 Good morning and welcome to the 14th meeting in 2016 of the Health and Sport Committee. Indeed, the last meeting of the Health and Sport Committee in this session. I would ask everyone, as I normally do at this point, to switch off mobile phones as they can often interfere with the proceedings and, indeed, the sound system. However, you also note that members and others are using tablet devices instead of the hard copies of the papers. We have apologies this morning from Bob Doris and Dennis Robertson, who, for very understandable reasons, cannot be with us this morning. Hi, Nenet. We move on at this point. Are you okay, Nenet? I suppose that, if you indulge me, it's great to have the chief medical officer along this morning, but I just take this opportunity at being the last meeting to thank Bob Doris and his absence, who has been my vice-communer throughout this period of time. Many of my colleagues here this morning have made my job easier over that five years. I think that you will all agree that it's been, those of us who have been on the committee for that length of time, it's been a very hard working committee, but it's been a very interesting job over that last five years, and we hope that we've made some changes. I think that we can take some credit from this in terms of our level engagement, which we're very proud of, which will feature in our annual report. This is from Leslie Wallinger, chair of PNH Scotland. I'd like to thank you and the committee for the work carried out on our petition. The willingness to understand such a complex subject and determination to continue until a better system was in place was extraordinary. The chair of a tiny charity with no background in political matters, I was extremely nervous each time I was called to give evidence, and it was, however, treated with such kindness and courtesy that the whole process proved extremely rewarding. The health and sport committee has, through its handling of our petition, shown the best of politics and demonstrated how Government can and should work, and I think that we will take credit from that. No more of that. Thanks, Duncan. I don't have any answers. I was in a previous health committee with you at the time the smoking ban went through, and you're very kind to me in that committee as I struggled as a new member on my own in the committee. Likewise, as convener here, I think that you've been very good, very helpful. I'd just like to thank you in a personal capacity. Thank you very much, but we nearly need to press on now. That was nice of me, thank you. Our first item of business on the agenda today is, of course, the session with the chief medical officer for Scotland to look at her first annual report. I welcome on behalf of the committee Catherine Calderwood, chief medical officer Scotland, Professor Craig White, divisional clinical lead healthcare quality and strategy, Graham Cramer, national clinical lead for self-management and health literacy, all of the Scottish Government and Angus Cameron, medical director NHS Dumfries in Galloway. Thank you all very much for giving your time to be with us this morning. I now invite chief medical officer to put some comments on the record and they will go immediately to questions. Thank you very much. Thank you very much, convener, and I'm delighted to be here talking about my first annual report. I believe that this is the first time that the chief medical officer's annual report has been taken as an item of business at the health and sport committee. There are several firsts. My report is entitled Realistic Medicine, and it contains, as has always been traditional, the state of the health of the nation in the statistics in the second part of the report. However, in the first part, what I wanted to do was to write to the doctors across Scotland reflecting what I had been hearing from them as I had been travelling around the country in my first few months as chief medical officer. I was hearing about the pressures in the NHS, their desire to keep caring for their patients as they always have done, but finding that that was difficult at times, finding that some doctors were disillusioned or unhappy in their jobs and that morale was low. I was also hearing from them that they worried about the advances of medicine and whether we were having treatment and procedures for people that were perhaps not what the doctors themselves would choose if they were in the same circumstance. There is quite a lot of evidence in the literature where doctors would choose less treatment, less tests, less procedures than they offer to their patients and perhaps a disconnect between what they feel the people they are treating prioritise versus what they would prioritise. I wanted to talk to people about that. I also wanted to reflect on this personalised care and patient-centred, patient-focused care. My children talked to me about what is an out-patient mummy. I described that this was a patient that was not in the hospital. My 12-year-old daughter said, ìIsnít that a person then?î I think that we are moving from very much the person as a patient to the person with needing some treatment in our NHS as part of their much wider lives and living in the rest of their lives with no other concerns to do with the NHS. We were starting on a conversation. It has been extremely well received. I have had letters, emails and there has been a Twitter activity all over the world. In one single week, realistic medicine was retreated and reached 133,000 people. I have not had across Twitter anything other than positive responses with people saying that this is a conversation that they are welcoming. It has not just been doctors, but nurses, pharmacists and members of the public. I will finish my opening remarks by reading a quote from a GP in Aberdeenshire. Your document is probably the first CMO annual report that I have ever read. I was really impressed that it appears to challenge the status quo. It chimes with my feeling that we should be moving to finally confront what I see as the elephant in the room, the adverse effect of our own actions on demands that fall upon the NHS that we so often blame on patients. There are many similar comments and personal stories that have been shared with me because of starting this conversation. I am very pleased to be here and to hear the questions and hope to answer them from the committee. We are going to deal with that in two parts. I want to ask about obesity later on, but on the first part, which you have introduced, I think that, like all the people that you mentioned, I think that it has been positively received. I am just trying to tease out what I might think of as the detail of it. On the one hand, I think that some of it is not at all very controversial when you describe people with multiple conditions and just following the guidelines and perhaps getting over medicated and all that kind of thing, but on the other hand, I did particularly one particular paragraph, which I will read a bit of in a moment. It just made me wonder whether, in fact, you were going a lot further than that and perhaps getting into more controversial tenages. I can just read the couple of sentences that I have in mind. On page 14, while the reduction in heart disease rates can be attributed to the use of primary prevention with status and better control of hypertension and diabetes, trends show that the fall in heart disease rates predated widespread use of these treatments and has continued at the same rate as before. One explanation might be that the majority of the decrease has come about from the improvement of lifetails and environment. Some people reading that might think that you are going further than they are comfortable with because one interpretation of that would be to have statins and medication for blood pressure actually had a major effect and people might even then draw the conclusion that you are questioning them. Perhaps you do not have that in mind, but I suppose that I did find that section very interesting. Of course, it relates to the whole general issue of managing risk and to what extent you do that. Thank you for your question. I think that this is something that has been raised. You are not alone in thinking that this is perhaps going down a line that is more controversial. I will bring in Dr Cameron in a moment, who is a former GP, to talk specifically about the figures around statins. We have evidence for over-prescription across Scotland. For example, 30 to 40 per cent of our antibiotics are prescribed for self-limiting respiratory illnesses, ie illnesses that would get better if we did nothing. I do not need to tell this committee of the harms of over-prescription of antibiotics. We also have evidence of a lot of variation in prescription patterns across Scotland. We look at prescribing across different GP practices, and the same drug is prescribed very variably, not able to be explained by variations in the demography of the populations. There is certainly good evidence for over-prescription and over-treatment, and we then come to where that risk would lie for an individual. Angus, your example of the risk benefits of statins, as Mr Chisholm has brought up specifically, is important to recognise that the graph shows a steady decline from about the 1950s in the rate of heart disease in the population. The important thing is to distinguish between the onset of heart disease and having a heart attack and death. The rate of people who die following a heart attack has come down steadily. There is no doubt about that, and that improvement coincides with statins. The conclusion that you draw from that is that if you have a heart attack or a stroke or for a vascular disease, you would be very well advised to take a statin. When you look at primary prevention, which is giving a medicine before people have any illness, when they are totally asymptomatic, it is a little bit more difficult to be certain about which individual patient will benefit. The big trial in the west of Scotland, which was a groundbreaking, the Wazcox study, showed that if you give people who do not have heart disease statins, then you do reduce the incidence of their first heart attack. However, it requires almost 400 people to be on the medication for a year for one heart attack to be avoided. Because statins are basically safe and they are now very affordable, you can make a strong case for saying that, if you are at risk, you should take them. I think that it is important that patients understand—because I do not think that they do—that you may require to take a medicine, which may do you no benefit because you are not at risk anyway. A bigger impact on your risk is still reducing smoking and taking more exercise. I think that the important thing is that patients understand the limitations of statins. Presumably, medication for blood pressure is not, although you referred to it in that particular paragraph. There are other interventions that are very effective in reducing blood pressure, such as weight loss, stopping smoking and more exercise. Again, for one individual, the blood pressure tablet will work, but is that the right treatment for them? Might there be other effective interventions? I think that it comes back to this personalised care. It is discussing that and the possible side effects of any treatment with that individual and bearing in mind their own individual risk, which will be different from the next person in the waiting room. That leads to the whole question. Although your first part is addressed to doctors, your narrative is very much about talking to patients about what they want. However, I suppose that scenarios can be imagined in which the medical profession takes all this on board in terms of the possibility of over-treatment, yet it may well be that patients are demanding things that you do not think are strictly necessary or only marginally beneficial. How does that particular potential conflict get resolved? I will bring Dr Cramer in a moment as well. That is a question that I have asked myself. I needed to start somewhere with this report. The doctors, as being the chief medical officer, were the obvious start, but we are very keen to have engagement with patients and people. The alliance is going to do some work with us on that. You are absolutely right that this needs to move in parallel. Graham, do you want to come in? Yes, thanks very much. In my other job, I am a GP up in Tayside. I think that this is a very good question and it is a real issue. I think that the worry that patients may opt for more complex and expensive treatment than the doctors perhaps would recommend and have higher expectations of their treatment can happen, but I think that most of the evidence suggests that when you discuss things with people and share all your concerns, they often opt for the less invasive and the less expensive when they really appreciate the risks and when you can really align those treatments to their particular preferences and what matters to them. The evidence suggests that it is the other way and we won't see so much over treatment. Other effective interventions—I suppose that's where the confidence comes in, where the GPs can imagine beyond statins a defending group rather than any depressants and on and on, but if you have not got confidence as a GP or the knowledge of the GP about the community capacity to offer that realistic alternative that will address those issues, you hope that your debate will encourage—we have long said in this committee that sometimes you don't need a doctor, it's just a good friend of that type of support. These type of facilities are already thin in the ground and the rest are actually cutting the budgets of them. Do you hope to encourage some of that work as an alternative to pills? A good example is some of the walking groups that have been set up, they are run by charities who are really wanting to come in and offer these alternatives, and that's partly friendship as well as the benefits of physical activity. World walking, for example, started as a rehabilitation for people who'd had heart attacks and has then expanded. What I'm hearing when I'm giving talks around the country, they are frustrated because they feel they are not known about. At the moment, there is a disconnect with the GPs wanting to do something different and perhaps there's something different not being in the same area or not knowing about each other. I would hope to facilitate much better linkage with the GPs knowing what's available in their local area. Those charities are very willing and able to help. We need to evaluate some of those because I think that this would be something that we would want to provide much more systematically. It wouldn't be the right thing for charities to have to provide some of those interventions if they are doing a lot of good. It is very difficult to build up capacity in communities to provide alternatives to a medical approach or a biomedical approach, but Kaiser Permanente, the American healthcare group, describes it very well that we too often respond to what are primarily social problems with a medical model. If I can explain that, if you are elderly and you have difficulty with mobility and maybe breathlessness or visual impairment or hearing loss, the consequence of several long-term conditions that you've accumulated is social isolation, which makes your experience of the illness far, far worse. You get it to a stage where, while medicine might be helpful, the thing that really makes a difference to your life is relieving the social isolation, helping you to get out, helping you to re-engage in the community. My concern in the clinical strategy is that, if you put too much resource into medicine at the expense of addressing the patient's real need, which is much more social than psychological, you use up a lot of resource. The other problem is that you use more medicines in an older person, you cause more harm, you undoubtedly cause falls, confusions, etc. I think that it's really important to perhaps do what has been achieved in Scotland, which is the integration of health and social care, and maybe to rebalance for a lot of people the emphasis on providing medical and social care. I hope that that seems... I understand the point, but the health and social care is a structural thing. What we're dealing with is a cultural thing, the patient demand. You need to do something here. I'm in the pressure from the GP responding to that, because he's not got any confidence or knowledge that there are other alternatives out there. He supports that demand and need. How do we break that cycle of patient demand and GP responding to that demand? I'm just a very quick response, really. I think you're right. There is this patient expectation and there's GPs who are working in a time famine situation and having to come up with pragmatic medical solutions. They don't have an understanding or knowledge or relationships of what's available in the community. That will encourage prescribing medicines, rather than prescribing more than medicine. As a GP, I find that really challenging to be able to prescribe other than tablets. I think that's where some of the examples, like the links worker programme in some of the deep end practices in Glasgow is really useful, because they've got a trained worker who is able to find out what's in the community, make those connections between the community resources and the practice and also make those personal connections for the individual patient as well. I think we don't necessarily have to ride purely on GPs, but use the skill mixes that are available to be able to increase social prescribing. This year, I was home to explore a similar issue, but perhaps more of a rural focus, because I represent the Highlands and Islands. I was talking to some GPs recently, and they were making the same point to me about over-treatment and over-investigation, but with a slightly different emphasis. We've heard in the committee over some time that this trend is supposed that health boards under financial pressures and resource pressures are a kind of trend towards a lot of care, a lot of clinical decisions and diagnosis being carried out by people, health professionals that are further down the salary scale than GPs. I think that we can all understand why there is that pressure to operate on that basis, but the point that they were making is that it takes a certain amount of experience, it takes a certain amount of training, and that really only GPs can, with confidence, take the decisions not to treat. They were worried that far from cost-reducing, there could be larger cost pressures that are associated with slavishly following protocols and so on. What are your thoughts on that? There is a lot of evidence that more junior doctors do more investigation and more treatment than more senior doctors. That is absolutely the point that you are making about the seniority and the experience of more senior doctors, allowing them, if you like, to recognise that they do not need to take every single blood test, do every single scan or X-ray. The GPs often have the advantage of knowing someone over a period of time and knowing their family and their social situation. I hear equal frustrations from GPs who have sent someone who has been seen as an emergency in A&E and investigated up, down and sideways, admitted. Of course, the GPs would have a different view as to how that should have been handled, and possibly much less investigation would be better for the patient, too. Again, that is part of our conversation. I think that we as the medical profession need to recognise some of those issues. I was definitely getting, before starting on this report, those sorts of stories that are part of what my incentive is to write it and to start the conversation. I do not think that I have solutions for you yet, but I think that we need to start putting those things out in the open and discussing them. I am going to visit all the deans of the five medical schools across Scotland. I am going to take my report. One of the thoughts there is that we should be talking to the trainees, the medical students, before they even become doctors about realistic medicine and about the practice of medicine so that that becomes embedded in the way that they are trained and the way that they start to think right from the beginning. That is useful. The point that we are making was not so much about junior doctors but about other health professions. Nurses doing work that previously would have been done by GPs, but doing it with less certainty or perhaps in a more risk averse way, which would ultimately lead to higher, not lower costs. I am glad that you have identified that issue. If I can touch on one of the big problems across the Highlands and Islands, that is attracting rural GPs. That is something that has mystified me in as much as I cannot think of any more rewarding and fulfilling career than being a GP, particularly in a rural area. However, I wonder how much the over-management and a trend towards employed Salary GPs eroding the sense of vocation that was part of the motivating force that led people to stay in rural areas. We have traditionally seen people from rural areas move to the cities in all sorts of professions and occupations. I think that we are much more recognising your point about that. That is a very positive different way of practising medicine with a lot of different opportunities, but perhaps we need to train the doctors differently rather than a generic GP. There are remote and rural training programmes. We have just had a recruitment drive in the last month or so. We are also talking to the universities—Glasgow already does that—where people are coming from a remote and rural area that they would be allowed to do some of their placements back at home or close to home in the thought that they will then learn that remote and rural practice. I think that we have started to recognise that we need to do things differently in order to recruit people and retain them in those areas rather than the traditional migration to the cities and to train people in a different way that reflects much more what the needs of that population are. It is completely different from being a GP in inner city Glasgow than where you are from. Our courses at the moment until recently have not reflected that. We hope to make progress because we have recognised that. I think that your report is very exciting. The work that we did for instance on pallidive care, the work that Lewis Ritchie did on the out-of-hours, all really link in and together make me really quite sorry to believe in the Parliament at this point in time because I think that there are potentially very exciting developments for the future. I graduated in medicine in 1965 when it was a very paternalistic setup. I know that a number of people in my generation, my survey group, actually quite liked it that way and I think almost dread what might lie ahead and I think that particular group of people will probably need some convincing that a new form of NHS is actually better than what they grew up with and I think that's a job of work that needs to be done. However, when we are talking about prescribing and so on, I think that that also links in to what the work that the committee has been doing on cancer medicines. I think that there is a big ethical thing in there to the benefit that patients may derive from end-of-life drugs and not. I think that that probably needs to be thrashed out. End-of-life care, that Marie Curie is always on, people don't speak about death, we just don't speak about it as a society and I think that's important as well. My question is kind of linked into that. As far as drugs are concerned, we know that they are very heavily evaluated, quite rightly so and cost-effectiveness really has to be looked at. I have a worry and I know how other people do as well. There are many other things in the NHS that are not scrutinised in that way at all and there must be many procedures or systems that are currently in existence, which probably really have gone out of fashion, but new things get tagged on to the old, which must be at a cost because some people are still using them and must be at a significant cost to an NHS that is under financial pressure and always will be. I just wondered what your thoughts are on that. Is there a sensible way to evaluate other parts of the NHS? I'm pleased that you brought that up. I had considered bringing some sort of chapter about value-based medicine and decided that Mr Chisholm's point about controversy, that perhaps for my first annual report that was a little bit too controversial, so maybe next year. I would agree with you entirely. We have the quality-adjusted life years measure and we apply that very rigorously to drugs because they have a cost and a price that someone has to pay the money for them. If I give an example of someone with head and neck cancer who has a five-hour operation several days later and spends a prolonged time in intensive care, we do not evaluate the cost of that or have a conversation about whether that should or should not be done either on cost or other basis. We don't come out at the end with a price tag. That particular example that I have chosen deliberately because that would be a very significant price tag with very often very poor outcomes and a very low amount of additional quality of life gained from that. I think that it's almost inequitable to have these conversations about drugs just because they have a price ticket on them and not to have the conversations in other areas of practice. It almost disadvantages the people who need the drugs. I worked, as you may know, for Bruce Keogh in NHS England in the last couple of years before starting this job. Under the English commissioning system, the cost is carefully looked at. For example, a receiving trust will have a menu, somebody comes for that head and neck procedure and they predict as far as they can the ICU length of stay and that comes with a price on it and the referring trust will have to talk about that cost and where they are going to find it. I think that my mindset in England was that that was the way that it worked. Many, many more doctors have an awareness of that than doctors in Scotland do simply because we don't have to. Christine, who is behind us, is our clinical leadership fellow in my office for a year. She has to take some of the credit for this report. Christine was my editor-in-chief and she is a trainee in junior doctor in Lothian. I have asked her to look at this subject to see if there is appetite for looking at the value down to cost of some of the other procedures. I think that I will talk to some of the chief executives across NHS Scotland. They might be a group that we would be interested in. It is what we do with that information, I suppose, that concerns me. That is not about rationing. That is not about saying that your procedures are too expensive or that you are not someone whom we think that money should be spent on. Maybe that is the danger zone that I did not want to stray into in my annual report, but perhaps we could turn it the other way because what I saw in England was that it drove quality of care so that you, as a trust, were not going to be paid unless you provided multidisciplinary team, specialist nursing, et cetera, et cetera, so that the trusts that were giving very good care got more business, if you like. The ones where the GPs are deciding this, of course, where the GPs did not think that care was as full or as specialist or as good, well, then they did not have the patients being sent to them. I think that you can turn it into a very positive discussion, but it is difficult. To pick up the parallels with the committee's work on palliative and end-of-life care, it is not a coincidence that you are seeing a resonance with some of the issues that have been considered. I think that the title of your inquiry report, we need to talk about palliative care very much, reflects that in that area we know that conversation and greater openness can lead to different decisions and higher quality care and also less costly, less invasive interventions. That is very similar to the chief medical officer's commitment to have the similar sorts of conversations against other branches of medicine. One of the Government's 10 commitments in the strategic framework for action in palliative and end-of-life care, which, as you know, is not just about prescribing. There are multiple dimensions of care there, which might be more difficult to evaluate. We are commissioning clinical and health economic evaluations as part of the framework, where we hope to be able to start to link the impact on quality and cost with more and more people having the opportunity to discuss what matters at the end of life. Because we are linking this work, we will be able to use that to link with the conversations that will come out of the realistic medicine work and plan our improvement plans for other conditions and other parts of the system. Thank you both for that. I was very interested in what Dr Caldwood said about the commissioning in NHS England. Obviously, the parallel here would have been GP fund-holding, which I do have some experience of. My husband was a GP fund-holder, but, of course, as we know that, that was not politically acceptable in Scotland. I do not think that we will see that coming back to something nowhere in the near future anyway. I think that there were parallels there, which I think were in many instances in patients' interests. I do remember that my husband had one of the first things that he did as fund-holders was to employ a firm of physiotherapists, so that the people with bad backs were seen straight away. Those days, there was quite a long waiting list for physiotherapy, and they got back to work. That was cost effective, good for the patient, cost effective for the health service. That type of thing, I quite liked it, but I am not in a political majority in this country. We wish you well and make you understand from a committee point of view, because we have touched on that value base in a number of pieces of work, including access to new dogs and rare diseases and assisted suicide. What else? We have all the fun stuff here in our work on palliative care and end-of-life. We would agree that the language that you use and how you take that forward has got to be very sensitive, but the committee's view has never actually got to that either. I think that I would be speaking for the committee when we recognised that as an issue about what was best for the patient in the question of informed choice. We know from some of the evidence that we took that it is very difficult from all patients who have felt that they were being sent home and clinicians and doctors felt that they continued to treat people. It was not cancer, but it was COPD, which was going to have a similar outcome. They were treated completely differently, but there is, again, the future committee will want to look at some of these issues, because you get that new drug or that innovation and you have got to sometimes wonder who it is for. If the outcomes are poor and the last days of your life are miserable, how do you have that discussion was where we focused. It is very difficult indeed, but that is a thing. I have got Rhoda Grant. I suppose that, on the question that has taken place, the report seems to focus on doctors. One of the quotes from the report is that I want to start a conversation among doctors about changing healthcare. It seems to me that it is not doctors, it is about including other people, because doctors have a prescription pad and that seems to be the concern. Everyone who goes to the doctor tends to come out clutching a prescription to do something quickly to change. Probably a problem that has been caused by a lifetime of bad lifestyle choices that can not be changed in a 10-minute conversation. Therefore, you hand over the prescription with a medication that might make a difference. Surely, then, we need to think about how we have that conversation about future healthcare with some much wider healthcare practitioners than doctors, and indeed, as you said yourself, into the voluntary sector about how we have that time to work with people to provide them with the alternatives to medication, because either you are going to say to a GP 10 minutes, you tell them bad, or you give them a prescription and nobody is going to sit there for 10 minutes lecturing somebody knowing that they are not going to take the blindest bit of difference because this is habit. How do we have that conversation much more widely than just with doctors? In a way, doctors should be the last resort and not the first resort, and yet they seem to be at the forefront of all medical treatment. First of all, I suppose to explain that my report as chief medical officer was to the doctors because I am regarded as the leader of that profession. I felt that, when I was starting out, I needed, first of all, to speak to the people that I know, I am one, and to start somewhere, if you like, but I absolutely agree with you that this is, of course, about a multidisciplinary team. It is about a whole range of NHS professionals who provide care. The report addressed to the doctors is really as a start as chief medical officer, but it does not mean to exclude other groups. We have a meeting within St Andrew's House to set up myself, chief nursing officer, chief pharmaceutical officer and others, to discuss realistic medicine as part of a multidisciplinary team. We intend to take that wider conversation further. It is interesting that my responses have been from a great range of practitioners as well, so I think that there is recognition that this was not just about doctors or for doctors. We are moving towards recognising the benefit of other groups, so that our intention to practice particularly primary care differently involving other groups of people is going to take some time, because my GP colleagues tell me that the patient people want to come and see the doctor, so that they do not want to be palmed off with someone else, they would sometimes see it as. There is something about that education that, in fact, the best person to see may not be the doctor. The GP practices, such as Dr Mone's husband, have a musculoskeletal specialist at the front door, so that the GP does not even see the patient. They go to them first, they are triaged before they even get an appointment. Pharmacists working in GP practices, you will know that we are setting up an increased training for pharmacists. 140 pharmacists are across GP practices in Scotland, and I know that you are going to tell me that there are nearly 1,000 GP practices in Scotland, so there are not enough for anything like one in each. Again, that is a start. Those pharmacists would be seeing patients completely separately to the GP so that they are coming from medicine reconciliation with advice from the GP only as necessary. There are two prongs to this. I think that there is very welcome upskilling of different professions to take on different aspects of people's care, but there is also a change in culture needed so that it is not seen as being a need to see the doctor each time. In fact, someone else may be better. Nurse specialists are a particularly good example. I have an antinatal clinic. I still see patients on a Friday, and we have an epilepsy specialist nurse who comes to see the women who are pregnant and have epilepsy. That nurse is much, much the best person to see. I see the women from the obstetric point of view, from the risk counselling, etc., but the drugs and the conversations from somebody whose whole life is spent and training is spent in epilepsy is the right person to see. It is about sharing those conversations. Again, I do not think that I am proposing that this is a quick fix or an immediate solution, but we do have a recognition that things need to change. It is not always about the doctor being the right one to solve the problems. Professor White, perhaps to extend and engage with a part of the net milms question around people themselves and the changing models of care, our voice framework, which has been developed following work with Scottish Government, COSLA and other third sector organisations, including the health and social care alliance, is going to be looking at different local infrastructure so that people can be involved in planning and commissioning new models of care and new services, where some of the issues are about the way people are involved in discussions and how they might traditionally have been supported and how that might need to change in the future. Our voice work and some of the learning from the national conversation on the future of health and social care, which the cabinet secretary has spoken about before, is linked with the conversation with the professions. How do you change the NHS? This is a bit of an enormous question, but the structures of training are very much stuck. The structures of delivery are stuck, so we find new and innovative projects all over the place. For example, on something that Mike McKenzie was talking about, rural health, we know that that is exciting and interesting, but it is not rewarded, neither is it held in the steam and some things like GPs that we are now hearing in the same breath. The career structures and the steam that certain professions are being held in actually become a block on encouraging people into those professions and allowing them to learn. Rural medicine is general medicine. I was speaking to nurses at what was in our rural hospital. They needed to deal with everything from the road accident to the periatrics to heart. They had a range of general knowledge that was enormous. They were not rewarded for that. If they were a specialist nurse, they would have gone up the grades, but because they had that broad knowledge, they did not. I suspect that that is the same with medics. We do not look at what is required in different areas, what is going to make that change, the same in deprived areas, which we will come to in health inequalities. How do we make those careers attractive and almost get away from the old structures that almost bind us to the way things were to change it, to make it a health service fit for the future, not one that was created in the past and stuck in the past? I think that you are raising a very good point as I was talking to Mr McKenzie about the GPs training being recognised as needing to be different and special for remote and rural practice because of the broad range. That is certainly something that I would talk to Fiona McQueen, our chief nurse, about, because you are right that it is not regarded as a specialism in its own right. Remote and rural practice is where you happen to work rather than being defined as an additional set of specialist skills. The opportunity of us meeting together within St Andrew's house is a point that I could make to her about whether we need to recognise a specialism of nursing or other practice that is remote and rural practice in itself, requiring some different training and requiring to be treated as a specialist subject. I will take that away. The director of health workforce is one of the people who has been involved in looking at the workforce planning and skill mix. It is going to be required for the different models of care. As the committee might remember from the palliative care work, we are looking at an educational and workforce framework for health and social care to reflect the skills that might be required in the future, both in terms of location and rurality, but as well as the conditions that the future models of workforce planning and development are going to need to be different to. Can I pick up on Rhoda's theme about this unequal staff? The clinic assist in the national health service, they have a cabinet secretary, they have a chief medical officer, they talk about doctors and nurses and we look at the workforce and we measure success on the basis of how many doctors and nurses that we have got, not what they are doing or anything but how they are doing it. Are you satisfied at this point that the job description that is applied to the chief medical officer is, should it be broader than it currently is, should our perception of the national health service say something about social care and wellbeing, which we have all discussed here, are equally important, are sometimes more important than some of these medical interventions, but we are struggling here as a committee over the piece where we have got this gold standard on one side and an adversarial system that delivers much of our social care and our wellbeing, which is in some cases privatised, outsourced, where time is limited, where continuity of care is not a concept that is followed quality. What is the chief medical officer to say about some of these issues? How does that affect the strategist like Professor White? How do we feed in to Government and being independent of Government? How do we feed that in? What influence have we got there to affect the political landscape that might deliver some sort of change over a period of time? You are really starting to talk a different language now with entering into that territory. At the risk of bringing on more questions, I also worry about the preventative side, so we concentrate on picking up the pieces and we have not invested in stopping the problems that are happening in the first place. To your point about after hospital care or care that is longer social care, it has not been valued. We have not got a real emphasis on how important that is. We have not looked at how long people spend in care and at that being as important as the shiny hospitals with operating theatres and the expensive equipment and machines. I think absolutely as chief medical officer that some of that needs to be brought out into the open and into discussion. I think that a very good start is integration because we no longer are saying that that is a hospital's problem, that is a social care problem and there the twain shall meet. There is a them and us with all this negative language about bed blocking and burden of old age. I keep saying to people that it is not a burden of old age that the people living longer are a success story. We are living longer healthier lives because of the progress that medicine has made. That is not a burden. The other aspect is of course that it is not going to go away and you will see in my figures that there are more people living longer with more comorbidities, so we absolutely need to tackle that. I think that starting a conversation would be the first thing. The integration is going to, with the budget changes, force change because the acute and social care have to speak and communicate with each other, but I think that your point is very well made about racking this up. Do you think that some of these moves are based on evidence? Are you confident that they will return? Who is driving this? The title of chief medical officer and the influence that that can apply with privately or publicly? How is it driving the strategy? It is out with your remit, is it not? It is out with your remit. We have been talking for years about why there is not any separation, the patient journey, but it is out with your remit. Who is driving that? There is not a cabinet secretary in that cabinet driving that other side of the coin. How does it fit into the strategies? Mr Cameron is quite as bleak as you are suggesting out there. I think that the tensions between health and social care will be picked up by integrated joint boards and the structures underneath some down into localities. We are placing quite a lot of weight on the integrated resource framework, which is another set of initials, I am afraid, but we are really looking at where the costs are spent and where the value is obtained, because ultimately they will be faced with, I suspect, a decision about whether we go for more medicine over here or whether we deal with more care workers to provide support for our elderly. Once they have that tension, which they do with integration of budgets, and once they have the information in an incredibly rich and detailed way, they can start to make decisions that move resources and new commitments to the most appropriate area. That does not deal with your question about the remit of the chief medical officer, but I do think that the world is going to be changing and, hopefully, significantly changing to meet a very improved balance between health and social care. That is what I am suggesting in a bleak way, is that there is a clinical dominance of this debate. They are the insiders here. If that continues to be the structure and the way that you can influence it, then it will continue to be. It is already uneven, unequal, not just in terms of terms and conditions or whatever, but how it is recognised. We are very supportive of the committee of integrated joint boards, but what is the game changer? What changes that to ensure that the sports scientist, the sports person who is taking those people with weight problems or high blood pressure and whatever, who can get better outcomes than a GP or many of the other things, the innovations that go on out there? It is an unequal battle for them. I completely agree. I think that realistic medicine is trying to talk about exactly that, being realistic about what medicine can add value to. I think that there are a lot of areas where it adds fabulous value without any doubt, and I am sure that we would all agree with that, but there are times when perhaps we in medicine have overreached. What do I mean by that? If you treat people at a low threshold, you obviously cannot get as much benefit because they are not very ill anyway, but the risk of intervention is usually exactly the same whether they are very mildly ill or extremely ill. If you look at trends in medicine over the last 20 years, it is to lower the threshold for treatment lower and lower. That gets to the stage where we are being unrealistic. If you want an example, chronic kidney disease is a condition that has been guided by the output of an expert committee. The analysis of when you have chronic kidney disease means that the vast majority of people over the age of 80 are labelled as chronic kidney disease. Therefore, once you have a disease label, you need treatment—one follows the other. We have to accept that once you reach 80, your kidneys slow down. Are we trying to be unrealistic in putting a lot of resource into treating what many doctors feel is normality rather than pursuing a medical thing? Realistic medicine, the whole scope of the document, is to try to say that medicine offers massive value. It has conquered a large number of diseases and I think that we will still continue to do so. We have to be realistic both as doctors and suppliers of it and to spread the message to the public that there are limits to what we can achieve. Professor Weight, do you want to comment on that? I am interested in your point about the balance of who is involved in commissioning and planning services related to Dr Cameron's point about integrated joint boards. There is an opportunity when the health and social care partnerships are submitting their plans for local communities to ensure that, yes, the chief medical officer, chief nursing officer, national clinical director for quality who all were involved with the clinical strategy, but also chief social work advisor and other experts within government are looking at those local plans and, as you say, challenging and providing scrutiny and questions around are the models of care shifting to be of the sort that we are talking about. We do have opportunities to make sure that there is not that clinical dominance around the scrutiny and review of the plans that the partnerships will be submitting. Malcolm, do you want to comment on some of the issues on the second part? I will go on to the second part. I just had one final question on the first part, if that is all right. I was just wondering what the implications of all this is for the clinical guidelines, because Scotland has been proud of the sign guidelines for years. One interpretation of what you are saying is that you will have to rip them all up. That is probably a bit extreme, but you are saying that everybody is agreeing with you. Does that mean that the royal colleges and all those people are quite happy to rewrite their guidelines, or is there any resistance at all to what you are saying? I think that the point is being made about guidelines that people with multiple conditions end up being treated for one part, for one guideline, and we do not join up the person as well as we might do. It is not about ripping up the guidelines, but it is treating that person with all their multiple conditions as a whole person, not as an individual. One guideline says one thing and something else says something else, but you have to temper what we are doing for individuals. I think that the increased number of guidelines has made that an issue, and we perhaps have not stepped back to say are those guidelines actually some of them not acting in synergy with each other, but in fact causing problems for people. A pharmacy colleague of mine had sent a man for review because he was being prescribed 58 different tablets, with all the side effects, etc., that you could imagine whether he was taking them, of course, is another question. Not advocating ripping up the guidelines, but merely using them in the context of the whole person, rather than the disease. I was interested in obesity and, of course, the information that you provide is very alarming. For example, you say that almost two thirds of adults in Scotland were overweight or obese, but perhaps it is not your report function to come up with detailed solutions to this, but you refer to the supporting healthy choices framework. A lot of that, in the summary bullet points, is about promotion and education, but we do not seem to be getting anywhere very fast on that, so I just wondered in terms of action on obesity. I suppose that the one that was to do with action more directly was formulating healthier products and menus across retail and out-of-home catering. I suppose that if you want me to put one specific question and suggestion, it is given that we have the extension of free school meals announced a few days ago. It seems to me that whatever the controversy is about, it is a very good opportunity to promote healthy eating. Is it time perhaps to revisit the guidelines about that? Some people who know of young children eating school meals are not always over impressed by the healthy nature of what they are eating. Is that one area? I suppose that it is a more general question about how we can really deal with that. I suppose that I am thinking particularly of childhood obesity, but of course it is a massive problem for older people as well. Thank you for your question. It is an area that I am very interested in. I am almost at the stage of saying that sugar is the new tobacco because we have the evidence of all the harms that overweight and obesity are causing. We need a raft of measures as we have done very successfully with tobacco reduction. You are right to be worried about the children and you have perhaps seen the inequalities that the graph in my report outlines. Although primary one children obesity is falling in Scotland as a whole, that is only because the children in the most wealthy communities' obesity rate is falling very fast. In fact, the children in our most deprived communities' obesity rate is rising very fast. We have not solved that problem at all, even though overall our obesity rate in children looks better. The messages are getting through, but they are not getting through to everyone equally. I firmly believe that we need to take this as we took tobacco. We have a big and growing problem and it is starting early, and we are some of the worst in Europe if not the world. Why has not it worked? It is because it is more complicated than people simply eating too much and not having the will part to stop themselves eating. That is very oversimplistic. A lot of new evidence about the availability of food and the price of food being the drivers for people's choices. We have an obesogenic environment and school meals is one area. I also have issues with NHS premises and NHS staff canteens. Our healthy choices, I do not think, are ambitious enough. A healthy living award is awarded for 50 per cent of produce being healthy. The other 50 per cent, of course, is not. Both of the choices are freely available to people. Promotions are always on on healthy foods, sugary foods. We do not promote fruit and vegetables. We have a multi-layered of issues to tackle. We are making some inroads and we are going to refresh the obesity strategy for Scotland. I was at a ministerial meeting just last week discussing that. Some of the points that you are making about reformulation were part of that discussion, but, pardon the pun, it is a big problem. We are losing the battle at the moment. Mike McKenzie, Rhoda Grant. Thank you, convener. Just in this area of general public health outcomes, I am always struck by the fact that Orkney, Shetland and Wester Niles always perform very highly in UK quality of life surveys. They are almost always in the top three. That includes very good health outcomes, despite the fact that per capita incomes tend to be pretty low. I wonder what lessons we can learn from that that may be applicable to other parts of Scotland. The first thing that I immediately think of is the association between mental wellbeing and physical wellbeing. Undoubtedly, the two are interlinked. They like living where they are, their lives are happier and their health outcomes are better. Maybe that is where we should start. Income is irrelevant to that if your mental wellbeing is good. You are right to make the point about the inequalities not only being down to income. Again, that is one of the parts of the report that worries me that our health outcomes are so inequitable. A lot of that is to do with income, but making everybody more wealthy will undoubtedly improve some aspects, but that is not the only solution. I think that we in Scotland recognise our problems, whether we have the solutions for them yet, I do not know, and perhaps looking at highlands and islands and those examples of where people feel better in themselves. There are lessons to be learned. There is some scope for our planners to think about. Planning has been dominated with the idea of place making. The possibility of a positive contribution for planners in terms of thinking about healthy places. You mentioned that in England last week that announcement of 10 times to be built with an environment that promotes health, walking, safe play, green spaces and availability of the less good things is very much restricted. A limit on fast food outlets, a limit on places selling alcohol, etc. There is also some evidence that some of our inequalities are due to not focusing on people's environment enough. The poor housing in Glasgow, particularly in our city Glasgow, has not tackled and been part of our inequalities that we see in people in our big inner cities? The recognition of health being much wider than the doctors, nurses and staff that look after health and the promotion of all those other aspects of people's lives is really just getting it and the importance of it. We have started to see it with mental health. However, there is a lot of emerging evidence about physical health. Rhoda Cymru, do you want a supplementary on this one and then I will get you in? Thank you very much, convener. Good morning to you. It is just what you are saying about the answer to the question from Mike Mackenzie in terms of the planners taking it in. I worry that they perhaps do not quite have the understanding in what sort of discussions could take place. For instance, in my constituency in the west side of Edinburgh, there are plans for major growth around the urban area of west into the rural part. It is very controversial all the rest of it. Every plan that comes up states that we will put a new GP or general surgery into whatever it is that we want to put. Is there any formal consultation that you are aware of in any discussion that goes on with planners at this minute in time as to the availability of people or are these planners just looking at an area that we put a building in that will eventually be filled? I am not aware that there is consultation along those lines. I do not know of others. I add in a couple of comments, which might not be terribly helpful. As I understand it, developers have to describe if they are going to get approval from planners, the community benefit that might stem, and they often provide health centres and so on as part of the community benefit. If I may, could I address another question? As I think I understand it, why is the health status of people living in the islands perhaps surprisingly good? There is so much evidence that it is not so much about planning of buildings and environment, but about community cohesion. Our previous director of public health did a lot of work on that and showed that small communities that are cohesive with a lot of interaction tend to be healthier. He was able to do some measurements on correlating feelings of wellbeing with some inflammatory markers that act as an indicator of imminent disease. It is a significant effect. It is not the only effect, obviously, that does not mean that you can abandon healthy lifestyles and so on. However, there is something about establishing communities, and a lot of the work was done in South American Indians. I am really getting a little bit broad here. The preservation of the cultural identities, in particular the elders telling stories in one group, seemed to be the deciding factor that gave them a much greater health benefit than a more dispersed group that mixed in with the other communities in the area, and all their traditions and cohesion were lost. It is very interesting. You could say that this is getting a little bit speculative, but I think that there is a strong hint that community cohesion helps health. That is very interesting. I could maybe try to find a reference for that, which I have not correctly described and maybe sent it on to you. That would be useful. I would be very keen to read that. I have a slight health warning with the island statistics. Certainly in the western islands, there are statistics about life expectancy that puts them in a par with some of the worst in Glasgow. It is just where that happens. It is in small numbers, and they tend to get hidden in a much wider survey. We have to be careful, but those areas probably bear out the community cohesion. Certainly, some of the things that are spoken about in the report are things such as the unwirried unwell. I am not sure that they are unwirried. I think that they are disempowered unwell, things that Malcolm had spoken about diet and them not listening to messages. It is very difficult to listen to a message if you are living on an income that most of us could not understand how you would feed a family on and having pie beans and chips stops a child crying. It might not be very nourishing, but it might be the best that you can do. There is a gap in our understanding about what people are up against. Giving them healthy messages is not helpful, because it disempowers them rather than empowers them. That came across in the report, too. How do you empower those suffering health inequalities? Those health inequalities are a symptom of disempowerment that has happened much earlier on. How do we change that? How do we give people the same opportunities towards health, which is coupled with wealth, to a huge extent? By giving out some of the health promotion messages on tobacco and sugar and the like, we empower the better off, because they cannot take steps to deal with all that. However, we are going further to disempower, because we are eating up the little self-esteem that those people have by telling them that they are also being bad. How do we change the message and provide the opportunity for those choices to be made? You have hit the nail on the head about the messaging. It is not working in the way that we would like it to. In fact, it is worsening inequalities, as you have said. I am speaking at a conference on health literacy, so I will bring in Graham, who is an expert on all of this area. You are absolutely right. Most of the health messages, and particularly the language that we use, are not applicable to those from very low-income groups and disadvantaged groups. It is really difficult. I think that maybe the solution there is multifactorial. I do not think that we are going to say that there is one solution, but I think that it is tackling it on all levels. I think that it is tackling it on an individual level, so it is empowering people within their interactions with their health professionals, not disempowering them. It is also about empowering communities as well, and how we can give voice to some of the most people who have the least voice, which is really difficult. There is some work that I am hoping to show on Friday from the States, where they have done some work with children in deprived communities who have been taking on some of the food industry, the junk food industry, and creating stories about how they feel targeted by some of the big corporations, particularly around sugar. They have developed poems around these, and they have gone into their own schools and delivered these messages. There is something about that communication through peers, which is really powerful, and seems to be translating into greater health awareness and greater desire to tackle it from those communities themselves. It is really powerful. I will send you some stuff relating to that, because it is very powerful stuff. There is one brief question before we let you go. I read through the second part of the report the whole question, and we have not done much in this either, in terms of mental health and that driver for some of that inequality in short of life. I was just to give you an opportunity to say something about that, because I took the impression in my read that there was a more serious focus on that and building the story in that that is very predictable and that mental health problems translate into greater illness and earlier death. How does that fit into the strategy, I suppose? It brings us back to your point about the status of different aspects of health. Mental health has not had a high priority status. People with mental illness are stigmatism, lack of awareness, and we have not invested in our mental health services in the same way as we have in physical health. There are a lot of statistics about poor physical health in people with mental illness, because even though they are in a health service, they are not getting the same level of care as other people. We have recognised that now, and we have recent large amounts of investment announced for adult mental health services in Scotland and child and adolescent mental health services to try to improve access particularly, where there has not been access to good psychological therapies. I think that we are starting this journey. We are needing to reframe what people feel about mental illness, about people coming forward and presenting when they have problems and then having our services as good as they can be to treat people. I often give the statistic from my own specialty of obstetrics that postnatal depression is in fact the most common complication of pregnancy—12 per cent of women have postnatal depression. Yet we treat clots in the leg, we treat blood pressure, we treat lots and lots of other things. Most people do not even know that the figure is as high as that. We have a long way to go, but the recognition is always the start. We have now recognised that mental health services need investment, and I think that the commitment to changing that level of investment, which has recently happened, will be a good start. Thank you very much to you all for your attendance. It is a valuable time this morning. Thank you very much indeed. We are already looking forward to your next annual report. We are suspended at this point. I allow the panel to leave. We are now moving to agenda item number two, which is subordinate legislation. We have two negative instruments to dispose of today. The first instrument is healthcare improvement Scotland, the delegation of functions order 2016, SSI 2016, backslash 86. I would ask you to note that this is the instrument that the committee took on oral evidence last week. There has been no motion to allow, and the delegated powers and law reform committee has not made any comments on the instrument. Is there any comment from members? There is not. I take it from that that the committee has agreed to make no recommendation. Is that agreed? Thank you. The second instrument is the national health service optical charges and payment Scotland amendment regulations 2016, SSI 2016, backslash 127. Again, there has been no motion to annull, and the delegated powers and law reform committee has not made any comments on the instrument. Is there any comment from members? We haven't. Can I take it from that then that the committee has agreed to make no recommendations? Thank you, we are agreed. We now move to the annual report in our consideration. I suppose that I should point out at this time that you will see the report before me. It is a factual account of the work that the committee has carried out this session. Do any members have any comments at this point? For seven mills that must be a record per one year. The seven bills are a record. There has been a very busy committee over the peace. Can I presume that we have agreement and that we need to get the committee's agreement that we would publish the annual report on 30 March 2017? At this point, we now move into private session.