 2015 forward slash 102. Again, there has been no motion to anil. The Delegated Powers and Law Reform Committee has in this instance not made any comments on the instrument. Do members have any comments this morning? OK. There have been no comments from members this morning. Is the committee agreed to make no recommendations? OK. That has agreed. Thank you. We got there. Once I have some water, I've got a very sore throat this morning, my apologies. It's a wise decision, Rhoda. We'll move on to agenda item 3 on fertility treatment. OK. As I said, our main business of the day is to look at fertility services. Last week, we heard from the patient groups and today we hear from a selection of NHS boards. Can I ask the committee to welcome Dr Vanessa K, consultant obstetrics and gynaecology, NHS Tayside, Dr Abba Maheshwari, consultant gynaecologist and subspecialist in reproductive medicine and surgery NHS Grampian, Dr Graham Mackenzie, consultant in public health NHS Lothian, and Helen Lyle, consultant gynaecologist and clinical lead, assisted conception unit, Glasgow Oil and Firmory, NHS Greater Glasgow and Clyde. Thank you for your attendance this morning. We have agreed to go straight to questions, if witnesses are OK with that. Colin Kier has informed me he would like to ask the first question. Thank you convener and good morning. I suppose it's a degree of parochialism here being an Edinburgh MSP that perhaps I can ask Dr Mackenzie the first question. Not from your submission that NHS Lothian and its fertility service have been successful and significantly improving the waiting times for IVF, ICSI since 2009 and really just wondering in your view what the main factors are behind this welcome development. Thank you for the question. We had a long waiting list back in 2009 and that had accumulated over many years. We put in submissions for extra funding to the health board over a period of two years and on the second occasion we received that funding and that funding has increased since then. I think it's partly because we have a management team that includes representation from strategic planning and from public health in addition to the traditional management team which has clinicians and management on it. We have a person on the management team who is able to understand how the health board's funding processes work and he's been very successful in securing that funding. It wasn't a difficult argument to make. We had a very long waiting time and now we've reduced that very dramatically. Was there any fundamental changes in the way that you approach the delivery of service? As written in the submission, we did take the opportunity at that point when we had more funding to look at how we provided the service. Back in 2010 we were doing the traditional approach of providing three cycles of treatment and at this point I think it would be helpful to define what a cycle means. At that point a cycle was implanting the embryo into the uterus at one point. It didn't include all the other cycles that we now think of as being part of a cycle. We changed the terminology at that point locally to make that clear so we would describe a round of treatment where a round would be everything from the ovarian stimulation through to harvesting the embryos and implanting first the fresh embryo and then sequentially the frozen embryos. At that point we did some modelling and we increased the chances of a couple having a successful pregnancy by increasing the number of cycles that a couple could have. Is that point clear? A round is all the way through. It is described in the nice guideline as a full cycle. Collar, I apologise, I will let you back in as the clarity of all the committee members there. Are you saying, Mr Mackenzie, that previously a cycle was one embryo transfer? Yes, one embryo transfer, yes. Now the situation is that if you have a number of embryos, a cycle will be using all those embryos for a number of transfers of thoughts that it takes to have a successful pregnancy. That's absolutely right. Would it be reasonable to ask the other witnesses, and I will let you back in, Mr Mackenzie, of course, whether that's the same situation across each of the health boards? It's better to go back and explain. A cycle of IVF or ICSI is where the female patient has injections to stimulate the ovaries to produce more eggs. Those eggs are harvested and then are fertilised with the sperm in different ways for IVF and ICSI. Traditionally, I think what Dr Mackenzie is saying is that one cycle was viewed as the fresh embryo transfer, so in other words, the eggs are harvested, they're fertilised, the embryo is created, and that's what we call a fresh embryo transfer. In some occasions, not all, about 30% of couples would have sufficient embryos of good quality that could be frozen for use in subsequent cycles. Now, we in Glasgow have always regarded a cycle as the fresh embryo transfer and any frozen embryo transfers that have accrued from that one embryo, one egg collection, does that make sense? So we've always viewed that as one cycle, but I think what you're saying is that you used to see the fresh transfer was one cycle and the frozen transfers were a different cycle is what you're saying, isn't it? That's correct. In the past, we used to do two fresh cycles and one frozen cycle, and that was the three that couples were allocated. Can I ask the other two witnesses, because it seems as if there was a postcode lottery previously of what was determined to be a cycle also. Has this now been standardised? Is it the same across each health board? It's certainly now standardised, but it was a lottery. We treat patients in Tayside from Fife and from 4th Valley and each of them in different roles, but now with the National Fertility Group it's standardised, and so a cycle includes any frozen, and I think that's much better for patients because in the past there was a pressure that some patients would decide to keep the frozen embryos frozen and go for another fresh cycle with all the risks involved, including the risk of a very high stimulation in order to have two fresh cycles and then pay for the frozen ones. I think that it is better now. Dr Maheshwar, is that the same? It used to be the same in Grampian as well, and in Grampian we are the tertiary care centre for Grampian, Highland, Ocne and Shetland. All four had different criteria. Some even funded only two cycles, some funded three cycles, so if you were across the road in a postcode in Highland where you come in Grampian area or in Highland area, things were different age group wise, but because of the new criteria it's all uniform, and one cycle is all embryos related from that cycle and used, so that is very uniform. Okay, thank you. Dennis, I am going to let you in, but I'm conscious that I, a couple of colleagues called hereof because he was clear and I wasn't clear, which is why I had to ask those follow-up questions, so I will let you in next as a supplementary, Dennis, but calling here, did you have some follow-up questions? No, no, thank you, Kevin. Let things carry on. Okay, Dennis. Thank you very much indeed, convener. I was just clarifying from the Grampian perspective, are all treatments carried out at Aberdeen Royal? At Aberdeen Fertility Centre, yes. That's right. So patients from Orkney, Shetland et cetera have got to travel? They have to. Are they subsidised in their travel? They are subsidised by the health boards in their travel, yes. Thank you very much. Can I ask about the third cycle? We took some evidence last week about it. Obviously, I think that the optimum point is to have three cycles if that is clinically recommended, but there seem to be a reluctance to move to that third cycle. Can I ask if you are aware of that reluctance and what it might be based on? I don't think, I mean, reluctance is probably not from the providing community. As I understand, that national infertility group was set up before that some of the health boards were providing, such as Grampian were providing three cycles. But the waiting list was very long, so it was just to equate the waiting list and to bring it down to less than 12 months. This was agreed and the plan was as the national infertility group, which Dr Lyle would be able to allude to much better, is to look at the third cycle provision and the other provision such as having no genetic child in the family as well. So, there is no reluctance from our side to provide it. It's just the funding and current criteria is two cycles, but it has to be for couples where there is good chances of success rather than a blanket policy of saying everybody can have it if there is any good chance of success or not. Would that not be the case with any cycle, if there were issues that would say that a cycle was very unlikely to be successful? You wouldn't go ahead with that cycle even though someone was entitled, I guess, for one of a better phrase. It's always down to clinical judgment. Absolutely, and this is written in the national infertility group guidelines, absolutely. I'm conscious that Dr Lyle was named checked, so I was wondering if you wanted to add to that. I would agree with Aber. I was part of the national infertility group, and I think there are probably a number of factors here. I'm, like Aber, not aware of any reluctance in terms of provision of extra cycles, but I think the whole thing needs to be seen in a wider context. When the national infertility group took over two years to reach its conclusions, and then the report was produced looking at the criteria which achieved equity of access for assisted conception treatment in Scotland, and also equity in terms of waiting times, and that has now been achieved, which is something that we're very proud of. I think it's fair to say that any number of additional cycles that you provide to a couple will increase their chances of a pregnancy. Ultimately, what we all want to do is give couples the best chance of achieving a pregnancy. That's why we do what we do, but I think the factors that come into play here are similar to the factors when the national infertility group was convened in the first place. Although it's desirable to provide as many cycles as possible, you have to see that in a context of what is possible within the wider health service. At the time of the national infertility group, the evidence was very much looking towards the fact that three cycles was the optimum number of cycles. That may still be the case, but what we also need to understand is that since 2010, when that evidence was available, the clinical service has moved on very much, and that picks up some of the points that Mr Kerr mentioned earlier, that things have changed in terms of the eligibility criteria, so part of the reason for optimising body mass index, smoking, alcohol consumption was to improve success rates, and that has definitely been seen. Units also now are providing what we call extended embryo culture, so what that means is that we have the facility to keep embryos in culture for longer, up to five days, which means we can get more information about the embryos before we replace them into the woman. And when we get more information, we're better able to identify embryos with the best implantation potential, so that also has increased success rates. So that's one side of it. The other side of it is that because we're getting better at culturing and creating embryos, we're going to have more issues around freezing, so we're going to be able to freeze more. Techniques of freezing have improved. The more frozen transfers a patient has, the more resource that's going to take. So I think what I'm saying is that it's not an easy answer. Yes, I think everybody would like to see patients receive their best chance, but I think very much that needs to be seen in a wider context of service improvements and also the demands on a service in providing that changed service. So what you're saying is that there isn't the capacity in the system at the moment to deal with offering a third as just the norm? I don't know that it's right to say there isn't capacity in the system because I think there probably is. But what I'm saying is that when you look at the implications, say a third cycle, there are going to be staffing implications. There are going to be implications for additional freezing, embryo transfers, but also the need for that third cycle is going to be different to three years ago because the service has improved. So I think that all needs to be looked at and also the implications for staffing to provide that. I think the wider picture needs to be considered. You seem to be slightly, I may be picking you up wrong, but you seem to be slightly at cross purposes but you're saying because the service has improved so much, there seems to be less need of a third cycle on one hand, but also that a third cycle would create quite a lot of extra work. Those things seem to be... No, sorry. I think... No, I mean, if you give couples more cycles of treatment, they're going to have more chance of success. But what I'm saying is that the number of couples who perhaps would need a third cycle is different now to, say, three years ago, but however many cycles you provide, that is going to generate an increased workload which will need to be factored into the service provision. It's not saying we shouldn't do it, it's just saying that that needs to be part of the consideration. The other thing was that when the National Infertility Group considered the original criteria, there was always the intention to review the criteria once the waiting times had been met, and that review process has only just started. So that review process is happening, but it has only just started. We always said it would be March 2015, and that process, we've had two meetings now to begin that review process. During the third cycle? It would, because as part of that review process, we're liaising with colleagues in ISD, and they're able to generate the data that I've been explaining, so that will help us to understand the impact on the service of whatever we provide. OK, and before we move on to Dennis in a second, I'm just dealing with other witnesses of something to add to that, or are you content that that kind of represents where you are in terms of capacity to start cycling in your health boards also? I think about that very well, thank you. OK. I agree with that, but I'm just to add that NHS Grampian has recently inputted more into the reproductive medicine services, and instead of four years ago, when there used to be only one consultant, we have now have got three consultants, so they have put it on their agenda as well, so we will have capacity to provide extra cycles. That's very helpful, Dr Mashwary. Thank you for that. Dennis Robertson. Thank you very much, convener. The national infertility report, paragraph 197, is more or less suggesting that three cycles could happen, but it's based on affordability. It's asking obviously the group when it next meets to look at the specifications and the criteria as to moving to that. I hear what you're saying in the answers to Rhoda Grant, but a lot of it seems to be based on the affordability for each health board in moving to that third cycle. Would you agree with that? Sorry, was that a question? Sorry. I think inevitably the question of affordability has to come into it because the impact on the service and how that's going to be delivered has to be considered. With regard to criteria when we're looking at eligibility, what factors other than BMI? I always find that BMI is a very strange one because there are so many other different factors that can impact on a person's BMI. Obviously, I look at the factors of smoking, alcohol or obesity. Are there any other factors in terms of the eligibility criteria? Dr Lyle again, maybe? Maybe you move on. Lifestyle factors, we would always discuss general lifestyle factors with couples. We'd also take cognisance of any pre-existing health conditions that they have and make sure that we have a very close liaison with physicians who are managing those conditions so that a diabetic would be a good example to make sure that their diabetic control is optimal before we start treatment. I was going to say obviously the thing. I don't know if any of our other witnesses want to add on to that in terms of criteria. Apart from the BMI, there's the one on smoking, so they both have to be tested as non-smokers before their name on the waiting list and before they start treatment. As Helen said, we need to say that they're medically suitable for treatment, so we have to look at the obstetric risk and we have to, under the human embryo authority, look at the welfare of the child issues that they're going to be good parents. There's age criteria, so they have to be below the age of 42 at the time of starting treatment and if they're 40 they have to have a good ovar in reserve. We have to assess, as a reasonable chance of treatment, being successful to balance the risks because IVF treatment does have risks involved as well. There are quite a few different criteria we look at. I may have missed it in the report but there doesn't seem to be a definition with regard to couples or partners. What's your view on what is defined as a couple? We treat same-sex couples. We don't treat single people at the moment for fertility on the NHS. They have to be in a stable relationship for at least a year to qualify as a couple. You do treat same-sex couples? We do, yes. Is that across all health boards? It is, yes. Was that in the report itself? As I say, I may have missed it but just for clarity and putting on the record here when we're looking at the definition of couples would it not be advisable to have that embedded in the report? You said that you're part of the fertility group. We have a definition of a couple which is a couple living together in a stable relationship for at least two years. We also have a statement that says that there is no discrimination on the grounds of race, gender, sexual orientation or words to that effect but there is wording around that. Clearly, the definition of a couple is difficult in terms of whether couples maybe don't live together all the time or what is a stable relationship and we had a lot of debate about that but that is the definition we settled on cohabiting in a stable relationship for at least two years. It's based on the Equalities agenda. Excellent, thank you very much indeed. Dr Mackenzie, I wish to come in on that. I think it's worth reflecting on the fact that years ago, we used to have separate patient information leaflets for same-sex couples and heterosexual couples and now we've moved away from that. We treat all couples the same. It's the same documentation, it's the same guidance and I think that's a very positive thing that there isn't a distinction. The guidance is obviously out there for the GPs to make that initial referral in the first place so that you take all your referrals via GPs. Dr Mackenzie? The guidance in Lothian is on the Reff help system which is an openly accessible system that people can use across... well, any internet user can use it so a patient can look at it, a GP can look at it so although it's aimed at Lothian GPs everyone can look at it and that takes the big guidance that you're talking about and turns it into a manageable piece of guidance and a protocol for GPs to use and referrals are through GPs or through hospital specialists in some circumstances, I think. Is that the same for every board? Dr Kay? Yes, it's the same for us, all our referrals are through GPs they have access to our guidance, we have a website for the sister conception so patients and GPs can access but when the criteria were introduced all GPs were sent information about that as well. Dr Maswale? We have guidance for GPs in our internet as well as on our website we also do regular GP teachings to update them with the criteria and guidelines especially when the new guidance came and like they said, we did send them later and we are the secondary care centre as well as the tertiary care centre for fertility referrals so we do a lot of secondary care work as well for the assisted conception and the referrals to secondary care are from GPs as well as the consultant colleagues from Highland, Okne, Shetland as well. Okay, and Dr Lowell? Yes, we'll have a full house, Dr Lowell. Similar to Aberdeen, we have GP referrals we also have referrals from what we call the secondary centres which are for us Ayrshire, Lanarkshire, Dumfriesen, Galloway, Highland because like Aberdeen, we act as the secondary centre for Greater Glasgow and Clyde. Our guidelines will be on our website and also we've done a lot of work recently with GPs locally engaging with them to try and streamline the referral process. Thank you very much. Two committee colleagues wish to get in Dennis but is it a supplementary on the same theme? It's just on a question of the term infertility. There is a view that perhaps we should be using a much more positive term such as fertility as opposed to infertility. Do you have a view on that in terms of the patients? Is that a much more positive guidance in terms of what we call the clinics? Dr Mishwara, yes. Ideally infertility as you say is not a very positive term. In today's world, when there is so much advances in fertility treatment infertility as such doesn't exist it's sub-fertility rather than infertility. More and more we are calling our clinics as fertility clinics or reproductive medicine centre where these clinics are held rather than just saying this is the infertility centre or whatever. At least in Aberdeen we have changed our name to Aberdeen centre of reproduction. I hope so. Do you have any other witnesses leading the way? Assisted conception? Is that not the normalised terminology? Dr McHenry's hand up first? Yes. In Edinburgh it's called the Edinburgh Fertility and Reproductive Endocrine Centre and has been for years. That positive fertility I can't tell you when it started using that name. I better just check what everyone calls the system. We call ourselves the Assisted Conception Unit but I was discussing it this morning with my colleague and I think we still have letters going out to the infertility clinic for those coming to the secondary level clinic and I think that's something we need to review. Okay, thank you. Dr Lyle at the GRI. Assisted Conception Services Units are similar to Dundee. Okay, thank you very much. Thank you, Dennis. Richard Lyle. Thank you, convener. Has that listened to Dr Lyle? The same name but different spelling. Can I go back to the cost and how many cycles we have? The information we're getting is an average of £3,600 per cycle. A number of health boards over the last few years have made significant changes. You've got £12 million from this Government to improve it. But some NHS boards are not investing the appropriate amounts in the service. Why can't we move to three? We've been told last week by witnesses that, basically, after two, it's very traumatic for people to go to three. Anyone trying to have a baby, any lady who's going through this must be totally traumatic to everyone. So when we get to a situation when we're getting to near three, we're down to quite a low number of patients who actually need three. So why isn't it universal in Scotland to have three? I don't think anybody is saying that we can't go to three, not at all, nor is anyone saying that we don't want to go to three. I think all anybody is saying is that we need to understand the implications of that first. In terms of investment, the other centres can speak as well, but in terms of investment, we were delighted to have the funding from the Scottish Government and that has made a huge difference. The Scottish Glasgow and Clyde have also invested over three million pounds in a new unit, and we're certainly seeing the effects of that in terms of success rates and just in terms of provision of service to patients. Certainly in Glasgow, the health board has very much responded very positively to the Scottish Government investment. But I think, like everything else in life, you wouldn't just go ahead and do something without understanding the implications of it. We don't want to or we can't. It's just saying that, as the National Infertility Group promised, before it was implemented, we need to understand what those implications are, and that process has been started off now as it was always said it would be, with engagement with ISD to gain the relevant data, and once that is understood, a decision can be made. But I don't think anybody could just say in anything in life, oh yes, we can just do that, without fully understanding the implications of it. The implications for any couple is, if you can get to what you've done to, but you still, let's be honest about it, people who are in this situation grasp it's choice, and they get to a situation where it's a very, very, very traumatic situation for that couple. So they've been through to, they sit down with their doctor, or yourself, and say, well, we want to go for free, and someone turns around and says, we only do too, sorry. I think we're talking about two different things, so the implications for the couple, I think, there's no debate there. Of course, if a couple has had unsuccessful treatment after two cycles, a couple are going to want a third cycle, provided they've been counselled appropriately, and a third cycle would be in their best interests, but that would always be understood. I'm talking more about the implications for the service provision, because that's going to have an impact on everything that unit does, and everything else the NHS can provide. It's not saying that we don't want to do it. As I said earlier, we're all committed to providing the absolute best treatment for couples that we can. It's just saying that, as the national group said from the outset, we need to understand what the implications of those changes are going to be, and that work has been started, so that will happen. This is where I don't get it. Right? We need to go to the, but you're saying, well, we have to look at that and the implications. So the implications is that a person who wants to go to three, and, as far as we're concerned, this committee or this health service or this Government want to go to three, but, yes, I do understand that there are implications on course of the implications. Is the staff available? Is the basically everything there in order to move to three? But that's the point that I don't get. Let me turn it around. You're not, with the greatest respect to you, you're not clarifying why we can't vote to three. Can we give them the chance to do that, Dr Lyle? I hope that this might be helpful, but what I had in my head in terms of implications would be whether each health board had done some modelling work or was about to do some modelling work on what the knock-on consequences would be. For example, with moving to a third cycle for a couple already in the system, a couple getting to their first cycle and that kind of thing. Is that modelling work taking place? Yes, it is. That work is being done through liaison with ISD. What I was going to say was that perhaps I could turn the question round to you and say suppose we say today for every couple that come to the assisted conception services, we will provide a third cycle for all couples who are deemed clinically eligible for that. Because we don't understand at the minute how many couples that's going to affect, we don't understand how many frozen transfers that's going to generate. Suppose we get 12 months down the line and we haven't changed anything about money into the service or staffing, we just provide the third cycle and we get 12 months down the line and our waiting times are back up to 24 months. What do we do then? We were told last week that sorry, I need to say this. I'm just wondering whether we could get the views of what the consequences could be from the other health boards as well because we've got four health boards there and I promise you, I'm not trying to cut you off I've all let you back in with the follow-up but just to get a broad spectrum from across the country about what the consequences or implications could be for moving to a third cycle in the near future, how close are you to teasing out what that would mean if we had a third cycle in that area? I would support Dr Lyle's argument that nobody is saying that we shouldn't provide third cycle we are all keen to provide and with the nice guidelines that's what they say that is optimum. However, the implications of it has to be thought through and planning has to be done. Now the reason it is taking time as I understand because of the legality the way data is put in is because of HFA which is our regulatory authority regulations data is just not available like that data has to be put in and ISD has to come in and help us to get the data across the board so that there is uniformity across all the four health boards and we have equitable distribution for IVFs so that that waiting list remains the same and we input into the service accordingly what the data comes out Dr McKenzie, do you want to add anything to that Dr McKenzie? We've done some data and data side looking at the number needing three cycles and it's not a huge number but I think we are looking at more in depth in that but my understanding is if we were to provide it immediately then within the same funding other patients wouldn't get treatment and I think it's deciding whether you'd increase your waiting list or who would be denied treatment so it's not that we haven't got the capacity but of course there's a funding issue if we were to provide it we couldn't provide treatment for other patients but I am clear we haven't got all the data we need to make decisions on this yet and so ISD is going to be coming round shortly to generate more data so we can look at this in more depth and we couldn't have had that data two years ago because things have changed usually so success rates were freezing are better, our care pathways are better we're treating people quicker younger so success rates will be better so I'm hoping that will be less people will need a three cycles than perhaps if we looked at this data and started this process two or three years ago okay, thank you doctor we're waiting for the national infertility group and we have members on that group the other important thing to say here is understanding the published evidence as well and the published evidence doesn't always make clear what it's talking about whether it's talking about a cycle or a full cycle and we made that distinction earlier and that's important to understand and the randomized controlled trials and published evidence doesn't make that clear so we're not exactly sure where we are and the other thing to put into the equation is the potential for harm the potential for harm of going through that third a variant stimulation is quite considerable and we know that the couples who are going through that have some of the poorest outcomes in terms of infertility outcomes and so we've got to put that into the equation that's a fundamental part of being a clinician is to look at the potential to minimise harm okay Richard Lyle, I did Rhoda, what's the supplement that Richard had promised to let you back in I wasn't here to cut you off I just wanted to make sure all our witnesses get the opportunity to put their views on the record as I said at the end of the day I'm not getting at what you're doing you're doing a very good job but I really want to get to this situation on the third cycle if there's a reduction in the service or if we have a hundred couples even to Dr Varissa Keith if we have a hundred couples how many couples do you think need to go through a third cycle, a new experience I think it'll probably it'll be less than 20% yeah, that's the point so what we're saying is that 20% if they were going for a third cycle could actually affect the 80% who are starting their cycle within the same budget, yes yeah so that's why we're not doing three cycles would you agree with that I think, as Helen Stredd explained we need to understand what the cost implications are so until we know the numbers at the moment we're just guessing figures aren't we Richard, I think you've got your answers I think maybe the one thing that we should have asked was just timescale, so there's a lot of work going on ISD, modelling work what the implications might be looking at the figures, lots of new evidence these things are always better the take is long as they take was also quite good politicians love targets and timescales don't they so what do you think the timescale around that would be the end of 2015 Sarah might be able to comment on the national infertility report, we were hoping for the end of 2015 weren't we so that's helpful and there was a supplementary relation to that from the grant as well so I just wanted to ask about harm obviously any procedure has a risk attached to it but I got the impression from Dr McKenzie that that risk increased with the number of cycles so that there was maybe an increased risk with the third cycle it would be good an idea of what that was I wasn't saying that it was an increased risk necessary but there is a risk and that's I'll pass on to specialist colleagues in a second but any risk can be measured and you would want to try and avoid that risk which is in large part why we introduced criteria around smoking, obesity and other things, you're always working to reduce risk so that's a very important part of the equation I see a supplementary from Dennis Robertson's life for your patients Dr Simpson I thank you very much and my apologies to Dr Simpson with regard to the risk does this include psychological risk as opposed to just a medical one Dr McKenzie that is an important part of the equation for an individual couple I completely understand having seen complaints and having discussed this with clinicians in the Edinburgh Fertility Reproductive Endocrine Centre that some couples do become very distressed when they hear that they haven't got any other opportunities for treatment through NHS funded cycles and that has to be added into the equation as well but actually an important part of counselling is to be open and honest about their chances and if their chances of success are very very low that has to be considered by the couple as well in discussion with the clinicians and counsellor Dr Simpson I'm just indulged me just slightly I just want to make sure because Dr McKenzie said that he may seek some additional information from other specialist where I feel that in relation to harm does anyone want to add anything in relation to that before we move to Dr Simpson I would probably just say just to explain a little bit around the risk the risk in terms of IVF is partly in the egg collection which is very small risk but we always counsel patients that there's a risk of damaging blood vessel or bowel or infection there's also a risk of over stimulation which we would counsel patients about so there they if you like tangible medical risks they are small but they do exist and that's one of the reasons that we if possible like to use frozen embryos before a further fresh cycle so the enhanced ability to freeze is good because it means that it gives patients more opportunities to conceive without going through another fresh cycle so that's a good thing and yes I would agree psychological risk is something that we do take very seriously all the units have a counselling service all of the staff in the unit have had training in counselling and we're all very used to talking to patients through those difficult times If there are any questions you can add to that before we move to Dr Simpson The risks of multiple pregnancy and that's something that we've moved very much towards elective single embryo transfers so I think all the units now have multiple pregnancy rates within guidelines of 10% so there's much less risk of multiple pregnancy but there's still a higher risk so a natural chance of a twin pregnancy is about 1 in 80 but we're looking around 10% and multiple pregnancy carries a higher risk maternally and for the children born from that so that's something we also counsel patients about and that risk does go up as you get older so if you're looking at the third cycle often by the time they're having a third cycle the risks are slightly higher for that Dr Simpson thank you for your patience Okay I think we've clarified the third cycle business anyway at long last and it was very helpful to Dr Mackenzie describing cycle and full cycle because I think that's something that we weren't clear on before I've got two questions once technical and that is I understand that actually the results from frozen embryos are better than fresh embryos and I just wonder how that's going to affect things or whether it does affect things going forward that's my first question and my second question I'll maybe come back if I may it's on counselling I think we heard last week it was emerging evidence in relation to frozen embryos any additional information you can provide as in how that's coming along Dr Mashfarray In the terms of frozen embryo there is emerging evidence that it may be better but that's maybe the evidence currently is based on trials which have got small numbers one of them have been withdrawn because of methodological flaws and there are two others one is on hyper responders as Dr Lyle mentioned that if somebody is at a risk of hyper stimulation that they produce lots of eggs that can actually lead is one of the causes of death when we are treating fit young healthy women and our patient can go to ITU I mean it is associated with lots of risk hyper stimulation and we do everything to prevent it and now there are strategies to prevent it much more than what they were previously so out of the two trials which are left one of them is on those patients which are hyper responders so that doesn't give you the norm so that leaves with only one trial which is small in number and doesn't provide enough evidence but there is enough in the literature to say that frozen embryos use have improved their success rate have improved as compared to what it was previously however currently still frozen is slightly less than fresh and the main reason probably is the norm is that you select the best embryo to put in the fresh cycle and it's only the second best which get frozen so that is why we are doing a big randomized controlled trial which NIHR HTA has provided 1.4 million funding for which is going to start in this August and Aberdeen is leading that trial and I am the chief investigator for that trial and to compare in a randomized situation in 12 centres over the country whether if we do in a routine patients freezing all embryos and transfer frozen embryos 2-3 months later versus fresh embryo transfer and our outcome is looking at not only pregnancy rate we are looking at healthy baby rate which means term singleton, life birth which is appropriate weight for gestation and we are going to look at the cost as well as the long term societal cost and that but that evidence will be there in 2020 I just wanted to get that clarified to get where we are going forward can I just say also I'm really very pleased that we've got a situation where when one partner has no genetic child that is not going to be a bar to having treatment now I understand so that will be immediately introduced I presume as it's on the record of saying one partner has no genetic child as long as all further criteria met by both partners currently the criteria is that no child in the home and that's going to be stopped because it seems to be quite unfair that if you had a couple who split up custody and the other didn't the one that didn't could actually in their new relationship get into treatment the one who did take custody could not get into treatment and that seemed to be the complete opposite of any sort of social justice so I'm really delighted that that is now being eliminated can you just confirm that is the case standing from the national fertility group that's something that's been looked at along with the third cycle it's quite difficult to get that data because it's not easily available how many patients are not being referred because of that so it's not something that's being introduced immediately, no I just read it out for the record for the NSS report that we had the group is keen to introduce the following criteria when affordable and suggests that the 2015 review proposes a timescale for further assessments so you're correct it hasn't come in yet but it says one partner has no genetic child the criteria are met by both partners currently the criteria is there should be no child in the home so it is being reviewed I would urge that that be dealt with as quickly as possible because it seems to me to be the opposite of justice it seems to me and I hope my other committee members will agree in our report that we should do that my second question however is about counselling convener when I sat on the infertility group back in 1987 and recommended two cycles for everybody in Scotland and I'm glad we've finally reached that almost 20 years on one of the recommendations that I got into the report because I was the GP and psychiatrist on that group as opposed to someone from an assisted conception unit was that everyone should have a named individual to see them right through the process because my concern was that at that stage I hardly met any couples who weren't depressed at some point it's a very stressful process going through you know the whole business so do you feel there's an adequate provision of funding to ensure appropriate counselling and continuity of support through the process okay, who would like to comment on counselling Tayside we have a counsellor I think our current waiting lists are four to six weeks we allow patients to have information about that counsellor and certainly at review appointments encourage to see her if they feel that would help them we also have nurses who provide and doctors who provide supportive counselling throughout the treatment but in answer to your question patients do not have a named support person throughout their treatment no What's the situation? In Grampian again we have a named counsellor who works within the unit all of our nurses we have a very stable staffing situation we are very lucky about it and all the nurses are being trained in the counselling and they attend regular courses so they provide continuous support and again the counsellor appointment is arranged both in Grampian as well as they go to Highlands as well to provide support so patients do get within three to four weeks and we encourage patients to have counselling even before the treatment during the treatment as well as post treatment we don't just leave it for post treatment Doctor Mackenzie We have a local counsellor in our centre and the information about that is provided in written documentation to the patients before they come to the unit and is offered verbally during the consultations as well and that's throughout as well in coming with the other answers we also have information about the patient satisfaction survey about the experience of using the counsellors it's surprising actually that some couples who are offered it don't take it up so that's something that we need to look at to make that a more attractive option for them because I think they would benefit even if they don't think that they would themselves Doctor Lyle to tell you anything Yes we have a named counsellor who's been with us for a long time now we recognise that you can always do with more counselling provision and we're looking at the moment to appointing a second counsellor to add additional counselling hours we have a system whereby patients can self refer or if they're uncomfortable about that we can refer directly but it's very open access and also we have support from nursing staff and medical staff as with the other centres The question of continuity wasn't really fully addressed it seems to me that in this particular sphere it's important in every sphere of medicine but in this particular sphere for example if you have one nurse is it possible to actually have the same nurse providing that support particularly grampian you've got them trained in counselling now to have that person that you know you can ring up you can make contact to with the new system of effectively partnership in medicine instead of an even partnership it's become much more even have we got that sort of are you happy that we've got enough resource to provide that sort of level of continuity Dr MacKenzie I would need to go back and ask the centre about that I'm not sure but you're absolutely right that that is what we should be providing we provide that for example in maternity care that the same midwife is the aspiration throughout so you're quite right With some of our witnesses like to comment on the stability of the nursing and staffing rotor at the units to provide that continuity Some of our nursing staff are part time and obviously people take holidays I find it difficult to see how you can provide one name person throughout we have patients who we do try and support with the same nurse where they form a good rapport it would be quite difficult to achieve throughout so it's not something we've looked at and yes we'd have resource implications if we were to introduce that We do try, I mean we're a small group and we do try that same person but it can't be possible 100% of the times but as Dr MacKenzie pointed out I'd just like to point that even if we are recommending counselling to the patients they see the label of counselling counselling probably is not the right word we need to invent another word because they don't see that they need counselling despite the fact we advise them this is not this is for their benefit and whatever so I think that name needs to be revamped if you want to My apologies I've been to cut you off Dr Lyle do you want to add anything to that? Excuse me I agree with Aber that I mean often if I'm suggesting counselling to a couple I would tend to see that you know I would actually highlight the fact that counselling is perhaps not the right word and I explained that our counsellor is very much somebody who is just a very good listening ear who can discuss the issues with them and that seems to sit a bit better sometimes with couples in terms of named nurse support we've tried various permutations over the years and have found exactly the same challenges as Vanessa articulated which is a large number of the nurses work part time but as far as we can we do try to do that and you know recognising that patients often do develop a rapport with one nurse more than another but as far as we can we try I realise no one can provide 100% 365 one person care the days when that happened with GPs has even gone I might be used to but it's gone so I understand that but if it is an aspiration to meet that as far as possible it actually helps to reduce the need for formal counselling so I very much welcome that Can I just ask a brief supplementary on that myself because was it Dr Kate that spoke about trying to train front-line nursing staff and counselling or is it about yourself Dr McFaddy the reason for asking that is because it's about I think it was Dr Mackenzie that mentioned the patient satisfaction survey I'm just wondering in terms of like any front-saving facing health and empathy in the bonds and the interpersonal skills that all front-line staff be it receptionist or nursing staff is there any kind of evidence into it how do you measure satisfaction I mean I understand you're not satisfied if you don't get the child you're looking for but the human touch goes a long way to easing a lot of that pressure and strain even if it's not formal counselling the culture in the assisted conception units how do you foster a positive culture I'm sure you do but it's an opportunity to put some of that on the record We recently within last couple of weeks only had the survey report published which was done through NHS Grampian and one of the people from the patient safety group came in and interviewed some of the patients and some of the staff as well in the different times of the day for different clinics because clinics for people who are having difficulty in conceiving adolescent clinic all within the same setup and they talked about the reception staff they talked about the nursing staff they talked about the doctors they see and it was very very positive which was very positive for the team and that survey got fed back to team because it was immediate feedback and then they obviously it gets reinforced and they try to provide it better so it's just getting that culture of providing feedback immediate feedback it's not only the negative feedback that gets provided it's the positive feedback and most places I think are doing now the improvement tree the tree that what we did better and what we can improve on and you say we did kind of stuff so that patients also see that whatever they see they say we also act on that I'm glad I actually got there with my supplementary team to get to the point that I was trying to make but that gave you the opportunity to put that on the record with any of the other witnesses similarly we have a suggestions box in our unit and use that similarly but also it's probably worth saying that all the units are licensed by the human fertilisation embryology authority and as part of that inspection process we have to do a patient satisfaction questionnaire and the results of that are always fed back and like Aberdeen certainly when we had our last inspection the results were very positive Good Opportunity Dr McKenzie you have to say something but you're welcome to I think very much what Helen's saying I mean we're inspected regularly we do patient satisfaction surveys and in general compared to other departments I work in within obstetrics and gynaecology I think infertility is a very supportive environment we have a small group of staff so patients do get to know us I think we all work in the field very well and I see that in our satisfaction surveys we will always get patients who aren't happy and we take that on board and constantly try to improve our service Dr McKenzie I would echo what's been said before I'm always very impressed by the dedication and long experience of the staff that we have in our unit the one thing that I would point out though is that I don't know that patients who are coming to would know that from looking at our website and trying to unpick what our service is like and I don't think that the NHS is particularly good at using modern technology to show what the staff do and what the centre is like which I think is a pity and we see that reflected when we meet people for example through complaints if we meet somebody through a complaint who is unhappy with access to the service and they actually meet the staff they are often very impressed but they haven't had a chance to talk to them about things because they haven't actually accessed the service yet so I think we need to get better at that side of things That's very helpful Dr McKenzie I think the final question we have from committee members I don't see any other bids please correct me if I'm wrong but Rhoda Grant followed by two more questions Can I just ask about a topic that we covered last week about self-funding patients and the impact that that income to the units has does that allow you to treat more people who are dependent on that income Any takers on that This is the first question where witnesses have not been very keen Dr Lyle We have a very small number of self-funding patients in Glasgow The vast majority of our services are NHS funded We do about a thousand cycles of treatment in Glasgow and about 75 are self-funders They are managed through the University of Glasgow and it's slightly different to the situation in the other centres which I'm sure they'll be able to explain to you but in Glasgow the money generated by the self-funding service goes back into the university so the NHS service is not dependent on that for its provision of service and there's no impact on or very little impact on capacity in terms of numbers of cycles because it's so small Same as Dr Lyle the number of self-funding patients is much less because the waiting list has come down which has helped more people to access NHS funded cycles and our unit is slightly different that the assisted conception unit particularly is under the umbrella of University of Aberdeen and that's a joint partnership between NHS Crampian and University of Aberdeen so any self-funded patients go through the University of Aberdeen payment system and that has no impact on our ability to provide when the NHS funded patient is ready to be provided with them because we have enough staff to provide enough number of cycles so that doesn't delay NHS funded patient and another point I would like to mention here is Crampian is probably the only place where there is no separate private unit so everybody from the Crampian comes to Crampian and North East of Scotland comes to the Aberdeen Centre of Reproductive Medicine and none of our consultants who works in the Reproductive Medicine do any private practice at all and so if patients were to go for a private centre or elsewhere then it's not convenient for patients to travel that far as well so that's why we provide that service for who don't fulfil the NHS criteria currently Doctor MacKenzie In Dundee it's all within the NHS the number of private self-funded patients has gone down significantly with the new criteria but I think it's around 15% at the moment the private, the self-funded patients don't affect access for the NHS I think by having self-funded it does improve the service though it's given us stability over the years in the past it was about 50% self-funded so it gives us security in terms of staff funding it's not done deliberately to income generate but does on the whole income generate and I suspect that that does support the NHS service we provide as well so I think it works well because we have self-funded patients within our service we don't have a private IVF centre in Tayside either Doctor MacKenzie I was quite opposed to the idea of self-funding when I first took up this post seven or eight years ago but I've been persuaded by discussing with colleagues that it's actually a good thing to do it meant that we had the unit in the first place 25 years or so ago it was formed on that principle we do much less as a proportion self-funding than we ever used to for the reasons that we've heard just now there is one further point I would like to make though and that is that it allows us to provide treatment for siblings as well to produce siblings a couple who has appreciated the staff input and the centres input throughout their first pregnancy for a sibling and that provides that continuity that we were describing just now so that's another positive I think of having a self-funded part but again in Lothian it is completely separate we have a certain number of allocated NHS funded cycles and the self-funding cycles do not get in the way of that Can I ask that just raises a question in my mind which I hadn't been thinking of previously if someone has frozen embryos and has had a successful pregnancy can they finish that cycle that complete cycle to have a sibling That's a good question is a question that we have had referred to us before I can't tell you the detail actually I'm embarrassed to say I can go back and ask about that but it would make sense that that was an option there but I would have to ask the unit could you provide a bit more information on that Yes, if someone has had a live birth then they would have to self-fund any subsequent frozen transfers and perhaps the easiest way to explain that is that after every treatment episode the criteria are reapplied so if someone has had a live birth they then wouldn't be eligible for further NHS funded treatment Can I ask what the difference in cost would be for example if someone was going for a third cycle as a self-funded or going to complete a cycle for a sibling as a self-funded is there a difference in cost to them Do you mean the difference between a fresh and a frozen cycle or do you mean Yes, basically the difference between a third cycle a totally full third cycle or having embryos left over from the second cycle as part of a second child if you understand If they'd had a baby from a fresh cycle in the NHS but had generated frozen embryos in the NHS and then came to use those in a self-funding unit this is a ballpark figure frozen embryo transfer I think is around about £800-900 against a fresh cycle which is probably between about £3,000-4,000 there's quite a difference in cost but that's very much a ballpark figure Can I just say that Dr McKenzie had indicated what he asked something It wasn't to ask it was to actually say that my previous answer it wasn't clear that it's exactly the same as Dr Nile's answer that we certainly wouldn't provide NHS funding for that sibling but my point was that I don't know the process for the couple accessing that frozen embryo for self-funding but I think that they can access that frozen embryo for self-funded treatment for the sibling You can after Colin Kear has already got my attention for supplementary, yes Thanks, convener some of the questions that we've just heard in terms of the those who put themselves forward for self-funded treatment in terms of excuse me Do we have an idea of the people who are actually putting themselves forward Is it a case of maybe in the past it's been the length of the waiting times heading decided they wanted to self-fund because of that or do we have a situation these days given the fact that waiting times have come down as you said earlier that we have a situation where perhaps we've gone through two cycles already and perhaps been maybe the discussion that's taken place between patient and the services that are third cycles not appropriate is there the element of inspiration type aspect to self-fund after that Do we have an idea of these people who are going through to self-funding Just before someone asks that if someone answers that because time is short if I see nodding heads from other witnesses I might not take a second witness for comments and my apologies for that so Dr Ke The essay has been a big change when our waiting lists were for example from 4th valley for four years 50% of our patients were self-funded because of the long time to wait and you can understand that's particularly important if you're older because success rates go down so the difference in treating somebody at 38 compared to 42 is huge so we had a lot of self-funders because of the long waiting lists now most of our self-funders are because they don't fit the NHS criteria so it may be regarding the current rules of the child in their home or their age or their BMI or smoking so it's because they don't fit the criteria I can't give you figures but my feeling is it be a small number of the desperate ones who go on to have a third cycle but there will be some in that group I'm going to give my colleagues a name check for them who's coming in so I've got supplementaries from the net and then Richard Simpson but I've also got Dennis Roberts and Richard Lyle on a list and that will definitely be it so my apologies if I asked to keep your questions short but time is upon us but in the net my little things had an opportunity to ask a question It is a short question in the back of Rhoda Grant's comments so what are the rules and embryos keep them for HFE allows us to keep them for 10 years and for 55 years for people who are going to be prematurely infertiles so that we are doing for fertility preservation but we ask them to be sign the consent again after 10 years and a medically qualified practitioners have to justify why they are in storage for more than 10 years but patient can choose to do it for less time and they are allowed for 10 years so patients could access those embryos at any time within the time they are preserved provided all of the criteria are fulfilled and it's safe to have a child for them thank you part of that question is adding on who funds that bit the retention or any cost involved for NHS funded cycle it is funded by NHS even if you have one child the frozen embryos are freezing is funded by NHS but they come to use it as we have heard I am sorry I missed that freezing of embryos for NHS funded cycle is funded by NHS and for those who are self funding their treatment they have to fund the freezing but if you have had a child you have got some frozen embryos left over and you are going to retain them thinking about self funding for a second child who is paying for that freezing retention and freezing or is there no real cost involved though there are costs involved but currently it is being funded by NHS but when they come to use it the preparation and all the procedure involved would be self funding Doctor Lyle could you add to that a pertinent question because I think certainly in many units the answer is there is no funding for that storage and it does incur staff time a process that has to be gone through regularly for the HFE and just for general clinical governance there also is a huge administrative workload in terms of maintaining contact with these patients to find out their wishes regarding the embryos and I think part of the problem here is that there was a cost assigned to a cycle of IVF many many years ago and it has never really been revised and of course it is difficult to do and it goes back to a lot of things we have said earlier that as freezing techniques have improved more freezing is happening all of these things have a knock-on effect but it has been absorbed but there is no defined funding mechanism for it Apologies for just sneaking in a quick question of my own here is it a bit complex in relation to what the costs are because if a cycle is now not just a fresh embryo transfer but also frozen embryo transfer that is less costly than a second fresh cycle with all the medicines that are involved so is there swings around about some terms of where the costs come in? Well in a way but if you've got if you say previously you costed for a fresh cycle for a fresh transfer say but now that cycle is encompassing fresh and frozen you've got the cost of the freezing the cost of the storage the cost of the admin staff so it's all of those things which have never really been factored into the equation That's something that we have to be teased out going forward particularly before we go to the consequences of third cycles and that kind of thing I've seen lots of nodding heads there thank you for putting that on the record I think that's helpful, a helpful supplementary from Richard Simpson as well Dennis Robertson Thank you very much, convener and I'll try and be very brief about the fertility in that process I'm just wondering if there's a recognised genetic hereditary condition and the couples are saying they want to avoid passing that on to the new baby hopefully Is the same process used? I mean I know you can have AID, artificial insemination by donor Would you be applying the same sort of criteria in the process obviously the same clinic but there might not be any stimulation or would there be a stimulation from the woman in terms of the eggs to try and ensure there was impregnation Doctor Lyle, could you? The process that you're referring to is pre-implantation genetic diagnosis and we run the national service for that in Glasgow It's funded by NSD who fund 30 cycles annually for that service I'll try and be brief The couples go through a cycle of IVF or ICSI the embryos are created and then a cell is taken from the embryo and tested either for the defective usually for the defective gene or for any chromosome rearrangement which may be implicated in the problem In answer to your question yes, the same criteria to both services But there's also another way of doing that is the insemination by donor if the woman doesn't have a genetic or a healthy condition but it's the male so he doesn't want to pass on that condition obviously by the impregnation of his sperm they can do it by donor Ideally, you would still as long as the man was producing sperm pre-implantation genetic diagnosis would still be appropriate The embryo you're testing so you're right donor treatment is a possible route but for couples to achieve a genetic child which is what most couples would aspire to then whether the problem was either on the male side or the female side PGD would still be in defined circumstances would still be appropriate Thank you very much for that Unless any witness wants in to the final question Excellent Richard Lyle, you have the last question In your medical opinion when do you think that every NHS health board will reach and be able to give three cycles When the evidence has been gathered which hopefully will have been done by the end of this year and everybody is able to take stock then they'll be able to make a reason decision whether that's something which they can provide or can't provide but underpinning that is that the aspiration would be from all of us that we give couples the best chance possible Can I Richard Lyle perhaps try and be helpful by saying that once you have that more information analysed by the end of the year do you think you'll then be in a position to put a time frame around when you move to a third cycle December 2015 is not a dead line but once we get to the start of 2016 would you expect a time frame to emerge from the national strategy Again I think it's difficult to answer that definitively but I would expect what would happen is once the evidence is available then boards will need the opportunity to consider the implications of that and I guess they would be in more of a position to let the time scale around that then we would be Maybe that's something we can take up early 2016 Richard We can have a look at that Thank you very much for that We are over time but given the fact that we've been asking all the questions is there anything that any of our witnesses would like to put on the record so it's there in the public domain just before we close this public session The opportunity to speak to you is available to make this difficult process clearer to you Thank you I thank all of you for taking the time this morning to Oh right My clerk will keep me right We're conscious that it's four boards we've got here today I think we're keen perhaps to write to each of the other health boards and just find out what the situation is Ask them to reflect on the evidence that they've heard today and I think we're just keen to put that on record in the public session so that for anyone following the evidence sessions they would know what some of our next steps are in relation to that so thank you for keeping me right there but as I was saying I thank all of you for taking the time to give pretty detailed expert evidence today on our personal level I thank you very much for the work that you do and I know bringing a lot of happiness to families across Scotland and I know my colleagues in the committee would like to do like why so thank you again for your time this morning and we close this item of the agenda and we move into private session