 I have apologies from David Torrance, but this morning we will continue to take evidence as part of our inquiry into alternative pathways to primary care, and we welcome to our committee—hung on, sorry, I have forgotten to ask you if you are content to take item 5 in private members. We are content, thank you. Our second item today is a further evidence session that is part of our inquiry into alternative pathways to primary care, and I welcome to the committee, Humza Yousaf, the Cabinet Secretary for Health and Social Care. Good morning, Cabinet Secretary, and accompanying the Cabinet Secretary online, we have Scottish Government officials, Noreen Amad, the head of general practice policy division, Tom Fethys, the chief dental officer, Alison Strath, the chief pharmaceutical officer, and Michelle Watt, the senior medical advisor of the Scottish Government. Good morning to you all. Cabinet Secretary, I believe that you have a brief opening statement to make. Brief words, Camila. Thank you so much, and good morning to you and to committee members. I hope that you are all keeping safe and you are all keeping well. For one of your first inquiries, I am really pleased and I am very glad that you have chosen an area that is often referred to as the bedrock of our health and social care services and is often referred to as the front door for a number of people, for most people, when it comes to accessing the health service. I am really impressed by the way that committee has gathered quite a diverse range of views in this inquiry, both from primary care providers but also very importantly from the wider public who use those services. It has been extremely interesting getting feedback and reading some of the feedback from those evidence sessions. I have read with interest the comments of contributors to the evidence sessions over the last number of months. Those reflections point out that, like in most areas of health and social care, we have engaged in significant redesign of primary care both before and during the pandemic. It goes without saying that the contribution primary care service makes each day to the health and wellbeing of Scotland through continuity of care and meaningful relationships with patients is foundational to our public services. Let me take this opportunity to thank every single member of the primary care family for their incredible efforts during the pandemic. Prior to the pandemic, we were already engaged in significant reform of pathways through the 2018 GP contract. That has been a real step change in primary care pathways in the community with people accessing a wider range of healthcare professionals through their practice while freeing up GP time to focus on more complex care. By March 2021, 2,463 staff had been recruited to the MDTs, the multidisciplinary teams. That is over two and a half whole-time equivalents per practice. That number will have risen significantly over this year. For our part, we have allocated every penny of the £360 million investment committed to recruiting those teams over four years. We are delivering a further £170 million investment as part of the 2022-23 budget to continue the expansion of the important MDTs. Injecting that additional capacity into practices has been a real boon in allowing our wider primary care system to respond flexibly to the pandemic, staffing Covid hubs and assessment centres supporting the Covid vaccination roll-out, while keeping core GP services going to address the wide array of patient issues. Of those core services, it is worth pointing out that, even before the pandemic, video and telephone consultations were, of course, a part of how care was delivered in general practice. While, over time and as restrictions ease the balance, we will shift towards more face-to-face appointments as they should, a mixture of appointment types will remain a core part of general practice, as we know that it suits many patients to have their consultations with general practice over the telephone or over video. It is not just general practice that has adapted significantly throughout the pandemic and changed to meet the needs of its patients while keeping them safe. For example, we launched NHS Pharmacy First Scotland in summer 2020, seeing it increase the range of common clinical conditions that are able to be treated by the community pharmacists. NHS 24 has also seen a significant increase in demand over the past year as a consequence of Covid. The expansion of mental health hubs and access through 111 to the national redesign of urgent care pathway all delivered 24-7, where previously NHS 24 operated largely out-of-hours. As we look forward and look to the horizon and recover from the worst of this pandemic, it is important that we continue to shape our pathways to address demand that has risen and that we learn from the experience of the pandemic. GP's are, as I said earlier on, usually the first port of call for people seeking professional help. For mental health issues, the vast majority of mental health consultations occur in primary care, covering a diverse range of needs. That is why we are investing in 1,000 additional mental health workers in primary care by the end of this Parliament. Primary care services are often dealing with far more than clinical issues. That is why we are investing in providing non-clinical and social support and advice, including support for individuals experiencing social and financial disadvantage and exclusion, such as community links workers who can help with those concerns, welfare advisers and mental health workers. We are committed to a range of recommendations tackling inequalities following a publication of an expert group last month. I see this focus on mental health and health inequalities as complementing and further developing the primary care reforms that we have already instigated. To conclude, more multidisciplinary, multi-agency working, shifting our focus to the community to ensure that we get the right care to the people at the right time is what we will continue to commit our efforts towards. On that note, of course, I am happy to take questions from the committee. As you have mentioned, it has been a number of years since 2018 that the Scottish Government started the reforms on the pathways and the multidisciplinary teams. Previous to that, it was a traditional model of the GP being the first and often the only port of call for people to get access to healthcare. Obviously, the plan is to widen that out. One of the reasons that we decided to do this inquiry was in speaking to stakeholders and getting a sense that the public awareness around this is not quite where it could be. Certainly, we had responses in our survey from patients across Scotland and discussions with patient groups. The model that the Government wants to promote is not quite landing in every area of Scotland. I want to know your thoughts on how you think the Government can take this forward and check the culture change, but, given that assurance to patients that an alternative pathway is not a wrong pathway, you do not have to see your GP for everything. In fact, it might be better to access an alternative pathway. I think that that was a fair comment. It came out quite loud and clear from the various evidence sessions that you heard as well. That message came across really clearly. There are a couple of points to make. One is that, for anybody who has accessed and had treatment from the various different members of a multidisciplinary team at a GP's practice—whether that is the physio, the advanced nurse practitioner, the pharmacist and the quality of the service that I hope the vast majority of people will have received or have been expert or extraordinarily helpful to them. One thing that I suppose is that the more and more people get access to those individuals, I have no doubt that they will absolutely understand the value of the multidisciplinary team model. Secondly, on the comms and the communication, that is something that has been raised with me by, as you would imagine, not just patient groups, but also by clinical representative organisations such as the BMA and the Royal College of GPs, latter of whom I met just a couple of weeks ago. For me, a couple of things we can do. First of all, the work that we are doing with the Alliance is really important, but the Alliance will be well known to you, convener and committee members, around this table. We recently commissioned the Alliance to conduct a qualitative survey into patients' experience of accessing general practice. That forms part of a wider 10-year monitoring and evaluation strategy of primary care. For us, the pandemic—and it is not to use the pandemic—has been challenging, but one thing that we can all recognise is that so much of our marketing and communication has gone into how to behave during Covid, the latest Covid-related regulations, the latest Covid rules, rules around testing, self-isolation, et cetera, et cetera. I hope that, as we recover, there will still be Covid communication. In fact, we are running a Covid-sense marketing campaign at the moment, but we can begin to rebalance some of that communication to the public, which is exactly about the redesign of urgent care programme. Actually, even if you are not seeing your GP, it might be better for you to see another member of the team at the GP practice or within the community. As part of that, we delivered at the end of last year a leaflet to every single household, within accompanying letter from the chief medical officer and the national clinical director. That leaflet, I think, well produced, showed the various different alternative pathways for somebody to access treatment, including GPs, and what services you can expect GPs, but also the other pathways, including pharmacy first, NHS 24, et cetera. I take the point and don't disagree with it that there's going to be a bit of a cultural shift and it's something that we're very focused on. We certainly heard that accessing your pharmacy and the minor ailments system there was something that probably has probably been more successful than others. The Cabinet Secretary of State sees any areas in which specifically a little bit more work needs to be done in giving patients confidence, particularly the patients that will say, you know, I need to see my GP and feel that they're actually been phobbed off by suggesting something else. I mean, I think that that's a key point in terms of the cultural mindset that you can get. I think you're absolutely spot on. It's why this month we've launched a campaign specifically to support our receptionists. I was at Taymount surgery a couple of weeks ago where I had a discussion with Dr David Shackles of the Royal College of GPs and, you know, you could just see how, I mean, immediately obvious from when you walk into the surgery just how busy our receptionists are, and we've unfortunately heard reports of receptionists in particular facing abuse over the phone, sometimes in person. It's completely unacceptable, I think, everybody around this table would agree completely unacceptable. It doesn't matter the pressure that the individual is no doubt under or their need to see a GP or a member of a GP practice aiming at abuse at receptionists or any member of our health and social care staff is unacceptable, but clearly there are people who feel that receptionist almost acts like a gatekeeper. That's why we've launched this campaign this month to say, actually, when our receptionist is redirecting you, then it's being done because it's in the best interest of your clinical care. There may be others that can see you and it allows the GP, hopefully, to focus on those complex cases, as expert medical general practice, general experts, and then, I hope, is a better experience for the GP, but also, importantly, a better experience for the people that we're looking to serve. Just one final question before I go to Karen Walker. You mentioned a better experience for GPs, obviously, taking the fact that GP's workload is extremely pressurised. Do you think that, when this model really starts to click in and we have this public acceptance of the fact that there are a number of different ways that it actually might make GP practice a very attractive to medical graduates? I'm dealing with the acute stuff, the stuff that's really going to put the training into action as opposed to some of the other things that are the nurse practitioner side of things. That is certainly part of the feedback that we get. This focus on being an expert medical generalist is what certainly makes that option more attractive. I think that easing the workload burden so that they can again focus on those complex cases, I think that that does help. I think that there are other issues around retention as well. I'm very aware that, while I'm speaking well, we have a practising GP as part of this committee. Of course, I'm interested to hear his thoughts. The feedback that we get from GPs is that the contract and the work that we're doing around MDTs, in particular, if we get this absolutely right and is embedded in, then it certainly could make general practice a more attractive proposition. That being said, last year's fill rate was about 98 per cent, so we're doing well in that. However, retention is really important for you, and that could be key to that retention. I think that it is clear from the evidence now that we have listened to the evidence that patients do see GPs as the gold standard, so it is understandable that they sometimes find a new way of working, or not so new now, but this alternative way of working is quite difficult. It is our responsibility to try and support them to these new routes in a way that makes them feel engaged and valued in getting the best treatment. My question would be about patients, and the evidence is clear that we've taken and also I get this in my constituency all the time. They do feel a bit past around. They feel that the systems are not working very well and that there's no clear leadership at the health board levels about how those pathways work and what happens when you go all the way around the system and back again because we have heard that quite a number of times. I would suggest that there is some urgency around sorting this and that some serious financial investment would probably be required, and I wonder where you are with that in your plans for the next coming few years. On the serious financial investment, £360 million to deliver those multidiscipline teams, I hope, is a sign of our investment and the importance that we attach to that. I hope that we would certainly meet that ambition. We also know, and I know what can be known as well as the entire committee, that the last two years have been absolutely unbelievable in terms of the pressure that everybody across the NHS and social care has faced. If we did not have a pandemic, I don't doubt for a minute that we would be able to use more of our communications muscle and the weight of the Government in terms of communication to get some of those key messages out. All that being said, I take Carol Mawkins' point that during a pandemic perhaps even more important to be doing that. On people being passed around, it is something that I hear too, and again I think that it is a fair comment. From our perspective, it is why the work that we have done and are doing in terms of the digital health and care strategy, which is available online, I am certain members, will have seen it. If you have not seen it, I would commend it to every committee member to look at it. It lays the foundation for that cloud-based architecture, where information can be shared a lot better than it currently is, and we know that that is still an area that needs significant improvement. With the embedding of the likes of community link workers, for example, that the sharing of that information about a patient is better, and therefore, hopefully, people are not being passed around as much between whether it is third sector support, primary care or secondary care. The last thing that I would say is that the interface working between primary and secondary care is of extreme importance to us. Every time I meet the BMA in the Royal College of GPs, they stress to me just the importance of that interface working. Again, people are not passed between primary and secondary care, which in fairness is a bit of an artificial boundary that we have created as opposed to a boundary that means anything to patients who just need to receive either treatment or diagnosis or care for the condition that they have. I think that the key thing is to remember that the patients are central to it, and so their experiences are really important to move it forward. I urge the cabinet secretary to make sure that there is serious commitment put into alternative pathways, because we all believe that it will have good outcomes for patients. Changing the way in which public access, primary care is key to really make this a reality, alternative pathways must deliver for our patients. In evidence, we have heard about long-wasting lists that can encourage patients to default back to the GP. How will the Scottish Government improve staff capacity and reduce waiting times? Is there enough investment in recruiting staff to deliver the Scottish Government's vision? It is a really good and important question. There is no getting away from the fact that the last two years have seen significant increases in backlogs. On a waiting list, this is a really important point that was stressed to me by a number of orthopedic consultants that I met recently, that waiting on a waiting list is not a benign act. It comes with real, serious, significant impacts on the individual that is waiting, and that can be a deterioration in their health. It can be increased chronic pain. Therefore, if they do not know how long it will be until their procedure or their operation, then to manage that, they will often go to primary care and often to GP practice. I entirely accept the point that, as the backlog continues for treatment, it will undoubtedly continue to be a level of pressure from that backlog on to primary care. Tackling the backlog is key to that. The key to tackling the backlog is controlling transmission of Covid. We know that. For example, between the Delta wave and the Omicron wave between October and November last year, for example, and we had just a bit of a breather that alone allowed, for example, scheduled operations to increase by around about 23 odd per cent in the space of a month. We know that the NHS has the ability to recover if we can insulate it from the worst impacts of Covid-19. I agree with that point. Staffing is key to that. I will not rehearse in too much detail the good record that we have on staffing that is not to say that there are not vacancies. We know that there are, but under this Government, more than 28,000 additional whole-time equivalents in our NHS is an impressive record in terms of staffing. The third point that I would make in relation to the issue at hand is why we are investing heavily in the multidisciplinary team model. If we think about it, somebody who has been waiting for an operation, unfortunately due to the pandemic that has been postponed, going to see the physio based on your GP practice could be of more value to you or be of real importance and value to you. At the same time, it frees up the GP, as we say, to be those expert medical journalists to deal with more complex cases. The points that Stephanie Callan makes are well made and are really important. That is why the recovery of the NHS is so vital. Good to hear you mentioned multidisciplinary teams. It is great that they are really expanding as well. We have now got physios, pharmacists, OTs, mental health nurses, dentists, optometrists, pharmacists, psychiatrists, paramedics, so getting bigger and bigger and expanding all the time, I think that that is really important. However, what we have heard in previous evidence as well around the workforce planning is concerns that what we are going to end up doing is really moving people around rather than creating that new capacity that we need there. And how important it is for investment in planning and integrating primary care across the workforce and right across services there. So how will the Scottish Government look at creating that new capacity and planning and implementing primary care workforce and services right across the board? There is a little in there that you have said that I would disagree with. I think that there has been a valid concern on the one that we have always had, is that we are not just creating these multidisciplinary teams and taking them from other services in the community. So I think that as a valid concern, particularly given the impact that the pandemic has had on being able to attract staff from outside of Scotland too, so for this specific programme, these concerns surfaced in early years of reform. However, in recent years, they have levelled off. We are confident that there is a genuine additional capacity in primary care complementing existing teams. What we are seeing with recruitment of MDTs is a much greater emphasis on training, a much greater emphasis on growing your own. Pharmacotherapy is a good example of that. We are plans in year 1 and 2. They were very pharmacist heavy, if I can put it that way. Recently, the skill mix is moving more towards the use of pharmacy technicians, with a projected 75 pharmacy technicians and posts for every 100 pharmacists in 2023. That compared to 29 for every 1,000 pharmacists. Training a pharmacy technician for reference takes about two years considerably less than a pharmacist. Ensuring that we have that pipeline for the future is really important, so we do not just end up cannibalising the workforce that is already out there. I am keen to attract a lot of the workforce from other parts of the UK, and the common travel area, as well as overseas, putting a lot of emphasis on international recruitment. I was pleased to see some of our international nurse recruits in NHS5 in hospital and acute site in secondary care. Equally, there is a role there for primary care, too. I am not sure that it will be a nice short answer, but I wonder if you could comment on what the implications of the national care service might be on workforce capacity and planning? I will try to be brief in the sense that it is an issue that has definitely gathered a fair bit of attention. When I talk about my conversations with the RCGP and the BMA, it will not be a surprise to anybody. I do not think that I would be articulating a state secret if I say that they have got some concerns around some of the consultation proposals around moving GPs from their current employment model into potentially being employed as part of the national care service. We are yet to come to a determination on that, but I will say at this stage that I think that they make quite persuasive and strong arguments for retention of the current employment model, but let's see when it comes to national care service how we are truly integrating primary care as part of the national care service. We have to do that. Integration has got to be key, and with the reformed IGB's proposal, I will be careful what I say, because we are still going through the consultation responses. We would hope that there is real integration from inception, from the creation of the national care service, with, for example, health boards. That will be really vital. We are considering those consultation responses. We have to be a bit careful, because we are hurtling into pre-election periods. My desire would be to pick up the conversations with COSLA, in particular in earnest, post the elections at very quick speed and come to Parliament, I would hope, with the legislation being introduced before we go into summer recess for the national care service. Of course, I look forward to being able to articulate what our vision is for the national care service in that period. Recruitment and retention in general practice continues to be a critical issue as we recover from the pandemic, but even before Covid, the Audit Scotland reports were showing that the Scottish Government's plans to increase the GP workforce by 800 by 2027 is on course to be all but wiped out by the number of doctors expected to retire or change their working patterns. What needs to happen to improve retention among general practitioners? That is a great question. You are absolutely right, because you can recruit and be as ambitious in the recruitment side, but if you are not retaining, where is the value in that? I hear a number of things from our general practitioners and those who work as part of a GP team. It goes back to some of what the convener was saying. If we can ensure that the workload—well, the burden is eased and spread out across those multiplicity teams, I think that that absolutely helps, because I do not think that I will be given away any surprises when I speak to GPs and tell them that they are exhausted. The second thing that we need to ensure that we do is to remove any potential disincentives. Again, the BMA, for example, has asked me to look at whether there is anything that we can do on the pension side of things. I have written to the UK Government on that, but I am looking to see what the Scottish Government may be able to do in terms of potential schemes in relation to pensions. I have not come to a firm conclusion on that yet, but I am looking with an open mind. We need to continue to make progress with the current contract and, of course, the next phase of that contract, which, again, I would hope, would make becoming a GP not just an attractive proposition, but staying in that profession would be attractive. I think that there is a lot that we probably can do that we are working on. I think that there is more that we can do that I am giving active consideration to, but I think that the points that whoever makes are absolutely right. You have got to focus on retention as much as you are focusing on recruitment. Thank you, cabinet secretary, for that answer. One other question. Can you maybe help and explain what assessment you have made with your team of the provision of the GP out of ours services during the pandemic? We keep those under our regular review, as you would imagine. Again, it would be fair to say that there has been some challenge in that. I know that, for example, recently there has been a focus on a number of health boards and out of our services, Lanarkshire, 4th valley, perhaps being the ones that have been most recent. We continue to keep that under review. There has been challenge throughout the course of the pandemic. My hope is that that pressure eases and we are still in a very tricky position at the moment. However, as that pressure eases, how do we make those out of ours options more attractive and sustainable? We know that people need that out of our access. In fact, if we look at the demand on NHS 24 and as an example of that, the demand for NHS 24 services has been through the roof in recent months and even the last couple of years. I keep that under regular review, but I also recognise that there has been some challenge in that regard. I have a number of colleagues who want to come in on workforce. I will come to Paul Cain first of all. Thank you, convener, and good morning to the cabinet secretary. I want to just follow on from some of those questions. My point is just about the data that is available. Figures by Public Health Scotland have showed that the number of whole-time equivalent GPs has actually gone down. We are at the lowest level now since 2013. I think that although the head count is going up, whole-time equivalent is often a better yardstick in terms of understanding the picture of service across the country. We have not had figures on whole-time equivalents in GPs since 2019, so I do not know if the cabinet secretary has information available, but I think that committee would be keen to see that information about where we are in terms of whole-time equivalent GPs, so I do not know if he can make a commitment to maybe provide that information. Yes, if that information is able to be published and there is not management information, and even if it is, let me find a way of making sure that we are able to publish that and it is quality assured. I am happy to write to the convener who will then pass that information on, but Paul Cain knows our commitments to additional head counties right to make that difference, of course, but it is a significant target. I go back to the points that I made to Sue Webber and others have raised that that is just one part of the strategy for making sure that we have a sustainable GPs service in primary care and the future retention is going to be a key part of that, too. Emma Harper, do you have a question on that? Yes, thanks, convener. Good morning, cabinet secretary. It comes to me to think about recruitment of GPs. The SCOTGEM programme was created and it is unique to Scotland with a collaboration between St Andrews and Indeed to support training GPs. I am assuming that it is going well. It might take longer answer than we can do here today, but just a wee update on how SCOTGEM is going. It is going well, and probably for the sake of better writing to you with more detail, it is a programme that we are continually looking to see how we can expand, how we can increase the capacity of the SCOTGEM programme because of the value of it that we have seen in the early years of it. I am happy to provide it again through the convener, perhaps in my written response, because there will be a number of things that I suspect I will want to come back on if I just give you some more detailed data on how that programme is going. However, there is not a conversation that I have with my primary care team around GP services where SCOTGEM is not seen as a critical component of that. It has a particular focus on rural in general practice? Yes, absolutely. That is the primary focus of that work. There are some real issues around rurality, not that I need to explain to Emma Harper about GP recruitment and retention. SCOTGEM is an absolute vital part of that. I think that some of the work that we are taking forward after Sir Louis Ritchie's report—I have already spoken to him last week—is going to be vital for sustainability. It is absolutely key to the rural challenges that we still continue to face in GP practices and in primary care more generally. My question is just going to come back on to one of the things that you spoke about when it came to pensions. We look at Wales, and it has solved the issue of doctors paying to go to work through pensions by the recycling of the employer's contribution, which then allows the doctors further in danger of paying to go to work to actually not do that and come out of the scheme for that. It is a fairly good solution because it brings in more taxation as well because that money is intact. My question would be why we have not gone down that route quicker because it does seem to be working in another devolved area. As I understand, the position in England is that NHS trusts are able to bring forward a rake scheme. You are right to point out that in England and Wales that option exists is why I am very actively considering it. I have to think carefully about the financial impact for the Scottish Government for a group of clinicians who work incredibly hard, but I think that we would all accept it at the higher end of the pay scale. If we are to do that, then what about those at the lower end of the pay scale? How do we ensure that we are either removing disincentives but also putting our money and our resources towards those who are at the lower end of the pay scale, which is the progressive thing to do? I am certainly not ruling out a rake scheme and introducing one. In fact, far from ruling it out, I am doing the opposite. I am very actively considering it. I would expect to be able to say something more on that in the coming months, but it should not be more than that. We are in the middle of discussions about pay for agenda for change staff, but we are also waiting for recommendations from the DDRB. We are in a really important juncture when it comes to discussions about pay, terms and conditions, but the rake scheme is being actively considered and discussions with the Welsh Government and the UK Government on the rake scheme and the effect of it on those discussions are on-going. Evelyn Tweed has got some more in-depth questions on signposting and joises online. The cabinet secretary had mentioned the key role of receptionists and the role that they have to play in primary care reforms. Often, receptionists can be seen as a barrier rather than a facility. What would the cabinet secretary have to say on how we can improve interactions between patients and receptionists? Do you also raise the point about raising the profile of receptionists? I was just referring to my earlier comments that we, first of all, abhor any abuse to any staff. It is unacceptable. We know that our receptionists are a vital component of that GP team and that primary care team. Any abuse that they are suffering is just unacceptable. We have heard evidence of that from a number of different sources. That is why the big messaging campaign in primary care at the moment is focusing on the role of receptionists. We launched it on 3 March earlier this month. It was a reception awareness campaign, a raising campaign across Scotland. It is aimed at the general public and it is raising awareness of the important role that receptionists play. If anybody has not seen the advert again who is sitting around this table, I would commend it to you. We are happy to, perhaps in the response to the community, send you a link across to the video that is playing out there. It is an excellent advert and shows the various different pathways that are available and that receptionists are trying their best to be helpful. They are not trying to be blockers, they are not trying to be gatekeepers, they are not trying to be difficult. What they are actually doing is caring for the person on the other side of the telephone while they are under significant pressure themselves and say, well, actually, we think that the best route for you is X, Y, Z. I think that that is part of it. I think that messaging is definitely part of it. I suppose that my appeal to people would be that, notwithstanding, I know how difficult it can be, how frustrating I can imagine it can be. Also, given the demand that is on the service, you are maybe not being seen straight away or you are not getting a consultation straight away that it can feel like you are being fobbed off, but that is not what GPs are doing, not what receptionists are doing either. We do have a short-life working group that focuses on the role of receptionist. They are going to meet again. That short-life working group was a number of years ago. We are going to restart it again to meet for the first time since the pandemic in April. The group, chaired by Fiona Duff, senior adviser to the primary care directorate, will focus on development, but also on the future needs of GP practice managers and some of the admin staff as well. We can pick up some of that in that working group. What is the future role of our receptionists in that work? How can it be ensured that, in promoting alternative pathways to primary care, that patients consistently access the most appropriate care for their needs? What safeguards will be in place in that sector? For me, it is about ensuring that we are investing in those multidisciplinary teams. I have every trust that the clinical advice that a person will receive will mean that they will get the best care possible. For example, if they were signposted towards the physio, the physio will be so interconnected as part of that multidisciplinary team. We will say that perhaps the best thing for you is going to see the pharmacist, because, potentially, the mixture of medicines that you are taking—there is a particular side effect that is causing the issue that I am looking at here—is passed on to the pharmacist, who is then able to perhaps provide different medicines or a combination of different medicines that will help with the pain that they are feeling. We have a trust in that clinical judgment. I certainly do, and we have a collectively trust in that clinical judgment. Where things go wrong in the few instances where they do, and we have to acknowledge that that can be the case, there are obviously avenues to pursue those complaints and so on and so forth. However, I would hope in the vast majority of cases that, because clinicians are working as part of that multidisciplinary team, but there is also a multi-agency approach, I would hope that most people, of course, the vast overwhelming majority of people will get the right care at the right place at the right time. So you have a supplementary question on this issue. Thanks, convener. Yes, cabinet secretary, it is following on what Evelyn was saying about the role of the receptionist. We hear in some of the papers that there is a gatekeeper, but they are called signposts and gateway. It is that positive versus negative language, but still the people accessing all these MDTs have to contact that individual, and that is still very much often the bottleneck that causes the frustration. So I am just wondering what your thoughts are about how we might look to overcome that. Yeah, again, I think it is a really good question. So I think there is a few things we can do, but if I try to keep it brief, one is we are investing into lefini system, so we have provided around £2 million to health boards to improve those to lefini systems. However, that might be something that we will perhaps cover more in detail later on. I do not know, but digital access to health services through digital means, I think, is hugely important to that. That is why, again, as part of a digital health and care strategy, we talk about the digital front door, so that there is maybe less reliance in the future on having to pick up the phone and having to phone at 8 in the morning, for example, and all having to rush and then you've got to hit redial 16 times and then you possibly get an appointment or not. That's frustrating for everybody. It's frustrating for the reception, I suspect, at 7.59, feeling quite anxious, and it's pretty frustrating, I suspect, for the individuals on the other side of that call. So I think digital has a real role to play on that, too. Thank you. Paul, you have a question on this? Thank you, convener. I think just following on from that point, and I think a lot of the staff in practice aren't just receptionists. I think we know that. We've heard about signposting and gatekeeping and all those sorts of things. I mean, we had some good evidence, I think, from Dr Graham Marshall, who talked about training for reception teams and doing training, sorry, with both clinical staff and the more administrative staff. I'm just wondering if there is opportunity at the UC to perhaps standardise some of that training. I think that it's hard because of the nature of GP practices, but to probably look at paying conditions in terms of that more administrative side and how do we enhance the roles that are there, because we know that, as I say, they're doing more than just answering the phone and talking to patients. Yeah, I agree with all those points. That's why the discussions that we have with the BMA in the Royal College of GPs is really collaborative, because given the model of the independent contractor model that we have, it's really important that we keep close to our GP colleagues just in relation to those terms and conditions as you rightly reference. The only thing that I would say is that I would go back to my answer about the short-life working group, which is a meeting again next month, and they are looking at those very issues that Paul O'Kee references around administration, development, training, and I think that there's a very key point. I think that difficulty absolutely is that question of standardising right across the country, and that has its benefits for sure, also has its disadvantages in terms of flexibility for more rural, remote areas, but I don't disagree with the substantive points that Paul O'Kee makes. Thank you. We'll move on to talk about social prescriber, and then questions led by Sue Webber. Thank you, convener. Cabinet Secretary, one-third of the respondents to the committee's public survey said that their experience of social prescribing was either bad or very bad, while some respondents said that they would be insulted if directed to those services. A common theme in particular among respondents was that they could have found the same or better information elsewhere, so you get a sense that there's a bit of frustration there. So what needs to happen to make those pathways perceived and indeed more valuable and more credible to the public? Yeah, again, that's a really good question. So that was about a third, so I don't know, I'll need to look at the survey, but I'm hoping that that means that the majority of people found it quite helpful in terms of a pathway for that, but that third is still significant, it's not an insignificant number of people. So I think a few things need to be done. I think we need to be able to extol the virtues collectively of social prescribing. I'm a real believer in the ability of social prescribing to play a positive impact for people because I've seen it, you can say, first hand, second hand, certainly in my personal experiences. I see it in a constituency MSP level. I've got a fantastic community link worker in Pollock, and she's just a moment and over from an equally fantastic community link worker at the Hill Centre in Pollock. So I'm certainly in some sense an evangelist for this. I would also say that consistency, so messaging is absolutely needed and key, and so there's maybe something here for government to think about, given what you said, about how to be again, articulate the virtues of social prescribing. Because it's not just about signposting people to look here's XYZ service in your local community, it's about that link worker building up a relationship with that individual and saying, look, this is how I think it could really support you and really taking them on that journey with them. So I think that that's key. There is something about consistency across the country, I think that's a fair point. So we've commissioned Voluntary Health Scotland to develop a national network of community link workers, where they can share that best practice, be peer to peer supporters, support for each other as well, but how do they share that knowledge across the country? So we're undertaking, I should say, a review of support and training needs of link workers, and we'll build on the findings of that review as well. So I think there's a lot to do in this space, but I would hope that most people that experience and have an interaction with a community link worker, I think for most people I would hope that it would be a very positive experience. Thank you. And following on from that, the hope that they are having that good experience, Healthcare Improvement Scotland also highlighted in their response to our consultation that the increase of social prescribing is dependent on continuous monitoring. So are you aware of the monitoring that is currently being undertaken? And if so, how extensive is it? Yeah, I think again that's probably something without prejudging the review that will come through, is that we tend to try to leave in some respects this to local community link workers and the way that they work, how they interact with the third sector, how they interact with community groups. We generally leave that to the expertise of the community link worker, plus the general practice that they work in and the other members of the multidisciplinary plenary team that they work with. So there's not that kind of standardised one-size-fits-all top-down approach, here's what we think you should do, here's how we think you should do it, et cetera, because we've got to have that local flexibility. What works for a community link worker in my patch and in my constituency in Pollock isn't necessarily going to work for a community link worker in Peebles, for example, or Perthshire, or whatever P you want to use, it is different to Pollock. So it is clearly important that we retain that local flexibility. I think what we're hearing back from people is, well, how do you, and this is a key to your central to your question, is well, how do you then monitor the impact that they're having. So I think there's probably a bit of work for us to do nationally around monitoring that impact in perhaps greater detail. That's great. Thanks very much, convener. And Gillian Mackay, you have some questions around social prescribing. Thanks, convener, more on that, secretary. Witnesses to the committee have highlighted that a culture change is needed with regard to social prescribing as many patients are still not comfortable with the idea of it. Some organisations have heard that people felt short changed when they were redirected to links practitioners rather than a GP, and GPs have also highlighted time constraints limit their ability to explain social prescribing to patients. What action is being taken at a national level to facilitate this and to promote and explain social prescribing and its benefits to the public? I'll try to repeat what I said before too much detail at all, but I think that we have done marketing communications around social prescribing. I think that we probably want to help the ante on that, particularly given the effects that the pandemic has had on people's mental health in particular. I think that there's a real role for social prescribing to play in those mental health challenges and overcoming some of those mental health or helping to overcome some of those mental health challenges. I think that there's a need for us to re-energise some of the national communication around that. I would hope that, again, through the measures that we've taken in terms of expanding the MDTs, that that eases the workload pressures on GPs and that they have that time to be able to explain to an individual that this is not about, again, being fobbed off or passed on, there is real value in what the community of links worker can do and having them embedded as part of that team, I think, is really valuable. I do think that there's work for us to do on that, but I do believe that it's the right way to go. It's why we've obviously committed to 1,000 mental health workers and GB practices in the future, because, again, we think that there's real value to those individuals connecting with services in the community, so more to do on that and perhaps we've got to think a little bit more about national messaging around the value of social prescribing. I am very interested in social prescribing as well, but it's about how we signpost folk to some of the services that are out there. During this inquiry, we have focused on additional third sector services and helping people to signpost them to using ALICE, which is the Government-funded local information system. I know that we heard last time about evoke, which is an Edinburgh-based one, and then one in Dumfries and Galloway called DG locator. I'm interested to hear from you, Cabinet Secretary, about what we can do to help enhance the ALICE system so that we can better support it or look at how we can direct people to mental health services, for instance, because we have seen the benefits of men's sheds, walking football, walking groups and just social groups as well, which third sector can help direct people to. How can we help to support ALICE in order to help to signpost people? That's a good point about ALICE. It came across quite clearly from the evidence sessions. I didn't get to see it, but I was reading about the evidence sessions that you were taking. ALICE was seen as an important tool, or certainly had the potential to be a really important tool, but it was felt that it wasn't updated enough that the functionality could be better. All that feedback that we have from your committee evidence sessions is really helpful to us. ALICE is a great resource. It has over 5,500 services available from over 800 organisations, so it's got quite a significant amount of detail. It was searched over 26,000 times in the space of the three months of October to December last year, but we recognise that it needs some work done to it because it is an important tool. Some of that work is being done at the moment. Work to enhance the performance and accessibility of ALICE is being undertaken by the Alliance, and we are hoping that work finishes in the summer of this year. That's good to hear. I'm thinking about the way that we direct people. For instance, we've heard in some of the feedback that people will go and see their GP and expect a tablet for their diabetes, for instance, when maybe a social prescribing programme will help to reverse type 2 diabetes, and we saw that with the Fixing Dad programme where Jeff Whittingdon lost 20 stone and he lost so much weight. That was part of helping to support that family and they managed to help their dad lose a lot of weight. I'm just wondering what else we should be able to do to help to show people that the alternative pathways are adjuncts and not necessarily standard B instead of class A out of the whole process. We have seen, especially during the Covid pandemic, how important it is to support people's mental health and get them out outside and walking, for instance. I don't think that there's a magic wand or silver bullet to all of this. Communication is certainly part of it. I think that people will see the value and the more and more people that we can get access to social prescribing and give them access to social prescribing, then I think that they will see the value of it themselves as individuals. I think that they will hopefully then, through word of mouth, tell other people about the benefits of it. I think that we will do clearly what we can and I've referenced in a previous answer a moment ago that perhaps there is a role for more national type messaging, maybe linking in with the third sector around some of that. I do think that experiencing the benefits, just as you very articulately put across from your constituent, if people hear those stories and maybe there's something to do around the case examples, then I think that that will speak volumes in comparison to necessarily a Government marketing campaign. I think that those personal experiences are hugely important to all of this. People will see the expansion. I mentioned our increase of mental health workers, which could absolutely include community-linked workers, but it could be even broader than that. I think that as we see more and more of those individuals embedded within the GPs' practice, then more and more people will clearly have access to them and hopefully benefit from them and speak to others about the positive impact that they had in their lives. We now move on to talking about digital health and care. Questions led by Paul O'Kane. Thank you, convener. We've heard evidence from patient groups, particularly the Riverside patient participation group, who I think are muscle group, and they've spoken about digital exclusion and health needs and I think that those two things coincide. Do we understand that approximately 10 per cent of the population doesn't have access to or the skills required to use new technology? Those patients are most likely to have the greatest health needs. There's a clear correlation there. I'd be keen just to get the cabinet secretary's sense of how can their route into primary care be protected and enhanced, given the challenges? Something that we're really conscious of and aware of. Again, if you haven't read the report that was published from the short-life working group, the expert working group on primary care and health inequalities, I would definitely recommend it to you. You may have done so already, but if you haven't, because I know how busy we all are, it's certainly worth just taking a bit of time to go through that. Again, the points around digital exclusion are well made by the likes of again somebody who was involved in that working group, Dr Carrie Lunan, who is part of the deep end project, which again I know that committee members are very aware of. So those 100gp practices that are in our most deprived areas often talk to us about digital exclusion. A couple of things. One is that anything that we do in the digital space, we have to ensure that one, we're not just aware and acknowledging digital exclusion, but we're assuring there's an alternative pathway for people that just do not have access, no matter how hard we may try. There will be some people who just either will not feel comfortable or will not feel able to use those particular digital routes and therefore we have to ensure that those alternative pathways are still available for them. The other thing we should do and we are doing, of course, is trying to focus in on that digital inclusion piece. This is where I, you can imagine, work closely with colleagues right across Government because this is an agenda that is important to many cabinet secretaries, all cabinet secretaries and ministers. The Connecting Scotland programme aims to support an additional 300,000 households to get online, so let's connect as much of Scotland as possible, but let's also accept that even doing that, there will be some people whereby the alternative non-digital pathway will be important, so that is absolutely a part of our thinking moving forward. We've also had discussions, and I've been kind of staggered on slightly about the need for provision of digital spaces within our community locations. Libraries is the obvious one that comes to mind, and I've spoken about that before, about how do we utilise libraries and improve their services and protect their services so that people can access digital where they need to? Not necessarily in the public part of the library, I think that there's definitely spaces where people can be supported to do that in communities. I think also part of the challenge can often be that, in a lot of communities, the GP surgery is one of the few kind of amenities that there is, I'm thinking particularly in rural locations, so it becomes very much the hub and the focus. I'm just keen to understand how do we do more of—because people might not want to get online on their own at home—that can be the challenge and that can be the barrier. So how do we ensure that there are more and more facilities available to people within community settings where they can access information online, advice online or, indeed, to consult consultation online as well? Again, there's nothing that I disagree with that Paul Cain said there. I think that's why investing in our public services locally is so important. We reference library in my own community and the constituency that I represent not only has the public space but has acquired our space for people to be able to go online if there's something particularly sensitive that they need to look at with all the appropriate checks and safety measures that you'd expect. I think that that's a good point about whether or not we can explore if there's more that we can do within GP practices and health centres probably easier to do in the larger health centres that we have. How do we do it in smaller locations where space is already at a premium? I think that that's a really good point and one that I'll take away in the back of the comments that Paul Cain has made. Paul, you have some questions around that. Thank you very much. We spoke earlier about some of the potential changes that you're talking about the telephony system for the GPs and the adoption of digital health and care information has really accelerated through the pandemic. You've seen that with the but has the quality and the quantity of resources kept up with demand and our relevant websites easy to navigate and including those that are with only a limited digital understanding. So I'm trying to figure out are we keeping up with the development needed and I'm thinking back to an article that was in the Scotsman the other week about having an app that you could access your test results and your make appointments etc where we are sitting not with that available to us in Scotland but NHS England has that app available now and we're just wondering why there's not a bit more cross-border sharing in terms of that technology development as well. Yeah, so there's a couple of things I would say on that front. One is there has been an explosion of interest in digital health and accessing health information digitally throughout the course of the pandemic out of necessity, no doubt, but I would hope that NHS Inform is a good example of a service that has been well used at the course of the pandemic and perhaps in my response to the convener, the written response to the convener, I can share with you some of the data behind how well NHS Inform has been used. As have other digital platforms so near me again would be the obvious example, again the explosion and the use of that. I think the point that Sue Webber makes around the digital app is a really important one so it's a manifestal commitment from us to develop that NHS app, that digital front door so we're working on that where it's sensible to have that discussion with other parts of the UK. We are doing and will do that. I think there's no point in reinventing the wheel if there's something that works particularly well. There may be challenges, we may not just be able to, I know you're not suggesting this of course, but we may not just be able to pluck the app from one part of the UK and just transplant it here. So certainly I'm going to have a really good relationship with the other health secretaries and ministers across the UK, so absolutely we can share that information knowledge, I would be keen to do that. So I think there's a lot of progress to be made in this area and a potential digital front door app that can do a whole host of things from picking appointments to receiving results is something we're very focused on. In previous sessions some of the officers, the government officials that work with that digital platform have stated there's a disconnect between the level of investment that we have in the people developing the technology compared to other parts of the UK. So do you have plans to upscale and have more people working behind the scenes to develop these? Yeah, in short yes, it's been a digital team will know this, I'm constantly speaking to them about it. It's certainly an area, I mean the team here for me regularly that I say that more investment, more resources will come their way as a digital team and it's something I'm committed to doing because it needs, I think it needs beefed up that current digital team, they're a great team to do a heck of a lot and blooming heck they've worked really hard throughout the course of the pandemic but I definitely think that there's value in not just upskilling but actually increasing just the numbers in that team. I think the second thing I would say is I've also said the same to our health board chief execs and chairs in fact I said it to them just yesterday when we had a session which was you know we understandably put a lot of focus when we talk about infrastructure on bricks and mortar, it's important to build health centres, hospitals, community services but we should be I think putting equally as much focus on when we talk about infrastructure excuse me on digital infrastructure and the need to invest in that so certainly in that discussion yesterday there was lots of broad agreement on that so in short the answer to your question is yes the digital team in government is going to be appropriate resource and that resource is undoubtedly going to have to increase to meet our ambitions. Thank you. Alan, on that you mentioned near me I was going to ask you a bit near me in an assessment of one of those things in the pandemic one of those very few things in the pandemic that actually might be a positive that's come out of it that perhaps that face to face that video conference in the aspect of healthcare for some people has actually been really helpful and possibly something that they would want to opt for in the future and the word opt is important here I was going to be an assessment of like some of the learning that's come out of the pandemic in terms of digital healthcare and things where we want to keep and maybe you know further investment in it. Yeah again I agree entirely with your articulation of it that you know should be part of a hybrid model telephone consultation video consultation face to face consultation it's all part of that hybrid model and of course for people that should be seen even now with the current pressures people that should be seen face to face that should be happening if that's not happening then I'm not happy about that but I certainly know that in the futures we look towards a hybrid model for many people continuing with video or telephone consultation will be their preferred option and there's a preferred option for me. I've used it during the pandemic. It wasn't necessarily the most comfortable experience trying to show the back of my knee where I have some eczema to the doctor but you know we got there and we got the worked well and you know within you know that that was in the morning of by the afternoon I had the the ointment that I needed at the pharmacy down the road and it saved me the journey taking time out of quite important meetings to travel to the GP, wait in the waiting room, get assessed so for me it worked perfectly and there'll be many people who have work pressures, family pressures you know and so on but it's just far more convenient to be seen over video or indeed a telephone consultation. What I would say is that I suppose it goes back in some respects to Paul O'Kane's point about digital inclusion, stroke exclusion, got to be really careful that those people who are digitally excluded will get them digitally included as best as possible but accepting that that won't be the case for everybody, those alternative pathways have to be available so nobody is talking about you know removing the need for face-to-face appointments and certainly not a single GP I've ever met has ever suggested that so we want to work collaboratively with GPs on this and it's probably just worth me stating for the record that you know I think it's been quite upsetting to see some of the kind of finger pointing and almost blaming towards some elements of primary care, GPs included, from again some sections of the public discourse, press, political, I just think it's undervaluing a really important contribution that GPs and GP staff in their entirety have made so you know just to put on record that I'm really thankful for their efforts. I also understand the frustration some people are trying desperately to get an appointment and not being able to and you know that is the challenge that the pandemic has brought to us but I don't doubt that as we ease our way out of the pandemic or certainly into a more endemic phase that things will certainly, access to primary care will certainly improve. Emma, you have a quick question on this. Yep, thanks, convener. I mentioned rural earlier and we're talking about digital inclusivity or exclusion and we've found that people have been able to have telephone calls or video calls or even see their for mental health consultations in rural areas using the digital access so is that something that we will continue to be measuring to see how you know how that benefits people so rurally you do get to see somebody and yes we still have the ability to see face to face because that might be the absolute best way forward for some people but for our rural areas that it's it could be quite positive to continue to use near me for instance. Yeah absolutely, again I think there's little for me to add because Emma Harper's articulated it well. I think there's a continued role for the hybrid model but there is a maybe particular importance in areas of rurality and also island communities as well and that goes back to the point I made earlier we've got to ensure as the Government is doing that there is good digital coverage right across the entire country and we know that that can be particularly important in remote rural and island communities as well but our investment I think speaks for itself in that respect but I don't have a little to add other than to agree with Emma Harper's assessment. Now we want to talk about the single electronic patient record which come up frequently in our other sessions and questions led by Stephanie Callaghan. Thanks very much convener. A couple of weeks ago we got some really very strong evidence about the importance of the electronic single patient record, the need for that easy, seamless and secure access to shared healthcare, health and care records at the point of care and how this will improve like continuity of care and will also ease the frustration for patients and workers. Then last week in the evidence we heard from some of the digital professionals and there certainly seems to have been some good progress on a central cloud-based platform that allows different systems to talk to each other. We're also made as a pilot in the data strategy engagement programmes so I wonder are you able to provide us with a bit more information on the kind of positive progress that we've got towards a national digital platform and the committee keeping us updated on that work going forward in the committee. Can you be relatively brief in that all of the points that you've made are clearly ones that are our priority for us? I think that there's a real recognition here that the sharing of information of data is absolutely crucial to make sure that people aren't passed from pillar to post as Sue River had made the point earlier on. What I would say is that what is really important is in our digital health strategy, I was just double checking the detail of it but it's really clear there and the strategy about that cloud-based architecture and how important that could be and again I would commend the strategy for anybody to see if they haven't seen it so the national digital platform detail of that is on page 18 of that strategy and again it's not about necessarily just a single product you don't need to have a single product and that could take a lot of time and considerable investment but actually that integrated approach to those cloud-based digital components and capabilities that's what's going to play a real important significant role in that data sharing that Stephanie Callaghan talks about so yes investment has been made will continue to have to be made because it is not without a financial implication here but some of that roll out some of that work is already very much under way but I think we is incumbent on us in government and certainly my role to accelerate that given the the challenges that pandemic has brought and will continue to I'm afraid have on our health service for many years to come okay thanks I know a few my colleagues a good question so thank you very much thanks thanks thanks for that Stephanie sandesh gohani has a question on this specifically or from online sandesh thank you convener campus if you as you said just there data is absolutely vital as a GP I can't see what my psychiatric colleagues have written when I was doing my psychiatric block I couldn't see what the CAMHS doctors had written and I was yet covering the CAMHS service overnight we've got patients who have to tell their story and repeated occasions and out of hours though we have KISS service is unable to see what was written by myself and I'm unable to see what the out of hours have written so all in all the sharing of information in a patient's journey is not adequate at the moment and I think this is a real safety concern now what can we do quickly to try and solve this and secondly when we do get data sharing what is the implications and the data protection implications that arise through this I think they're both good questions and look I would defer to to your to dr gohani's expertise in this regard and he speaks from a professional experience and I think he's articulated well where some of those as he put it rightly I think safety concerns are when it comes to to the sharing of data because we can talk about data as though there's not a person behind it that very much is a person behind it and potential implications for that individual so so so again I will commend to him the national the the the the the the works sorry in the digital health and care strategy it says and outlines very clearly what our actions are and how we're undertaking them with pace I would say so the national digital platform work is very much under way it's under new leadership within NHS national education for Scotland and it's very much we're very much investing in it it would be wrong for me to say that it's going to be done overnight or in a matter of weeks there are some really complex digitality solutions that have to be found in this work as it develops but that goes back to the point I made to Sue Webber that's why the investment in government in that team is so so important in terms of the second part of your question again I think it's a really important point to make we all are aware of the importance of ensuring that we safeguard this information very sensitive health information and it can be about people's mental health as much as their physical health so as part of that digital strategy again you can see it quite clearly in that digital strategy one of the key pillars is to ensure that information governance is at the heart of that including ensuring the right assessments are in place ensuring that we do the appropriate assessments so that's data protection impact assessments equality impact assessments as well so at the heart of that strategy again the confidentiality of patient medical records and ensuring that we live up to our responsibilities in terms of the sharing of that data is at the core and the root of everything we do and again as I say it's a key component as part of that national care and health and care digital strategy and I move on to a theme that has come up as as we expected throughout the session and indeed all of the sessions that we've had on this and that's inequalities and questions are led by Gillian Mackay. Gillian. Thank you convener. In a previous meeting I asked witnesses about the inverse care law and how as the system becomes more complicated to navigate with people expected to self refer to different services we mitigate the risk of those with lower levels of health literacy becoming less likely to engage with health services the highlighted that targeted communication was vital as well as detailed analysis of the data that's being collected on who is accessing different services directly instead of through GP referrals what action is the Scottish Government taking on this and what plans are there to collect and analyse this data? Yeah again I think it's a really good question so again I would commend if you haven't though you may have already seen this work in terms of the shortly working group recommendations that are published and key to that is data and I think while the data collection that we have is relatively good in the inequality space it can be far better and key to that is developing services co-produced with those people that are being affected the most by those changes so I think the work that we're doing with patient groups but particularly in areas of deprivation where we know inequality is worse there's clearly a need for us to develop those services with those individuals going forward so I'm very keen that now that we have the working group's recommendations we now have a development group that will take forward a number of those recommendations that my instruction to that team is to make sure that we are co-producing the work that we do with those that there are spearing those inequalities at the sharp end and that is not to place an additional burden on those individuals we've got enough to do and no doubt as we all will do in our daily lives but that qualitative data for us can be really important so while we have robust I would say quantitative data I think is that qualitative piece that can add some significant value. We know that in urban areas there can sometimes be barriers to people having to attend different sites to attend different appointments and things like that. Do you think that geographical variation in provision of alternative pathways could exacerbate inequalities particularly in rural areas where some of those distance between appointments could be quite significant? I mean to get again hopefully give you as much reassurance as possible we can we are so aware of that point that anything that we are doing we're hoping to be able to mitigate some of those challenges so you know whether we need to look at as part of the work that we're doing in this regard transport solutions that's got to be a part of that conversation. The question that Emma Harper asked a moment ago I think is also pertinent to this so as opposed to having people travel 50, 60, 70 plus miles in some parts of Scotland to a different service can something be done remote through digital means in a way that currently isn't being delivered and for those people that do have to end up travelling whether that's in an urban landscape or indeed in a remote or rural link that landscape really important that we're putting the solutions in place at inception as opposed to having designed the service gone oh goodness well there's some challenges here and then try to fix it thereafter so if it gives us some level of assurance it's absolutely a fundamental part of our thinking as we deliver the services moving forward. Carol you have some questions on inequalities? Please thank you. I want to take the opportunity to really raise something that I think is extremely important and that is as we change pathways we know that screening particularly in women in young girls and into private areas is definitely what needs to be looked at there's a significant difference and for screening we can make outcomes so much different so I wonder just if the cabinet secretary prioritises screening or sees how we make sure that screening is taken up in those groups particularly as the pathways changed but just one of the most important questions I think is does the Scottish Government health and equality proof all its policies and all its practices as we move through and make any changes within particularly primary care? Yeah but look I first of all want to recognise how important an agenda this is for all of us but I know it's one that Karen Watkins has raised with regularity both here in the committee but also in the chamber as well and the second thing I would say is absolutely we see but first of all we value the importance of screening I mean it saves lives and it has the ability to save lives right across a variety of different cancer types equally let me recognise the point that Carol Watkins makes that we know that there are disparities between how often the uptake of screening for those in the least deprived areas versus those that are in the most deprived areas and that's why a lot of our focus is going into how to increase the uptake so I had a recent discussion with those officials involved in the national screening programme about this very issue and so how do we use for example our mobile units and we have a number of I think over 20 for memory mobile units mobile screening units for this is breast cancer so I should say how do we use those mobile units to get into those areas of higher deprivation so that is some of the work that's being undertaken as we speak targeted communications because back to actually the point Gillian McImade her first question how do we ensure that we have more targeted communication to again individuals and perhaps the areas of highest deprivation and the third point is we're thinking about is how do we ensure that there is appropriate voices from those communities where uptake is lower so ethnic minority communities would be an example I know you've asked about those and deprivation is often intersectionalities here but we know that for example in certain screening programmes the uptake for ethnic minority women is lower than it is for for their white Scottish counterparts and therefore how do we use voices from those minority communities as opposed to for example a middle-aged white male doctor who of course has great clinical expertise but might not be as impactful as for example again a female doctor from an Asian background speaking about the importance of of ensuring you go to your screening appointment so a lot of effort and work going into this because we recognise the disparities that exist and just on sort of you know equality proofing policies and things like that do you have a plan within the department of that we have well established plans obviously as you know in terms of inequality impact assessment and so again anything any policy of significance we would absolutely test that within the quality impact assessment I think I think if I can give you some level of assurance when it comes to our health policies and initiatives that we take forward you know I've not I've not in the ten on months that I've been health secretary had a discussion about initiatives that were taking forward that hasn't included some sort of discussion about inequality at the heart of it and at the root of it because you know the figures are stark they do speak for themselves and therefore a concerted effort in all areas not just screening in all areas of health policy absolutely has to be focused on driving down those inequalities and that's why for example I can reference the work that the excellent health and equalities primary care team have have just done that we just published earlier this month thank you can I bring in sir has got a question on this yeah thank you a convener yes cabinet secretary again on we know that screening saves lives and we know that early detection saves lives and I have a lady that's contacted me she's over 70 and is desperate to get abreast screening due to some medication that she's on there is a significant increase in risk of her getting breast cancer yet she's been denied this what can we do I mean she has is as a she should be able to access equally treatment and screening that anyone else has even specifically given the risk factor that has clearly been identified how can we help this lady in particular so thank you ever for what is a really important question and I hope she will take my answer in the spirit that is intended and I hope she will absolutely fundamentally choose to believe that we the decisions we've taken about self-refero for those who are kind of 71 plus is not one that we take lightly it's a really difficult decision to to take and and I spoke to again those that are leading our screening programme breast screening programme in particular about this very issue just a couple of weeks ago and the fundamental decision we have to arrive at here is that for the women that are the highest risk so those that are 50 to 70 and that kind of age bracket the the period they are waiting between screening screens is at the moment too long and there's no doubt that pandemic has had an impact we I think a really difficult decision is the member knows at the beginning of the pandemic to pause those screening programmes and then restart them in the summer of 2020 so because of the gap between screening programmes I think is around about 39 odd months but just forgive me if that's incorrect I'll correct it when I write to the convener but at the moment if we were to introduce the self-refero route for those that are 71 plus then the estimate is that that would add an additional four months on to the gap between screening cycles now the question is and this is the question I've asked officials to explore with pace is does the benefit of the over 70 referral route outweigh the additional few months that might be added on to the gap between screening that we have to accept will happen if we take that decision so that work is underway because I'm very aware that in other parts of the UK that self-refero route for older women does exist and is open so it does look like there's a difference between the UK nations but I am exploring it I would hope to have an update in the relatively short future but I am saying to officials that we need to just take out and I need a clinical view here I'm not a clinician I need a clinical view from those experts if we were to increase the gap what would be the significant impact or actually is that outweighed by the benefit of the the older women received I understand what you're saying thank you we have our final question from Sandesh Gohani Sandesh thank you convener we touched on this when we're talking about inequality not just being about wealth and how rurality actually causes an inherent inequality and it's clear that staffing issues are not evenly distributed around the country and we just go back to link work as the earlier cabinet secretary you were extolling of how good they are and actually I I love my link work I think they're absolutely brilliant but they're not available to people say for value of Aberdeenshire and and so at the heart of trying to to have equality is ensuring that the staff who are available here in Glasgow or Edinburgh are available throughout the country so how are you going to ensure that areas that are hard to recruit to areas that don't have staff will get the staff and and that will be rolled out in a manner which means going forwards that will that will be at the heart of recruitment strategies again I think it's a it's a really important question that's being asked so first and foremost where we can incentivise recruitment and retention in in rural areas we will certainly do that Emma Harper previously spoke about the scottgen programme which is an excellent example of that golden hellos in terms of bursaries that have been available rediscover the joy programme it's a number of different programmes I could point to where the focus is on rural recruitment retention in terms of the community link workers and mental health workers that's why our ambition is to have a thousand of those individuals recruited by 2026 so that they're available in every single GP practice in the country and again if I can give some sort of assurance to Sandesh Gohani it is that this element of rural provision and island provision is central to our thoughts in this respect thank you thank you sorry just to follow up on that you're a golden hellos and trying to incentivise people to to go to in areas it is important because you need that incentivisation but we're seeing a significant difference in pay when it comes to our our colleagues and we were hearing in previous evidence that sometimes they're bound three sometimes they're bound four and the the amount that they would make and obviously that will play a huge role there's no point in incentivising someone if they're going to make up that significantly less money so should we be standardising the level that certainly at the start that our allied health professionals start on and and then have those incentivisations to get them into those harder to recruit rural areas so I can absolutely see the argument being made and again uh Sandesh Gohani uh articulate some well my difficulty is that in well the mechanism is not the difficulty because you can ultimately do that if if if if there's a desire to do it my my difficulty is then when we talk about the a thousand additional mental health workers they could be various different workers so it may be that a GP practice doesn't need an additional community link worker but actually what they want is somebody specialising in particular mental health expertise and therefore there may be different workers with different specialities and different practices so that's one thing we've got to be cognisant of. The second thing is that if we in some respects impose a national structure to this then then then does that remove the flexibility that is required in various localities including our island communities or rural communities but you know and but is that a trade-off work making and the answer to that might well be yes and therefore it's something as I say it's something we are exploring when we talk about the additional a thousand that we've committed to but I think we just have to be careful that we don't remove entirely the local flexibility but I take the points that Dr Glehane is making and I can give him assurance that it's all part of the thinking and the development particularly of the a thousand additional mental health workers that we've committed to. Thanks thanks convener it is just a quick supplementary question I understand that community link workers will be required to do different duties depending on where they are working in a local authority or health board area and according to an FOI that has been published in the government website it says that there were 218 link workers in post at the end of March 2021 and I know there's been a pandemic for two years and that's why some of this data might not be as up to date as we want but it has a projected total by March 2022 of 323 link workers so I'm just interested to hear the cabinet secretary's thoughts again to reinforce that link workers might be doing different things across different health boards and we should support the health boards to know their own area and their own places to support their own GP practices whether they're rural or urban. Yeah again a lot of me to add other than to say that's part of the reason why the thousand additional mental health workers we've committed to we've kind of left it as broad as that because for some areas absolute community link worker with all again the different specialities that they will have might be important but actually it may be more important for GP practice to have a particular specialist excuse me in a particular area of mental health for example focused on young people's mental health so allowing that flexibility for a local area and that's also why the relationship with the integration authorities at a local level is really important as is the relationship with third sector so yes little for me to say other than I agree with Emma Harper's assessment that retaining that local flexibility is important and I suppose when in answer to my previous question that is the the the the sometimes the tension we've got to try to try to work through you know because there are challenges around standardisation and there are good arguments made for why that standardisation is necessary but could that have a diminishing effect on the local the local flexibility anything that is an important discussion that is under way and and and we need to continue thank you cabinet secretary for all your your answers this morning we're going to and thank you to your officials as well online we're going to take a 10 minute break before we're going to our next agenda item thank you right welcome back everyone our third item today is consideration of an affirmative instrument and that's a prohibition of smoking outside hospital building scotland regulations 2022 and we'll have an evidence session with the cabinet secretary for health and social care and officials joining us online on the instrument and once with all our questions answered we'll then have formal debate on the motion now welcome who's continuing to to stay with us in the committee hams the use of the cabinet secretary for health and social care and his accompanying Scottish government officials are Claire McGill slister and Jules Godlett Rowley head of healthy living unit both from the Scottish government thank you to you all for joining us and cabinet secretary you have an open statement thank you very much convener and thanks for letting me stay on to talk about these important regulations and they of course at their heart they set up no smoking perimeters around NHS hospital buildings hospitals as we i think all i can agree should be places of health promotion with healthy ways of living are demonstrated and environments within which people are protected from harm and supported in making really positive lifestyle choices unfortunately it's become commonplace to see patients visitors and at times staff standing close to hospital buildings entrances smoking this is despite an existing voluntary smoking ban on hospital grounds those entering and leaving buildings some of whom are vulnerable and very unwell may have to walk through smoke and there's no means of approaching those who ignore the request not to smoke our current tobacco action plan raising scottans tobacco free generation confirmed our intention to progress the work needed excuse me to introduce a mandatory ban on smoking near hospital buildings this will support the existing voluntary ban and introduce fixed penalties and fines for those smoking near hospital buildings or allowing others to smoke there but the this effectively extends the successful 2004 indoor smoking ban on smoking and enclosed public spaces to an area outside the building it will reduce the risk of exposure to second hand smoke near entrances and windows it will prevent smoke drifting into hospital buildings and ultimately protect those using hospitals particularly our most vulnerable smoke from a single cigarette can be detected from at least nine meters away weather conditions and wind speed can cause further drift to account for that a 15 meter distance is proposed this focuses on the high traffic areas where people leave and enter the building just like the indoor smoking ban these regulations are primarily about behaviour change to denormalise the act of smoking by making it socially unacceptable to smoke near hospital buildings and it reinforces the NHS as an exemplar of health promotion smoking can be a hard habit to break and people are advised to seek support anyone smoking in the perimeter could receive a fixed penalty notice of 50 pounds if an individual is taken to court they could be liable to a fine not exceeding 1000 pounds those with management and control of the no smoking area have responsibility to ensure compliance should they knowingly permit someone to smoke there could be a fine of up to two and a half thousand pounds we will ask health boards and those with management and control of the area to work with local authorities enforcement initiatives and agree in arrangements to ensure compliance the Scottish government will provide a signage for all signages I should say for hospitals they will prepare we will prepare prepare information we will also ensure everyone is aware of the change before it is introduced every year tobacco use is associated with over 100 000 smoking attributable admissions and unfortunately 9332 deaths that is one fifth of all deaths it contributes significantly to scotland's unfair and unjust health inequalities as both cause both a cause and effect smoking rates have reduced from 31% of the adult population in 1990-19 to 17% in 2019 but we still have some way to go if we're to meet our ambition of 5% or less by 2034 when asked 66% of smokers want to quit a clear majority of respondents to the 2019 consultation on these regulations supported these proposals around 70% in fact over 70% supported these proposals and they see the benefits of removing tobacco smoke from NHS properties and I think it's now time to make that a reality and with that I'm happy to take any questions the committee may have thank you very much cabinet secretary we have a couple of members wanting to ask questions Paul okay thank you very much convener and thank you to the cabinet secretary for that statement I think you know this legislation is supported and attracts a degree of support I think as you outlined I suppose the question I have relates to the responsibility for enforcement I think the big challenge with many of these interventions are if they're not enforced then very often I think people will become frustrated by that I note from the papers that the duty will fall upon local authorities and environmental health officers within local authorities to enforce and as opposed linked to that really is what does that mean in terms of financial implication for local authorities and of course a point to my register of interests as an outgoing local authority councillor but we know that throughout the pandemic there was extra pressure upon environmental health teams in terms of enforcement of coronavirus regulations we know that that came with a cost I noticed from the financial effects paragraph within the report that there won't be additional funding because it expected that additional costs will be covered under existing budgets but I'm sure the cabinet secretary will agree that local councils are stretched there are huge challenges in terms of the finances available so I wonder what scope there is to look at the workload to review the workload as it's implemented and consider what extra resources might be required. That's a good point. I would say two things. One is that although there is a fixed penalty if you do not comply we do hope that the introduction of these regulations if they are passed will enact behavioural change and I think the vast overwhelming majority of people will behave responsibly and make sure that they are out with the perimeter if they are wanting to continue smoking. That is one point I would make. The second point is an important one and one I will agree with Paul O'Kane that we will continue to keep the issue absolutely under review and it should be said that in the local government settlement there is baseline funding of £2.8 million to Scotland's local authorities to support measures related to tobacco control so there is their money baseline and that's why we don't think there's a need for any additional funding and certainly I've not heard that articulated to me from COSLA but his question to me to keep that under review is one that I will commit to doing. William Sandesh Cullhane. Thank you convener. Behaveal change is very important of course it is but let me give you two examples. When I was at York hill children's hospital people were smoking by a big sign with a picture of a sick child saying please don't smoke here it drifts up to my window. When I was in fourth valley they have done more than I've seen other hospitals doing they have signs big signs everywhere. There's also crosshatching on the floor saying do not smoke here and they employed somebody who went round to tell people not to smoke there and tried to take details and tried to issue fines as was the right thing for him to do. He's a lovely guy but people just abused him and ignored him and they ignore these things and getting behavioural change when when you're standing in front of a picture of a sick kid smoking that is something that's going to be really difficult so initially as with the smoking ban indoors it needs to be policed and it needs to be policed with teeth and that's something that I think I'm picking up from Paul O'Kane as well and we need to police that really well to start with especially to start with to get and kickstart the behavioural change so would you be able to relook at this and see what we can do to really clamp down in those initial phases? I think the point is well made I think the point is well made that in the beginning of of introducing these regulations again if they're passed by this committee in parliament then we will ensure that there's good education and public knowledge about the regulations coming into place which they would be in September so there's a period of time for us to really ramp up the communications around the thing that's really important for us to do. I take Sandra Cunhani's point though that people maybe aren't paying attention to the current voluntary ban that's in place even if there's pictures of sick children saying don't smoke because your smoke drifts up to potentially drifts up to my room you know I think that's where the enforcement element could be quite crucial you know 50 pounds is a really expensive fag to have you know it's a really expensive cigarette to end up smoking if you have to pay that fixed penalty notice and there may be some health boards in conjunction with the local authorities at the beginning of the regulation choose to just make sure they are clamping down on those who are ignoring it now I would always expect that as we've done throughout the pandemic that there would be a really sensible approach to enforcement I don't think it would be heavy handed to begin with but if people are ignoring and continue to ignore then of course that option for a fixed penalty does exist and I think some people being hit in their pocket and realising that this is something that has to be done isn't voluntary may well be something that we see across the country but I would hope that the vast majority of those individuals who do smoke one they would understand the change in the regulation through our communication but secondly that they would comply get any other questions no I don't think he does can I come to him a harper yep thanks convener good morning again cabinet secretary I'm interested in how the regulations will be communicated to the local authorities and health boards and just because of the I know as a nurse the exacerbations of COPD that lead to hospital admissions and the respiratory care action plan that's now been you know developed and then delivered and tomorrow I'm actually heading to Belfast to talk at the breadth project which is about COPD causes prevention and treatment so I think it's welcome that we have these regulations so how are how is this going to be communicated to our local authorities and health board areas yeah so again when it comes to the signage we will provide absolutely that and but also we will work with providing information on the ban and enforcement will be available to patients in different languages which I think is quite important as well although the no smoking symbol I think is an internationally recognised no smoking symbol and that's why it's obviously used that being said the information on it will be really important so we will work really closely with health boards I think there is a period if the regulation is passed and I've got every confidence it will be the period between now and it coming into force is going to be really important for us so we'll make sure it's communicated well that there is a lot of attention on this particular ban coming into place and actually the consequences of ignoring it are also in place too so that is all work that is currently being discussed between ourselves and local partners in advance of hopefully this regulation being passed. Do you see any difficulty around enforcement where a 15 meter no smoking zone encompasses areas which are obviously not part of a hospital ground such as public footpaths? Potentially people might think they're far enough away and that's why the signage is going to be really important effectively to continue to reinforce the message that you are still within the no smoking perimeter and my hope is that for the vast majority of people that that walk 15 meters away is enough for them not to have to light up and have a cigarette but for some people they will still wish to smoke and therefore that's why there is a need for a period of time to be able to remove smoking shelters for example that are within that 15 meter boundary and make sure that they're out with that 15 meter boundary but I would hope that if there are areas for smoking that are obviously out with the perimeter that there are people cognisant of footpaths areas that people walk in and so on and so forth because it's an unpleasant experience if you're not a smoker having to walk past a crowded smoking shelter and catching that second hand smoke and we know the dangers of second hand smoke that are well articulated by a number of studies and third sector organisations particularly I think of the good work that Roy Castle Foundation does in that regard. I'm not seeing any other colleagues. Yes Paul? Sorry I think just following on from that point obviously the regulations as I understand it cover hospitals particularly but I mean does the government actually feel that there's scope to extend that I mean particularly given that we now have a number of health and social care centres very often in our town centres that are new builds that are well used, that have treatment rooms and all the rest of it I mean is there a sense that we should be looking to extend this across the estate more widely? Yeah I mean the short answer to that is yes I think we're starting because we obviously already have the voluntary ban in place for NHS hospitals and I should say as NHS hospitals we are talking about here and therefore it's perhaps easier to turn that voluntary ban into something in statute and the problem is probably more acute in our hospital sites given the size of the scale of those hospital sites it's maybe less pronounced to the GP surgery for example you're less likely to come but I'm not saying it's impossible but probably less likely to come by somebody smoking at the entrance of your GP surgery in comparison to a hospital site so definitely open minded to that but I hope it's understood the logic of why we're progressing with this step first. Thank you, just looking across my colleagues to see if there's any other questions I don't think there are. We'll now move on to agenda item four which is the formal debate on the made affirmative instrument in which we've just taken evidence and can I remind the committee that members should not put questions to the minister, the cabinet secretary during the formal debate and officials may not speak in the debate. Cabinet secretary, before I invite you to move is there any further you wish to say in relation to motion S6M-03434? No closing remarks to me. Thank you. Cabinet secretary can I ask you to formally move motion S6M-03434 in your name? I contend to put the motion in my name. Thank you. The question then is that motion S6M-03434 be approved. Are we all agreed? Yes. We are all agreed. Thank you. That concludes the consideration of the instrument. I'd like to thank the cabinet secretary and his officials for attending today's meeting. Our next meeting on 19 April the committee will take evidence from the Auditor General for Scotland on Audit Scotland's NHS in Scotland 2021 report and that concludes the public part of our meeting today. Thank you all. Thank you.