 We welcome everyone to the 24th meeting of the Health, Social Care and Support Committee in 2022. I have received apologies from the convener this morning. The first item of the agenda is to decide whether to take items 6, 7 and 8 in private today and whether to take the next meeting on 6 September 2022 in private. Are members agreed? Thank you very much. Our second item is our final evidence session as part of our inquiry into health inequalities. I welcome to the committee Marie Todd, the Minister for Public Health, Women's Health and Sport. She is soon to be joined by Michael Kellett, the director of population health for the Scottish Government. I will now invite the minister to make a brief opening statement. Thank you very much. I thank the convener for inviting me to give evidence today to this inquiry. I am aware that my officials in Public Health Scotland took part in a private session with you all last month where they outlined the range of work that we are all undertaking in Scotland to support a reduction in health inequalities. I was very pleased to hear that you found the session useful. We have indeed made many positive changes. However, I want to be upfront about the challenges that we all face on that issue. Scotland's long-standing health inequalities are fundamentally about income, wealth and poverty. The recent report from the University of Glasgow and the Glasgow Centre for Population Health attributes stalling life expectancy trends in Scotland directly to UK-led austerity measures. The report makes a number of key recommendations, including protecting the real incomes of the poorest groups, especially with current escalating inflation rates. That evidence strongly suggests that implementing such measures would reverse death rates and reduce the widening health inequalities that we are seeing. We are doing all that we can to mitigate the impact of such policies. The introduction, for example, of the Scottish child payment of £20 per week is just one of the measures that we are taking to mitigate the adverse impact of UK Government-led reforms and put money back in the pockets of those hit hardest. We have over 200 community link workers across Scotland playing a vital role by supporting people with issues such as debt, as well as social isolation and housing. Our welfare advice and health partnerships are now well embedded in 150gp surgeries in Scotland's most deprived areas. However, we simply do not have all of the levers at our disposal to tip the balance and change the trajectory of life expectancy. I have stressed in previous debates and sessions that this Parliament needs to be a public health Parliament where all parties come together to consider how we jointly tackle those issues. Our work on child poverty provides us with an opportunity to live up to that expectation. It is a national mission and our commitment to wide-ranging action is demonstrated by the work taking place across portfolios looking at outcomes for children and young people. That includes a collective focus on what we are doing in childcare, what we are doing to support people into work and what we are doing to support those farthest away from the labour market. None of that is easy, and we are learning as we go, but that is precisely the kind of approach that we need to help to address health inequalities across all the social determinants of health. As part of the strategic reform of health, our emerging care and wellbeing portfolio is creating a sustainable health and social care system that will promote new and innovative ways of working. That includes our place in wellbeing programme, which is bringing together all sectors to jointly drive change locally to reduce health inequalities. An example of that is our work to position NHS and social care providers as anchor institutions within our communities. Working with others such as housing associations, local government and universities to nurture the conditions for health and wellbeing. NHS and social care providers are significant sectors in Scotland and across Scotland. They are well placed to provide opportunities within local communities through increasing access to employment in health and care and making available to communities, NHS land and buildings to support their health and wellbeing. Our role is to enable local change, not to dictate what form that takes, and the voice with those with lived experience will be crucial to guide and shape local action on health inequalities. To reiterate, we have all got a collective responsibility to address health inequalities. It is not the sole responsibility for health and social care. I am committed to playing my role in that endeavour. I know that there is a real appetite for change amongst us all. That consensus and support is both welcome and necessary. I am pleased that we are having an open and honest discussion on the subject. We are now going to move to questions on a variety of themes in terms of some of the issues that you have covered in your opening remarks. I am going to start this morning just in terms of the progress that we are making on health inequalities. I appreciate that the minister has covered in her opening remarks the progress of perhaps the past seven-year period. I think that I have pointed to some of the reasons for poor health equality in terms of UK Government decision making and austerity, but I can just broaden that out a little more. Why does the minister think that we have been unable to make greater progress in addressing health inequalities over a seven-year period, notwithstanding the issue that she has raised? Essentially, what more do we need to do in terms of making progress? I thank the convener for that question. I will focus on what the Scottish Government can do, but I do not think that we can ignore it. I have said this before in front of the committee that it feels like I am working with one hand to tie behind my back what the Scottish Government would give us with one hand, and the UK Government takes away with the other. It is a very unwelcome reality that health inequalities are widening, including the gap in healthy life expectancy. That is completely unacceptable, and we know that we need to do more, particularly on the implementation gap. We recognise that addressing the wider determinants of health, such as poverty and inequality, requires cross-government working and partner-led action. The answers to health inequality are not simply in my portfolio in public health, where potential levers for tackling poverty are reserved. We will continue to put pressure on the UK Government on the need to rethink its social and welfare policies, for example, which absolutely help poverty to persist. We are introducing extra social security programmes that are well beyond anything that the UK Government offers. We know that we have lots still to do to tackle the determinants of health, where we have control of the levers, and we are making progress in lots of key policy areas. Let me give you an example of some around the tackling child poverty delivery plan. That puts money into the pockets of families now, helping to tackle the cost of living crisis, setting a course for sustainable reductions in child poverty by 2030. I have already mentioned the game-changing Scottish child payment, which is £20, and it will increase to £25 when it is extended to cover under 16s by the end of this year. Our five family benefits, including the Scottish child payment, will be worth up to a maximum of over £10,000 by the time a first child turns six, £9,700 for subsequent children. We have also extended our fuel and security fund by making available a further £10 million to the third sector organisations to support those facing fuel insecurity. That means that we have allocated over £1 billion since 2009 to tackling fuel poverty and to improving energy efficiency. I have to say, though, that that particular policy area highlights the challenges for the Scottish Government in fully tackling those issues. My constituency, in Case Nice Sutherland and Ross, is the furthest north mainland constituency in Scotland. We pay the highest prices for our electricity, and we pay more for our electricity than people down here in the central belt do. Despite the fact that we are net producers of green energy, and despite the fact that we are largely off-gas grid, so electricity is a really important source of energy for us, that is fully reserved to the UK Government, and it is a UK Government policy choice to continue that injustice. I have written to the chancellor, I think, on a constituency basis about six weeks ago, when I haven't even had the courtesy of a response yet. They have no interest in fixing those appalling injustices, which means that so many of my constituents where I live in Scotland are living in extreme fuel poverty, entirely caused by a UK Government policy choice. I thank the minister for that initial response. I wonder if I can go a little further into exploring some of the policies and some of the objectives that we can move forward in addressing health inequalities. Last week, we had some quite compelling evidence from Professor Sir Michael Marmot, who has given evidence to this committee before about the measures that his work has taken in England, particularly in Wolverhampton and Manchester, around his Marmot cities model. He has six approaches that can make a fundamental difference and has been proven through the reports from those cities to make a difference. Last week, I said that they are not rocket science. They are things that we probably would all recognise as being important things to do that make a difference. Those things, though, I think, are often offered and supported by local government and by third sector. We know that funding is reducing and is challenging. I suppose that I am keen to get the minister's sense of how we move forward on Marmot cities agenda in Scotland, particularly with our city regions, and how we might help to sustain funding into the six areas that Professor Marmot has identified. In the Scottish Government, we welcome Professor Marmot's work. We are very interested in his approach and his thoughts on how we tackle those thorny issues. They are not easy for any Government to tackle and resolve, frankly. We need to work—you talk about the powers being largely in local authority in third sector hands—we need to work really closely with partners. I mentioned that in my introduction. It is really significantly important that we all work together with the same aim. I always think of health inequalities as being a golden thread that should run through all our work as a public sector. Professor Marmot is coming to meet Scottish Government officials today. I will let my colleague Michael tell you a little bit more about that. We are so interested in the work that he is doing and I am keen to learn from him that we have asked him to come and spend some time with Government officials, so I will let Mr Kelly fill in on that. I apologise, minister. I was here on time and was sitting in the reception parliament, so I apologise to you, convener, and to the committee. Had I not been here this morning, given the evidence, I would have been in a virtual session with Michael Marmot, with official colleagues from health and social care and beyond in Government, hearing directly from him and being challenged by him. We have explained to him the place and wellbeing programme, the Cain wellbeing portfolio that the minister set out, and we are really interested in his approach to marmot cities. That place-based approach is fundamental to the place and wellbeing programme that the minister set out about partnerships with public sector, but also the third sector and potentially private and independent sectors in localities about how inequalities can best be tackled. We want to learn those lessons, and I think that there is real potential in them. Clearly, the context is different in Scotland, but we are certainly learning there that we want to take. I think that it is good to hear that that meeting is taking place today, and there is progress in terms of that work, because I think that the committee felt very strongly about that evidence. Finally, in terms of my contribution, I can ask about health inequalities that are driven by poverty. The committee heard evidence from many organisations that the only proven policy in relation to poverty and its impact has been, to some extent, the child payment and the progress that has been made around that. Because of that direct income going to the poorest families in our society, would the minister support a further increase to the child payment in order to tackle those inequalities? We have committed to a further increase, so we have committed to increasing it to £25 by the end of this year, and also to extending those families who are eligible to be available to all children up to the age of 16 by the end of this year. That is a further increase. It is, I agree, an extremely helpful way to get money into pockets, but relying on social security alone is not the only thing that we can do, and we do need to—again, my frustration at not having the levers available to us and all of the levers that could be available to us will show that we really would benefit from being able to have some of the powers over employment law, which would mean that we could ensure that work pays. We have seen just a couple of weeks ago with the white paper from the Government looking at Scotland within the UK and comparing ourselves to a number of near European neighbours. We live in a very unequal country. We have a large income gap. We have a very large gender pay gap. There is only one of our close neighbours that has a larger one. We have a high number of people living in poverty. We have a really high number of children and pensioners living in poverty. We have a high level of in-work poverty. Some of the structural issues are extremely challenging to tackle and change when you have only one effective lever—as you say—one very effective lever. We will use it, but it is only limited in the impact that it can have on the whole system problem. Thank you very much. I am going to move on to questions from my colleague Emma Harper. Thank you. Good morning, Minister, and good morning, Mr Kelly. Cross-portfolio working is something that I am interested in because, as you have said, the austerity that has been inflicted on Scotland by the UK Government is costing £770 million a year at the moment. You said that we do not have all the levers in order to tackle what we need to do to help support tackling health inequalities. I am interested in, as a public health minister, what work has been done in other parts of the Government in other portfolios to support tackling health inequalities? We recognise that it requires that cross-portfolio approach. If we did not know it before, which we did do, certainly the pandemic absolutely shone a light on those pre-existing health inequalities. It not only shone a light on them, but it worsened them. The Scottish Government recognises that. We also recognise that it has been such a terrible experience the last couple of years for almost everyone in Scotland. However, the learning that has come from the pandemic means that we found, for certain issues, that we were able to turn and face these really difficult issues and have an impact that we had been unable to have before. For example, rough sleeping has been a priority to tackle for the Scottish Government ever since we came into power in the SNP in 2007. It took until March 2020 in the face of a national emergency for us to successfully be able to end rough sleeping because it was a necessity for the country. What we found was that in the face of that national emergency, everybody collectively came together. I always say in Government what we found was that we did things that we thought were impossible. I tell you what, we have a taste for that now. We are going to keep trying to do impossible things. We are going to keep trying to do these things that are really challenging. Deputy First Minister has a role right across Government, so it is a really key part of our Covid recovery. He has a role right across Government to try to bust the silos. It seems to me that it is almost a human norm that we create the silos in the way that we work. His role across Government is to bust those, to bring groups of ministers together on a regular basis to ensure that we are all aware of each other's work. It is all aligned and we are getting the maximum impact from across Government in tackling those really thorny issues that Scotland faces. Obviously, the challenges are not just urban, they are rural as well. You are a rural MSP like I am, so it is a specific work that has been done looking at housing for instance, looking at other wider areas that would help and support and will raise awareness of health inequalities in rural areas You are absolutely right to look at the differences. You and I, but every MSP around the table knows very well that you cannot have a one-size-fits-all in Scotland. We might be a small country, but there are lots of different areas with very unique factors in each of them. One of the things that differentiates Scotland from the rest of the UK, so the Round Tree Foundation looked a number of years ago at the level of poverty in each of the UK countries and one of the things that was protecting people in Scotland was the quality of our housing stock and the availability of social housing. Of course, the Scottish Government has had a huge programme of investment in social housing and we have built more social housing. There is a challenge in terms of rural housing stock and the quality of it and the difficulty of bringing it up to an appropriate grade in terms of insulation for fuel poverty. That is vitally important both in terms of tackling our net zero ambition but also in tackling fuel poverty. We need to find ways to—we have done the low-hanging fruit—it is quite easy with large-scale modern housing in an urban setting to upgrade the insulation. It is much tougher in a rural setting with more dispersed housing, different types of housing and different qualities of housing stock. It is a much tougher job and we are really going to have to get into that, but that kind of illustrates that need to work together. If we are going to achieve either or both of those ambitions with regard to tackling fuel poverty and aiming for net zero, we are going to have to get in about that challenging issue of improving housing stock in the rural areas. I do not need to tell you about the impact of the cost of fuel on a rural area, so, while you have cheaper electricity in the south than we do in the far north, one of the things that is really challenging in my community at the moment is the cost of fuel for cars. The lack of public transport option and the need to run a car however well off you are is a real challenge in rural communities. At the moment, I had an absolutely heartbreaking communication from a constituent who was a pensioner who lived 20 miles from his local shop, had no fuel in his car, had £11 in his bank account, could not heat his house, could not afford to fill his oil tank. That was his form of heating, so you will all be aware that in many parts of rural Scotland you have to have this huge outlay in order to fill your oil tank, in order to get any heat and hot water, and he could not afford that outlay. He was in a cold house gathering wood for his wood fire—this is in 2022—gathering wood for his wood fire in order to heat his house and enable to access his nearest shop to buy food. It is just a disgrace and it is absolutely about policy choices. To relieve that situation, reducing the vat on housing fuel, reducing or making it zero, reducing the vat on fuel for his car, we can help with welfare policies. Of course, my office directed him to all the funding that is available through the Scottish Government, but it is very difficult to tackle those particularly grisly issues and it is only going to get worse. It is absolutely heartbreaking. Those people in my constituency, and I am sure in your constituency, feel like those stories are hidden because urban deprivation is so challenging for Scotland. About anti-poverty measures that are being delivered and stopping folk working in silos, I know that there is good work that is being done in Dumfries and Galloway Council of anti-poverty approaches using their budgeting and participative budgeting and things like that. Are we good at breaking down silos between local authority areas and the Government? Are people embracing that? You said that the Deputy First Minister has oversight of this issue of trying to get people to get round the table. Are we embracing this non-silo working? I have grown to believe that it is a human trait to silo off and to protect your own little area. I think that we are recognising the benefits of working together to tackle it because we are in difficult times. There is absolutely no denying it. I think that people are recognising the benefit of working together in a way that we have not ever before. I think that it is key that you talked about participative budgeting and getting the community involved. One of the really powerful means to keep us all working together in that way is to bring in the voices of lived experience because it is easy sometimes to dismiss evidence when it is just on the page. It is very hard to have somebody look you in the eye, tell you their story and then choose not to work together to make things better for that person. Having the voice of lived experience at the heart of our policy making and at the heart of our policy implementation is key to ensuring that we continue to work together. Perhaps it is just me, but I suspect that it is not a desperately natural way for people to be. There are often sensitivities between local government, central government, central government in Scotland and central government in the UK with our third sector partners, but we will get the most powerful impact if we are able to work together. That needs to be the goal. I am just interested in that cross-government department working. I would be really interested to know if you have any examples where you feel that you have done it well. Transport that you mentioned has been a really important one, particularly in rural areas. I would also be interested to know whether you could commit to asking the Deputy First Minister to give us some kind of plan because I think that it is key that the ministerial departments work closely together. Perhaps if we had some kind of plan about how he would see the next year going ahead, it would be very helpful, particularly in that stream of health inequalities. Certainly more than happy to ask the First Minister to bring forward a plan of what is happening over the course of the next year or an outline of the type of cross-portfolio working that he does. One of the areas that is outside of public health where we see real laser focus on tackling health inequalities is in the child poverty plan. It is a national mission for this Government and you saw it prioritised, even in the RSR, which was a really challenging set of figures for the Government to receive, work through and share with our partners and local authorities and in the public domain, but you see that tackling child poverty is still a priority within that. Our action against child poverty is firmly rooted in evidence with a very robust evaluation strategy in there, and we are looking at cumulative impact assessment, wide-ranging analytical materials underpinning the approach outlined in our second tackling child poverty delivery plan. That is called best start bright futures. We see that plan has a really sharp focus on six priority family types, who we know are at the greatest risk of poverty, including those from a minority ethnic background, those with a disabled household member, those with a lone parent family. Based on evidence, we are taking that balanced approach to tackling poverty, focusing on increasing household incomes through social security and employment, reducing household costs, and action focusing on those drivers of poverty balanced with a focus on the next generation supporting children to thrive, ensuring that we support the wider wellbeing of families. We have already talked about the Scottish child payment, which we have already doubled in value, will further increase to £25, and we will extend it to our children under 16. In my last portfolio, we had a massive social infrastructure investment in early learning and childcare, which we doubled the entitlement of it. Of course, that is where we get the biggest bang for our buck as a Government. We all know and cannot deny the impact of poverty on a child. It can be lifelong, and tackling child poverty will absolutely deliver benefits in tackling health inequalities. It will be decades before we see those benefits, but it is absolutely the right thing to do. I was just going down to that. I think that the child poverty example is a really good example, and it certainly, as an official in Government, I felt part of that broader team pooling together the child poverty strategy. Another area of policy that I think is a good example is around drugs and the national drugs mission. I support Angela Constance in that work, too. We are using the structure of the DfM group that the minister talked about to focus on the underlying causes of addiction. As the committee will know, there is a real focus in relation to the mission on standards, treatment and residential rehabilitation, but we also need to look at the underlying causes of addiction. We are using that DfM group to think about how we can assist drugs policy officials and Ms Constance with ministers in education and local government and transport in the economy around employment to tackle some of those underlying causes. That gives us a structure. If I am being honest from an official level, a pressure or a requirement and a real clarity from ministers that they need us to work better on a cross-portfolio basis in a way that I think is significant, feels different and is making real changes. We are going to move on to questions on national strategy. I will be led by my colleague Evelyn Tweed. At our meeting on 24 May, I asked Dr Walsh that, as we do not have overall powers for social security, taxation or employment in Scotland, would it make any difference if we had an overall strategy to reduce health inequalities? Dr Walsh replied that, though a strategy would be great, if the aim was to narrow health inequalities across society, the relevant powers would also be required. Could the minister offer a view to us on those comments? It will be no surprise to hear that I do not disagree with David Walsh's assessment, and that is why, at the beginning of the meeting, I was very keen to put on the record very quickly that, although I absolutely welcome the scrutiny of what the Scottish Government is doing, I do not think that any of us should kid ourselves where the power lies to tackle this, and where the responsibility lies for the situation that we are in. The UK is a wealthy country, and it is a policy choice to perpetuate poverty. Those choices that that coalition Government made—the Lib Dem and Tory coalition in 2010—absolutely chose to pursue austerity policies. They reduced the funding to the Scottish Government, reduced the funding to local authorities and brought in punishing welfare reform. We are witnessing the tragic consequences of that now. This is one of the reasons that I was politicised and came into politics in 2010. I worked as a mental health pharmacist in a psychiatric hospital, and I saw first hand the impact of that welfare reform on the vulnerable citizens that I worked with. I worked mainly with people with schizophrenia and bipolar affective disorder—quite severe and enduring lifelong disabilities—and they were put through a system that was unable to recognise that their illnesses were disabling them and thrust them out into poverty and destitution without a second thought. I saw that first hand. I will not deny the role that the UK Government has in this. It is a profound impact. If we think about some of the particular policies, we have the two-child cap, which contravenes the UNCRC. A child who requires the support of the state is entitled to the support of the state, however many brothers and sisters they have. There is no conditionality in the requirement for the support. Think about the impact of that policy. It is a choice to put children into destitution. We cannot shy away from that. If the Scottish Government had a policy in which academics were clearly stating that life was shortening, I am sure that I would be facing a great deal of scrutiny on that front. I think that the UK Government and the coalition Government who made those decisions for which we are now all paying the price should absolutely face scrutiny on the consequences of those decisions. I think that I have forgotten your answer. I am so mad at your question. It was, would it make any difference if we had an overall national strategy? I do not think that we can excuse ourselves. I cannot be faced with this need and not take action. I am absolutely clear that the powers of the lion Westminster are to tackle this fully, but that does not mean that the Scottish Government cannot do anything. We have to do everything that we can. We are faced with immense need on a daily basis, and we have to do what we can to rise and meet that need. There is no way of avoiding that, I would say, but I would say that there are bigger challenges placed at the door of the UK Government. Of course, my solution would be for us not to be subject to the whims of the UK Government, but that is a choice for the people of Scotland. Does the minister feel that health inequalities are a top priority for other organisations outwith the health service that will all need to assist with health targets, such as local authorities, etc.? It is easy to lose focus on health inequalities, but I genuinely believe that my local authority colleagues are as troubled about this as I am. There is amazing work going on in the third sector that does a power of creative work in difficult circumstances and insecure financial circumstances, so they do amazing things. I think that it is easy to lose focus and it is easy to take your eye off the evidence and it is easy to feel overwhelmed by the situation that we face, because when you are faced with such desperate need—and we are hearing it day in, day out on the news from many people—the length and breadth of Scotland—just the diff—and there is an understanding that it is only going to get worse. It is easy to lose focus on health inequalities. Part of my job is to ensure that we keep an eye on the golden thread of health inequalities that runs through everything. Remember what causes health inequalities. Health inequalities are fundamentally caused by inequalities in wealth, inequalities in power, inequalities in status, and all of our partners who are trying to tackle health inequalities need to remember that in everything that we do. We must not disempower our communities and not disempower individuals. Every policy that we bring together should be empowering them and should be helping to tackle inequalities. That is probably fundamentally why putting money in people's pockets is a far more powerful tool than giving them a box of food. It is a much more empowering experience. Just a quick supplementary minister, just to back up what you said. We are constantly hearing about choices that are being made or we are constantly talking about constraints, about mitigating austerity. We are constantly talking about those issues all the time. When choices need to be made, I think that when Scotland becomes an independent country, will this Government continue to pursue the policies that will tackle the issues that are affecting people's lives and are causing them to be facing poverty issues and leading to the health inequality. That is the bottom line for me. We cannot constantly talk about mitigation, mitigation, mitigation. We need to be able to have the tools, levers and powers to do what we want. For me, that is the bottom line. We will still need to make those choices when Scotland is an independent country and those will continue to be the choices that we need to make. You are absolutely right. Those are not easy choices for any Government, and we see issues around health inequality affecting many countries around the world. But, fundamentally, the UK is one of the most unequal countries in Europe. When we compare it to our neighbours, it stands out that it is not a great record to have the second highest gender pay gap. It is not a great record to have such high levels of in-work poverty. The policy choices that any Government makes will make a fundamental difference to the level of inequality that is experienced. I will pick up on your point about mitigations. The situation that we are in at the moment is that we are a devolved Government and our money that we have, as we are all aware, is largely dictated by the Barnett formula. The choices that the UK Government makes on spending account for the bulk of our budget. We get a population-based percentage of what it chooses to spend in Scotland, and that restricts how much money we have. We have some levers over raising money in income tax, but we do not have all of the tax levers. We have no power over national insurance. Some economists would say that it is pointless having any power over income tax if you do not also have power over national insurance. The two are almost always requiring to be balanced. The other thing that it does is that money is for our devolved responsibilities. About 70 per cent of Scottish revenue spending is by the Scottish Government on devolved issues. Every time we make a choice to mitigate a reserved issue, that means that there is less money in the pot to spend on devolved issues. That is why it cannot go on forever. That is not a limitless pot. We have devolved responsibilities, that we have to spend money on, and we have limited means of raising extra money should we choose to do something different from the UK. It is a difficult situation for any Government to be in. Of course, another issue that came up time and time again during the pandemic is the inability to borrow. Most Governments around the world are struggling at this moment in time to balance their budgets, but most Governments have the opportunity to borrow. The Scottish Government has to bring its budget and bang on the money every time. What is the gender pay gap in Scotland in the Scottish NHS? I cannot give you that number at the moment. It is 18.2 per cent. The Scottish NHS is fully devolved. Why have you not improved that? There is a lot of work going on in order to improve the pay of the Scottish NHS. As you know, people who work under a gender for change in Scotland are paid more than there are counterparts in the rest of the UK. The gender pay gap in the NHS, I imagine, arises from the fact that there is a great deal of women working largely in the NHS, more than 50 per cent of the employees in the NHS will be women. As we see in many other aspects of society, the people who are in the highest paid jobs, the managerial jobs, tend to be men. That is reflected right across society. However, you are absolutely right to draw attention to that huge gender pay gap. My own profession of pharmacy has one of the biggest gender pay gaps that there are. That starts not at the point where women go to have children. That gender pay gap starts at the point when we graduate from university. From the point of leaving university, female pharmacists tend to earn less than male pharmacists, and we need to put in place policies to tackle that. It is my intention now to move to our next theme, which is tackling the fundamentals of health inequality in Scotland, and Carol Mawrkin will lead. I want to start by saying that I absolutely condemn the policies from the current Conservative UK Government. I thought that it was interesting that Dr Welsh did also talk about if we had a change in government at UK level, that would make an enormous difference to what we could do and what we could do in a devolved nation as well. What is really important in this sense in this committee is what we can do in Scotland, and I absolutely welcome her commitment to everything that we can. I assure you that I will do my very best to hold you to that. I want to talk a bit about the evidence that Claire Sweeney gave us. I might just read a few points that she made if you do not mind. Claire Sweeney from Public Health Scotland said that although we have talked a lot about the challenges that we are facing in Scotland, the big message that I want to emphasise and get across is that we can do a lot about inequality. There are lots of levers and opportunities in Scotland to address that, it is by no means something that is intractable and we can address it. Given the millions of pounds that the public sector spends in Scotland every year, there is a huge opportunity to use that money to good effect, and we see many things that we could do in Scotland. For example, we hold public bodies to account for financial and access targets, but we do not hold public leaders to account as strongly. That is something really clear and tangible that could be done. She also asks that she would like to see budgets spent across Scotland to be more closely aligned to impact things such as reducing inequality and child poverty. Her very last statement was that it is about the early years' access to education and training, having good and fair work, having a good and affordable standard of living, and having healthy communities in place so that people have access to green space, good transport. There is a lot of agreement on what can be done. We in Scotland need to mobilise the rest of the system to do that. I would not disagree with anything there. I will not get into the details of your first comment about the Government in the UK can change. Scotland has consistently voted left-wing either Labour or SNP for many, many decades, and we do not always get the Government that we vote for. We get the Government that our neighbours choose, and that is fundamentally a challenge for the health of Scotland, frankly. I doubtedly, if we look at the totality of the issues, I think that there is much that Carol has said there that would chime with some of the policies that we are developing in the Scottish Government, things like the anchor institutions. That is a recognition, and I will let Michael Cymyn in and say a little bit more about that. That is a recognition that we have a powerful spending opportunity through spending on our NHS. That could be used to benefit communities. We could use that spending power to ensure that, for example, individuals who are less likely to be in the workforce have opportunities to be employed, to be trained and are supported to fulfil their potential. We could use that spending power on local procurement policies, which mean that all the things that we have to buy to run the NHS could benefit local communities. We could use some of the assets that the NHS has for community empowerment projects, so handing over buildings and land to support communities to do what they want. That is a hugely exciting opportunity. If we get it right, it will absolutely have an impact. You mentioned the generalty of the space that we live in. There is a lot of work going on right across the board in that. We talk about 20-minute neighbourhoods. There are different opinions and the length and breadth of Scotland about how doable that is in different areas, but it is a great concept to have everything that you need within walking distance of your house. If you think about the twin challenges that we are facing in tackling poverty and our ambition towards net zero, those are really important aspects for us to consider when we are thinking about what our environment looks like. I would like us, if I am honest, to be thinking a little bit more about it in how we deliver our public services. As Public Health Minister, I am a little bit tormented if I am honest that we keep centralising public services so that people have to travel a distance, often in my part of the world, in a car in order to access things like healthcare services and local authority services. We need to think a little bit more about how we can ensure that we deliver those services closer to home, which will be better for people's health. It will make it easier and will not put barriers in their way in terms of accessing those vitally important public services. It will also make a difference to our net zero ambition if we think about how many journeys are caused by travelling for NHS appointments. A final point that you mentioned early learning and childcare, and I would have to say that it was absolutely a huge privilege to be involved with delivering that policy last term of Parliament. I cannot tell you how significant that social infrastructure investment is, and that will be benefiting children the length and breadth of Scotland and their families. What we found was that investment in high quality early learning of childcare, early learning and childcare, has a direct impact on the individual child. It can literally close the attainment gap before it appears. We know that the children from the poorest backgrounds are at the point that they present at school, five years old, about 18 months behind their peers in terms of their language literacy and numeracy. High quality early learning and childcare can reverse that gap. That is why we made the priority on eligible two-year-olds. About 25 per cent of children in Scotland are eligible to access that early to try to close that attainment gap, but the benefit does not stop there. It does not just benefit the individual child, it benefits the families. I heard time and time again that those families who are really struggling and many of us who are parents around this table will remember that tag team parenting, where one parent comes into the house and another parent leaves the house in order to work, a lot of families are living like that and living under immense pressure just to earn enough money to cover their household bills. What early learning and childcare does, high quality, provided free by the state, gives them room to manoeuvre, room to have family time, which is also really important for them and for their children. The final thing, which is just mind blowing, and I used to get very excited when I thought about it, is the impact of high quality early learning and childcare. We see that in studies from the US. It is not just for that child as they reach their school years and through their education, but it is lifelong. Children who have experienced high quality ELC have a measurable impact on their parenting ability when they have their own children. As a Government, how much do we love having policies that can effectively tackle some of the real intergenerational long-standing challenges that are being faced in Scotland? That is absolutely something that we are committed to in the Scottish Government. That is why, despite all the economic benefits that come from ELC, our ELC was absolutely focused on the beneficial impact on the child, making sure that it was high quality. Anker's agenda is an important and exciting one. It goes to the point that Clare made that you quoted about making full and best use of the collective power of particularly public sector institutions to improve the economy, the wellbeing, the health, tackle health and the qualities of the communities that those institutions serve. It has been a real priority for us. It is a top priority in the place and wellbeing programme that the minister referenced earlier. There is a real connection with the community wealth building agenda as well. It is quite simple. It is about using the power of the NHS and other local partners as an employer, recognising the huge number of people employed by the NHS as a contractor for services and huge amounts that are spent by NHS and other public sector borders on contracts. It is also an owner and user of buildings located in communities. We have prioritised that work. We have recently set up a particular steering group to take that forward. Carol Potter, who is the chief executive of NHS Fife, has agreed to chair that group to drive it forward. There might be two or three examples that I could give the committee just now about the benefits of the supports. One is the new north-east Glasgow hub health and care centre. It is a development in the north-east of Glasgow that will host three GP practices and a whole host of public and other third sector services. Maybe people can get the support that they need. Whether it is health-related, financial or just social connection, there will be a community space there, including a cafe in the Parkhead library. It will also be a net zero facility. An excellent illustration of how an NHS facility can become an anchor within its community. I know that you have taken evidence from Clackmannasher Council as part of this inquiry, and the work that it is doing on its wellbeing in the county pilot project has a real focus on anchors at its centre. Colleagues from Fort Valley NHS and from the council are part of our work. There is also work that NES is doing on the youth academy, partnering with schools in areas of deprivation right across Scotland to think about how they can encourage kids into working for the NHS and the range of roles that would not otherwise have thought about those opportunities. I might be closer to Mr Torrance's heart. As you know, I used to be the chief officer of the health and social care partnership fight. There is a really good example. I am aware of a project at the Victoria infirmary of Concordia about encouraging people into working in health and social care, supporting them through that, people who would have been nowhere near the labour market and encouraging them into full-time employment for NHS files. There is a whole range of those agendas happening across Scotland. What we want to do is identify and press-packs and make sure that all of our institutions working with local partners are making the most of that to improve the well-being of their communities and tackle the health and the qualities that we are focused on today. I hope that that is helpful. Yes, I mean very exciting and stuff to work towards. I think that to get the full power behind it, I think that what Claire Sweeney was saying is that Government needs to be stronger in pushing the public leaders and just some kind of commitment from the minister around that. I think that we would all agree that sometimes we do need to push people at the top to really see this as a priority, which can bring all those things to the fore. I couldn't agree more and more than happy to do that and you are very welcome to hold my feet to the fire if you see that not happening. Thank you. I have a particular supplementary from Tess White. Thank you. I have a question on the women's health champion minister. Before I ask my question, I just want to refer to something. As a fellow of the Chartered Institute of Personnel Development, I am delighted to hear you say that closing the gender pay gap is a really important area for you, a focus area for you, and that you will be taking action in Scotland. Thank you for that. In terms of my question about the women's health champion, the women's groups were delighted to hear last week that the First Minister said that you will be appointing a health champion by the end of the summer. My question, Minister, is what steps are you personally taking to ensure that the women's health champion will be in place by the end of the summer? I am confident that the women's health champion will be in place by the end of the summer. The women's health plan, which was, of course, the first such plan set out in the UK, I was really privileged and proud to do that last year. We had a number of short, medium and long term outcomes that we hoped to achieve. We've, I would say, and there will be an update to Parliament in autumn, but we are very much on track to achieving and surpassing all of our short term outcomes. We've made huge progress in improving the information available to women on a variety of different conditions, such as endometriosis, menopause and all of those things. No, no, I haven't finished yet, though, Tess. I'm sorry. I'm sorry. Chair, convener, the minister. I just want to know what steps the minister is taking. I think we all know we've had various, a lot of work and know about the role of the women's health champion, which we fully support. It's just my question was what steps is the minister taking to ensure that the women's health champion is in place by the end of the summer. I'd just like an answer to that question, please. Minister. So, thank you. You're clearly not interested in the steps we're taking to implement the women's health plan. I'm very interested. I just want to know what steps can be, convener. Thank you. So, we are working together with officials to make sure that the spec for that person's recruitment is absolutely where we want it to be. You'll know that the women's health champion, the national health champion, will have to liaise with individual board champions who will also be put into place, who I think will make a significant difference in women's health plan. We set that out as a medium term ambition. So, at the moment, we are working on the job specification and looking to see how that is going to be funded and what it will be funded at, whether it is likely that it will be what sort of people we think might apply for that role and what tightening up exactly what we think that that role will require before we put it out to advertisement. As the First Minister set out last week in Parliament, we expect that person to be recruited by the end of summer. Again, as a fellow of the Institute of Personal Development, it can take longer. Just saying that the First Minister has committed by the end of the summer, if the job spec and person spec haven't been drafted yet, is the minister saying that it is unlikely that the role will be filled? Thank you, convener. Thank you, Ms White. I think that it's perhaps something that we can take up as committee with the minister after the session. I'm just conscious of time. I'm going to take a brief supplementary from Sandesh Gohani and then I'm going to move on to our next theme. Thank you. Minister, you spoke about the ELC, the 1140 hours. May I ask, minister, if your child turns three between March and August, there is no funding until August? That's six months of no funding. You spoke of the importance of being able to pair, and you spoke of the importance of allowing that to happen. Why is it that if you're born between March and August, your child turns three, there's no funding available? That's a standard way of delivering all sorts of education, as they have certain dates in the year in which there is an intake. That is the way that education works. In Scotland, if your child turns four in a year, you're only going to be able to send them to school if they are four before a certain date, and if they aren't four before that certain date, they're going to have to wait the whole year before they can go to primary one. It's just a function of delivering these policies, and it makes it manageable for local authorities. They know how many children they're going to have to come into the system over the course of the year. Of course, some local authorities make the decision to enable discretion on that point, so some local authorities will fund a child's place at early learning and child care from the point of their third birthday. Other local authorities choose not to. I'm sure that my Conservative colleague is supportive of ensuring that those local decisions are made according to local priorities and not taking that power away from local authorities. Let me also emphasise that those children who are particularly vulnerable in Scotland—those eligible two-year-olds—about 25 per cent of the children in Scotland are funded from the age of two. This is different to schooling when you turn up to school, because you can have your funding put over 52 weeks. If your child is born in February, for those six months, you are funded for a place, and yet if your child is born in March to August, you are not. That is different to your answer, so why is that? It's simply a function of the way that education is delivered in Scotland local authorities. I can use flexibility on that point—many of them do, but not all of them choose to. I'm going to come on to proportionate universalism in questions from Stephanie Callaghan. Thank you very much, convener. We got there, and thanks to the panel for attending today. In evidence that we've heard about the effects of proportionate universalism and about the inverse care law, the fact that those most needable services are often the most likely to miss out on them, so they're not turning up for tests, x-rays, hospital appointments, etc. I wonder if the minister is supportive of the concept of proportionate universalism and how Professor Marmot's work is influencing your approach to tackling health inequalities. I am supportive of the concept of proportionate universalism. I agree with Sir Michael Marmot's position that action to reduce health inequalities has to be proportionate with more intensive action lower down the social gradient, but action does also have to be universal to raise and flatten the whole gradient, so I absolutely agree. We do already deliver a number of services in that way. For example, we're currently refreshing our tobacco action plan. We're considering, among other initiatives, the role of minimum and maximum pricing on tobacco, as well as initiatives like the New Zealand-phased approach to a smoking ban that could be developed. Such action is universal in nature and it would have an impact right across the population, so every citizen in Scotland would benefit from those policies. However, we also target services in smoking cessation. We provide £9.1 million a year to health boards to fund smoking cessation services targeted at the most deprived areas, because that's where smoking rates are significantly higher. There's a big as Karen Mocken regularly points out in the chamber that there's a huge difference in numbers of people who smoke according to your socioeconomic background. It's something like 6 to 7 per cent for people of the highest income and up near 30 per cent for those of the lowest income. As well, Dr Peter Causton, in his evidence, has a huge impact on those most deprived people. He spoke about safety netting, which I thought was interesting, but he also spoke about the chance to change project group, which is working alongside the Scottish Government, which is about helping people to help each other to make a difference to health and well-being. Is there any kind of comment, if you could give us a little bit more information behind that? There is a recognition from this Government that adverse childhood experiences blight the lives of our citizens and can blight them for the entirety of their lives. There's no determinism about it, but there is a lot of evidence that the more adverse childhood experiences you have, the more likely you are to suffer ill health, for example, in adult food, the more likely you are to smoke, the more likely you are to drink heavily. There's lots of work going in around that. There's lots of work about developing trauma-informed services. One of the things that you're alluding to and chipping if I'm on the wrong track, when I think about safety nets, it's not an obvious policy, but that policy of extending free bus travel to children up to the age of 21. When we look at the growing up in Scotland data, we see that there is one of the things that is protective for children experiencing. Having adverse childhood experiences is the ability to travel. It seems like it's not directly related to tackling adverse childhood experiences, but it's quite a powerful policy in terms of relieving them. I was quite blown away when I first came across that link, but when I stopped and thought about it, I thought, of course, if you are able to travel, you are able to get out of very difficult life circumstances should you need to escape, you are also able to access public services in a way that people who don't have access to public transport can't. It's clear that policies such as that, which are universal, are also definitely having an impact on some of the most vulnerable people in our society. In terms of the chance to change, I'll ask Michael to say a little bit more about that, but I was very struck when you were talking about communities helping themselves and supporting communities to help themselves. Just last week, I met a group of gypsy travellers who had a remarkable piece of work going on that was facilitated by MECOP here in Edinburgh, training community health workers, and they were having a profound impact on their own community, a community that is much less likely to come forward and have, for example, cervical smears. Cervical smears are a really powerful preventative tool for maintaining good health. They catch cancer before it's even cancer, and that work was just an insight into the impact that people can have in their own communities, which are marginalised, find it very hard to trust people outside the community. Of course they do, they've had a lifetime and sometimes millennia of abuse and discrimination, so finding and identifying those people in the community who can help their own community to access healthcare is really, really important. There's powerful, powerful work and powerful testimonies and case studies coming forward in that meeting last week. Michael. Thank you. I'm very happy to provide further information to the committee who like it and the chance to change group. However, the key thing, I think, from my perspective, is that focus on supporting communities, particularly those communities suffering from the most deprivation, to support themselves to tackle health and the qualities as a fundamental part of placing wellbeing programme alongside the work on anchors that I talked about earlier. So we're seeking to learn from best practice. So there are a range of initiatives that I work closely with Inspiring Scotland. They do work in a number of communities across Scotland, grass-roots organisations, building local social capacity to support communities to support themselves. Part of the challenge, though, is that work tends to be episodic. Quite often the funding isn't maintained in terms of long-term impacts on tackling the health and the qualities that we've talked about. That is a challenge. So one of the things that we're doing as part of that programme is thinking about how do we better share best practice, how do we ensure funding and support is sustainable and mainstreamed in the way that will work in the longer term. So that focus on community-based support is something that's really important to us and we're taking forward under the placing wellbeing programme. I can provide more details about that too, if that would be helpful. Thanks very much. Can I just say that it would be really great to have some more information? It would be some written information in the gypsy travel work. That would be fantastic. Thank you very much. Thank you. Okay, I'm going to take Emma Harper as a supplementary, so we're going to take Emma and then ask Emma to move on to our next theme after that, which is on health and all policies. Okay, thanks. It's just to pick up on what you said about gypsy travellers and cervical cancer, because I know that there are a reduced uptake or participation in cervical cancer screening in areas of higher deprivation, but also in black, Asian and minority ethnic women as well. I know that there's a self-sampling of HPV cervical cancer research that's being done right now and NHS Dumfries and Galloway is part of that, so is that something that will help then tackle the reduction of uptake in cervical cancer screening if we can move forward the self-sampling process? Absolutely. I think that self-sampling will help. There are a number of reasons why people don't engage in the cervical screening programme. Sometimes there are disability issues, which make it very difficult for women to access somewhere that they can actually get a smear. There are sometimes issues, cultural issues, which make it less likely that women will come forward for a smear and more likely that they would do it at home. A big factor that we often don't talk about is the women who have experienced sexual violence and how hard it is for them to undergo such an invasive test. Of course, we know that many women in society have experienced sexual violence, so there are a number of reasons why women don't come forward for cervical smears. I absolutely believe that self-testing at home will improve the situation. It's not the entirety of the solution, so, if you look at, for example, our bowel screening programme, it's all done at home, it's not invasive, it's easy for people to do and we don't have 100 per cent uptake on that. We have more work to do to make it easy for people and to help them to understand why it's so important tragically. We have an opportunity to eradicate cervical cancer now because of the advances in smear in sampling and the advances in vaccination. The World Health Organization is very keen in developing a programme of work on that, and I in Scotland am very keen that Scotland should participate in that. I would love to see cervical cancer eradicated, but tragically one of the associations that we see is the very people who are less likely to participate in the vaccine programme are also the people who are less likely to come forward for a smear, so that makes it very difficult. I'm seeing that in my work on blood-borne viruses. We have to work extra hard to understand why some people do not participate and we have to go to extra lengths to reach them. However, eradicating blood-borne viruses, eradicating the hep C and eradicating the transmission of HIV is also thanks to advances in technology within our grasp. We just have to work really hard to find the people and make sure that we get them into treatment. In a previous session, I asked about health inequality impact assessments being included in planning, for instance. It's across other portfolios looking at the inclusion of health inequality impact assessments. Can the minister describe what the Scottish Government is doing or what is the Scottish Government's work to include health inequality impact assessments in all policy areas? The Scottish Government continues to advocate the use of HIIIs in a health in all policies approach to policy teams across Government, across public bodies and wider stakeholders, supporting colleagues to embed them in practice and ensure that the potential impact of policies and programmes on health inequalities and the wider determinants of health is fully considered. The HIIA guidance was last updated in 2016, and Public Health Scotland will be updating it later this year. We are also working very closely with Glasgow City Region, Glasgow GCPH and PHS in the development of a new tool to measure the impact that major housing and transport projects can have on improving health and wellbeing and reducing health inequalities across the Glasgow City Region. Ultimately, we would like to see the use of HIIIs in a health in all policies approach. There is a great deal of learning to be taken from countries like Wales. They made the statutory requirement for public bodies when the Public Health Bill was passed in the Welsh Senate in 2016. I am interested in taking that approach in Scotland, too. We come now to questions on public services, and Gillian Mackay will lead on that. Last week, at committee, I asked Dr Peter Costin a deep NGP about whether services are trauma-informed and highlighted that tackling stigma involves everyone who works in a health and social care setting, having a better understanding of how trauma impacts throughout a person's life and how trauma affects behaviour. He said that trauma-informed training is more available, but there is still much work to do. What is the Government doing to promote the importance of services being trauma-informed and ensure that all health and care staff undergo trauma-informed training? It is a really, really important point. I talked about how the Government well recognises and understands the impact of adverse childhood experiences on somebody's entire life course. It is really important that our public services are trauma-informed. It is disappointing that there are times when we feel that people presenting, looking for support from public services, are further traumatised by what they meet in our public services, and we really have to work hard to get that right. The Deputy First Minister told the Finance and Public Administration Committee in November 2021 that we need our public services to wrap around people and to be person-centred and holistic and responsive to their needs instead of expecting people to fit around what public services offer and expecting them to navigate complicated systems from positions of vulnerability and from need. We are backing this up with action. One of those actions is increasing the availability of training in trauma-informed practice. We are also trying to simplify. It is an almost impossible task, but trying to simplify the way that some of our services are delivered in order that that is much simpler. We are thinking more and more now, and again, Michael might wish to say more. You will all know that, for our children and young people, we talk about GERFIC, regularly getting it right for every child. We are now thinking for our adult population, we need to think GERF-E, and I would say E, GERF-E. We haven't quite decided on that or at least I haven't settled on it yet. I'm campaigning for it to be GERF-E, but that's about getting it right for everyone, every time, so that our services, instead of when you think of people who are presenting, if we think about, for example, the work that Angela Constance is doing in drug addiction, a very important example, one of the challenges in that area is that it is quite hard for people to get into treatment and very easy for them to fall out of it. We need to make it easier for people to present, we need to make it easier for people to get treatment quickly when they present, and we need to make it hard for them to come out of treatment. We need to be trauma informed, understand where that individual is in their journey to recovery, and catch them and hold on to them until we can get them better. There needs to be a reduction in stigma in these services, there needs to be dignity in everything that we do, but that's a classic example of how we can transform these services. It takes a lot of work, but we are absolutely on it and working. That's just one little microcosm when I think about, you know, I have responsibility for a lot of chronic illnesses and the last thing I want is for people, for individuals, to feel like they are a collection of conditions. I'm really keen to ensure that people are able to access holistic person-centred care, that they don't have to present several weeks running at different clinics for different bloodletting for different things, and that actually they can present in one place and have holistic person-centred care. That will make their lives easier, it will make them more productive economically and it will save money to the NHS. Why wouldn't you do it? It's a bit trickier to achieve in reality than it is in our imagination, but we are definitely recognising the benefits for us, but also absolutely for individuals who are trying to access public services. Thanks minister. A couple of things to say if that's all right. On Goerffy, Goerffet is another example, which I think is getting right for everyone together. The minister and others will decide what the best one is, but that focus on how we wrap our services around an individual to understand them, to best meet their needs, building on the GP contract, and it's the central focus of the preventative and proactive care reform programme that the minister talked about earlier. That's about building that multidisciplinary team, something that's called the principal care team, ensuring that care, and that's right, that's beyond health, it's into housing and other support as well, so I think that that is really important. The second thing is just to cycle back to your question about trauma-informed training. The committee is probably aware of that, so it's probably useful to say that, since 2018, the Government has invested over 5 million pounds in a national trauma training programme. A total of 3.2 million of that has been funding distributed to local authorities to work with community planning partners to further that agenda and our commitment. By April next year, we will publish a long-term delivery plan for the next phase of the national trauma training programme. The other thing that I'd like to say, and that cycles back to the question that Ms Harper asked earlier, I saw recently the minister, you may not be aware of this, but a really fantastic programme that the Meadows Clinic is developing. The Meadows Clinic is a facility in NHS Forth Valley that supports women who are the victims of sexual violence around all their healthcare needs, including the acute point after the attack. However, one of the initiatives that the Meadows Clinic told us about was how they support victims of sexual violence through to access cervical smears, and they do that on a trauma-informed basis. They have had early success because of their way of working, building trust, working with those women and persuading and encouraging women who were refusing to access cervical smears for some of the reasons that will be obvious to the committee to go through that process. One of the discussions that we had is about if that is successful in its early days, how do we think about rolling that out nationally so that the victims of sexual violence across Scotland can be supported in that trauma-informed way. I thought that it was a really inspiring project and that it was useful to share with the committee. No, absolutely. Thank you both for those answers. Dr Shari MacDade highlighted that if there are just one-off training sessions in the trauma-informed approach, people will be expected to go back to their systems of working and try to remember what they learned during that one-off programme. They emphasised the need to ensure that there is on-going reflection and said that embedding reflective practice is the next step that needs to accompany the training programmes and education in the trauma-informed approach. What action is the Government taking to ensure that reflective practice accompanies trauma-informed training? I think that many health and social care professionals already embed reflective practice into their—certainly the regulated professionals already embed reflective practice into their development. I have taken board the point that you have made about making sure that that becomes part of the trauma-informed package, because I know that that goes out to a much wider staff pool or than simply the regulated health professionals, and it is well worth me going back and checking that that is there. I think that as well as the reflective practice, it is not just about an individual's practice, it is about changing the system so that it is more person-centred, more flexible, more holistic in the way that it is built and designed and delivered and implemented rather than just the individual practice. If we focus on the individual's practice, firstly, I do not think we will achieve our goal, and secondly, we run the risk of an extremely weary workforce feeling like the reason that things are not working is their fault, and it absolutely isn't. We have built these systems, and we did not deliberately build them this way. They evolved over time to meet needs, but most people would acknowledge that some of our most vulnerable citizens are having to navigate a really complex, bureaucratic system on a day-to-day basis, simply to get the help that they have a right to. That is not good enough, and we need to really reflect on that and build it better. We are now going to move on to questions about the role of community link workers. I am going to ask Tess White to lead the area. In 2016, the Scottish Government set a target to recruit 250 community link workers by the end of the parliamentary term. In your area, in the Highlands and in my area in Aberdeenshire, we still haven't got any community link workers accepting that you weren't the minister then, but now you are. Can you share with us please what work you are leading on to make sure that the target is delivered? We have delivered the target for Scotland. There are now more than 300 community link workers employed across Scotland through the primary care improvement fund. From this year, we are going to build on their successes with the introduction of the new multidisciplinary mental health and wellbeing teams in primary care, which will include new community link workers and an emphasis on social support and social prescribing, where that is appropriate for the person. In 2021, we commissioned Voluntary Health Scotland to establish the Scottish Community Link Worker Network to strengthen that role and to increase the wider understanding of the contribution that link workers make to tackling health inequalities. We are also embedding welfare rights and money advice services across 150 primary care settings over two years in deprived communities across Scotland. If I can follow up, so minister you haven't answered the question. The question was just in Aberdeenshire not a single link worker has been, unless I've got my figures wrong, has not been appointed and in your area in the highlands still not a single link worker. So can you assure us that action you are leading on action to make sure those posts are filled? Thank you. Yes, I can and I will take action and come back to you. Thank you. I've got a supplementary from Gillian Mackayf. Gillian, so where's my name and I'll bring David Torrance in, so Gillian. A lack of joined up care has been highlighted by the committee with some patients falling off the cliff edge once they're discharged from services. As an example, patients are not always connected with community care once discharged from hospital. So how can we ensure that there are better links between acute and community care and what role can link workers play in that regard? I think that link workers can be a really important tool in terms of that holistic care that I talked about, that understanding of the social determinants of ill health and the work that they do to maximise income and ensure that people don't fall through the net, frankly. So I think that they're a really powerful tool. I think also, though, we have to reflect on the systems that are leading to that sensation of people falling out of the net as they go from secondary care into primary care. I think that everybody would acknowledge that there is a risk at every interface within the health service, of which there are many, that communication can fail and that vote can be lost to follow-up, that interface between, and we're looking very carefully at it just now as we build a social care system and look at how we improve communication between health and social care. There is a recognition that that communication, even within health, is challenging at times. We think that there could be digital solutions that make it simpler to transfer information from one area of the health service to another and potentially to areas outside the health service or to social care and, with the individual's permission, perhaps to third sector organisations. We're definitely a little distanced away from those digital solutions. Another thing that might come with some of those digital solutions is that people would be in charge of their own information and it would be an empowering experience. My colleague Kevin Stewart, if you were here, would talk eloquently, I have no doubt, about the many, many people he meets who are re-traumatised by having to tell their story time and time and time again and they can understand why their story, having told it once to somebody in the system, does not then follow them through that system. We're very aware of those issues. We're working hard to improve and to resolve them. One of the ways that we will build those systems better in the future is by having lived experience at the heart of it. I think that if we have lived experience at the heart of policy development, we're much more likely to get policy right. I think that it also holds us to account with policy implementation because we are much more likely to find out the gulf that there sometimes is, but often a gap between what we intend and what actually happens on the ground. I think that that's the best way of making sure that we achieve our policy aims is by having lived experience hold us to account. I don't know if you have any more to say on that, Michael. I think that you've covered it, minister. No, thank you. Thank you. David Townsend. Thank you, convener, and good morning, minister and Mr Kelly. Minister, can you expand on the success that community-link workers have had in the most deprived areas? How do we make sure that these workers have the resources to engage with the other key sectors, like the first sector, which are really important? How do we get that information back from the first sector to show that we're having that success? I mean, data collection is a challenge right across the board, isn't it? But it is important that we show how effective these policies are, absolutely. Community-link workers are at the forefront of our efforts to tackle the consequences and the determinants of health inequalities, and they work directly with individuals to help them to navigate and engage with wider services. We know that it's invaluable in supporting people with issues such as debt, benefits advice, social isolation and housing, and they also are really important at connecting individuals to community resources, so they are helping to make sure that individual folk find out about food banks and are able to take that first step to get that kind of support, helping them into mental health provision, and they provide people with on-going emotional support. That is all quite hard to capture. We can say that we've employed x number of community health workers, but as Tess White pointed out, that doesn't necessarily mean that we've got national coverage. We have achieved the national aim. It doesn't necessarily mean that we have national coverage, so we need to keep going back and looking at the data and looking at the outcomes and looking at the difference, perhaps, with qualitative data rather than quantitative data, just at the impact and see if we can capture the impact that community link workers are making. If I might come in. Thanks, minister. Just to build on that, I think that there's real power in this community of community link workers. The minister spoke recently at an event, a reception here in the Parliament for the... I might get the name wrong, but I think that it was a social prescribing Scotland network members of the committee may have been there as well. I think that point about capturing qualitative evidence is really important. Real passion from that group self-organised association of effectively community link workers, and they told a couple of stories that evening, one about a young man living in Westerhale, supported by community link worker, a veteran who had disengaged from society living in the house without electricity, heating his water on a billy can type scenario, and in a really difficult position around his mental health. The community link worker told the story of her engagement with him, how that built over time, built trust, connected him with housing services, got his electricity, reconnected, and there are stories like that that those colleagues tell time and time again. So I think that the power of that, those community link workers, that social prescribing approach is really profound. One of the things we are doing in government again as part of the care and wellbeing portfolio is seeing how we can further support social prescribing and community link workers to really improve the health and wellbeing and tackle some pretty profound health inequalities as well. I must admit that they were a very, very impressive bunch, and I absolutely got the impression of a passionate army of social justice warriors out there doing their best for Scotland. It was really, really powerful, the presentations that they made, and I had met them shortly before the work that they are doing is really, really impressive in that, you know, absolutely getting alongside people and helping them to flourish. Thank you. We now come to questions on systemic inequality, and Sandesh Gohani will be in this section. Thank you. Just before I get into my questions on systemic inequality, I would wonder if the minister would join me in asking anyone who is available for any screening programme to attend it. Absolutely. I couldn't agree more. We have really effective screening programmes that are well evidenced, that are largely easy to access, and it is really important that people attend and participate in screening. For most of them, it is about early detection of problems, which, as everyone knows, means that they are much more treatable if they are caught at an early stage. For cervical cancer, it is unique in that it catches it before it is even cancer. It is not about catching cancer early, it is about preventing cervical cancer, and for me that is a really powerful reason to participate in that screening programme. Thank you minister. On to the topic. Do you feel that there is systemic racism in the Scottish NHS? I think that there is systemic racism in every aspect of society. I think that it would be foolish to deny it, frankly. I think that we have seen over the last couple of years, with the Black Lives Matter movement, has shone a light on systemic inequalities. The experience of the pandemic, where we saw that Black and minority ethnic communities were more likely to work in jobs, meant that they were exposed to the virus, more likely to live in housing, meant that the virus spread right through their families, and they were more likely to live in poverty. Those are all systemic issues that we cannot close our eyes to and we have to acknowledge. That does not mean that they are easy to tackle. I think that every society has to be focused on ways of tackling the systemic inequalities that have built up over centuries, sometimes millennia in the case of women. There is not a society in the world, I do not think, that does not have a challenge with inequality for women. Acknowledging how difficult it is to tackle those things and acknowledging that they are there and absolutely eyes open and mind open to ways to improve the situation. With systemic racism within the Scottish Health Service, which you have said exists, not only is that a problem for the staff, but it is also a problem for the patients. One of the big issues that patients have—we will set aside the staff issue for now—is the accessing of healthcare, because they do not feel that it is for them. How can we address that and improve that? You are absolutely right. When people are experiencing systemic racism, it is very hard for them to access public services because it feels like society is not built for them. An acknowledgement of that and an endeavour to improve the situation is really important. If I go back to talking about the work that we are doing and the Gypsy Traveller community that I met recently, that is one example of how community health workers from within that community were able to make a significant difference to the health of their community. That is an issue worth exploring. Another issue is that it is important that we have good data to guide us. It is always difficult to find data for people who are outside of the system. We have been better and better, and the vaccine programme was one of the first areas where we collected ethnicity data at the time of administration. That has been really helpful in focusing our efforts on outreach programmes to ensure that those minority ethnic communities who were less likely to take up our offer of the vaccine were put in special programmes to go and reach them. With the Polish community, with the Black community, with the Pakistani community, there were extra efforts made and successfully. It is much more difficult to capture those people who are not participating at all. The Gypsy Traveller community talked to me about just how difficult it is for them to register with the GP because they move around all the time, but they are not in one location. That, by definition, made it almost impossible for them to even get into the healthcare system. It is very difficult to capture data on the people who are completely excluded from the healthcare system. A final point that I would make is an issue around research and studying. Women have suffered from this being a man's world and much of the medical research that has gone on over the last century in terms of development in medical understanding has been focused on men. Men are much more likely to participate in clinical trials than women are for understandable reasons around pregnancy and childbearing. However, that means that our understanding of men—those are largely white men in the developed world—is far greater than our understanding of women and our understanding of men from ethnic minorities, and particularly of women from ethnic minorities that are real get-ups in our understanding. We can see that played out in real life, so there are a couple of studies going on in England. I think that one or two of them have recently reported the impact of ethnicity on outcomes in maternity through and in birth. While those are English studies, academic studies, I am absolutely sure that there will be lessons for us to learn in Scotland from that understanding, because there is a solid evidence of health inequalities and of those black and minority ethnic women suffering quite severe health inequalities as they pass through the maternity services. We need to look at that, understand it, learn from it and implement changes in Scotland, too. You are right, minister, when you say that, because black and ethnic minority women are more likely to die when they are pregnant. I have two examples with my final question. The first one, it seems very simple and small, but if we talk about sticky plasters and band-aids, I would have a cut and I would have a sticky plaster and a band-aid on. I did not realise that they were supposed to be skin-coloured. When they were produced in different colours, it made a world of a difference, because you put a sticky plaster on and it is not big and obvious and showing that some things happened. It is things like that that really matter. It really does. It is only when I saw it that I noticed how awful it was. My other example, and this is where my question is going to come in, if we look at the Indian community with Sikhs and Hindus, there are no information leaflets available in greater Glasgow, Clyde and Hindi. Public Health Scotland produced a report and it talked about the Muslim community, it talks about Polish, it talks about black community, but nothing in there about Indian communities about Hindus and Sikhs. My question is, why not and why is this rather large community excluded? I would need to be asking greater Glasgow and Clyde precisely that question and I will go and do that. You are absolutely right about these tiny things making a big difference. I think that as a woman, I absolutely recognise that I live in a man's world and I have daily reminders of that. I think that it is exactly the same for people of black and ethnic minority. Those small reminders that this world is not your world will have a profound effect on them, far greater than whether they have a plaster on their cut or not, frankly. I think that you are right to point to these small things making a big difference. I think that it is important that we take care of these small things and it is frankly incredible that we have not thus far. In terms of ensuring that health information is available in many different languages, I am sure that Greater Glasgow and Clyde makes sure that health information is available in multiple languages and I know that they have access to translators. There is the greatest ethnic diversity in that particular health board area in the whole of Scotland and I know that making sure that things are available in different languages might not go far enough. There may be other alternatives where things can be easily translated and available on a website or something like that. The final point that I would make is that we need to go a little further than just ensuring that we have information available in different languages. We need to make sure that our work is culturally sensitive to whoever we are caring for. I hear that time and time again from people, from minority communities. I am sure that almost all of you here on the committee will have heard about how LGBTQ plus community feels and that there is evidence that alcohol services are not meeting their needs. I am saying that we need to go further than a tick box exercise of ensuring that information is available in different languages. We absolutely need to do that, but we need to go further. We need to have person-centred services that absolutely get alongside people and are sensitive to the culture that they are from and ensure that we can deliver care that is sensitive to their cultural needs and that they do not feel like they are outside of that community. We are going to move now to our final theme this morning, which is the pandemic and indeed the cost of living crisis. I am going to begin just by asking what is the Scottish Government doing to ensure that those who are already vulnerable and have been affected by health inequalities are not further disadvantaged in terms of Covid recovery and the cost of living crisis? The cost of living crisis is impacting absolutely every household in the UK, and the Scottish Government will continue to do everything in its powers and within its fixed budgets to ensure that people, communities and businesses are supported as far as possible. Through the budget for 2022-23, the Scottish Government has allocated almost £3 billion to a range of supports that will contribute to mitigating the impact of increased cost of living on households. For people living in Scotland, that means a £150 payment for those in receipt of council tax reduction and for those in council tax bans A to D, supporting 1.85 million households, a further £10 million for the fuel insecurity fund, helping households at risk of severely rationing their energy use or self-disconnecting entirely. Investments in a range of measures unique to Scotland, such as £520 paid for around 144,000 school-aged children from low-income families through bridging payments in 2021-22, nearly £82,000 unpaid carers receiving £491.40 of additional support this year through the carers allowance supplement. Eight Scottish benefits, including the best start grant payments, are uprated by 6 per cent to ensure that those essential payments keep pace with rising cost. 92,000 households protected from the UK Government's bedroom tax, which, as I'm sure you're all aware, was a policy that was particularly had an impact on people with disabilities. Action to protect further 4,000 households, which 97 per cent of those 4,000 households, have dependent children protecting them from the UK Government benefit kit, which reduces benefit awards by an average of £2,500 a year. I thank the minister for that summary of actions. I wonder if I can just ask on the point about the cost of living payment. The payment, obviously, is the same strategy that was employed by the UK Government in terms of council tax. There are people sitting around this table who will have received that £150. Does the minister feel that there would be better ways to deliver that in terms of looking at a more focused approach to supporting people, particularly those who are in the most need, because this inquiry is interested in the inequalities and trying to protect from the exacerbation of inequalities? Kate Forbes was very clear when she announced that payment that she was balancing the tension between getting it to the right people and absolutely focused on the people who needed it most, and the speed required to get it out the door and into people's hands. I think that there is a frustration in the Scottish Government that we found, and we found that through the pandemic, and I am absolutely sure that there will be reflection on it, that there are not always easy mechanisms in place to get money into people's hands. That will improve with the growth of the social security system, but it is not always easy for us to identify the individuals who need the most help and to get the money directly to them. I believe that Kate Forbes was very frank about it at the time that it was announced that it was a compromise between getting it out fast to the people who needed it most, knowing that some people who got it would not be in need of it. I wonder if I can ask a question related to my previous questions in terms of support for local government. I think that local government, again, will be at the forefront of the impending storm, the storm that we are currently in around the cost of living. That is evident in terms of services like welfare rights and money advice. In terms of all public health approaches, local government needs to do more. I think that they have been asked to do more with less, and the Accounts Commission, for example, has pointed to a 4.2 per cent real-time cut in terms of local government budgets. Do you feel that it is sustainable for that level of cut to local government to deliver what we want to try and achieve? It is absolutely challenging times ahead at the moment. If I think about the cost of fuel energy prices rises and the impact that that has on public services, the cost of heating a nursing home is higher, the cost of heating a hospital is higher, the cost of heating a sports hall is higher, the cost of running a swimming pool is higher. And all those things were uncalculated for largely when budgets were being set just a few months ago, so that inflationary increase in energy costs alone is having an immense impact on people's ability to deliver public services. If you think about the cost of inflation and capital costs, I mean, I was chatting to a sports organisation recently who had managed to get a great deal of money in order to renew their ground, and they recognised that within a year, £1 million becomes £0.9 million. That is how high inflation is at the moment, and that is how fast the pot of money is going down. It is challenging times for absolutely everyone, and it is particularly challenging for those who are required to deliver public services. It is a challenge for the Scottish Government, and it is a challenge for local authorities. It is a challenge for our NHS boards, too. I think that what that requires in order to rise and meet that challenge is that we innovate and think creatively, and that we really carefully prioritise what it is that we need to do. We work collaboratively in a way that we are, if I go back to very early in this evidence session, in a way that may not be particularly natural for us, because in order to achieve some of the things that we want to achieve and that we have to achieve in Scotland, we are absolutely going to have to work together and pool our efforts in order to achieve those outcomes. There is just no way around it. Financially, things are really difficult at the moment, and it is going to be necessary to collaborate to an extent that we never have before. Would you accept that, because of the year-on-year cuts to services—I say that this is someone who served 10 years in a local authority as a councillor—that many of the services that we really need do not exist anymore and that innovation and collaboration cannot often take place because we do not have the people or the skill sets in local authorities to be able to do that? I guess that you and I are absolutely agreed that the austerity politics that came in in 2010 have been severely detrimental to our local authority colleagues and to Scotland as a whole. There have been policy decisions made to cut Government budget, to cut the Scottish Government budget. Some of those cuts have had to be passed on, but when I look at the numbers, I see that local authority has been largely protected from a lot of the cuts compared to local authority services in England, some of whom have found themselves in a really precarious situation. All of us—well, not all of us—would agree that austerity politics has been really harmful. I go back to David Welsh's testament, which is that we are paying tragic consequences for decisions that were made some time ago. We went into the pandemic in 2020 on the back of 10 years of austerity politics, and I think that there is absolutely no doubt that we would have feared better in the pandemic had we not been in that situation when the pandemic hit. The minister and I, and I am very conscious of time, could have a back-and-forth on that, because I think that the feeling on the ground on local government might be that Scottish Government decision making has had a huge impact on the choices and decisions that were made, particularly around often the underfunding of Scottish Government-led initiatives, some of which we have had a discussion about this morning. I am very conscious of the time this morning that led to the committee. As I say, we could have a further discussion on that, but I think that the point that has now been made from both our points of view and is now on the record. I know that Gillian Mackay had a supplementary on this, so I am willing to give the last word to Gillian Mackay. In the submission to the committee, the health and social care alliance highlighted that people with long-term conditions have been particularly impacted by deterioration in their health and wellbeing due to the cost of living crisis and having to use different healthcare aids and support along those lines. What action is the Government taking to help to support those people, to give them access to support from other places and to address that as a whole? There is absolutely a recognition that people with disabilities or with long-term conditions will be more impacted by the cost of living crisis. If you just think about it on a very human basis, quite often, as you say, they have equipment that requires to run on electricity. The cost of charging that equipment and running it is significantly more today than it was this time last year. If people are at home all day and almost all of us have an insight into that, there is, after the pandemic, the cost of heating your own home to a standard that makes it livable. I can move around more and put more layers on. That is not an option for people with profound disabilities and it is not an option that I would want them to face. There is work, as you would expect, going on within Government to assess the situation and to see what we can do to meet those needs. I do not know if Michael Scott wants to say anything particularly more or if it is something that we can write back to you in terms of what support might be offered to those particularly vulnerable groups as we face this cost of living crisis, which is something that we have not—and it comes on the back of another crisis, so in the back of an epidemic, in the back of Brexit, in the back of an epidemic. Right into a cost of living crisis, where food is costing more and energy prices are costing more, it is a really difficult time for society. Scottish Government is trying hard to make sure that our attention is well and truly focused on the people who need our care most. I have not much to add. The Alliance are key partners. They are very good advocates for the people that they represent and we work with them very closely. I think that the points that you made around the inequity, even in terms of impact on people with disabilities, are a very good one. I know that we are working really hard in the short term to look at what further support we can put in place. I suppose that the only other thing that I would say is that, in the longer term, the national care service is hugely important and is being welcomed by the Alliance and other groups in terms of ensuring consistent social care of high quality across the country. However, I recognise the point that you made about the short term support and if there is more, we can provide to the committee to be very happy to do that. I thank the minister for her contribution in this regard. I am conscious that we have another item of business with the minister. Would the minister want a comfort break at this stage? I am fine, actually. Our third item today is consideration of an affirmative instrument, which is the health, tobacco, nicotine, etc. and care Scotland Act 2016, supplementary provision regulations 2022. The purpose of the instrument is to ensure that environmental health officers are able to issue fixed penalty notices in respect of the offence of smoking in a no smoking area outside a hospital building and the offence of failing to comply with signage requirements at entrances to hospital buildings regarding the no smoking area outside those buildings. The Delegated Powers and Law Reform Committee considered this instrument at its meeting on 21 June 2022 and made no recommendations in relation to the instrument. We will have an evidence session with the Minister for Public Health, Women's Health and Sport and Sporting official on the instrument. Once we have had questions answered, we will have the formal debate on the motion. I welcome now to the committee, the minister, and accompanying the minister online, Jules Goodluck Rowley, the head of a healthy living unit at the Scottish Government. I would invite the minister to make a brief opening statement. Thank you for inviting me here to discuss the regulations that make supplementary provision to the legislation that creates the no smoking perimeter around hospital buildings. Today, I seek your agreement to giving designated officers of local authorities the power to issue fixed penalty notices in respect of two new offences relating to the ban on smoking outside hospital buildings. There are three new offences relating to the ban without the SSI local authority officers such as environmental health officers, which will only be able to issue fixed penalty notices in respect of one of those three offences. The instrument will enable local authority officers to issue fixed penalty notices in respect of the two other offences. As previously noted by the committee, the prohibition on smoking outside hospital buildings requires effective enforcement to ensure compliance, especially during the introduction of the 15-metre boundary. It was the intention that local authority officers would lead on the enforcement of the ban, much like they led on the enforcement of the indoor smoking ban. As drafted, however, the provisions for the enforcement of the ban do not fully reflect that intention. That issue was only identified after the prohibition of smoking outside hospital buildings. Scotland regulations 2022 were made earlier this year. The ban on smoking outside hospital buildings will come into force on 5 September 2022. On this date, section 20 of the Health, Tobacco, Nicotine etc. and Care Scotland Act 2016 will amend the Smoking, Health and Social Care Scotland Act 2005. The 2022 regulations will also come into force. The 2005 act, once amended, will contain three new offences relating to the ban. Those offences are knowingly permitting people to smoke in the no smoking area and failing to conspicuously display no smoking notices at the entrance of hospitals. The 2005 act will also give the police and local authority officers such as the EHOs powers to issue fixed penalty notices in respect of those offences. However, only the police will have power to issue fixed penalty notices in respect of all three offences. EHOs will only have the power to issue fixed penalty notices in respect of the first offence, allowing people to smoke in the no smoking area. The intention is to allow EHOs to lead on enforcement. It is critical that EHOs can also issue fixed penalty notices in respect of the other two offences, particularly the offence of smoking in the no smoking area. Giving EHOs that power will ensure effective enforcement of the perimeter by hospitals should, I am sure that we all agree, be places of health promotion where healthy ways of living are demonstrated. They should be environments in which people are protected from harm and supported in making positive lifestyle choices. The sight of people congregating near doorways to smoke outside our hospitals is incongruous to this. The no smoking perimeter will reduce the risk of exposure to second-hand smoke near entrances and windows. It will prevent smoke drifting into hospital buildings and it will protect those using hospitals, particularly the vulnerable. The regulations that we are discussing today will help to deliver the effective enforcement of the ban that committee members called for during the passage of the prohibition of smoking outside hospital buildings Scotland regulations 2022 earlier this year. It provides local authority officers with the same enforcement powers granted to Police Scotland who have indicated that it would be operationally difficult for them to be solely responsible for enforcement. This is a team effort. We have been working with health boards, local authorities, Police Scotland and others to bring this to fruition. Without those additional powers, we are limiting the effectiveness of the restrictions before they have even come into force, so I urge you to pass the instrument and help us to stop smoking near Scotland's hospitals. I invite any questions from the committee on the issue, Dr Gohani. Minister, I am obviously, as a doctor, very supportive of the idea of not smoking around hospitals and around entrances. I have actually seen people smoking outside the children's hospital in Glasgow with the smoke going up to the children up there. I have a few questions. My first one, in Fourth Valley, they have been trying to enforce a no-smoking area. They have big cross-hatches, somebody that goes around and tells people not to smoke, and that person gets an awful lot of abuse. I understand that we are allowing environmental health officers to issue these penalties, but how do we prevent this abuse? That is a challenge in healthcare environments across the board. I think that it is really important that we think about the cultural impact of legislation like that. It gives clarity and certainty to people in Scotland. People in Scotland will know that hospitals are not allowing smoking in the perimeter, and I think that that alone will reduce the level of conflict in implementing the ban. We heard that there was a lot of concern in advance of the smoking ban around how it would be implemented. When we had no smoking areas before the smoking ban, there was often friction around how that was implemented. The smoking ban brought clarity to the situation, and people know that they are not allowed to smoke there. They know that there will be consequences if they smoke. It is not simply appealing to their good nature. There is the potential for assuring a fine should they not comply with the legislation, and I think that that brings clarity and will reduce conflict, if I am honest. I ask you for clarity for everyone to find smoking. Obviously, cigarettes are smoking, but does that include heated tobacco? Does it include vaping? Some people would say that there is no nicotine in their vape, so they should be allowed to do it. Could I just get some clarity on that, please? The use of nicotine vapour products is not affected by those regulations. We do not have the power to include MVPs within those regulations because they were not included in the 2016 act. The permitting of MVPs used within this perimeter and on hospital grounds will continue to be at the discretion of each health board. I know that that is likely to lead to a lack of clarity. At the moment, the evidence on safety or otherwise of second hand exposure to vapes is not yet clear. I am deeply cynical. I think that vapes are a useful tool for smoking cessation. Potentially, they are likely to be less harmful than smoking tobacco, but I am deeply cynical about the efforts of tobacco companies to market them widely and to ensure that they find a replacement market for the reduction in smoking. I think that we need to go very carefully with our use of vaping products in health promotion, frankly. I would not rule out looking at vaping products should the evidence firm up that exposure to second hand vapes is problematic. I would not rule out including that or considering future legislation on that. It sounds to me like it would require new primary legislation given that the 2016 act does not give us the ability to regulate thus far. I am sorry, Minister. Just one final question is just on vaping. I agree. I feel that it can be quite an effective tool to help in the cessation of cigarette smoking. It probably has a significantly lower risk than smoking, but when I walk into a hospital, anywhere, to be honest, but especially a hospital, I do not particularly want to be faced with a cloud of cherry smelling, whatever smelling cloud, which is what happens in a vape. I would urge you, even though there might not be evidence about second hand harm, I would urge you to look at vaping and include that in the bill so that we have absolute clarity that you cannot smoke at all around hospital. I am certainly willing to take on board your view on that and we will be looking at some issues around vaping. We have had a consultation around the regulation of vaping and we will be looking at some of those issues later in the year. I am willing to take on board your view on that, but as I understand it—perhaps Jules will come in here—it would require primary legislation, because the original act, which has allowed me to bring this SSI before you, did not include vaping. It would require us to look at primary legislation on vaping, and that is an altogether larger test, but I am certainly willing to keep it on the radar and include it should that opportunity arise in future. All of our legislation, we try hard to make it evidence-based, because the evidence around second hand harm from second hand vaping is not particularly solid yet or clear yet. It would be hard to introduce primary legislation on that front right now, but I will ask if Jules has anything further to add on that. She is more familiar with the original 2016 act. At the moment, we do not have the powers to regulate MVPs in the regulations and the permitting of MVPs used in the perimeter and hospital grounds, so we will continue to be at the discretion of each health board. In a perfect word, the world would have foreseen this technology when we wrote that original piece of legislation. I remember one of the anesthetists telling me that she was waking up from a tonsillectomy surgery and where people smoked, it was right under the windows of the ENT ward and she remembers waking up from her anesthesia fog and smelling of cigarette smoke. I welcome that. I am the co-convener of the Lung Health Cross Party group and the nurse. I am keen to hear what is being done or what measures are being taken place to help health boards, local authorities and health and social care partnerships to educate people about that particular legislation so that it is easier to enforce it as we move forward. You are absolutely right to talk about how smoke drifts into hospital buildings from outside. I worked from 20 years as a hospital pharmacist and I also have asthma. I am one of those people in the workforce who would wheeze as I accessed areas of my workplace where smoke was. We had air conditioning that literally pulled the smoke in from the smoking area and pumped it into the ward. That is not an unusual situation. We need to think about the exposure to second-hand smoke that causes staff, patients accessing care and everyone visiting the hospital. That is why I think that that is an important measure. On raising the profile, it is a busy news day today, but I suspect that that will make the news. When it is introduced, I would expect it to be covered by our national news outlets. I would also expect the signage at hospitals to be very clear. I think that that two-week run-in was not our intention. That gives a little bit of time for awareness to be raised about the change in smoking around hospitals before people face fines for breaking the rules. I think that that is probably a helpful thing. I would like to hope that there will be absolute clarity to everyone that hospitals are not places where you can smoke near to. Can you just confirm again what the goal live date is for this? Was it September 8? I think that it is the fifth of September and it is two weeks later, about the 20th of September, that the SSI will mean that environmental health officers can use fixed penalty notices. I want to ask minister briefly on the financial effects. I have asked this question before to the cabinet secretary about funding for environmental health to carry out this. I appreciate that, in the financial effects paragraph, it states that local authorities are already funded to undertake tobacco work. If there were costs that were exorbitant or added pressures for particular departments—I am conscious that, in the city of Edinburgh and the city of Glasgow, for example—there will be a higher number of hospitals and there might be other local authorities. Therefore, there might be a corresponding pressure on those teams that will be monitored by Government and that any adjustments will be made if they are required. I would expect that to be an effective instrument in terms of preventing the problem, but you are right. If there are financial costs arising that have not been predicted, we will be more than happy to hear from local authorities. I would have to say as a Highlander whilst Edinburgh might have more hospitals, there will be a lot more travelling distance involved in monitoring the hospitals in Highlands and Islands. Those are just the challenges that our local authorities and our health boards face. That is very fair. I am sure that the ministers around me have my central belt biased, which often accidentally slips out. If there are no further questions, we will move to item 4 in the agenda, which is the formal debate on the made affirmative instrument, on which we have just taken evidence. I remind committee that members should not put questions to the minister during the formal debate, and officials may not speak in the debate. Before I invite you to move it, is there anything further that you wish to say in relation to motion S6M-04798? No, thank you. Can I invite any contributions in the debate? Just to reiterate that it is very important that we include all products, including vaping. Just in response to Dr Sandesh, I just wanted to make a weak comment about vaping as well. Someone who has given up smoking and currently vapes myself, I will get personal experience, but just statistically we are looking at you are twice as likely to give up smoking using vaping than you are using nicotine gum. The nicotine itself is pretty harmless in that form and you do not get the carbon monoxide etc. I do think that it is about a balance here as well, and we do not have the information and the evidence to back that up yet, but certainly the consensus across the NHS and elsewhere does seem to be that it is very, very, very much less harmful than smoking cigarettes. On a balanced approach as well, having more people vaping, having more patients perhaps, with the long-term smokers actually switching to vaping, could overall have a really, really positive impact. I agree in the comments that I made earlier that I do agree that vaping has a very important potential role to play in the reduction of cigarette smoking. I do not know many things that could be worse than cigarette smoking when it comes to harm, quite frankly, and we know that vaping is going to have less harm. The point that I am trying to raise is that if you look at a lot of vaping, it does produce a big cloud of smoke. Now, you might not be one of the people that does that, but if I am walking up to a hospital or through hospital doors or in a ground, what I do not really want to be faced with is that big plume of smoke, which even though we do not have a lot of evidence, I just do not think that I would like to be walking through that. If everyone is outside the entrances vaping, that is just absolutely not what I would like to see. I think that we could again have the balance. We heard from the Minister that we cannot put it in because it needs primary legislation, and that is absolutely fair enough, but it is a look, it is a way of ensuring that there is clarity that you do not have smoke on hospital grounds. I just do not want to be walking through a cloud of smoke. I am not sure that I have much to contribute in vaping versus non-vaping debate. I think that it is very clear that vaping is, for people who are choosing it as a means of smoking cessation, it is less harmful than smoking. There is absolutely no doubt about that. There are some concerns around the contribution to health and equalities, the attractiveness to children and young people, and there are real concerns around the role of vaping in the future that I think we need to very carefully consider. The Scottish Government has a commitment to a tobacco-free generation, whereas the contrast with the Government down south is that it is committed to a smoke-free generation, and it is actually very pro-vaping. I am at the moment quite open-minded, but skeptical and cynical about the role of the tobacco industry and how those cessation aids are portrayed. That is the Scottish Government view on vaping, and I am content to formally move the SSI. Thank you. That was my next question. Having been formally moved by the minister, the question is that motion S6M-04798 be approved. Are we all agreed? We are agreed, and therefore the motion is agreed to. That concludes consideration of the instrument. I would like to thank the minister and, indeed, both of our officials for attending today. The fifth item on our agenda is consideration of two negative instruments, which were laid on Thursday 16 June and came into force on the same day. The Delegated Powers and Law Reform Committee considered those instruments at its meeting this morning. The committee decided to draw those instruments to the attention of the Parliament under reporting ground GI for failure to comply with the laying requirements in section 28, brackets 2, of the Interpretation and Legislative Reform Scotland Act 2010. However, the committee is content with the explanation provided by the Scottish Government for failure to comply with the laying requirements. The first instrument is the national health service, changes to overseas visitors' Scotland amendment number 2 regulations 2022. This instrument amends part 1 and 2 of schedule 1 of the Public Health, etc. Scotland Act 2008 to add monkeypox to the list of notifiable diseases and to add monkeypox virus to the list of notifiable organisms. It ensures certain NHS services for any overseas visitor who requires diagnosis or treatment for monkeypox are provided without charge to that overseas visitor. No motions to annul have been received in relation to the instrument. Does any member have a comment? No. I propose, therefore, that committee does not take any recommendations in relation to that negative instrument. Does any member disagree with that? No. The second instrument is the national health service, changes to overseas visitors' Scotland amendment number 2 regulations 2022. Those regulations will trigger duties on registered medical practitioners to share information with health boards where they have reasonable grounds to suspect that a person they are attending to has monkeypox. That information must then be shared onwards to the common services agency and Public Health Scotland. The regulations will also have the effect, if monkeypox virus is identified by a diagnostic laboratory in Scotland, that the director of that laboratory must provide information to the health board in the laboratory's area and to the common services agency and Public Health Scotland. No motions to annul have been received in relation to this instrument. Are there any comments? No. I propose, therefore, that the committee does not make any recommendations in relation to this negative instrument. Does any member disagree with that? No. Thank you very much. That is the final meeting of the committee ahead of the summer recess. Further details of the next meeting will be published towards the end of August. That concludes the public part of our meeting today.