 Good morning, and welcome to the 18th meeting of the Health, Social Care and Sport Committee in 2023. I have received apologies from Paul Sweeney. The first item on our agenda is to decide whether to take items 4 and 5 in private. Are members agreed? Thank you. The second item on our agenda is to undertake further periodic scrutiny of front-line NHS boards. For this morning's session, I welcome to the meeting Michael Dixon, chief executive of NHS Shetland, Gordon Jamieson, chief executive of NHS Eilinsar, who is joining us remotely, and Laura Scaife Knight, chief executive of NHS Orkney. We are going to move straight to questions and welcome to everyone in the panel. Thank you for joining us. I know from my time previously, as a health minister, one of the issues that was raised with me by island boards frequently was about the challenges and the associated costs of recruiting and retaining staff on the islands. I wonder if perhaps you could tell the committee how your health boards have met that challenge and what other challenges you still face. I do not know who wants to start off on that one. I would like to kick off if that would be useful. The principle remains the same. We are faced with a workforce shortage that has felt across the whole of the UK. We, as island communities, have to be innovative in the extreme to ensure that we are securing the right people, being able to attract the right people. We face challenges. Some of those relate to political decisions that sit out with us and the impact of leaving the European Union. They have felt not just within the NHS but across other sectors. Equally important, the way that the tax system works means that, if people are willing to come and spend a period of time working in the island communities and they have a home, they are penalised as a benefit and kind if they are provided with accommodation. It is an interesting quirk of the tax system that they are penalised for wanting to come and work in different places. Flexibility is key. We are seeing more and more people that are interested in their mixed careers. They have either reached a certain point in their career or they have had a pandemic wake-up moment where they want to give something back to society, either from a global health platform or alternative that they want to teach or travel. Offering people spaces where they can come and work and they know that they have a period of time that they are employed and then the rest of the time that they can go off and do these innovative, really exciting pieces of work and come back to us is an important way that we are recruiting staff. We do also still have challenges around housing and housing in the islands is under huge demand. It is also about suitable housing because the people that we may choose to try and recruit would be about families, people who want to come and live and build a life in Shetland. There are ongoing discussions about having a local authority level to see what we can do. NHS Shetland has recently secured funding from the Scottish Government to purchase a former guest house so that we can use that for some of our parapetetic staff and provide good quality accommodation for them. Understandably, if you are travelling up to do work on behalf of NHS Shetland, you want somewhere nice to be able to stay. You cannot just expect to be staying in a rundown location, but we do face and we will continue to face challenges. That has felt in terms of the long-term use of high-cost locums, which we are doing a huge amount of work to try and mitigate and ameliorate, but fundamentally that is likely to remain a consistent feature for now and in the future. Does anyone else want to come in? Thank you. Consistent with Michael's observations, we face real challenges when it comes to the fragility of our medical workforce. As you can see in the submission we sent in advance, last year alone we spent across agency and locum in excess of £6 million, and our task this year is to try and reduce that wherever possible and convert that arrangement into substantive arrangements, notwithstanding the challenges that come with that. I am pleased in your opening remarks you mentioned the equal focus on recruitment and retention. It is both. I know recruitment attends to dominate conversations, but it absolutely must be both. From an NHS Orkney perspective, we face additional challenges on top of the medical workforce challenges, notably that sum 22% of our workforce and now over the age of 56, so we have a conundrum and a ticking time bomb, if you like, in terms of that retirement question that we need to address now rather than walk into that in the years to come. We also, in addition to the challenges in the acute setting, have particular challenges in the community. So, as of today, we have 27 vacancies in our care at home team and some vacancies from a social worker and community nursing perspective. That said, as Michael said, it makes us think differently and creatively and innovatively, and that's one of the many benefits of working for an island board. There are some success stories in addition to those which I won't repeat. Michael has already mentioned from an NHS Shetland perspective. We've seen real success when it comes to GP recruitment in terms of the GPs who we recruit from the board perspective who are up to full complement. Actually, post Covid, GPs have told us they want to come back to really feel part of a community in an island setting, so that's a success story. From a CAMHS perspective, we've moved from two members of staff now to 10. We hope to get to 15, and we're optimistic we can do that. Just building on the observation and the submission that we sent through, I'm really pleased to let colleagues know that yesterday we recruited a GP with a special interest in dementia. Again, that just builds us the support we have. We will mention fragile services, I'm sure, quite a lot in the time we've got this morning. Those are the kind of solutions that we need to put in place. Finally, for my perspective, you asked, in terms of headline perspective, some of the other challenges we face, fragile services, and that goes hand in hand with the workforce challenges we face. Michael has mentioned the chronic shortage of housing. I think also, from an NHS Orkney perspective, I'm sure Gordon will return to this. The demographics and the shift that we're forecasting over the next decade are significant, and we need to plan for that now. We think we've done that if we look at our clinical strategy. We know for those over the age of 65, we're forecasting between 2020 and 2035, a 30 per cent increase. If we look at those over the age of 85, that will double, which is significant. We need to start not just solving the issues of now and today, but planning for the future. Gordon, do you want to come in here? Yes, thank you. Our experience over the years, what we find is that we want to attract and retain specific individuals, but what happens when people come to live and work and stay in the Western Isles is that we find that providing support for the whole family is really, really important. We get a lot of people who come for a single member of the family job, and then a partner can't get a job that they don't have housing and have access to things like childcare. There's a complete package that makes the difference for people who come to live and work and stay, because staying is the really, really important part. We try to support people with housing, and we've got good relationships and prioritisation with the local housing partnership to get accommodation. We work with all our partners. We certainly help people with relocation and visas. At the moment, we are considering the local provision of childcare for zero to five-year-olds, because again, access to childcare for our staff is absolutely critical. There's a whole package of issues that we try to bring about for each person who comes to work with us. Being flexible about working arrangements as far as we can is really, really important. Being carer friendly is also important, because people have broader responsibilities. We find as an employer that the more receptive and supportive we are, the better chance we've got of holding on to people for the longer term. However, the single biggest issue clearly, as you will have seen in my evidence, the single biggest threat to health and social care services in the Western Isles is the very alarming population decline and our current vacancies. The number of times we've had to try and recruit to different posts mirrors that population decline. We work with partners across. It's a community effort to keep people here and to get people here, so we all work together similarly to Michael and Laura. To me, it would seem that what you're describing there is that whole system approach of child care housing, et cetera, which would potentially have a double whammy in terms of you get staffing, but you also helped to bring families to the Western Isles and increasing that population, and that's sustainability of your communities. Yes, we have people who come up, and even more recently, an aesthetic staff, for example, who come up who. We have this almost common experience, the working environment before you sign up to a permanent job, so we kind of have this try before you buy type of approach where we're quite flexible to bring people up for a few weeks or a month, let them see the environment, let's just see how the facilities are in the community, what's the access to child care, so that whole package is the approach that we think is the only approach. If we just go out to recruit a single individual and we just focus on that, the success or not of that, we will fail on a much wider basis. I was reading through the submissions, and I'm particularly interested, Laura, if I could ask you, in your submission you said NHS Orkney remains at 0.8% from NRA Parity. Why? Thank you. This is a construct of the way the national funding works, and I'm sure Michael and Gordon will support me in this. It is one of the areas in which we think we remain as an island board at a somewhat disadvantage in terms of how the funding is allocated, and what it means, and I'm really oversimplifying this, but just to labour the point, it means we get funding in dribs and drabs, and it is one-off funds from an island board perspective, which makes it very difficult to spend it in a meaningful way, given the size of the board, and the infrastructure we have as an organisation. As an example, at times when money comes down the line in terms of how the national funding is allocated, we get parts of a post, so 0.8%, for instance, of a whole-time equivalent, or it doesn't help us to be agile, given the size of our boards, in order to spend that money to the best effect in a way that is best for our patients and local communities. So you feel that you're about £500,000 short of where you should be? That's correct. Can I turn to Gordon online, please? One of the things in your submission said that innovation in medicine was a challenge facing your health boards. Can I ask you to expand on that a little bit, please? Is clinical trials not part of where you need to be as well for this? I think that innovation in our service, and I apologise if I misrepresented what I've said there, but certainly innovation is something that we approach very enthusiastically. In fact, we've had some excellent successes in using innovation. The heart flow example that I've given in the evidence is probably one of the best examples of innovation using digital technology and artificial intelligence. The reference that I was trying to make was that, in cost pressure terms, some of the new medicines that are coming along do put pressure on healthcare systems, but generally innovation in many, many areas then we are entirely wedded to that. Our workforce, we can only sustain the service if we get the balance between our staff and the use of innovation digital and otherwise correctly balanced, and that does link back a bit to the workforce and population decline. So we are very proactive in terms of developing different methods of innovation, whether that's in diabetes or heart failure or cardiac or anywhere, but it's probably the cost of new medicines that gives the biggest pressure. We participate mainly in national research and occasionally in trials, but innovation, we are absolutely enthusiastic about that across the board. Thank you. My final question is to stay with you, Gordon, if that's okay. Population decline is a serious issue, as is housing. If you are earning 100,000 plus, then you'll be able to probably find accommodation, but not everyone is fortunate enough to be earning that type of money. A lot of the jobs that you're looking to get are not in that type of bracket. One of the things that I saw was a consultant post. I admitted that that's a very well-paid job, but there was a £1,279 addition annually for a distant island allowance. It doesn't seem a huge amount to really attract people into the Western Isles, so what measures need to be taken to make it more attractive for people to come and work where you are? Well, again, we approach it in partnership, trying to support people with housing, and you're right, we have a growing supply of houses in the Western Isles that come through the local housing partnership. We have an agreement with them that health staff will be prioritised. We ourselves, to use, for example, the Isle of Barra as an example, we rent a house on Barra on a continuous basis to allow us to be able to put senior medical staff and general practice staff into accommodation. In areas such as Barra where there are only 1,150 or so people and, again, that limited housing, we have had to take measures to provide houses. The health board itself has houses that are under its endowment infrastructure. Again, those can be used to support people in the short term until, I suppose, when you come to the Western Isles, some people would say, why would you come to the Western Isles and not have a house by the sea? What we try to do is support people when they come up to be around for a little while, give them supported accommodation and then let them choose if they're going to stay and support them in that decision about where they want to live. The distant island allowance is there as an additional incentive to people, but we look more at work and flexibility, annualised ours and support, as I said, with childcare, visas, relocation and try to look at the family. It's not everybody that comes with a family, but we are trying to attract individuals and families, but we look at everybody to see how we can support them. It's very much a bespoke individual approach, picking out of the range of support measures that we've got, what best suits that individual or family. Thanks, convener. Good morning to you all and good morning Gordon Jimison online as well, former senior nurse when I was an NHS nurse employee in Dumfries and Galloway. It's a question regarding innovation, Gordon, that you were talking about. Does that include enhancing the roles of allied health professionals and nursing staff, like for instance registered nurse first assist in the operating theatre or nurses being able to give medazolam, for instance, as part of an enhanced role for endoscopy and other areas where we're expanding the role of allied health professionals within their scope of the role, but using competency-based training and assessment, is that part of the innovation that you all take forward? If I can just reply to that. Yes, across, one of the things that we're very, very active is in whether it's allied health professionals and we have first contact practitioners and advances, we've got dandalone consultant physiotherapists who basically manage a musculoskeletal workload and do everything associated with the patient pathway and we've got advanced nurse practitioners, a growing number of advanced nurse practitioners, we've just appointed three in Barra, we've got them in Western Health hospital, we've got emergency nurse practitioners, all of them are trained up to level nine in acute assessment skills and they work very, very much hand in hand with junior medical and senior medical staff. So, again, that multidisciplinary, multi-professional approach, I personally get quite excited about how far can we take practice and I'm not a person that's constrained by conventional or historical boundaries, I look for the opportunity in doing things safely and effectively, but broadening it out as much as possible and I think that I find that the medical staff and all the other staff, when you get proper team working to look after patients, then, you know, that's an excellent environment to work in. Again, that ties back to a good experience for the patients and a really good experience for the staff. So, pushing the boundaries of practice, cardiology and the heart flow example is one where we've, we had our first in Scotland, if not the UK adoption of that heart flow technology, which of course is in partnership with the United States as well, but yeah, and that's led by a nurse consultant in cardiology, thank you. To Michael, who I know wants to come in this, you could perhaps explain, Gordon, what level nine nursing is? It's essentially training up to the level that a doctor would assess Clarke in an acute presentation of a patient, so it's common for a clinical support nurse or an advanced nurse practitioner to make that initial assessment. I mean, it's important that when patients present immediately that they are, that whoever meets them is capable of a comprehensive and very quick assessment and our nurses are trained up to, the advanced nurses are trained up to that level, thank you. Thanks, Gordon. I think just for, for Lee people, so they're aware of what you're saying. Michael? Thank you, yes. It's, as a nurse myself, I'm hugely proud of the workforce that we have and the enormous steps have taken to embrace new and innovative roles. The future of remote and rural really hangs around the principal advanced practice of all different professionals. I mentioned my submission about eye injectors, people not having to travel because they have age-related macular degeneration. To the point that because we've trained a nurse to undertake this procedure, people were choosing not to travel because it was so frequent and, as I'm sure we're all aware, travel from the islands can be somewhat challenging at times, so they were choosing to see their site deteriorate or even lose their site for the want of service in Shetland, a nurse injector who's being able to do that procedure. Nurse endoscopists, we see the roles of a, and Gordon stole all of my thunder there, thank you, Gordon. But in terms of their advanced practitioners to lead services very much from the front and developing new and innovative pathways, interest of fourth valley has led the way in nurse surgeons, undertaking breastwork and vasectomy, routine procedures that can be carried out in a very straightforward manner. For my perspective, for remote and rural advanced practitioners are a critical part of our future. Thank you. I'm going to now move on to Evelyn Tweed. Thanks, convener. Good morning, panel. Yes, Michael, it's along the theme that we've just been talking about there when you said about nurse injectors and what they do and how beneficial that is. Are there other areas that you would be interested in making sure they stay in the island so that people don't have to travel? Could you tell us about those areas and what support you might need to do that? The scope is pretty much endless, actually. The range of activities that advanced practitioners can do, whether that's working as a fly and fly out specialist environment to the remote communities that are in the Shetland Islands in terms of Macmillan's specialist support and extending prehabilitation, which is an important part of the future of cancer care and post care after their chemotherapy. Surgery is another good example where we can train practitioners. Again, the default is always nurse practitioners, but just distress. The professionals that we have within the NHS are phenomenal and bring a huge range. Pharmacists are an excellent resource to provide a different way of providing care to patients who may have had multiple drinks prescribed to them. A pharmacist can provide expert advice and the pharmacy first principle we're introducing is also really important. The scope is huge. We've got cardiac technicians that are using our recently refurbished CT scanner to review cardiac scans again, reducing the need for people to travel. The challenge, and again, to bring it back to a point that Laura was mentioning, is about NRAC that comes from this. It's often, and it's a common refrain in the islands, that people wear many hats. That means that structuring a role can be quite different and quite difficult because if that person goes, you don't just lose one job, you lose three jobs. That's where some of that NRAC parity comes in to create a challenge. It isn't just about the NRAC parity, it's about that we may only receive a portion of funding for a role that makes the sustainability of those. The next time you go and recruit, it means you're trying to find somebody to replace somebody who had two or three parts of their job to make up a whole, but the range is literally boundless. We see a significant portion of our workforce in the future, and our current estimates are about 30 per cent of that, undertaking an advanced role. I would like you, Michael, to tell us more about your, you mentioned in your submission about your work with LGBT young people. Can you tell us some more about that, please? So I was a Pritchway Aberty Youth Scotland, who obviously recently published a report about the experience of the youth of Scotland who are LGBT+, and remote and rural, there are a significant disadvantage. They feel more isolated, they feel more, you know, they don't have the same peer network, there isn't the same group of people that necessarily can reach out. So I took the opportunity at the time I was working between Shetland and Orkney, but to connect with the school nurses who were engaging with this group of young people and to find out what was going on in the schools, and absolutely astonishing work in Shetland. A youth worker who's been leading this work from the front, but there was innovation taking place across all three island boards. It's not a criticism, it's just the fact that all three islands were working in a slightly different way, reflect to their community, but connecting their school nurses up, connecting the youth workers, so there's the opportunity to learn from them. Most recently the LGBT youth workers in the Anderson High School in Shetland received an award for what they've done, and quite rightly too. I'm really proud that NHS Shetland participated in the first Shetland Pride that took place last year. It's an important part of a group of young people who are particularly vulnerable, particularly in the rural communities. So having that presence and that visibility, recognising their voice and their experience matters, that isn't just located within education, but also they can access all of our health services without fear, without prejudice, and knowing they'll be cared for is an important part of the NHS values and something I'm proud of. Okay. Laura, you had mentioned in your submission that there was IT system frailty. Is that, can you expand on that, and is that, for your area, is that nationwide, would you say? Sure, thank you. I think it's fair to say, from a digital perspective, we are somewhat immature, but we have, I think, an ambitious but suitably realistic digital road map to make sure we can see the progress that is needed in this area, and perhaps I could just share some examples of the work underway, and which Michael and team have led superbly over the last few years. The intra-island network, so the connectivity with our aisles is really, really important. Otherwise, there is a feeling in the community that, quite literally, the aisles are cut off, so we've done a lot of work to really improve that connectivity, and that really helps from a clinical perspective. For instance, just to give one example, the use of portable scanners on the aisles, just having joined up conversations using the same telephony systems and so on, so it might seem like going back to basics, but that has been absolutely necessary for us in terms of remaining connected between the mainland and the aisles. We're making good progress in terms of moving forward with systems such as Single Sign-On, so from our clinicians, as you can imagine, it's hugely frustrating for different clinical systems having to log in, log out, remember your password once, and remember it multiple times. We've moved to Single Sign-On again, which is a really important step forward, and more recently we've introduced e-prescribing. The end of the line, where I know we all want to get to, is an electronic patient record. We've started those conversations. Clearly that is dependent on securing the funding, but that's our ambition. What we have is a road map, so we can, with the funding we have from a capital perspective, in an incremental way, year on year, see that digital shift that we need to see. I think that we've made some good inroads there. Thank you very much, convener, and thank you for coming along this morning, everyone. Interested in the key performance standards? To what extent do these actually drive service delivery for you? We are not in control of all our and destiny in terms of performance standards. One of the key measures is accident and emergency performance. It has been sustained at a certain level, and I'm very comfortable with the level that's out. Every single case that is over the four hours is reviewed as a root cause analysis. Often those cases relate to transport off Ireland for people's require, for example, intensive care. Sometimes that can be an extended period of time. We had a patient who was delayed on Ireland for 36 hours because Shetland was fog-bound. There was nothing getting in, nothing getting out, and that's just the nature of providing health care in a remote setting, such as Shetland. For the services that we are able to provide on Ireland, the waiting times are very low, way below the 18 weeks TTG, or alternatively, we're talking about CAMHS performance or adult mental health services. We've got a small waiting list that is over the 18 weeks, but we do all that we can to make sure that it's as absolutely short as possible. Where we do have extended delays is where we have patients where the pathway leads them to the mainland boards. Therefore, our performance then is tied to that performance, and it's the same pressures that you will have heard from other colleagues from other mainland boards. We've got a very tight grip on that. I don't mean to dismiss performance targets at all, but it's not about a performance target. It's about our community having to wait for any longer than they need to for a procedure that's really important to them. Just really on that point there. I suppose that this ties into talking earlier about innovation as well. We hear a lot about air-intervention and preventative care and how critical that is. We also hear quite often how sometimes performance targets and priority targets actually drive you away from that. I'm just wondering specifically about those key performance standards. Could air-intervention and prevention be better reflected in their as higher priority? It could well do. I'll just obviously pick up the NHS that Shetland brought up, or with support from the Scottish Government, brought up the Vanguard Theatre to allow us to do hip and knee replacements, which was truly transformational for the community. Absolutely phenomenal. I'm coming from England where public health is very separate. We don't see that in Shetland. Our public health director is phenomenal. The public health team are absolutely integrated into the way we work. What we're talking about are returns that will be felt in possibly decades. If we can get weight management right, if we can get people's diabetes under control or even avoid it, then these are things that we can do to help prevent the health service experiencing that further down than them needing more support. We have a very strong public health focus in NHS Shetland, which I'm hugely proud of, and we saw that right the way out through the pandemic. The challenge is that you have to measure something. These are not bad measures. Is there more that we could look at? One of the interesting things of the knee replacement is the regret right that sits around knee replacement, because it's about 17%. Some work that we've been doing nationally across the elective waiting times is actually reviewing with patients. Do they understand the consequence of that? Do they understand what it means to have a knee replacement? If they know all that, do they still want to go ahead with it? So you're trying to reduce, at that point, people who may be having a procedure that they may choose further down the line that they would have rather not had. That's really helpful. Can you hear from either Laura or Gordon as well? I'm happy to come in next and just build on Michael's observations. From an operational performance perspective, there's a real risk here. We hit the target and missed the point. Fundamentally, this is about delivering high-quality, safe care and timely care across our elective pathways, our emergency pathway and for our cancer patients. As Michael said, for those standards within our gift at NHS Orkney, in the main, we do well if you look at our four-hour emergency access standard. Whilst it was short of the 95% requirement, we finished the year on 86% last year. We perform well and meet the standard around the 31-day cancer requirement and in 18 weeks we consistently perform well. The areas we need to do better, and this is not deflecting attention away from NHS Orkney in any way, are the areas in which we rely on other centres to support us and perhaps different in the last year or two from perhaps if we turn the clock back just three to five years, we know other centres are running at 100% bed occupancy or very close to that most of the time and we are relying through our service-level agreements on those other centres. So, when it comes to, for instance, 62-day cancer, whilst the numbers are small, it really doesn't matter. One delay for a cancer patient is one delay too many, but we are reliant on other centres. So, what we're trying to do around our cancer pathways, some of the areas where we've got longer waits than we would like. So, for instance, rheumatology and ophthalmology is have conversations with, for instance, ophthalmology, the golden jubilee. Can we use some of the capacity that is allocated to us in a different way to start addressing some of our longest waits? Ophthalmology is perhaps the best example of doing that and I would absolutely back up Michael's comments having worked in the NHS in England for the last 20 plus years. It may not feel like it at times, but trust me, integrated care significantly advanced here compared to England and we have very close relationships with our public health colleagues and with our local authority colleagues at Orkney Islands Council from an NHS Orkney perspective and there's huge opportunities there. One example, if I may, is around addressing delayed discharges. So, whilst we may be a small island board as of today, 19% of our beds are taken up by what are called delayed discharges. There are things we can do differently by working with our local authorities in a different way and we're looking at this ahead of next winter, for instance, using some community capacity differently, having a step down bed facility within the community so we can run at that 88% bed occupancy which we know is the optimal for us to deliver internally. So, there's room for improvement but relationships are really strong. I think that's my summary. Good to hear, Lauren. I don't know if Gordon wants to come in there. It's a similar picture in terms of local weights are really very short. We have expanded over the last number of years of our orthopedic service and we're very pleased with what we can deliver to the local population there. The targets, yes, some are reviewed daily, some are reviewed weekly. The cancer target, for example, our performance is very similar to what Michael and Laura have said, our 31-day performance, which is more local diagnostic, is very good. The 62-day target is a bit more challenging. We're currently at 53% there, which is, you know, we're at 93% for the 31-day performance, so we've got improvement to make there. But some of that is due to working in partnership and system pressures and clinical prioritisation and general lists that are elsewhere and we have to work within the NHS Scotland system for that. The target, yes, the ED target, it's a target that I think we would all want on presentation appropriately at an emergency department that you're seen as quickly as possible and you're diagnosed etc. The targets do driver performance. Alongside the targets, what we're doing just now is carrying out a population health needs assessment to revisit what are the five, 10-year predictions for the population of the Western Isles. What that does is it doesn't make us go into any kind of competition with the targets, but it allows us where we need to flex and change and develop services to now have a refreshed view of what the population health needs assessment is. That's what led us when we last did it, to really redesign and create a much larger orthopedic service, which, as I say, now delivers very well for the population. We're focused on recovery. We've got some areas where we're focused on continual improvement to get the waiting times down, but alongside that, I think that population health needs assessment will allow us as a health board to look at where do we really need to prioritise and flex local services and, at the same time, achieve the targets that are set. We'll move on to our next theme, which is mental health performance. Thank you, convener. I sort of have some general questions. I will pose the questions based around my experience as a doctor working in air hospital, which has a bit of a rural community along with an urban community. I know that you have a very different population, which is all rural, but when I was asked to go and see patients and I heard that they were a farmer, I would drop everything I did to go and see them because farmers don't come to hospital unless something catastrophic has happened. Someone amputated their finger when they were lambing and came to see me a good couple of weeks later. With this in mind and with the way that people in rural communities tend to be especially farmers, what different approaches do you need to take from a mental health perspective to look after your community compared to how the majority of the population in urban areas are treated? I'm happy to kick off. I don't think—there is a very shetland approach to this, which is that we have an incredibly strong third sector. I mentioned this in my submission. There is a default position that the NHS is the place that you go if you have mental health conditions or concerns. Actually, the research has proven time again that multiple points of entry is the best way to go. People need to be able to access services that are not just a case of between a nine-to-five Monday-Friday approach. It doesn't always need to be an NHS practitioner who is your best first point of contact. Actually, we've promoted the reliable connections through the NHS inform. We've provided through Mind Your Head some sustainability so that they can help build their service. Mind Your Head is a strong component that is very well known in Shetlanders to work that they do. Then it's about how people, when they are requiring further support that can't be provided through the third sector, first contact or on-going support, using a variety of methods from webchats to app on the phone. Again, some people are more comfortable. There is still a significant amount of stigma about mental health, particularly in the communities that you reference. However, when people do get through to where they've reached a point where they're requiring NHS level of services, we offer a range of approaches from face-to-face to digital appointments to try and flex around the needs of the individual, acknowledging one of the biggest challenges that we have is distance. If you have a mental health concern and you need to talk to a practitioner, it's two ferries and at least a couple of hours to be able to travel from Unst to Lerwick, where the predominant base for mental health services are. Being able to access the secure near me facility to be able to have a conversation that you know is confidential, you know is in the same space as you would do if you were walking into an NHS building can be really reassuring for people. That said, there's the other access, being able to message people on using a secure messaging facility so you can talk to someone and it doesn't have to be face-to-face, it doesn't have to be through an appointment method, but asynchronous consultations is another part of that. But the big thing, and it ties back to the earlier point, the more we can do about prevention, the more we can do about awareness, one of the things that I'm again very proud of being in in Shetland is the appelliar and the fire festivals that take place every year. Those communities that have really promoted the importance to talk, particularly for men who are really reluctant to come forward. And again, it's full credit to the appelliar squads that are committed to that, and being open about people's struggle and experience with mental health. Some very interesting points there about the importance to talk and the fact that my concern in rural and island areas is people seek help at crisis point rather than when things are beginning to be an issue, which is where it's much more easily sorted and probably quickly sorted rather than when you hit crisis. Social isolation is a huge issue in your rural communities, and obviously you're a health board that you don't particularly have control over that. But I was wondering, with all these methods, do you feel that you are able to help people with that social isolation? One of the things that's very special and Laura of us in Orkney is how we work together as a system. So the barriers that would routinely exist between, for example, police, social work, NHS provision, third sector, of course there are barriers with different organisations, but they're not the same constructs that you'd see in different spaces. So yes, we do collaborate, we work together, we know vulnerable individuals, and we will seek to try and find the right support for that individual, and that collaboration, that community is at the heart of all that we do. Do I think it's perfect and do I think everyone has access to all of the services that are near 24-7? I'm afraid we don't, but that is a reflection of we have a constraint on what our services are able to offer. What is important is that the community are able to access services easily, and again that's why the importance of investing on a longer-term basis in mind your head is so important. Can I turn to Gordon, if I may? I was on Uist and I was talking to someone there who said, he told me there are about 1200 people on his island, and he knows all of them. So with that type of community, which is probably one of the reasons a lot of people move out, but do you think the stigma of mental health in such a small community might be a hindrance to people seeking help? I'm not sure, I mean I think there's obviously there is a possibility that that would happen, but I think in terms of the interaction that we are seeing, and particularly when I think about Uist and Barra, then I think the work that's been done to strengthen our community services and to put much, much more support, signposting, awareness and resource into the community, whether that's face-to-face or digital, I think the communities are strong enough. There is definitely the chance that that stigma may be there, but the community spirit in most, if not all of the parts of the western Isles is incredibly supportive and I think probably is more helpful in terms of their own community and individuals within that. So I'm not seeing, you know, I mean most of our effort is in stronger community services, many more mental health workers and we've been very well supported over the last couple of years in terms of being able to strengthen our community services. So I'm not seeing, I mean, our CAMHS referrals and, you know, we're able to see people in CAMHS very, very quickly. Our psychology services have been strengthened considerably over the last five to ten years. A lot of training around about psychological first aid and suicide prevention, I mean loneliness is a huge problem up here without a shadow of doubt. It's more of a threat than most of the other illnesses if we don't tackle loneliness, but the communities are incredibly strong up here and incredibly supportive. So, and the third sector, again as Michael said, I mean a very strong third sector presence, which again is very supportive. On your third sector, I was hearing of the great work that Penumbra have been doing in the Western Isles and I was wondering what additional support you're giving Penumbra to do some of the great work that it is already doing. Specifically for Penumbra, we've got catch 23, we've got a range of providers across the islands. I mean, we're certainly regularly in contact with the third sector through the community-based network and, I mean, they have got more actually to offer than anybody else and so it is again a balance with them all, if they come forward with proposals or they're very much a part of our integrated planning, then we work with them. We've still got quite a distance to go in terms of reducing their acute mental health provision in order to strengthen the community provision. I don't think that at the moment when our mental health strategy was agreed it was quite clear that over time we would need significant additional investment and that includes investment in the third sector. I don't have any specific proposals just now that relate directly to Penumbra, but the third sector generally are very much a central part when we plan to change services. Thanks, convener. It is just to pick up a wee bit on what Sanchez Galhany is saying about social prescribing and third sector and independent organisations. We heard in our social prescribing inquiry some great work that's been done in Shetland about engaging people, so it's about supporting tackling isolation and learning and recognising it's a problem which in turn supports mental health as well. I suppose a question directly for Michael is about how each local authority, each NHS board and also interfacing and engaging to support all of that because we know how important our third sector organisations are. I'm just looking at one of the RSPB links with nature prescriptions that can help support people to get outside and tackle isolation and loneliness and join groups or whatever. Is that something that you see is happening on the ground as well now? Honestly, I've never worked in a place like Shetland. It is not about organisations and what names on your badge. It's about doing the right thing for Shetland, for the people of Shetland. There's a piece of work about Anker about working with vulnerable families. It could sit in a social work world. It could have sat in a health world. It didn't sit in either. It was about somebody without any of those statutory organisational badges working with really vulnerable families to make sure that they got the widest possible support they needed, and they wouldn't be families that would normally access support. By doing that, your preventing problems ties back to the key issue of prevention for decades and potentially for generations down the line. At no point did anyone go, oh, well, actually, I want to own that. That should be a social work thing. It was about what was right for Shetland. It guides all that we do across all of the organisations. It was about, and it's way before my time, this is a statement that the council and the NHS produced about 10, 12 years ago. Whatever happens, and I apologise for this statement politically, the council, the NHS and its key partners will work together regardless of what's going on. It guides what we do. It means that we do develop services that are about meeting the needs of our individual communities. It isn't a community. Shetland is not just one community. It's a community in communities now. I apologise to talk about that from Laura, but it's about how we do things local. We support activities that are taking place in Yel, Unst, Feral, Aetnology. It might not be us that are doing it. We've got a small island outskirts where we've put a healthcare assistant to support the small community out there, and it's linked to the way the council are working in terms of maintaining the island. It's a really innovative project, but it requires both statutory partners to step aside from our organisational boundaries and go, what's the right thing to do here? Because Shetland, Orkney and Wiston Isles are remote and rural, I'm thinking about Stranraer in the south-west of Scotland, it's pretty remote and rural for the rest of the NHS in Frees and Galloway, such as HQ and everything. Is that one of the strengths of the remote and rural areas? It's not just about everybody owning it as if it's there, we fiefdom, it's that whole thing about partnership working, so that is a strength of your remote and rural areas. I endorse that completely, I think, two aspects that Michael's already touched on, but just to press it. Just to say, I've been in post eight weeks, so I can share with you my raw experience. I think the relationship we have with our local communities is like nothing I've experienced in my career to date, and secondly, that collaboration and partnership working is so strong. The way I see it is this triangle between the local authorities, the health boards and the third sector, and the unique aspect for me is it's not just about the formal relationships and the formal set pieces that we go to, it's those informal relationships, and at the end of the day we don't let the governance and the structures get in the way of doing what's right for our patients and local communities, and that's the start of every conversation that we have. It's very different. Before we move on to our next theme, I'm just looking at the performance table that all three health boards submitted to us, but we didn't get any figures in from NHS Orkney on the percentage of CAMHS patients waiting within 18 weeks or 53 weeks or more, or CAMHS patients seen within 18 weeks, sorry. I wonder if you could perhaps write to us, Laura, with those figures. Of course I can. More than happy to. We're going to move on to theme 4, and I'm going to come to Tess White. Thank you, convener. I've got two questions around consultants and supplementary. My first question, if I may, is to Michael. At the end of last year, NHS Shetland had a vacancy rate of 39 per cent for medical and dental consultants, and that's against a backdrop of 6.5 per cent for the whole of Scotland. In your submission, you stated that it's difficult to recruit consultants with the breadth of skills needed for a remote and rural location because the NHS no longer trains staff in that way. Could you say a bit more about that? And then also, Michael, if you could give your view about some thoughts to overcome this, thank you. So, just to reflect that, that percentage of vacancy seems disproportionately high, but our consultant workforce is disproportionately small versus the overall board, so an increase in our consultant vacancy will shift that significantly. But the point is well made, our consultant vacancy is higher than we would like to see. I'm sadly old enough where I remember where general surgeons would be able to turn their hands to most things. Now, thankfully, a lot of that has moved away and we don't see surgeons having to go anymore, but actually that has a disadvantage. Now, we are fortunate that we still have surgeons that can turn their hands to most emergency procedures. The situation that you're talking about is that there is a major accident that happened in Shetland. It's a life-threatening issue and a surgeon needs to intervene, for example, to remove a kidney. Not a routine procedure they would do. We happen to have a stalwart of general surgeons who can still do that. They have their own subspeciality, but fundamentally, the surgical training that is undertaken right now, more so in England, but there's a degree of super-speciality occurring in Scotland. So you now have specifically breast surgeons that wouldn't be able to undertake a wider emergency piece, for example, a blocked bowel. They would be able to undertake more general stuff, but it's those sorts of life that are threatening critical issues. Our surgeons, as fantastic as they are, are reaching a point in their life where they're going to look to retire, and we already know that. We're starting to have a conversation about that. So what do we do? We've already put in place some of the foundations to be able to do that. We've taken on a new consultant who's going to be trained up in the wider, more frequent events that could require getting up at 2 in the morning and be able to provide that intervention. The comment about advanced practitioner also has a part to play in this, but there also needs to be a consideration of what does the future look like. So our current source of recruitment may well be out with the UK to ensure that we can sustain this, because outside the UK they still have a more generalist approach to training, for example, surgeons. That may form part of what we see in terms of the next few years' bridge as they retire and other people are brought on, but in the longer term I would hope that the majority of that work would be taken up by advanced practitioners under the supervision of a broadly skilled general surgeon. Just a quick follow-up on that, Michael if I may, rather than take it outside the UK do you think there's work that could be done to revisit that as an issue and say we need to have modified training? It is a challenge and my former life, when I worked down in England, we had a programme called Getting It Right First Time which looked at how surgical specialties operated. There is a really good reason of why surgeons are now more specialist. The more you do something the better the outcomes are. It is as simple as that. There was a great model between Brighton and Worthing where surgeons working in a particular speciality wouldn't routinely carry out surgery on children, but in the event of a three-in-a-clock in the morning major events they would need to come in and do that. They created a franchise so they would go and experience some pediatric surgery. They wouldn't count themselves as a specialist and they wouldn't do it all the time but enough to be able to keep their skills up. We see there is a remote and rural component of the training for surgeons and we're building on that to try and make that shatland proof as it were, but we still come back down to the if you are a surgeon on the whole you're expecting to specialise into a particular area rather than hold the general. I don't think we'll ever go back to the time and again there are good reasons of why that might be the case to a true general surgeon the likes who can turn their hand to a range of activities. That does create problems for the future and if we are to continue on a consultant-led model it is more likely it will get more expensive for the remote and rural communities to be able to sustain that. On the theme of consultants, Gordon, if I may, you've said a number of consultant roles take years to fill in some cases in a covered by agency staff which actually has a huge cost so just to how many years would you say it is taking to recruit consultants and then do you have a view on the cost implications of that, please, Gordon? Over half of our consultants now of the 16 or so that we have permanently here, we have about 32 visiting specialties, if you could bear that in mind, there's a lot of consultants that fly into the western Isles as they do in the other islands to provide excellent care from other health boards, but of our own core of consultants, about half of them just now are locum staff. Some of them have been locum staff for three, four years. It is very difficult to recruit permanent substantive consultants so medicine, surgery are specific examples, mental health is another one if I could mention three specialties that are particularly challenging at the moment. One of my observations that I've shared recently is that we seem to have in the health service. We have locums who want to work with us continuously, but they don't want to convert to a substantive post. They want to continue indefinitely on locum terms and conditions. Therefore, we've got locums that are with us for a very long time and we've been unable to get them to take up or apply for substantive posts. That in itself is a challenge. The flip side of that is that you get the continuity of a long-term locum and you get all the benefits for patients and the patient experience, but it does come a significant increased cost. When we're out to recruit new locums just now, some of the costs that come back from the locum agencies, we go to the on-frame work agencies first, where there is already an agreement, but sometimes we have to go off-frame work. As far as the costs are concerned, you have some high wateringly high locum rates that come back. I can give you a specialty where we went out to the market in the last two months and we were looking for the locum costs for a year to take someone on for a year. The lowest cost that I got back was £313,000. The highest cost I got back was just over £1 million. I've never come across that before. It is alarming. The costs are very significant. I have to say that we secured someone at the lower end, not at the higher end of that, but the costs are an on-going pressure. There is something for me about the people who want to continue to work, but they want to continue to work as locums. It's difficult to get them to convert, as I say, to full-time permanent members of staff. The Scottish Government put in place multiple schemes to bolster rural GP numbers. We've got feedback from Laura positively, so I won't ask Laura for me if I can ask Michael. The golden hello scheme and the bursary scheme, has it been helpful in Shetland? Is there anything else in addition to that that you think could be useful? I think that any initiative such as those is always really welcome. I must recognise the vast majority of practices that are operating in Shetland, the board run, so we're not tied in the same way. However, we do have a number of single-handed GP practices, and one particular in Hillswick has got a very committed, long-standing independent GP who has been trying to recruit her successor for the past six months. Moving to a place like Shetland is not something that you do lightly. People think that it's just an island. I was talking to an American tourist who thought that we would be able to catch a train somewhere, but there are no trains. You've got to understand the quantum of moving. You've got to want to go there, and that's part of it. No golden hello necessarily will do that for you. It has to be the desire to live and work as part of a committed community, knowing that there are trade-offs. It's incredibly safe, but it's really isolated. It's beautiful, but you may not be able to fly out for a number of days due to fog or due to fragilities around the airlines providing the services, or you might have a really rough ferry crossing. So, these are all factors that people consider. And I don't think just throwing money at a problem. We've got a, I think, cell, and I think Shetland and Orkney and West Nile sell the beauty of where we work, but fundamentally, you've got to have the right mindset. You've got to know what you're getting into, and that's part of it. It's a choice. Great, thank you. If I may convene, if Gordon, or should we move on? It just needs to be very, very brief. Gordon, if you could just give your view on that topic, please, thank you. Yes, thank you. We're about to go out to recruit either today or tomorrow for two GP posts for Barra, and, you know, the Golden Hallow is part of that. I think the point that Michael is making is really important. We're selling Barra where we happen to have two rural GP practitioners posts, and that's the important thing, that we can sell the location for people to want to come and live there. We have nine practices. There's one to see practice. Some of our GPs are retiring and returning, and they're very long-serving, as Michael has said, in many communities. But it is becoming increasingly a bit more challenging to get GPs in the outer hebrides, but the next test that we've got will be in the next few weeks to come when we go out for these two very different posts in Barra that will cover the GP practice out of ours and the inpatient beds in the hospital. We're going to move on to our next theme about Covid recovery and progress of the recovery plan. We're getting a bit tighter for time, so if I can have concise questions and answers, please, that would be very grateful. So I'm going to move on to Emma Harper. Thanks, convener. I was going to mention that Scott Jem is a success for us, for recruitment of GPs as well. As far as Covid recovery, I know it's not an overnight fix, and in the NHS recovery plan progress update, it basically says that Covid pandemic recovery is not going to take place in weeks or even months, it'll take years. So I'm interested to hear what your perspectives are for Covid recovery, because I know that we're using innovation near me, so digital appointments, that's obviously been part of the recovery, but how do you feel the recovery from the pandemic is affecting you or specifically for remote and island areas? I suppose Michael Snodden, if that's okay to go with Michael first. So I'll keep it brief because I'm aware of time. So our performance reduced slightly during Covid, and I'm thinking about the performance measures that we go against but actually didn't dip significantly. So from a performance metric perspective where we are and actually argue one of the best performing boards for performance, I think that the longer term consequences of Covid impacting on to the social and also to our workforce will continue to be played through for many years. And I think that's where we will continue to wrap up the rules around that. We're using trauma informed support for our staff to ensure that it was a very difficult period of time for the whole of Shetland, but trauma informed support is a key plank for how we continue supporting our workforce. If I may build it on Michael's observation, so Covid recovery remains one of our top priorities as an organisation. We are back to pre-pandemic levels of activity if you look at our elective and outpatient activity. As I've alluded to earlier, we have some particular pressure points in certain specialties where we have particularly long waits, but from a line of sight perspective we know in which specialties they are, both from an acute and community perspective. We have plans in place to address those areas and notably from an acute perspective for us that's pain services, rheumatology and ophthalmology. Michael importantly touched on the importance of staff health and wellbeing. I think we shouldn't lose sight of that. There's been a lot of burnout. Staff are tired. I think as health boards we invested strongly in health and wellbeing through Covid. We absolutely have to maintain that and actually readable our efforts moving forward and we're determined to do that. As already has been touched on, there were many good things to come out of Covid that we need to keep, not least the acceleration of digitisation and keeping things like virtual appointments where that's appropriate for patients, but also speed of decision making. We can take far too long in the NHS to get on and do things and we can have good governance but still work at speed and I think we've got to keep hold of those positives and build on those moving forward. I suppose I'm not sure if Gordon wants to come in but I'm interested also. I read in the recovery plan that there was a mobile operating theatre that was introduced in Orkney and Shetland. I think that the Scottish Government implemented £2.3 million to enable 350 elective surgeries to go ahead. Is that something that you've found has been quite beneficial to address some of the elective surgeries? It was in Shetland, so Shetland hosted it. If I'm so sorry, the Balfour has a truly fantastic first rate set of theatres, whereas the Gilbert Bayne due to its ageing very elderly infrastructure and building dozens. So a Van Gogh Theatre was supported, it was absolutely transformational. Also, if you layer on top of that the mobile MRI scanner that we have visiting, the routine diagnostics that we get visiting, it's that sort of innovative approach that really shows what we are able to do. It was over 400 operations by the time the Van Gogh Theatre went away. The opportunity for Scotland, and this is the whole of Scotland, is we used Van Gogh, which is a private company to do this, and that could be something that we could do within the NHS ourselves because a lot of those staff members were NHS staff members working in a different route. That's interesting. Okay, and as far as Covid recovery, do you agree that it isn't an overnight fix that it is going to take a long time because obviously we do, I absolutely endorse supporting the mental health of all of the workforce as well. That's really critical, but again it's something that has to be part of a long-term plan in order to address Covid recovery. Is that correct? I would agree entirely. We mentioned the pressures on the mainland boards. Our pathways lead to mainland boards, so even if we're doing the best that we can do, we're still tied to what's happening throughout the rest of the system, but you're absolutely right. I think we will feel the effects of Covid for many, many years to come. That's very great. You're just building on that. In terms of the specialties I mentioned, where we have particularly long waits, we have short, medium and long-term plans in most of those specialties, recognising that actually the fix in many cases is changing the model of care in these services, so hence why there needs to be some longevity to this. It will take several years to get these things fixed and working in a different way, in a way that's sustainable for the future. Gordon, I had wanted to comment on that previous question. I was just to say, there's a couple of things. One thing is that, as an NHS in Scotland, we really need to make sure that we don't slip back at all from using digital technology like attend anywhere or near me, and that's going to take a whole NHS Scotland approach. It's very easy to go to slip back, I think, and we saw huge benefits and want to push ahead with the appropriate and safe use of attend anywhere near me, so that's something I would like to see. For us, as a very small system, Covid is still around, and don't get me wrong, it is still causing us operational interruption problems. When I worked in Dumfries and Galloway, if we got a bit busy down there, I could redirect patients to south air or across to borders or even south to Carlisle. If the hospital here in Stornaby gets paralysed because of an outbreak of Covid, there is no other place for people to go. Our balance of risk and recovery has to be very carefully balanced. However, our recovery is good. Our patients are not waiting lengths of time at all, and I think that protecting the scheduled care is really important. The last thing that I would say is that one of the good things that came out of Covid was the renewed emphasis on staff wellbeing. We will keep that and we will hold that forever now. We will never slip back on that. I think that that has got many benefits as we move forward, that a focus on staff health and wellbeing, as well as full recovery and improvement for patients. We are going to move on to culture and governance on our next theme, but I will get a supplementary from Evelyn Tweed. I was interested in Gordon's positive comments about your board working with your local housing partnership and prioritising staff housing. I just wanted to ask Michael and Laura if you also have positive relationships with your local housing providers. I am a housing professional, so I am really interested in this. From an NHS orcney perspective, we have just recently set up a new strategic forum around housing, so we can make a proactive submission to the Scottish Government so that we can be very clear on what the gap is looking like for Orcney in the next five to ten years. Those relationships are absolutely there, but the partnership is even bigger than that in terms of the strategic contributions around the housing agenda. Yes, we have strong working relationships. We are taking the experience of Western Isles and we are starting to engage with our local housing association to see how we can take the experience of Gordon and the Western Isles into shambles. We are going to move on to culture and governance, and I am going to come to Gillian Mackay. Obviously, as well as small health boards, there are small teams with those health boards that you oversee. In terms of culture and particularly where there are complaints, how is that managed within these small teams and how are people encouraged to speak up when there are issues given that they may be working in a single digit number of staff teams? I have not worked anywhere in Northern Ireland where people felt the same way that there is a direct connection with the community. In a way that you may not experience if you are working on a larger board, we have been in some quite difficult complaints where things have not gone as we have wanted it to from a clinical care perspective, and the consultant has been beside themselves that this did not go the way they wanted. You are part of a community and you are incredibly visible. That also makes a difference to how you feel. How complaints are handled, we are fundamentally engaged to see if we can resolve it exactly as you would expect in terms of the pathway, the Scottish pathway that is being set out for complaints. We try and resolve it as quickly as we can, but we know that there will be some that will reach a certain threshold. I am involved in a number of them when they reach a certain point, but there is that visibility, so it makes it more visceral. It is not just a number or a name somewhere. Are staff and patients encouraged to speak up? Yes, absolutely. On the patient perspective, we offer people a range of ways to be able to engage with the health board. Social media has a significant part in all of this, and on the whole, the local population is comfortable that they can raise something anonymously, they can raise something with a name attached to it, they will always get a response and they will always have their response truly heard and responded. Of course, we can link back to the external process if need be. In terms of staff speaking up, we not only have our own internal processes for people to raise both data accesses, which is a system to be able to raise concern, but also great accesses, I cannot say that easily, which of them to be able to recognise good practice, so it is a two-way thing. We also have an independent whistleblowing champion who sits on the board who does a temperature check frequently about how people are feeling, as well as our iMatters survey, which is just being completed now. Thank you. I won't repeat too much, because some of these things, as you know, are national contracts, so to speak. You are right within health boards, lots of small teams make up one big team, and that can at times lead to silo working. In my experience, staff will speak up in multiple ways if they have confidence, knowing if they do speak up that their concerns have been listened to or heard or taken seriously. Fundamentally, I have been followed through on, and it is that closing the loop bit, so there is that element of trust in the system. One of the things that I have already started to do is to promote to staff. There are lots of ways in which you can speak up, both informal and formal, through to the whistleblowing end of the spectrum that Michael has talked about, but we still have some way to go there to build that trust and credibility, and that is something that we are working really hard on. From a patient complaint perspective, I insist on seeing every complaint that comes into the organisation and every complaint before it goes out as a response from me personally. Wherever possible, I will meet with complainants personally at a venue of their choice. Being cognizant of those complaint themes, so that when the red flags are there, you are nipping them in the bud and you are acting on those in real time is really important. One of the things that we have not mentioned is the importance of learning from complaints. Complaints are a gift, so it is about learning and truly demonstrating that something has changed in response to that feedback, no matter how small it may be. My final comment is however which way you look at it, you cannot disentangle patient and staff experience one impact on the other. As an example, when I often look at complaints trends, there is something going on in terms of staff sickness or absent or staff experience. That experience package is really important that those things are really together. Just a few comments, Shet. It is a hugely important area. I spent a lot of time in the world of patient safety before I came up to Western Isles. One of the things that I have always been alert to is the dangers of hierarchy and how they impact on clinical teams and multi-disciplinary teams. Constantly developing the culture of openness and speaking up is really critical. We have a range of things that we do. We have everything from an informal sounding board where staff can raise concerns through to the formal. I host open meetings with staff regularly where there is no agenda and they can come and raise issues with me personally. I do exit interviews with employee director to try to learn from people who move on. Is there anything that we can play back into the system? We have a real focus on early resolution for people where there is an issue and try to resolve issues informally before going down the formal route. The formal route always becomes quite elongated and can be a stress for everybody involved in that. If we can get early resolution, that is really important. For patients, we have a patient participation forum that feeds back to us. The point that Laura made is really important. We are doing a lot more direct contact with patients now, face-to-face or at least telephone conversations. The exchange of letters or correspondence is the end of the process, but it is really important to get to know people and be personal about their experience and understand their experience. You get a much fuller understanding of that from direct contact. It is a central mission critical issue all the time. Behaviour for us is everything. We try to make sure that everybody feels that they can speak up at any time about any issue. Likewise, we have the whistleblowing system, which is there when the business, as usual, methods do not work. How do the boards monitor bullying and harassment in your workforces, again reflecting on that small team nature and where that can cause issues if you are on a small island in Orkney or Shetland, where you know the whole community and can be raising an issue with your next door neighbour or someone across the road? We have staff governance, which is our key body for monitoring that. That is a separate governance pathway. Bullying and harassment does not come through to the management, the executive. It is rooted through that route. We have a strong HR department that is there and available. We also have spaces for listening for people to be able to engage in an informal basis, to be able to raise concerns at a lower level. There is a link to occupational health, which ties back to what Laura was saying about the component of staff sickness. Again, the place where all of that is reviewed is the staff governance, which ultimately feeds through to the board. I welcome the introduction of the eye matter system that we have where staff can fill in question areas and get right down to a team level. Where there are behavioural issues may be starting to come up and how teams interact. There is the opportunity to fix that very, very locally. We review on an on-going basis any cases that come up that are alleged bullying and harassment. It is quite simple. We have a zero-tolerance approach to that. There is absolutely no room for that kind of behaviour in any of our organisations. I have a very clear focus on that. The more important work is about developing teams, staff wellbeing, being alert, early resolution and using things like eye matter to pick up any themes that might be developing in the organisation. As Michael said, it goes through the area partnership forum, which is where we obviously meet our trade union colleagues. Again, that is a very open forum where we have very strong partnership working. Ultimately, the board statutory committee, the staff governance committee, will monitor as well the issues that come up. I have a question for Laura. I appreciate that you said that you have only been in post for eight weeks, but you will be aware that NHS Orkney had the lowest score on the employee engagement index and the overall experience score. As the committee began to hear what steps NHS Orkney has taken or are taking to address that. When I commenced in post, I published a 100-day plan in front and centre of that. That was how I would spend time, not just in my first three months but beyond, listening very carefully to the views of staff, recognising that our staff engagement and experience scores weren't where we wanted them to be. I am already very clear, after the first eight weeks, that there are some really clear themes that have been fed back from staff who don't consistently feel heard and listened to and don't feel that our internal communication is what it should be and find it really difficult to navigate through the organisation in terms of how decisions are made, how that feedback loop works, who to go to for help and support. So what we are doing is going back to basics to reset that with staff. I continue to hold listening sessions both in the week evenings and over weekends, recognising that I want to make sure that I am as accessible as I can be, and that will continue beyond my first three months. At the end of my first three months, I will then publish a report to be really clear and open and transparent internally with our staff but also externally with our partners and local community. Those are the themes that I have heard and this is what we are going to do about it, but fundamentally this is about leading with kindness, visible leadership and truly listening on a rolling basis, not just a one-off exercise. Gordon mentioned the importance of iMatter, as important as that is to give us a moment in time view from staff under benchmark, under comparison year on year in terms of how we are doing. When it comes to staff engagement and experience, this has to happen every day of the year and every month of the year and at the moment that isn't embedded from an NHS or any perspective. So we are in the process of putting in place regular listening sessions, both with myself and the exec team. We will start quarterly pull surveys in addition to the annual surveys that we have talked about today so that it just becomes part and parcel of this is what we do throughout the year and play in that back consistently into the organisation. As part of my 100 day plan, I was very clear that there were five top priorities, one of those was organisational culture, so I knew there was work to do. I am now getting underneath the bonnet of that and I am really clear where we need to focus our efforts in the next six to twelve months and beyond. I was happy to hear that the Clearing and Interest is an entry unison. You mentioned the staff partnership forum. Where do you see the role of staff side within assisting you with that? Absolutely central to moving us forward. In terms of the area partnership forum, we have really strong relationships. We are just resetting that agenda so that we can make sure that the staff experience engagement and culture programme is front and centre of that, consistent with our annual plan for this year that the board have just agreed and published. We have really healthy relationships with our employee director, but what I want that area partnership forum to do is literally what it says in the title, to work in partnership, to move forward on some of those big issues. I haven't held back. We need to move beyond tick box exercises and move towards meaningful engagement and partnership working. I think that we've got some great ideas as to how we can do that together. We're going to move on to our final theme, which is future work, and I'll pass to Carol Mawkin. Lovely, thanks, convener. Thank you very much for all the details information. This question possibly gives you a chance to give us some homework. The Scottish Government has committed to the development of a national centre for remote and rural healthcare for Scotland, so I'm really interested to know what your aspirations for that centre might be. The committee has also committed to trying to undertake an inquiry into remote and rural healthcare, so I would be interested to know if yous have anything you feel that we should specifically direct that information to. Please give us some work to do. Happy to kick off. We've touched on a lot of issues that I think will be pertinent in terms of that review. Front and centre has to be the workforce, and I personally see having worked in a remote setting as a badge of honour. There is huge experience you get. People often look at the islands and think it's just going to be easy. It's 22,500, 26,000 people. It's not a problem at all. Actually, you don't have the breadth of workforce that you have in other organisations, and you have to be more agile and you have to be more adept, but at the heart of that is our community and our workforce. I think you've heard from colleagues about the importance of that package, the valuable offer that people can have, and we've done some work through Discover the Joy GP recruitment process in Shetland where people come for a period of time, allowing flexible ways of working that recognise that working in a place like Shetland might not be for everybody forever, but it might be for some people for a period of time, and we can collectively build up a profile, but these aren't traditional models. Our current funding arrangements don't particularly support anything that's beyond the traditional models and certainly remains a challenge about NRAC. I think the workforce of the future is going to look different, and I would question that the biggest challenge that faces the River to Rural Centre has to be about working many years in advance, but we are facing challenges today. Separating the two is useful and ensuring that we've got a really broad focus rather than traditional models that have been defined by what happens, for example, in the mainland. Trying to lift a Glasgow model and put it into Shetland just doesn't work. What happens through our experience will be the same as the rural areas for Dumfries and Galloway, for the rural areas in Highland. Getting this right, and I say this often, the Australian doctors, the Australian flying doctors is a brand. Everyone knows that. It's a real thing, and I think we could replicate something like that in Scotland, not just doctors, hasten to add, but that could be an absolute badge of honour that people embrace as part of their lifelong career. Thank you. Laura, you're quite new in. As Michael has said, workforce has been the dominant theme throughout the meeting. I think perhaps returning to an earlier theme, innovation. We will all, Gordon, myself and I, in our own boards, have an ambition to be the best remote and rural care provider in some way, but there's something about, from a remote and rural board perspective, a healthcare provider perspective, what does that look like? If we could bottle all of those pockets of innovation from remote and rural settings, actually, how do we get all of that into one place, into one laboratory, if you like, to truly learn from that? We get pockets of it between ourselves, but if we could truly bring that together, I think that would be hugely powerful. Great, thank you. Gordon, is there anything you'd like to add? Thank you. I think there's three things, really. I think the point that both Michael and Laura have made about the breadth of practitioners that's needed for remote, so island healthcare, so I worked in Dumfries and Galloway and it was remote and rural. Island healthcare is quite unique in its health provision. For me, to give you an example, I was on-bar a couple of years ago with Chief Executive NHS Scotland and a GP that worked in Edinburgh and they were talking to me about the GP facilities and the GP service on-bar and we told them all the range of work that was involved, in particular the hospital work, the acute work and the retrieval work. That individual said to me, there is no way on this earth that I could even contemplate working in a location like that because the acuity of the patients and the presentations is just, I work in the centre of Edinburgh and, you know, half a mile away, I can just refer into the Edinburgh hospital, this is a completely different world. So the message there is, there's something about the type of practitioner that's needed for island and remote healthcare and when we go out to recruit for the bar of GPs, that'll be a real test of because it's GPs that will be looking after the GMS services, the hospital inpatients and the out of hours unscheduled care and I don't know how many of these particular people there are around just now but we're just about to test that. The second thing I'd like to see for remote and rural healthcare is a revisiting of the obligate networks. All our island systems are really dependent on very strong and good working relationships with other health boards. We've got relationships in the Western Isles with at least eight other health boards for a range of clinical services and service delivery but I'd like to see a revisiting of that obligation to keep that service up when the going gets tough. Sometimes we tend to see a pullback of it and we're very, very busy so we can't come up. So in rural healthcare that relationship and the sustaining that relationship is really, really important and the final thing for remote and rural healthcare is probably to try and take forward any single system working across health and social care where we can see the right type of practitioners being developed in remote and rural and island systems to provide because there's only one way in the islands and that is one system. It's too small to have multiple bodies trying to do the same or different things so anything that a remote and rural system could do to produce the right type of care provider and practitioner would be really helpful, thanks. Thank you. Can I just give one last question? That was really, really helpful. I was just wondering if any one of you have had information about when we might get some movement on the setup of the system. Have you had anything through the health boards? No, okay. That's helpful. Thanks very much. Thanks very much. If I can just ask one final question to the panel. Certainly when I was in Shetland a few years ago, one of their ambitions was to grow their own, that if you grow your own workforce people are already embedded in those communities, that they're more likely, if they leave to go to uni on the mainland, they're more likely to determine. I suppose I'd just be keen to hear if that's something that has been developed, if you've had any success with that and what perhaps challenges have been. I'll go to Gordon first as I see Edd's hand up. That's just such an important issue for us. We know that 54 per cent of people when they leave school leave the island and we know that very few of them return until they are in their 50s or 60s and the only return if they've got very strong family connections. Once we lose that 54 per cent, they're really lost to the mainland and other places. Very, very active just now in the schools in terms of we've got a summer programme just now where we've got multiple student summer posts offered out to the schools and the communities to bring people in and give them experience. We've had a very significant increase in apprenticeships and the movement forward in that area, that's again critical to us because we compete all the time with the offshore energy, the wind farms, the commercial sector, the hospitality sector here. We've put a big push into apprenticeships, but generally given folk experience, exposure, engaging with the schools and trying to reduce that 54 per cent that go off island and being as flexible as we can with the workforce in terms of working when they work, when they start, when they finish, we need to be carer friendly and family friendly. We can't just focus on the task that we've got. We've got to look at the person and then hopefully we'll be able to increase the number of people that stay and work and decrease that 54 per cent. Firstly, I just can't believe we've got to the stage in the meeting and not to have mentioned where you are. It's hugely important and really central to the conundrum we've talked about today in terms of addressing the workforce challenges we all face. Like Gordon, the trend in Orkney is that more younger people are leaving the island and we have a programme of work that we're just bolstering at the moment around growing our own, which includes some of the aspects Gordon has mentioned in terms of offering work experience, making sure those who come on placement with us have the best possible experience. One of the first meetings I had in my first couple of weeks was meeting all of those students who are on placement. Largely, it's a good experience, but there are things that would make it even better, so we know we need to invest more in that area. I'm already very clear that we've got some true stars of the future right in front of us at NHS Orkney. We need a proper programme to invest, grow and nurture those colleagues and a proper programme wrapped around that of succession planning in the organisation in a really systematic way, starting with the exact team down that we haven't in the organisation and that's locked into our plan starting from this year. Michael, do you want to comment? Yes, thank you. We've got strong pathways for healthcare support workers to be able to access nurse training, both with Robert Gordon University and also with Open University, Advantage with Open University. They don't need to leave Shetland to undertake their training. Of course, we support them on at least one placement on the mainland so they get a wider exposure so it's not just student-focused. It was flagged to me that the training GPs do struggle to be able to select their home board, if you like, if they want to come back home after they've done their key training, but as Laura says, and I have to say, I'm actually envious of Laura's got a very strong apprenticeship scheme. We currently share HR services across both Orkney and Shetland and I'm trying to steal that shamelessly because there's been some great work in terms of supporting people to be able to reach graduate level. We get really positive feedback from our junior doctors and our student nurses and that was highlighted in our recent board paper and we see that as an ideal opportunity. I know it's not traditional growing our own, but if people have that experience then they're more likely to come back, but we do think growing our own and that's about those people that are seeking to have a career in the whole of the NHS because it's not just health professionals, but also for those people who come and have an experience in Shetland and the breadth that gives them, they could easily be turned into one of our own and their future pathways. Developing, we've had two consultants that we brought on at a very early stage and worked with Grampian to provide their on-going support and development knowing that they will be our consultants of the future. Thank you very much to Laura, Michael and to Gordon for your participation this morning. Very much appreciated and I think he's certainly given us some food for thought, not only for the work that we're doing today but also for the future inquiry and I'm sure that once we're ready to progress that work we will be in touch with ourselves. Thank you very much and we'll suspend the meeting briefly. The next item on our agenda is a further evidence session as part of our inquiry into female participation in sport and physical activity. Today's panel will focus on island inequalities and additional barriers to sport participation faced by women and girls from marginalised communities and those experiencing physical and mental health challenges. I welcome to the committee Evelina Chin, CEO of HSTAR Scotland, which is a member of BEMIS. Lynn Glenn, Pathways Manager from Scottish Disability Sport. Baz Moffatt, CEO and co-founder of the WellHQ. Robert Nisbit, Head of Physical Activity and Sport, Sam H and Heidi Vistison, Policy Manager at Leap Sports Scotland. We're going to move straight to questions and I'm going to go to Gillian Mackay. What actions could be taken to better enable women and girls with disabilities to take part in sport and physical activity? I think I'll go to Lynn first if that's okay. I think it's hearing the voice of the young girls. We've got a great leadership programme. We're working in partnership with Sam H with and from that it's about listening to the girls, hearing their voice, making sure that anything across Scotland that represents physical activity and sport has explicit imagery because the message that the young girls are telling us is that if they don't see people like them playing or images of women with disabilities playing physical activity and sport or doing physical activity and sport, it's not relatable. We don't think it's for them and then there's the whole issue of body awareness, body imaging. So I think we need to get to a place where we listen. We hear the voice of young people and use more imagery, more explicit language around encouraging young females to participate in physical activity and sport and it's about working in partnership with other agencies to spread the word and encourage more young girls and that goes from a local level with local authorities and trusts to governing bodies at a national level and other third sector partners that some of which are here today. Coming back to that imagery part is well remembering that not all disabilities are visible and they affect different people playing different sports in different ways as someone with a vestibular related disability. How do we get some of those voices out there that doesn't fall into the, which is absolutely important, that we raise the people with different physical impairments as well? How do we get those less seen impairments out there and how that affects people's participation in sport throughout their lives? Absolutely, so it's about working in partnership and we have to reach wider and that's the challenges getting the message wider to more people but we're doing a lot of work with, we've got a national visual impairment sport group, so we work with the sight loss societies that support people in the ground and that's where it has to be, the connection is about connecting with agencies who are working locally with people in the ground because it's that extra support that's needed to get young people, young girls involved in physical activity and sport. So for me it's about working with the third sector agencies working with health and education because health and education are the two places where mostly everybody will, they will access their service from health and education so we need to keep getting the messaging and being clear about our key messages that sport and physical activity is for everyone and encourage more people to get involved, does that make sense? Yes, absolutely, I think Robert was looking to come in. Yeah, I was just going to highlight in terms of the work that we have engaged with Scottish Disability Sport about, and it goes back to my number of points that Lynn is making around the role models and us telling those stories and enabling people to see that in our work, particularly around mental health and disabilities, we've focused on hearing what people were telling us about that. Those individuals, those, for example, one of the programmes that Scottish Disability Sports does, the Young Start programme that we worked alongside with them, where they focused on mental health. Mental health was a huge barrier, a huge issue, often hidden for people with disabilities and with that work in that partnership and those young people's voice we were able to identify what those areas were and design programmes and design education around those particular areas that really helped to shine a light and bring greater understanding. Again, going back to the point that you're making, which then allows people to see themselves within that space and allows others to actually understand what that means, which again creates space to create greater participation in sport and physical activity. Just to come in there, there's two other points. One's around education and training, so we deliver inclusion training within every tertiary institution across Scotland. It's a really fragile programme because it's funding-dependent. We access the money to deliver that programme free to the universities, but it means that every PE teacher or classroom teacher is being trained up to offer inclusive opportunities within school. The second point is around we have a girls-only, we have the governing body for BoCHA as well, so we have a girls-only programme for BoCHA to encourage more girls, and I think we're working in partnership with more governing bodies who are now recognising that if you build it, they won't come that approach, and we need to have proactive interventions for young girls to participate, so girls-only programmes, we're appropriate as well. Do you think at the moment we're doing the work well in terms of joining up the physical health aspect with mental health with other issues as well in terms of that cross organisation working and recognising that individuals will have varying impacts from different parts of their life, or do you think there are areas within that that we can do better? I think we've got some really, really good examples of where we are engaging young women and women with disabilities and people who are able-bodied, and we are listening to that voice and we are designing programmes that are focused on, so designed by young women for young women, designed by young people with disabilities, young women with disabilities for other people with disabilities so that that grows, so I think we're taking really strong steps towards that. Of course we can do more and of course we can continue to look at what the research has done on us, the voices of individuals and then designing the right programmes. Lynn highlighted about funding, we continually look at funding, we continue to look at the way that we can create opportunities within those funding. Some of the challenges around those in terms of programmes is the short-term nature of those funding and we would continue to advocate for longer-term funding to allow us to really reach and engage and ensure that we are creating a real participation pathway for young women and women to be involved in physicality and sport. Looking at person-centred approach and giving opportunity for women to raise the voice and share their experiences is very important but we also believe education for those who respond is a vital because very often through the decades we were in position when we heard the voices and actually nothing appropriate happened after and it's not because someone was not willing to, there was a lack of understanding and follow up the inquiry to provide the right action. HSTAR works with so many women from ethnic minorities so I believe when you look at the disability apart from the physical, when we focus on mental health well being we need to realise this is a kind of complex city. Having a mental health problems, issues, struggles will be different for Afghan community, different for Ukrainian community through the religion beliefs, the way how we respond, how our body responds and I think we should be very well informed and Scotland is a beautiful place of great diversity so the knowledge needs to be there. Robert, just to touch on something that you said there as well, you talked about examples of actually working with people to design the spaces so I'm really interested in hearing more about that because training, education can take us so far but to what someone shows is something entirely difficult, entirely different even and that poor design and accessible infrastructure it can really tackle it so I'm wondering if you've got any examples of projects where people have been involved in the co-design and it's resulted in an increase in the numbers actually using and accessing those spaces. So there's two very strong areas that I'd want to highlight within that space for the last two years in Samhich. We have been developing a young women in leadership and sport leadership that really looks at the importance of leadership and the importance of mental health within that space. We've worked with a group of young women who have become an expert panel for us in that the looked at design in a programme that really addressed the barriers, issues that young women were facing within sports leadership or leadership as a whole. We also got, there were 74 women, young women who got involved in a survey with us and gave a rich sense of data that helped us to really focus that programme and within that we recognised the big areas that were coming through where self-belief, self-confidence and self-worth were strong barriers that were impacting and influencing young women's engagement in leadership. If we also look at the problem that we're trying to solve there, Scottish women in sport and one of their reports identified the gap between men in leadership and young women in leadership was widening and that was the area that we wanted to tackle. Those young women alongside my team and alongside a variety of partners helped to really design a programme that embedded leadership and mental health together and I'm really proud to turn around and say that we will be launching that shortly and we will bring in that across the whole of Scotland including the islands and the rural areas and the central belt bringing young women together so that's a real example of the voice of young women really shaping that has helped us to drive a programme and we will see over the next year young women really tackling those particular areas to have self-confidence, self-worth, self-belief. The other big area for us is women in menopause so we recently launched just at the beginning of May we launched our report with the University of Edinburgh and we had over 600 women shared their experience of menopause and the impact that it had on their mental health and the influence that had on engaging in physical activity in sport. As a result of that research and the findings that we have, we have now put nine recommendations out there for people to see. We are working with partners to bring those recommendations alive. We are speaking with Government and different individuals around that so that we can help shape and influence the practice that's there particularly around things like menopause friendly groups and activities and resources. We have got an expert group of women who have experienced menopause who are going to help shape and design and develop resources for women experiencing mental health and experiencing menopause which will then mean that we will be able to really help to influence shape practices out there right across the communities. So those are a couple examples of where we are really targeting this particular work which is based on research, based on the voice of women, young women, women experiencing menopause that will then make a difference within communities. Can I just come in there as well just around a project that we put in place and it was a pilot so it was particularly, it was through access and funding for a specific project and it was a project called Lady Goga and it was get out, get active so it was Robertson's trust funding and it was a UK wide funding but really it's about and it's a point around people understanding who is accessing physical activity in sport and I don't think we're quite there in Scotland where people understand that females are less, you know the participation rates are less or less or you know ethnic diverse communities are South Asians participate in sport less so the Lady Goga project gave us a bit of a resource, a bit of an intense approach and really the outcome was that we went from four valley area one in three so the ratio to one to two and ratio so it demonstrated for us how having a specific project targeted specifically at females can then encourage more females and obviously the group of women that weren't on the panel from four valley disability sport were then able to shape that programme and say right these are the activities we want so again it comes back to the design of activities by the women themselves saying what they wanted so the positive outcome there was the increased participation from females. Just conscious that we haven't heard from Baz or Heidi so I don't know if there's anything that either of you would want to contribute to the questions that have been asked so far. I'm happy to go I was just waiting to see if Baz was coming in online there. Yeah I think especially going back to some of the things that were said about the access to facilities and making sure that oh I'm trying to make sure that I don't lose my thought here you pulled me at a time I wasn't ready no we're talking about data we're talking about knowing who's participating and understanding that actually there are groups of people that we aren't aware of and we don't know how what the levels are of their participation and I think that's really an issue that we're seeing across the work that we do with lgbtiq people and specifically with lesbian bisexual and trans women in sport so we have some data and a lot of that data is coming from us as third sector organisations so with partners from across Europe or the rest of the UK however we don't know what's happening across different individual sports unless those individual sports ask those questions and ask for that data so there's no centralised system where we can say okay well actually the levels of athletes or participants we've got a mental health impairment or a who might be a lgbtiq or who might have a physical disability or anything else so it's really that that's really a point that we would recommend that the the inquiry would sort of look at and make sure that that's something we're looking at going forward but I think I'll probably leave it there and see if that's what's coming in maybe yeah thank you can you hear me yes you can hear me i think yeah okay perfect hi what I wanted to focus on was to go back to the educational aspect that we've been talking about and we have been doing some work with simspa and for those of you that don't know what simspa is it's the chartered institute of the management of sport physical activity and it's a UK wide organisation and it's responsible for setting the standards from which coach education whether that's vtex fitness professional fitness qualifications sports coach education they set the standard from which then qualifications can be written there hasn't been anything in the female health space so the only standard that has existed is in the pre-imposed natal space and so all the all the courses that are on menopause or training teenagers they don't have a standard to adhere to so there's been a real issue with regards to what the quality of the of these some of these qualifications are and in addition to that there is no standard level of education on female health in anything so like a PE teacher a fitness instructor a swimming coach a rugby coach a running coach they will they won't have any education on the on female health appropriate to their level of education as standard so you can go off and do a specialist course but you don't know if that's a good course or a bad course because there are no standards so this summer we've written the girls and women standard with simspa has been out for public consultation we've had input from lots of brilliant agencies working in this space and the standard is going to be published over the summer and then that now means that whenever anyone is wanting to produce a new coaching course or qualification and they they can they got a standard from which they can work out what they need to include or not in that and I think this is absolutely essential and I think that we can encourage people and we can do all the positive stuff around you know and like advertising of a health promotion and engaging females better but until we have a workforce that are educated about females we haven't created a system in which females feel that they truly belong like and even when you you know whether that's females with disabilities females from different cultures and backgrounds it's like until we create this education around female health covering all the live stages from puberty pre-posnate or menopause periods bras pelvic health like the way that the increased risk of injury all of that until all of that is kind of implemented into our coach education actually it kind of in my opinion doesn't really matter how much promotion we're doing to get girls in like until we educate the people that are going to be looking after them we're still going to be seeing this gender gap when it comes to participation and performance within females thanks bas that that sort of leads us very much into the into our next theme which I hope then how you'll come in on and I'm going to pass to Tess White on women's health thank you convener I've got one question but I'd like to just follow up on that what you've just said bas so I'm going through the coaching qualification right now and you have to do child protection anti-doping first aid are you suggesting that in addition to those and mandatory three models there could be a fourth module on women and girls I absolutely do think that but I also feel that it's on the same continuum as welfare and safeguarding because I genuinely and we just come from a sports lawyers conference and I and there's so many representatives from safeguarding there from lots of different national governing sports national governing bodies and that they had this penny drop moment where they were like oh if we get female health wrong then it becomes a safeguarding issue and so I think that instead of because often it can be presented as a conflict so it's like well if we put female health in what needs to come out whereas actually if we consider it as well-being and safeguarding as part of the same thing then we're not competing for space on coaching courses we're saying actually this is something that just needs to be integrated into it thank you and then a separate topic so we did go out to talk to women and girls doing sports and they raised the colour of their sports kit so we know that sport is is good for physical health but mental health and they talked about the huge anxiety that they feel about when their periods are coming so it's not just when they're on their periods but you know sometimes you don't know when it's coming and that stops them doing sport but some some organisations don't see it as an issue and it's not spoken about so what in your opinion what further steps could be taken to minimise the impact of periods on participation in sport and physical activity thank you yeah thank you tess I think that also you should broaden that it's not just the girls competing in sport it's the umpires it's the referees it's the it's the middle age women that are often expected to wear white shorts or white skirts or you know light coloured clothing and as we know that when you're entering perimenopause that your periods become really erratic too so that age group is so we're losing coaches and supporters of these women being active too purely because of what we're putting them in and I think that the light coloured shorts whatever you know whatever their bottom half of their kit is is that it's what I just consider low lying fruit it's something that could have been easily easily changed we need to be far less prescriptive in terms of what we are expecting our our young people and our people involved with sport to be wearing and needs to be giving everybody options so they feel genuinely comfortable doing the sport that they're participating in in whatever role that is um so I think that's absolutely a really easy win and I think but I think it's not enough and I think that's you know often people say oh we've changed the colour of our kit from white to blue we've done female health um so that the so let's change the colour of the kit and I know that in Scotland you do an absolutely brilliant job at making sure that sanitary products are freely available in all public places but we need to make sure that wherever girls are moving that they have really easy access to free sanitary products without having to ask anybody or unlock a locker or have a you know a conversation around that um and then I think that um the other the other things that we can do is educate girls around educate girls and those who are supporting them around how important the menstrual cycle is and how it is a vital sign of your health and if you are having a regular menstrual cycle then that's your body's way of saying brilliant you are doing a fantastic job you are eating enough food you are being active your body is in balance it's coping with the stress and the strain that you're putting on it um and educating girls around uh like how healthy it is but also when if if they are experiencing either heavy menstrual bleeding which we know 30 percent of girls and women do or they're having problematic periods so they're having to kind of like that their their symptoms are really affecting their their ability to engage in life whether that's education or sport or music or whatever that is um that we that we explore we have lots of tools available to help them manage their problematic periods or their symptoms and we don't just send them to the GP and put them on the pill and it's that kind of what can we do in terms of and sports coaches can cope with this it you know you'll put an ice pack on a sore knee we can put a hot water bottle on a tummy while you know while we're getting the team warm up so it's making sure that people have all the tools available to help girls manage their period symptoms thank you does anyone else in the panel want to comment Evelina I just would like to add something like the importance of dynamics when we talk sport we you know running a marathon being active in lifting weights it's not only the sport if we are here to empower and encourage women especially young girls who struggle with the mental and physical side of menstruation it doesn't mean we need to discourage them by not allowing them to participate excluding them this is also bringing the right dynamic of accepting of milder exercises of bringing a substitute of activities so they still follow the inclusion they still protect themselves they still do something great they still develop the physical skills they still active but what is requested if they fit if they okay if they're not bleeding is not relevant now so they feel full fully active participants of the activities yeah thank you we know from lbt women that being part of sport really is a part of their bodily autonomy and that the way that they are taking part in sport and the way that they're using their bodies really helps them find them find themselves and and feel good in who they are so i want to go just back to the sort of comments about kits and shorts i think it's much beyond the colour of the shorts i think it's much more about making sure that it's okay for participants and athletes to wear what they want to wear i'm sure lots of people are aware of how a women's kit shirt or a women's football shirt is probably more fitted than a men's one whereas actually it's it's just a sign to teams what they're supposed to play in they're supposed to play in these women's shirts that are tighter and fitter and shorts that are shorter rather than longer so i think it's a it's a recommendation of making sure that people are able to wear what they want to wear i think specifically when we're talking about non binary and trans people as well is making sure that they've got something that they can wear and they feel comfortable in they are more likely to sometimes wear clothes that's baggy or they maybe don't want to wear specific colours and it's really just about having the flexibility to be able to do all of that within different sports and settings as well robert did you want to come in yeah i just i just wanted to pick up and emphasise something that bas was talking around education what what we know from the menopause report that that came through one of the things that came very strongly through from the focus groups and the women within the focus groups was the importance of education around menopause for them themselves and many women were highlighting so the point that bas was making about those life stages that if they knew particular things before their experience of something that would have really helped them within that experience to then you know particularly maybe engage in sport or physical activity and recognise it's a tool to support through that experience as well so education is hugely important not just education for organisations and services to think about how they can create inclusivity within their groups beyond just policies but be really intentional around the approaches that they take that involve and a big part of that has to be to understand what it means and let me call it Heidi was was saying there about what that means from someone who has experienced a particular barrier who because of their situation that a kit or other things can really help to break down those barriers so we have to make sure that we educate beyond policy and actually look at practical application that is really intentional across the sport and physical activity communities to move to everyone who has got a supplementary on this thanks convener yes do we actually know our coach is being trained to understand how cycles are hormones impact performance and how are we helping young women and girls to understand these changes that can happen to their performance and why and I saw baz shaking her head there maybe baz would like to come in yeah thanks Evelyn no in summer we know they're not there's no education and I think that you know people in this room they say well I know a coach that knows about it so there may well be coaches going out there and finding this information out themselves but there isn't any standard education and that's why we do need to have it mandated that you know that coaches understand the hormonal cycle that the monthly hormonal cycle that females will be going through only 6% of sport science research is done exclusively on females now I when you hear about you know when an athlete pulls up or one of the footballers gets an ACL injury they'll say oh there's not enough research being done and the issue is saying there's not enough research being done is it lots of people then think oh well there's nothing we can do until we have the research but if we just focus on that that 6% of research done exclusively on females covers everything to do with females so it's pelvic health it's breast support it's hormones it's all the life stages we go to it's our injury risk there's a very little there's a really small amount of research from which we can start doing stuff but we're not even we're not even addressing that research at the moment we're not even using the research that we've got so we can we can do a huge amount there is no one no one's told about menstrual cycles no one's told about female health I mean we know that not even gps it's not even a gps are now like don't have as much information around women going to the menopause that has brilliantly changed recently but it absolutely hasn't filtered down into the world of sport and exercise and that's something that you know this standard that we produce from for sims but we've also produced we've produced four courses aligned to the female health stages which are that we've got a course on the female body a course on puberty a course on pre-imposnato and a course on menopause and what we truly believe is that we can demedicalise women because at the moment female health is very much in the hands of experts it's in the hands of gynaecologists women's health doctors academics who really truly understand this and we need those people we need these brilliant minds kind of doing all of this fabulous work but what we feel is that actually everybody can cope with understanding around female health on a level that is appropriate to the people and the populations they're supporting so as an example you know a 50 year old man who's coaching an under 14s women's football team doesn't need to know about the technicalities of sports bra or how to fit a sports bra but he needs to know how can I have a conversation with my you know with my 20 and my squad of 20 girls around what why they need to be wearing a bra and feel safe and appropriate to have that conversation and not but they're putting themselves at risk and so that's what that's what we're attempting to do is to kind of like get this education in place so that everyone feels because the majority of girls are coached by men and the majority of fitness trainers and the majority of sports coaches are men so we have to create education which everyone feels they can access and doesn't put themselves at risk having not had a lived experience or feeling that they may well be inappropriate. That's me can be honest. I'll pass to Emma Harper who's got a supplementary too. Thanks convener good morning to you all it's just to pick up on what Heidi said about uniforms in the last session I talked about the Norwegian handball team that got fine 1500 dollars because they wore shorts instead of bikinis right wow they they broke the rules right because they wanted to wear something that was more comfortable and then there was a German gymnastics team that wore the full length unitard because they were basically didn't want to wear the you know what was prescribed as as normal and in reading one of the articles from sportsanddevelopment.org talks about recent conversations around women's uniforms having have highlighted deep rooted sexism that often prevails in the sport and field so it's a question for Heidi and even bars is how important is it that we recognise that what women wear on the field for sports or physical activity needs to be their choice and not some kind of prescribed mandated historical sexist approach. Yeah thank you and good morning to you too I think I think especially what I just said there earlier you know that autonomy of being able to make your own choices and deciding what you want to wear you know we see people coming out wanting to make choices for themselves about what they wear and we also we see the the expression of their gender we see the way that people want to show who they are we have this idea of women having to look feminine that a real woman looks feminine and therefore we must put them into uniforms and full full gymnastics outfits and bikinis that recognise that and all of these decisions are made by leaders within sports governing bodies or within competitions that are all led by men and so I think this inherent misogynistic and sexist nature of how these sports have been set up and how they've been run for decades or hundreds of years to simply just filter down through how people are expected to dress and how they're expected to behave and I think that's having a really detrimental impact on all women and probably all participants but also especially LGBTQ participants in the way that they are expressing their often their sexuality and their gender in the way that they in the way that they dress in the way that they present themselves and and these sort of prescribed ways of presenting in a sports nature really has an impact on that. And we're going to move on to our next book I think that I was just going to say sorry I didn't I've got nothing else to add to that I absolutely agree that like and I think you know you've got a conversation to have when it becomes a team and when it becomes a there will need to be a unity in terms of like the look of those people involved with that team but that can be that nobody that that conversation can absolutely happen and we need to be giving people options to be wearing when they're doing their sport and activity. Thanks so we're going to move on to our next theme which is LGBTQ plus participation and I'm going to come back to Tess White. Thank you convener a question for Heidi if I may Heidi. So women in sport highlight that adult males have 40 to 50 percent greater upper strength, they have 20 to 40 percent greater lower limb strength and they have 12 kilograms more skeletal muscle mass than women and that can have implications for trans inclusion in women's sports as sports councils and governing bodies are finding. So how would you strike the balance between inclusion, fairness and safety in women's sport thank you. So I just want to highlight a couple of areas within this so I want to be completely clear trans women participating and competing in sport has been presented as a threat to women's sport on the basis of some of the evidence that you're sharing today Tess. I don't believe that there's any evidence that this is the case trans gender athletes are not and have never been a threat to women's sport and I don't know the direct evidence that you're sharing just there and the evidence that you're sharing in that way however we believe that trans women should be able to participate in sport and there are obviously areas where you want to consider any of the evidence in terms of participation and there might be areas where there should be restrictions on participation however any blanket exclusions and bans on participation of trans women in women's categories is not something that we would stand for. May I follow up that that's actually not asking my answering my question Heidi please my question was how would you strike the balance between inclusion, fairness and safety in women's sport thank you. Okay so I suppose I would disagree that that's a balance that isn't possible to do in what I've just described in the sense that if you are using the the lawful measures that are already available in terms of restricting access when necessary then that's how you strike the balance between fairness and inclusion that the participants of transgender people are able to participate where they would like to and any restrictions and policies that are already in place should be followed then that's the access that you'd be able to do in that sense. So it's not my final point it's not really answering the question of how you strike fairness balance and safety but we'll leave it there thank you convene. Well thank you Tess I am it might be worth for us to pick it up separately and I can answer your question better if that's all right. How do we ensure that we support trans people and non-binary people in particular because they're often lost in some of these conversations to participate in sport and on-going physical activity as well much of the inquiry that we're having is about physical activity and obviously some of the some of the issues we've seen around the way trans people are portrayed in the media and non-binary people are as I said often excluded from some of this narrative. How do we allow those spaces to be safe for them? How do we allow gyms particularly and and participative classes to be safe for these people? Yes thank you I'm assuming that question directed at me as well sorry no that's all right yeah thank you I think what's really important is that we we still see them as other people so you know we've we've heard from others today that we need to just make sure that the voice is heard of all of our participants and all the people that access our spaces so it's really making sure that we've got the indicators in place to be able to hear from people instead of saying well what is it you need why are why are you maybe not participating in this area and you know we hear about young women and girls who stop participating at a higher drop out rate than boys when they're 14 that's the exact same you know we ask we figure out what's happening what can we do to support you and where the levels of barriers that you're you're meeting in terms of very specific things you know we're talking about kit and uniforms and we're talking about changing villages and making sure that there's spaces that are relevant for for people to be able to to change in a safe space and making sure that there are spaces where people can can interact as well in that sense just come in there as well around and and I guess it's the whole intersectionality conversation and in Scottish disability sport we have an inclusion model that really can be used for anybody but it's about that participant-centred approach and it's bringing you know it's about listening to people it's bringing into the table all the ingredients that they need to participate in physical activity in sport and we also have a regional team who provide that bespoke support so should anyone who wanted to take part in physical activity in sport or come in through a physio referral to us and you know no matter their background or socioeconomic background or you know if they were if they were gay if they were from an ethnic diverse background or if they had poor mental health then we would work with them individually to support them into an opportunity of their choice and if changing places was it was a consideration that would need to be looked at if it was equipment if it was kit then our regional manager would provide that bespoke support and I guess that's something that we're all going to see across the board here is that it's about having that participant-centred approach it's about looking at it through intersectionality and not just in individual silos around you know different protective characteristics because we don't want to get into that that pecking order or you know bun fight for for status or whatever so for us we simply use our activity inclusion model and obviously when it comes to competition that's when other considerations come into place but in terms of general participation it's about having that participant-centred approach and using the model to bring to the table whatever that individual needs to access physical activity in sport and remove the barriers Sandish Gilhane has a subject thank you actually Lynn I would agree with everything you said there about ensuring that we try to get everyone in sport because we know it helps mental health we know it helps so many things and I think with the stigma that comes it puts a barrier in the way of people wanting to participate in sport from the LGBTQ plus community can I turn Heidi I've got direct questions I would like to ask in response to test white one of your responses said when necessary so where is it necessary so you'll you'll see from from guidance around gender affected sport and you'll obviously well I'm assuming you'd be aware of some of the UK sports council's guidance and we are under no illusion that there might be a competition and sports where you would need restrictions however we would always say that sports governing bodies should be making these restrictions based on the evidence available and make sure that they are based on actual information and research that would make make sure that the impact is is considered and my question was where necessary so yeah the the response you gave to test white you referenced where necessary could you give me some specific examples when necessary I'm afraid I can't because I can't give you any specific examples of specific sports so I think and apologies that might have been me broad-stroking an answer in that sense what I meant was making sure that we aren't just blanket banning trans women from a sport however we are potentially putting restrictions in or putting in supportive measures that mean that if you are able to meet specific levels for example to testosterone however I don't think that that's always necessarily the best measurement that if you are able to meet some of those you are also able to participate so that's my apologies if I've used language that's not completely clear however I'm not going to be able to go into specifics about where restrictions would be would be necessary however I do believe for supporting and inclusion and highlighting participation of specific trans women of specific people that it would be useful to have supportive guidance and measures in place okay so so for example if we look at anyone wanting to train to be a runner or an athlete there should be no barriers and training but when it comes to the competing side of it world athletics have said that trans people can't compete in women's categories so would that be an example of where the governing body has said something and that is a something that is what needs to be put into place at the more junior levels we are unfortunately seeing a trickle down effect of policies that are being put in place at a at a world level or a competition level however in many governing bodies that doesn't necessarily mean that the home nation so for example Scottish athletics or British athletics needing to follow that exact policy they can still in place their own policies in that sense however because of the focus on this at the moment there is a worry that the individual grassroots sports or the competition levels within the individual countries are being influenced by these policies that are coming on the world stage and I don't believe no that because of a world athletics rule set that a competition levels will be directly affected unless put into restrictions or rules within Scotland okay and my final question if we look at participation in sport for everyone who plays on whatever level that you play at so it's you know if I want to play squash I want to be playing that against somebody who's sort of at my level and I want the playing field to be level in everything that we do because sport inherently isn't fair you know there are categories in everything so do you think and I suppose this might might not be this might be your personal opinion might be your leaps opinion but do you feel that trans athletes have an unfair advantage in participating in competition compared to biological women no I don't thank you thank you we're going to move on to our next theme ethnicity and religion and I'm going to come to Emma Harper thank you convener it's kind of similar to what I was asking about earlier but I'll come to that as far as uniforms as well but I'm interested in what you think the particular challenges are for women and girls from ethnic minority groups to participate in sport and I think there are obviously real challenges and when we look at some of the statistics that have come out it's it's quite apparent that ethnic minority girls and women certainly don't either have the opportunity or even engage I'm I suppose Evelina I might come to you first on this one thank you definitely when we work with the female from ethnic minorities we need to understand the culture we need to understand religion and we need to respect what is linked to be who they are in terms of sport activities very often we receive very upset voices of young girls saying that having a hijab or scarf may affect their participation but they are okay with it what is not acceptable is the response from the peers and coaches who trying to encourage them sometimes they actually cannot understand this is a part of their being we need to understand that we can't change somebody's existence somebody's values based on the needs of the sport activity when we talk about changing rooms or same sex activities as as much we do support transgender women and we provide the therapy for them we need to follow the needs and requirements of let's say Muslim community where transgender is a table when it's very very hardly to understand which doesn't mean there is lack of respect or acceptance no in terms of sport or physical activities especially our Arabic clients our Pakistani girls they really need to be safe having same sex activity having opportunity to be surrounded by women only it is crucial for them to be heard as well and accommodate this when we look at other ethnic minorities it's not only Muslim community or Arabic community this is also Eastern European community which by engaging in a sport will look at things differently I'm a Polish person so I can really tell you that being a woman is a kind of dignity I would like to protect and I could not really feel free of not having opportunity to go to female toilets this is very basic need human need but I would like to be heard and understood and I love everyone I love human and I'm happy to support everyone who needs the support but ethnic minorities women needs to be heard as well and they rights they religion they beliefs cannot be violated by pushing a general agenda just because we need to be general so we getting back again it is very hard to find a gold solution for everyone but I believe by providing person centered approaches we are able to come to great solutions so in terms of the question that you asked there we also worked with on our partners Scottish Athletics and Jogh Scotland to create a project called community strides that aim to increase participation from people from ethnically and culturally diverse communities but also blend in mental health awareness because we knew there was massive stigma around mental health for for that particular community some of the things that we identified through working with community champions and community leaders from culturally ethnic diverse communities was the influence of religion the belief about clothes and how you wear clothes so short sleeve clothes to take part in sport sport or physical activity was a big issue and we had to address that we were really lucky that from that voice of people from that community helped us then to work with others to actually get sports clothes that actually covered the arms covered legs all this kind of thing that that meant that people the women could participate in that even the environment was something that we looked at so we had to look at a closed environment because the idea of people watching was a really big issue and a real barrier so we had to think of those particular areas within it but again what I would say is one of the really big solutions was about community leaders and community champions from from those communities who came in and helped to influence and shape the approach that we took so we have to do much much more of that where we are involving people in the co-production the co-design of projects that recognises those barriers and then finds the solution to it that means people are then far more engaged and to give you an example of that particular group of women there was about 12 women and because there was a champion within that group because of these activities they then went on and joined jogscotland networks so 12 of their women went in and joined the local group because barriers were broken down they felt included they were you know they were involved in the whole design and they were involved in what it meant to go elsewhere so that was really really important and again that voice is so important to listen to that recognises all those areas what you're saying about the environment about having the ability to participate without others watching I know there's a women's only gym in Dumfries and it's and the music coming out of it when I walk past with the dogs is amazing and I think that do you think having you know recognition of what we're talking about today is about how do we encourage women and girls to participate in sport having the ability to participate in a safe place without fear of being judged without fear of somebody criticising you for wearing a hijab for instance we know it's really now easier to buy sports hijabs and so do you think that would be part of the progress towards more awareness of and accepting of women from ethnic minorities participating in sports so get the rock music on and have a women's only gym I think I think the reality is that you can have a fantastic venue and you can have fantastic equipment in that venue or fantastic individuals but you have to reach out to people to help people to reach in so we have to listen to what that what that is and hear what is going to support someone to get to that particular place so we talk about three areas within environment about the culture of that environment as well it has to be safe it has to be secure that recognises the point so we covered windows that that meant people felt safe within that particular space and it has to be supported so as as my colleagues around the planet and buzz was talking about if we educate and we help people to understand ways in which they can bring those environments alive and be supportive we are going to see more people engage in them because their voices been heard and they're coming to spaces that have been designed and developed to take all those things into consideration and it's about choice as well and it's about choice in a way that people can engage, participate and achieve within that space. It's also as you mentioned when we think especially about a Muslim community we have the girls cannot do sport because of but in sterling we have extremely busy role-skating group and every session is fully booked and there is over 20-30 young people skating and you would not believe how great it is why it happened because we heard the voice because there was a need of organising this. We provide walking therapy, a group walking support and this is a beautiful act of inclusion it's not very heavy sport activity but this is the promotion of healthy lifestyle and we have groups sometimes of three women sometimes 14 and we go for a walk and we do breathing exercises and we do the grounding exercises and sometimes the 40 women are coming from 14 different countries so there is a lot of opportunities we can bring by the listening to the voices as Robert said. Just a wee final one so inclusion is an absolutely great way to tackle racism you know when we live in the same communities and work in the same communities we learn from each other what specific things do you think could be implemented to tackle racism in sport whether it's religious related or just the fact that some people don't understand certain cultures? It was looking at the hate crime strategies and I believe that was really great time and very meaningful documents created. There is still a lack of understanding what is a hate crime maybe if we could start from it raising awareness it's not only the verbal abuse we can fall into the hate it's not only the physical violence which creates the hate bringing awareness bringing a knowledge again as a part of education understanding what is a hate crime help us to understand all the aspects of racism and brings the importance of learning about other cultures and religions. I think what everybody is saying here is absolutely spot on but we need places for people to go and participate in sport and where you have smaller groups taking part there's a whole as you'll be aware you know the leisure facility crisis that's going on at the moment but we need places for people to go and play sport and where there isn't you know we need to we never get massive numbers to begin with but if if programs don't wash their face to begin with they're not allowed to grow and develop and we don't hear the voice of the people and that's where at the moment we're facing great challenges as we cannot find facilities for people to go and participate in sport and that's going to get even more because of the challenges faced within leisure facilities at the moment and you can understand their challenges but as a result of that and it's the wider health inequalities that are taken place at the moment people with disabilities in other groups as well have been the hardest tip by Covid we know that people with disabilities are the direct correlation there around affordability and employability and again it links back in to people from ethnically diverse backgrounds as well because employability is a real challenge as well so affordability comes into it there and you know we know that Muslim women and men were hardest tip with Covid as well so the health inequalities are getting greater we need places for people to go and participate in sport we're finding challenges with that and it's just really to make everybody in the room aware that that if we don't do something these health inequalities are just going to get greater and greater and it's a plea you know it's that income versus and and if you get two or three women together with disabilities in the want to grow program that's cut short because it's the programs the the facilities aren't working their face and that's that's a barrier that is a barrier thank you my first question and I just want to one word answer if that's okay and I might just go down the line do you hold data of the ethnicity of people who are in your organization so Heidi can I participate in sport in your organization not across the board no Lynn I assume that you don't worry you don't have that same it would depend on the program that are delivering and whether it was part of the processes the evaluation that we were doing so yeah we will have elements of that within the work that we do you do you do so you know I've asked many different people the same question from elite sport through to other areas and the answer invariably is no they don't hold records so if we don't know the ethnicity linear groups exceptional if we don't know the ethnicity of our women who are participating in sport how could we how can we know how to do better I think the basic information is a key for providing the right response part of our work is a something called intake assessment process when we need to gather basic information to provide a safe service getting to know the ethnicity as an integral part of bringing trauma sensitive person centered approaches we do not offer only free counseling in 26 languages but we follow the individual needs the intake assessment doesn't give us only information about the family status social inclusion ethnicity but it identifies the individual needs after the process of provided service is it advocacy befriending counseling therapy walking therapy no matter of what the person will define is needed we will follow up the feedback and the feedback is just bringing a solid evidence of how well we did but also how the service has made an impact of every individual person but then when we put the statistics via ethnicity let's say for Ukrainian ladies we can clearly identify which kind of activity works the best which kind of service is the most accurate for this certain group so I believe gathering basic information should be a part of every organisation work and actually something you said earlier but I don't think I want to highlight again you said that the culture is different so you highlighted Ukrainian women you highlighted Muslim women but we're also talking about different types of Muslim women you're talking about all the different ethnic groups are different and the data you collect will help you one of the things that there are two big things that I would like to ask about one is encourage how do we encourage more ethnic women into just doing some sport whether that be the gym or participation but then also how do we then get these women to be elite women so Lynn because your organisation has the data can I ask you first yes sure yeah it goes back to the voice it goes back to the opportunity it's that supported participant centered approach and working in partnership with agencies so that we can increase the reach but it goes back to the imagery the language the relatable opportunity you know whether it's the gym that people go to and it's women only so and it has to be fun that's the biggest thing it's fun and social and I think that's something that's been missed from the conversation today it has to be fun it has to be social and then it's about that opportunity to then dip your toe in a club or an appropriate competition in disability sport we support people into to access and competition access and opportunity and we've had some good examples in the past where we've worked with Scottish women in Scottish athletics where it's female only camps we bring people together and then what comes from that is peer support and then there's also an element of rivalry there as well in terms of progressing within the sport so for me it's partnership working it's participant centered approach it's listening to the individual and putting in place what they need to progress there's there's I think I think there's a whole variety of it's a very complex landscape to look at and we have to understand as we've said earlier about the needs of particular groups and how we engage and we need to start young you know we need to be thinking of it not sometimes we have to react to situations because we become aware of a need and we respond to it we need to start to be much more prevented and much more proactive at earlier stages so that that is a focus of where where we go the other aspect I think is is also recognising what is that need and what are the barriers to participation for particular groups because we can't take a blanket approach to that we have to be very specific with particular groups and see where their need is and respond to that appropriately and as part of that we also have to empower young women women to see themselves in particular places as well I think that's really important because in our research and in the feedback that we've received from women is that that sense of impact on self-belief self-confidence and self-worth are huge markers so the stigma that's associated for mental health for women and that experience of that are barriers that are preventing people young women and women seeing themselves in particular places so if we are going to really empower that we have to think at earlier stages we have to think about being proactive about that we have to think the language that she is we have to think about how we create those environments that are exclusive that are beyond just as I said earlier a policy that is intentional in your approach to do that and again if we look at what others have said in the panel how we educate how we connect and the way that we design programmes by the people that we are trying to support in this case young women and women has to be a big player in that and earlier on one of the things that was spoken about was that was the idea of role models we have to shine a light on role models that people can relate to and see and help them to understand not just what their story is but how they then got to a place that they are so that more young women and women can see themselves in that space as well so it's a very complex area but and there is work that's going on and we continue to need to enhance that work and we need to grow that work and we need to involve people in that space. Thank you. I just want to go back to data there for a second great question thanks for much for highlighting it. I want to clarify as well it's not that we don't care about that data at all that's not why we don't collect it and we do collect it when it's relevant so I suppose that we come from a place of trust you know we work with groups of people who are not always out in their sport settings or who aren't out to to the people that are around them or they maybe have only shared their sexuality maybe not their gender identity so we really come from a place of trust and we don't want to always ask lots of questions for the safety yeah sorry can yeah so what I'm saying is that we aren't asking questions that aren't necessarily always important to that specific piece of work so as you say often you're ethnicity is out there so therefore in the terms of our delivery it's not always important for us to ask that straight up however my point in that is that I don't always think that it's our responsibility as third sector organisations to have all of that data and have the relevant data of course it's important for us to ask it and we use it for lots of different pieces of work that we do ourselves we're just starting a project that's for lgbtiq refugees and asylum seekers and in that project it's very important for us to know more about the background of the people that are participating and we need a bit more detail in that sense however for someone to come join a volleyball session on a monday night it's not always important because they don't need to give us lots of information actually sometimes it's enough that we just get their first name and maybe a contact detail and that's it so therefore there are some instances where asking lots of information about their demographic and characteristics isn't relevant however i think we need to put more onus on governing bodies or sport scotland for example to bring up that data and making sure that they are asking those kinds of questions so that we know that they are recording the participation levels of different groups and therefore we'd be able to benchmark it against the percentage that maybe takes part in our groups or in others as well we also in terms of sorry who wants to come in with a brief supplementary which might tie in with some of us thank you thanks convener it actually might just tie in with what you're saying Heidi about the data the scottish government does have data it's the active scotland outcomes indicator equality analysis data and when you go through it it is very complicated because it lists seventy thousand seventy seven thousand people in scotland describing the religion as muslim sixteen thousand hindus other religions fifteen thousand buddhist thirteen thousand and i won't go on but it basically says when you combine them all that's still less than three percent of the overall population so it is really difficult to kind of take apart all this aggregate data but i think Heidi's point about how important is that when it's at grassroots level that we need to engage and develop folk is that what's important is getting out there and getting in about the communities and supporting people to participate in whatever sport they choose providing services for female survivors of trauma safeguarding comes as a first especially when we focus on ethnic minorities woman if we are meant to work in a partnership we need to make sure we share information about other partner organisation which are safe for our beneficiaries if that makes sense so i believe that transparency and detail gathering of basic information is vital for your for all of ours credibility trust recognition and quality of services and the three percent shown on the statistic i believe maybe the the percentage would be higher if more information could be gathered i'm i hope that makes sense is there anything you want to add when you can keep it brief just just quickly i will just two things sport scotland are starting to gather information around equality statistics and ethnicities included ethnicities included within that and just to say and this is an area where we're trying to do better and we're working with a consultancy called livestream consultancy he's coming in we have 14 member branches we're gradually working our way around about them and it's about coming in and educating our branches and their volunteers around different cultures and how we can engage better with with different groups across the country and some of that is is they are giving us the connection to the local groups and some of that's housing associations where we can go in and make connections and because sometimes they're the one stop shop for lots of different communities so we are trying to make a difference in this space so it's just to to make sure we do that okay thank you we're getting a bit tight for time so we've got two more themes to go on so if people can keep their answers short please and questions caram walking thanks thanks thank you very much i mean links in my question is about sort of social economic factors and social economic deprivation and learn i think your points were well well made so i just wonder if there's anything that yourself anything else yourself or other panel members would maybe want to highlight to us in order that we can maybe put some thought into how we help with this yeah we we know there's that natural correlation between disability and poverty we know that 47% of households who are living in poverty have someone with a disability living within it and so for the school the school is crucial for us and trying to access kids and go back to jillian's point earlier about you know where do we we reach different groups it's not just real chair users and we have to work with education we have to work in partnership and it's about that activity inclusion model bring to the table what that individual needs and sometimes it's about finding equipment it's about accessing funds so that they can access physical activity and sport is there anything particular to women and girls do you think or is it more a general point but do do we find there's some social economic factors that specifically affect women and girls yeah after you okay yeah well i think you know obviously benefits as well so we're females who have left school and we know that the drop-offs 14 but sometimes there's two things there's affordability once you're a female and you've got responsibilities and the other thing is around opportunities to come back into physical activity in sport aren't always there for women with disabilities so yeah and the affordability comes into it as well i think it's also to look at the place where there's a woman residing so all the rural places also places like more deprivated than others there is a massive restriction not only about the finances but also about the public transport the ladies very often are either scared of the safety or are not able to access so when we focus on the rural places there is just simply no accessibility provided when we look at the ladies we work with women in east at Easter house in Glasgow we just had a conversation the vast majority of the women do not participate in any sport activities they do not allow the girls to participate in sport activities because that is necessary to use a public transport which after darkness is not the safest moment most of the classes are held in the evening in a summertime is not an issue but the summer in here doesn't last for long so obviously very often giving a time like six seven eight o'clock for a mother for a child is unacceptable because the risk is too high so maybe by um i have no idea but maybe about creating a kind of safety of transportation gathering the communities together on the on the community level maybe that could bring a bit of higher participation in sport activities so helpful thank you to highlighted three particular areas that was significant in that area around poverty and barriers was the lack of available for an affordable childcare that enabled them to engage in sport and physical activity when that would be available and so forth affordable sports equipment and memberships to particular clubs and gyms and all these these particular things became a big area and again the transport particularly around safety you know leading a very busy life in terms of looking after children and then having to get public transport and that public transport being available and the safety of that going at certain times made it really difficult for women to participate in physical activity and sports at the time so there was that correlation between poverty and those other areas just last one for me care provision is that a huge factor for women with disabilities at the moment and we know the challenges being faced by health and social care partnerships across the country and it's absolutely vital to enabling women to access and children to access physical activity and sport thanks as wanted to come in briefly on this point can i'll come in very quickly I just wanted to say that there's picking up on Lynn and Robert about starting early and how there's a gender play gap from the age of five in girls and boys so girls girls move a lot less than boys do and they don't learn how to move their bodies in time and space so they're not rough and if you if you look at a playground that girls are not rough and tumbling they're not running they're not landing they're not throwing they're not and so they don't have they they are less mature physically in terms of their ability to move and so if you've got girls that their bodies don't feel good moving you then put them into puke world they then go into puberty and their bodies get longer and lankier and and they can't and it just feels even worse moving and this really exacerbates the the gender gap so the fact that we we it's not we have to really make sure that within the school setting we are specifically and we are intentionally teaching girls how to move their bodies well so that they then enjoy movement and then they have that they get much more of a desire to learn sport and I know that you know got all the social economic stuff layered on top of that but in terms of their physicality we can do a much better job within school teaching and coaching movement patterns we're going to move on to a final theme looking to the future and I'll pass to Stephanie Callaghan hopefully to fit in so looking to the future I need to mention the community approach that North Lancer Council are taking so they're looking at community hubs that are alongside schools early learning childcare they're looking at actually having them located alongside different activities like libraries cafes exercise so it's like keep the mums here afterwards and actually bring them in and get them involved and also in developing new activities that are around their own interests there and I think Evelina you mentioned about developing sessions like for example the roller skating that came from people who had an interest in doing it there so I'm wondering you know we had Rudy our back as well from Scottish Rugby in one of the previous sessions that we had to and he was talking about actually changing the rules to suit and work in with women and what they wanted to do and I'm wondering if perhaps that's something that really needs to start in schools and how do we stop those women and girls dropping out early in secondary schools and specifically those affected by other inequalities too? When we learn the most when we are a child this is we are like a sponge and I believe if we focus on the youngest and on the right approach if we will bring the model rule of the coach of a people who becoming a walking evidence of what we talk about if that person is well trained fully aware of the importance of a young girl participate in a sport sharing the benefits I believe it's much easier to make the young population be happy about participation and when you are passionate about something it's hard for you to resign after first mistake so I think the approach is very important if we do not come as a something what becomes mandatory but you actually show this is not because you have to do this is something what you may love with the giving a time for the young girls and your females to get to know if they like it so what Robert said what Lynn mentioned listening but not only listening prior providing the opportunity but giving the opportunity with letting them to withdraw from it without any consequence consequences by providing different opportunity no fits everyone but sometimes the trial period is great what I love I love the taster sessions why because that led me to really specify if I like it or not and sometimes young girls they have different expectations they join certain activity and they don't find it really enjoyable or they found it not what they would like to be and they feel gilded they feel embarrassed they cannot really feel comfortable to share their feedback because they don't know so maybe if we could just ease the pressure just bring some excitement passion so the passionate well qualified people is a key I believe so if I can just stay with you there and then maybe others can come in with my second questions there as well it's great to hear you talking about fun and enjoyment because really that's where it all starts and that's where the motivation is there and we have focused quite a lot on sport but health activity out with sport is incredibly important as well and in Vienna for example all government agencies are required to have a strategic plan and initiative that's about equitable policy and they have a gender mainstreaming model and the research has found for example that girls age nine and upwards barely use parks at all and that's been adopted as well by lots of other countries like Berlin, Barcelona, Stockholm and Copenhagen so I'm wondering if you think this is something that we should really be looking at and considering having that type of model that's about a holistic approach there that focuses on gender alongside race, disability, mental health etc is well there so I'm happy for you to answer until I can open up to anyone else. Building diverse equal community I don't believe exclusion is something what should happen holistic approach has a special power reducing any tenses of lack of understanding so providing equal approaches is definitely important. I believe this is again about creating the inclusive community and if there is a voice mentioning the the need of full inclusion I would say why not of course but if there is importance of creating sub community which would maybe not find comfortable everything it's it's worth to listen to them as well but holistic approach is a great tool definitely. I think having a material point keeping people involved it's about education it's about we know policy as everybody gets included within PE but does that actually happen in practice we still unfortunately hear instances where that doesn't happen for people with disabilities but to answer your second question I think it's that we need to go across sectors it's not just sport we need to work across health education local authorities trusts third sector organisations and for us to achieve our vision in Scottish disability sport of a welcome and inclusive Scottish sport and society to paraphrase we need to work across all sectors we need education across all sectors and we need the policy and strategy to back that up. I'm mindful that we've not got much time left there at all we tend to design for the default meal because of who's in positions I suppose about that I'm really really interested in is the fact that there's actually a gender mainstreaming policy that all the government departments have to use for the strategic plans etc there as well and that includes wider inequalities too is that something that we think that we should perhaps be centring on that could be helpful yeah if you don't have it in policy you don't have it in the strategy it gets lost in the operational plans then the resource doesn't even come in to back it up and make things happen so. Great thank you. On this question as well. Baz did you want to come in? Yeah sorry thank you. Yeah I absolutely think that we'll have to have a holistic approach and a comprehensive approach and you know Sport England said that they that to get Sport England funding you needed to work towards 30% female representation on boards and now all governing bodies that get Sport England funding have 30% female representation on their boards and it's the same happened with the research in America they said you know you're not going to be getting any research money unless you are studying females as well as males and suddenly everyone is now studying females alongside males which up until that point they were like oh it's too complicated to study females we'll just kind of apply what we've learned from the male population female population. So there isn't one fix we talked about kit we talked about facilities we talked about education we have to look at this whole we have to look at it as being a systemic change and really looking we call it through the female filter and looking at looking at sport and exercise participation through to podium or performance through that female filter and applying it to all aspects of this work and not just thinking there's a there's one thing that we can do so I think without a doubt in my mind we have to be holistic and comprehensive and mandate things but also you know do all the little things as well and sort of the carrot and the stick approach. Just before we finish up Tess White had a brief supplementary on one of the issues that we discussed earlier on. In fact it follows on what Baz was just saying so so Baz you've touched upon boards we've explored today the importance of role models whether they're role models female role models with disabilities or BAME and the importance of data. So in relation to coaches you said that most coaches and men how in your view do we shift the dial on this so we have more women and BAME and disabled and the cross section as leaders and coaches. Thank you. It's really how I've been a coach isn't it because it's generally weekends and it's generally evenings and that's often when you know if you have caring responsibilities you will be caring for those people that you are responsible for which predominantly is females and so I think we have to be looking at how can we support our workforce as well as those people as well as encouraging girls and women to be doing more sport and physical activity. So we are working with governing bodies to make sure that there is menopause policies in place that we are supporting that that that that we are creating supportive networks for females and and and you know giving them the leadership programs etc but actually it's creating the environments in which it's not it's not expected that they need to stick to this rigidity of the sporting structure so that kind of like well we have to train on a Tuesday night and a Saturday morning and you have to commit and you have to do everything it's being much more flexible in the approach to make sure that we've got more female volunteers and coaches supporting girls and women. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you for that. For everything that you've been talking about participation in getting women into sport how much does social media play as a role that stops them and the reason I'm going to give that is take your eyes of women's football every image you see on social media and every young woman uses it tick tock and everything and they could name one Aston Villa player which is always on it right it's an image that you are not portraying just now to encourage women into sport and even the equipment they're wearing like 250 pound predator football boots which in areas of deprivation young girls and women are just not going to be able to afford so how much is that social media play a role in discouraging women into sport and in some levels I think I was back to the point about some of those solutions that we were reflecting upon across across the panel and the importance of who those role models are the way that those role models recognising that they don't play a further part in driving the gap of inequalities across across our communities so I think those are significant we have to be able to tell different stories alongside those stories because some of those social media images actually do encourage other young women to take part because they see it and they have a dream and they have a hope and we need to nourish that and we need to empower that I think we need to work with role models and able to look at the message that is there and how that that comes across and to recognise that whilst that idea of what have taken your your your point about 250 pound boots for example yes that might be there but other images have different experiences in there where we take imagery we were working with public health Scotland recently on a campaign with sport Scotland and one of the things that we looked at was imagery and we looked at photos that were in places across the country that represented different places where people lived and that was a really concise and decisive decision that we made to do that so I think there's a real opportunity for us to find real solutions where we can share imagery that is representative of the diversity of of Scotland and represents different groups across our country thank you and can I just ask one final question because we didn't quite cover this when we were talking earlier about lgbtq plus participation in sport so I suppose it's specifically to Heidi so do you think that sport and physical activity are welcoming for lesbian women for for bi women and how do we ensure that they feel included within a sports and physical activity environment I really want to say yes they feel really welcome and they feel really included however that's not always what we hear we hear that about half of lesbian women aren't out in the sport that they play but we also hear that only a quarter of bisexual women that are out in the sport that they play so that's actually not very many and the reasons for that is simply that the stereotypes that come alongside being out in sport is that you are that you must be a lesbian if you take part in specific sports and we hear from women in the groups that we work with that they weren't out when they were younger because they didn't want to be branded a lesbian or they didn't they were worried that people would assume that their sexuality that they'd been turned or that people if they joined their team knowing that these women were lesbians that they would then also become a lesbian if they joined the team so I think there's a there are some clear barriers in the stereotypes that follow physically active women in that sense and that doesn't just affect lesbians and bisexual women it affects those who are potentially also on the teams of these women in that sense and I really want to come back to some of the comments about coaches and how we could get more women to be coaches and being those sorts of roles and we've heard from some of the people that we work with there's a woman we'll work with who's a football coach for young girls and she really wants to do this job really well because she's aware that there aren't very many like her she's a woman with a diverse sexuality and she she wants to do really well and she doesn't want to make sure that people are aware she doesn't want people to necessarily know that that she's got a sexual irritation that's not straight however the girls keep asking about it and she's getting complaints from parents saying you don't need to shove your sexuality down our girls throat because they are already at danger of becoming a lesbian for taking part in football so it's those sorts of instances that aren't going to make women more likely to become a coach and if they are already feeling like they can't be out in the sports that they play then why would they ever become a coach because their whole life would be centered around those sorts of stereotypes and escaping those can be really really challenging so there's definitely something about the media and the social media that we use and the imagery that we use around the people that are coaching. Women's football is coached by men for the majority of it you know we see great women leaders who are who we're doing that but there's definitely a lot of work to be done in the inclusion of LBTI women in that space. Thank you very much to the panel today and including Baz online. You've made a very valuable contribution to the committee's inquiry and you can now leave as we continue your meeting. You don't need to wait. So at our meeting next week we'll continue your inquiry into female participation in sport and physical activity and undertake further scrutiny of NHS boards and that concludes the public part of our meeting today.