 Good morning, and welcome to the 20th meeting of the Health, Social Care and Sport Committee in 2023. I have received apologies from Stephanie Callaghan and Tess White. James Dornan is joining us as a substitute and David Torrance is joining committee remotely. The first item on our agenda is to decide whether to take items 4 and 5 in private. Are members agreed? Agree. Thank you very much. The second item on our agenda is the continuation of our scrutiny of front-line NHS boards. For this morning's session, I welcome to the meeting Calum Campbell, chief executive of NHS Lothian, Professor Caroline Hyscock, chief executive of NHS Grampian and Carol Potter, chief executive of NHS Fife. We are going to move straight to questions. Thank you, panel, for being with us this morning. Given the increased costs, pressures and increasing demand that health boards are currently facing, what can boards do to reduce deficits as planned and achieve a break-even position? Caroline, are you going to get your light on first there? I'm happy to take that, convener, morning colleagues. I think that the underlying financial position is one part of a pretty complex picture, which I recognise colleagues of the committee have heard from our colleagues across Scotland. From NHS Grampian's perspective, we have a range of things that we are looking to do to move to address that. In 2022, NHS Grampian board endorsed our new strategic intent, which incorporated our learning from the pandemic and is called our plan for the future. The overarching principles within that and the aim of that is to move us to a more sustainable health and care system, which, obviously, finances are a core component of. In the current operating environment, we are very, very thoughtful of the interdependencies of our operating performance, our financial fragility, the fragility of our workforce and the quality and safety of our services. In our plan for the future, the sustainability and recovery of the financial position is key. Looking at the overarching position in relation to health and care, we have been cognisant of the challenges that we are faced with in Scotland and, specifically for me, in Grampian. Considering the financial sustainability and recovery of that, we have been thoughtful of the projections relating to the Scottish burden of disease, the population's current health and what we, as a health sector, can do to improve that, growing inequalities, particularly those relating to health and, of course, Scotland's demographic. In relation to our financial position, as we have shared with the committee, we have a very challenged financial position that is similar to the rest of the public sector in Scotland and, specifically, healthcare. Colleagues will have read the Audit Scotland report and, as I say, had evidence from other chief executives. For NHS Grampian in 2022-23, we returned a balanced position and that was not our projected position. In March 2022, we had reported a projected deficit of £19.9 million to Scottish Government. However, the revenue position improved significantly in March. That was because of a number of one-off funding streams from Scottish Government and something that we were able to do in regards to our annual leave accrual. However, even though the board managed to achieve that outturn this year, the underlying financial challenge for Grampian is significant. What is really interesting and important is that we have always achieved revenue balance in Grampian, but we are now staying a step change in the financial challenges that we face as a board, particularly balancing that with operational service pressures that we face. We have submitted a three-year financial plan, 2326, to Scottish Government, and we have a five-year medium-term financial framework that was endorsed by the board in April. The medium-term financial framework is to allow us to prioritise the resources that we have, both to deal with the immediate pressures but also really importantly, to move towards sustainable health and care. The medium-term financial framework acknowledges and reflects the complexity of our financial climate, such as the patterns of funding from Scottish Government, funding levels, predictive rising costs, our changing demographics, as I mentioned, and burden of disease. With current planning assumptions, NHS Grampian will not be in a position to balance the revenue position with funding levels and anticipated expenditure over the next five years. The in-year financial position is expected to improve year on year. However, by 2028, we anticipate that we will still have a deficit. However, we are absolutely moving towards, with our medium-term financial framework, understanding what we can do to improve that position. Part of that will be our 3 per cent savings that we have set out relating to the Value and Sustainability programme, which is being driven nationally as well as locally. To be explicit, our annual deficit position for this coming year is, as I said, looking at £60.6 million in the year, which will improve, but we will remain in deficit with the current projections in year 5. We are trying to balance that. We have value and sustainability, which we will absolutely focus on delivering the efficiencies where we can, and then focusing on our transformation programmes through our strategic intent and working really importantly with our partners in local authority, the IGBs, to redesign services. One of the biggest changes that we have in relation to the way in which we are spending our money is in relation to our staffing costs. We are now spending a higher proportion of our resources on pay costs—54 per cent and 46 per cent on non-pay. We do not have a particularly different story to tell than anyone else that you have heard giving evidence in the committee around the cost of inflation, increased demand on our health and care system and the planning assumptions that we are using, particularly around drugs. Specificly on that point on paying, it is an issue that will come on to it further on. What percentage of that, 54 per cent, is spent on locals? Our expenditure last year on medical locums was £17 million for nursing agencies. We would separate medical and nursing supplementary staffing and agencies in locums. Medical locums were £17 million and nursing agency was £12.6 million that we spent on agencies and locum. Is that number on bank or agency, or is that all one figure? For medical locums—No, no, for nursing. For nursing, no, that is agency. £12.6 million on agency? Yes, agency and our staffing. We would cut the overarching figure. Supplementary staffing is what I would consider all non-substantive staffing. That would include agency and bank. I am sorry, just to drill down on that, because that is what I am trying to get at. Is that £12.6 million bank and agency, or is it only agency? Only agency. Thank you, convener. It is actually just to drill a bit further. How much did you pay the locum agency fee? Not what proportion went to the medical staff or the nursing staff, how much money went to the actual agency? I do not have the specific figures in front of me, and I am happy to come back and confirm that in writing to the committee. That obviously varies, so if I speak specifically about nurse agency, it varies depending on the agency that we have to contract with. I am very pleased to say that we are now in the position where, in NHS Grampian, we have no colleagues working on what we would call off-contract frameworks. All our agency nurses are now on contract, which means that the percentage that goes directly to the agency is as low as it can be and is nationally agreed. We have only recently got to that position within the past month. We had a couple of theatre nurses that we were having to use, so I can get a specific figure back to the committee in writing. Will we maybe move to Carol or Callum? I do not know if you want to come in and answer the question that I have asked. I think that in relation to financial sustainability, I think that in Lothian, fortunately, we did manage to balance the books at the end of the financial year. However, going into the last financial year, we had a financial gap at the start of the year of £28 million. At the start of this financial year, we have a gap of £52 million, so it is quite a significant challenge for us. The largest part of the problem that we have is trying to balance performance with the money. I think that the job of the accountable officers is to do the best that they can with the money that is available to them for the population to serve. We are trying to get that balance, but the biggest element of that in Lothian is the fact that we have a gap between NRAC and what we actually get. That comes out of £15 million a year. That has resulted in us having a care deficit. Our sites are full, our infrastructure is ageing, so we are struggling to meet the demands of the population with that. There is a bit of growth that is required there over the next period. To pick up on NRAC and some other information in the NHS 5 briefing, it says that there is an increase of people over 65 per cent by 30 per cent projected by 2043. That means older population, frailer population need more issues. For me, that is an operating room nurse. It is hip replacements, knee replacements, cataract surgery and then some. How does that work when you are doing your financial planning, including NRAC, as far as how do you project that need? If I use Lothian as an example, over the last 15 years, there has been a growth of 156,000 in the population. That is without any additional general practices. That would equate on average to 21 additional general practices in Lothian, with the average list size being 7,500. The national records of Scotland estimate that 84 per cent of the population growth in Scotland will be in Lothian by 2033. When I talk about our sites currently being full and has been under pressure, that is why I am saying that there is a care deficit. The largest population growth will be in Lothian and the sites are already full. That is why we need to expand primary care and their secondary care capacity. The Royal Infirmary of Edinburgh, for instance, the A&E department was designed for a population coming through about 85,000 a year. We currently see 120,000 to 130,000 a year. That is 330 a day, so the infrastructure is under quite significant pressure. That is what the population change means. You are quite right, as that population gets older, the burden of disease will be with the car of U.S.N. but Fife. As Callum has mentioned, the NRAC issue is prevalent in Fife as well as in Lothian. Over the last since 2009, we have seen a shortfall of about £100 million in terms of cumulative position. As Callum has described, it is very much linked to the care deficit. What we are seeing is growing demand not just within our acute setting but also within the primary care setting. We have seen a reduction in the number of GP practices over the recent years, within Fife from 56 to 53. We have also seen the list sizes growing. We are seeing that, particularly in areas of higher deprivation. There is a pressure and there is a challenge on primary care and within our hospital settings. In terms of how we address that going forward in terms of the financials around all of that, what we are looking at locally is a two-pronged approach, essentially, to financial planning. We are looking at financial improvement and sustainability. We are looking at productivity. For example, we have got an excellent day surgery facility within Queen Margaret Hospital. That has been a real key in us continuing with our performance over the pandemic. What we are looking at there is that for minimal investment or managing the investment into that site, how much more activity can we do within the same level of resource? We are not adding additional costs but trying to see how more productive we can be in terms of increasing our day surgery capability. The NRAC gap does bring with it a particular challenge in terms of our cost reduction. Our ability to reduce cost is challenged when we have that lower funding base. Some of the opportunities that we are looking at, which my colleagues have described, Caroline spoke about the supplementary staffing. That is a particular challenge in Fife. In the last financial year, I do not have the breakdown between nursing and medical, but we spent £45 million out of a circa £900 million budget on supplementary staff. That is a mix of bank agency, both nursing and medics. The reduction in our supplementary staffing cost is a real priority for us in terms of looking to balance our position in the coming year. We are going to move to James Dornan, who is joining us remotely. I wonder if the panel can tell me, first of all, why is it that some boards struggle more than others to achieve financial sustainability, where all boards are facing significant pressures and costs, but why is there a variation? I am happy to start not so much at low then because they kind of explained why they think they have greater costs, but one of the others would be good. I am happy to take that question. Part of it, as I say, is linked to the funding envelope, which is the NRAC position, but I will not repeat that. I think that there are a number of different nuances within that. For example, because we have an ageing population, we are also seeing an increased pressure in relation to medicines. 12% growth in the cost and the volume of drugs. It is the second highest area of spend after our workforce. In areas where there is that more prevalent increase in the ageing of the population, we will see people living longer, which is fantastic, but an increased cost in medicines associated with that. The other comment that I would like to make, and I apologise, is not a political statement, but the health boards of PFI contracts, the inflationary uplift that is tied into those contractual agreements is often running much higher than the funding increases that we receive from governments. For example, within Fife, we have seen a 10% cost pressure as a result of our PFI contract is over and above the funding that we have available. There is not one single answer, but I think that it is a very complex and mixed position, but I do not have my comments. Can I just come back into caram first, convener? I get your answer and what you have done is you have named some of the issues, but I am wondering why there is a variation in some of those issues. You are talking about the elderly, thankfully living longer, as a 70-year-old, but why does it vary so much in one area than in the other? I am happy to attempt to answer that. I think that we have said when we were answering the previous question about the difference and the interdependencies with performance, and I suppose that, at its simplest, different health boards provide different functions to different populations. One of the key things that we have noticed in Grampian, which sets us on a different place to other boards, because, of course, as peers, we ask ourselves that very question and challenge ourselves all the time around the difference in our performance, in our financial position. Like Calum and Carol, enrack parity for Grampian is a challenge to the sum of about 18 million a month would be our position that would be different, but our performance is absolutely related to our financial position. Supplementary staffing, which has been touched on, depending on where you are in Scotland, your requirement to use the right workforce to maintain particular services can put an additional pressure on the money that you spend. We have had a question this morning already about agencies and locums. In Grampian, in particular, we have had an incredibly lean model, so we have one of the lowest bed bases in Scotland per head of the population. Actually, our performance from primary care and our performance flowing out of hospitals is relatively good in comparison nationally. However, one of the things that we are challenged with is not just the amount of money that we get from Scottish Government but the pattern in which it comes. If Grampian receives non-recurring funding, we do not have enough resilience in our system to utilise that with core services. Very often, our only option is to utilise the independent sector for things such as planned care. One of the pieces of work and the regular dialogues that we are having at the moment is around what we can do to change the pattern of funding. I am delighted to say that we have received, for the first time, a proportion of our planned care funding on a recurring basis, which allows us to recruit and grow services as core services, recruit local colleagues to support that and therefore make that more efficient financially and productivity-wise and also more sustainable. Just a quick supplementary question about financial planning. You talked about medications, but that includes things such as insulin pumps and continuous glucose monitoring. I am a type 1 diabetic and I have an insulin pump with continuous glucose monitoring. I am reading that there is a 43 per cent reduction in the risk of fatal cardiovascular disease and a 29 per cent reduction in all-cause mortality. That is when we use insulin via pumps, for instance. We know that we can reduce the complications by investing in pumps and technology, but that costs more money. How do you financially plan that? Do we have a national map of continuous glucose monitoring between the boards to see how we compare with complication reduction and insulin pumps and CGM roll-out? I am not aware if we have a map or not. I can talk about Lothian. We would try to look at the balance between them. You pick a really good example, but you could say the same about obesity management. You could say the same about exercise. Trying to get that balance between what we call primary prevention, early intervention and acute treatment is always a challenge. We should always try and look at where we can invest early to try and prevent it, but that is one of the challenges that we have with an ageing population. We do know, unfortunately, that with the age, the disease burden grows. While we can delay many things, we cannot always prevent them all, but early intervention is where we can use the universities to try and get that sweet spot about how much we need to invest early to get a proper return on investment. It should always be that way around if we can do it. We will move on to our next theme, which is performance, which we have touched on a little bit here, so I will move to Evelyn Tweed's questions. Carol, you talk about the waiting world process and how you send out letters to patients when there are long waits. Can you explain that process for us and tell us what sort of patient feedback you are getting? It seems eminently sensible to do this, but I do not think that all boards are doing this. Is this something that we can share good practice with? Yes, I am happy to answer that. It has been a real focus for us in terms of how we support our patients who are waiting longer. We have been in a fortunate position within five through the pandemic of being able to maintain a relatively high level of performance anyway, so whilst we do have delays and we do have patients waiting longer, we are currently functioning at almost pre-pandemic levels, so we would expect that to have helped the position for over recent years, but certainly the conversations and the processes within each of the different specialties around contact with patients is doing that. A very person-centred basis is giving them information about what the expected length of time will be, some of the reasons for that, but also signposting them to other opportunities, so perhaps on to online information, self-help guides and the ability to also just remain an open dialogue and have a contact for the patients to be able to get back in touch with their relevant consultant, but I know colleagues across Scotland have been working on that. It has been a national initiative and we are certainly not trailblazing the way in 5. I would like to see that we were, but colleagues with us this morning will also be adopting a very similar approach. Does anyone want to come in? I am happy to do that. We similarly have had a waiting well project underway for over the past year. In fact, we have just shared the first review report of that, which again I am happy to share with the committee. That has landed very well with patients who are waiting for too long, both for outpatient appointments and for planned care. We are continuing to evaluate that, but the initial findings are that it has been very successful from the perspective of clinicians and very importantly patients. We have identified funding to continue with that piece of work. As well as waiting well, which is a specific project, we have developed our fit surgery website. We have a process around our waiting list validation, which again will be not unique to Grampian and have an escalation system between patient secondary care, primary care colleagues for patients whose condition deteriorate while they are waiting. It does not solve the problem of patients who are most definitely waiting too long and that not just impacts on their physical health, their psychological health and that is nothing that any of us are content about, but trying to do the best that we can to manage the psychological wellbeing and mitigate any concerns that we can is a focus of our attention. Very, very similar in fairness. We are trying to do as much as we can, but certainly in William, we are piloting patient focus bookings to try and reduce our DNAs, so it is a time that is convenient for patients. We are using text reminders, we are trying to use virtual appointments, we are trying to do as much as we can about patient-initiated follow-up rather than automatically bringing you back, giving you the information and letting the patient highlight when they feel they want to come back and we are trying to move to as much online bookings as we can. We are trying to evaluate those to see how effective they are and to be sure that there are final reports when they come in. If I could come back to you, Calum, in terms of your performance and standards just now, some of the areas seem to be deteriorating and I think that you have issues in a number of areas. How are you going to get on top of that? I think that there are some areas of strength and there are some areas of weakness. I think that if you look at planned care, the treatment time guarantee in Lothian, if I look at March 23, we are back around about 90 per cent of our pre-pandemic capacity. I think that our Scotland is about 78 per cent in relation to outpatients. I think that Scotland is around about 86. Sorry, I have it the wrong way. Scotland, for outpatients, I think is 86 and Lothian is just above the 100 for its outpatients or maybe the Scotland figure is wrong, but within that we have got some particular hotspots. We are under a lot of pressure on urology and that particularly causes a concern. We are seeing quite a significant rise in men presenting with prostate cancer. We are trying to do something about that. We are trying to move to three session days at St John's. We have tried to recruit an additional surgeon. We have tried to all to the pathway for men coming in with query prostate cancer. That is a particular pressure for us. We are trying to recruit but we have got a significant challenge around theatre staffing. We have got a major focus on trying to recruit and retain theatre staff because that capacity is a real limiting step in our system. Getting that infrastructure in place, I touched on urology and the fact that our sites are regularly at 100 per cent. That is going to be a problem for us. We have challenges in our A&E department. I gave you the figures earlier on about the size of the A&E department versus the population we serve. One of our biggest weights is an elective orthopedics. At a time when we are trying to free up beds, we are going to have to ring-fence beds in the Royal Infirmary of Edinburgh for elective orthopedics to try and make sure that we are not cancelling them on the day. That means that we are going to have to do some orthopedic rehab out at East Lothian community hospital. We are trying to alter those pathways. Those are all steps that we are trying to do for each of those specialties, but it is going to be quite a long journey. As I say, without additional infrastructure, we will struggle. Thanks very much. I note some of the points that you have made about capacity and constraints. That is a major concern. You mentioned, for example, that the A&E department has been designed for a lower population. Do you have other metrics that you assess capacity and bottlenecks? Obviously, we are looking at a process mapping of your services, where there are areas of constraints around key items of capital equipment, like CT or MRI scanners. Are those areas that you have identified or needing extra capital investment that would improve patient flow? I wonder if you have particular examples that you have identified in your analysis of operations. I am happy to start with that. The picture is very similar to Calum's, but to answer your question specifically, one of the most helpful and emergent pieces of work that we have undertaken in Grampian has been what we would call breach analysis of our 62-day cancer pathway. So, like other parts of our system, access to the range of services that are required for a patient and their family in receiving a cancer diagnosis, we have reviewed and renewed our process for breach analysis. Every step in that pathway, how long does it take, what are the bits that are working well and what are the components that are challenged? We have designed that with colleagues who do this day in and day out, and that is a piece of work that has been shared across Scotland. What that has allowed us to do is to specifically identify bottlenecks, as you have asked for each cancer type and to target the resource that we have in the right place. For prostate cancer or for colonoscopies, understanding if the delay and performance relating to 62 days is because patients cannot get access to theatre, for a surgical intervention in a timely enough way, or if it is because they cannot get access to an MRI scanner or to other imaging. We now have that information, which we have not had before, to a level of detail that is incredibly useful to both our primary care and secondary care colleagues and to allow us, as I say, to target where we put the finite resource that we have to make pathways as efficient as possible. Some of the other things in relation to sustainability and what we do with those bottlenecks is not just about pieces of more of the same kit, but about brilliant innovations that are under way. When we spoke earlier about sustainability and planned care, innovation has to be part of how we move forward with that. A couple of examples, and because I have been talking about the cancer pathway, our ability to use artificial intelligence is piloting a piece of work for Scotland in collaboration with the Centre for Sustainable Delivery in breast and chest imaging. Chest x-rays are a pretty standard diagnostic tool. Most people who come into hospital will receive a chest x-ray. However, the ability for us to do that and report in a timely way has always been challenged. In Grampian, we have now been piloting artificial intelligence alongside the expertise of our radiology colleagues, which allows us to develop algorithms that prioritise patients who have red flags on their chest x-ray. What that means is that, as opposed to the historical process that meant that patient images waited in a queue from when they attended to be reported, which is the formal process, artificial intelligence now allows us to do that in a prioritised way and to potentially reduce our pathways and access and alleviate bottlenecks, because imaging reporting would have been a specific bottleneck. I will build on that. There are a few examples that I could offer in relation to—I take a question in two halves around capital investment, but also in the bottlenecks generally. In terms of capital investment, we certainly purchased in the last 12 months two additional CT scanners. That has supported the throughput of our radiology patients, which has been a particular challenge for us within five, so that is supporting that wider pathway. We have a rapid cancer diagnostic service again, which is also helping in terms of how we are seeing and treating our cancer patients, but Caroline has obviously touched on that. One particular investment I would want to mention is that through some innovation in terms of slightly different ways of working, we have increased and developed the use of a procedure room within Queen Margaret Hospital, but what that has done is that has allowed us to release one theatre per day within that site, which is where we do our day surgery. That has released, in some respects, a bottleneck in relation to elective care, thereby allowing that throughput. We are looking—we are challenging—the consultants are challenging themselves within a specialty level what more can be done in the day surgery basis that is not necessarily requiring the specialised in-patient hospital in the Victorian Cercody. So just looking inevitably and looking at redesign. In terms of other bottlenecks, it is maybe a slightly different angle that I would like to come at, but we often talk about bottlenecks at the front door of the hospital, and by that we are referring to ambulances and the emergency department, but if we go one step earlier into the front door of the patient themselves, one of the areas that we have been looking at with our colleagues in the health and social care partnership is how do we support people within care homes in a different way. So we have improved access to urgent care for a number of our care home residents, and that has allowed or that has involved through our flow and navigation centre, what we call a proff to proff, so professional to professional contacts of care homes can directly access a clinical professional to discuss one of the residents if they've got concerns around their particular health needs. We also have teams of advanced nurse practitioners and allied health professionals as part of a multidisciplinary team who are essentially doing virtual ward rounds within care homes across all seven of our localities, and we're also working with the ambulance service to deliver some direct unscheduled care into care homes, and the reason for me mentioning that is that that has directly resulted in a reduction of about 220 emergency admissions or emergency attendances a month that reduced it to just above 100, and the success of that really has come from that wider whole system working, so it's been taking a step back looking at the problem from a slightly different perspective and involving all the different teams and professionals across the NHS and the partnership, and it's been better for those residents in the care homes have been kept in their place of home with care wrapped around them, so avoiding that bottleneck for them in an ambulance or at the front door of the hospital. You've both highlighted what sounds quite impressive, process and improvement activities. I just wanted from a cultural perspective across the health boards how do you disseminate best practice and how do you benchmark against each other so that you are able to say right that it's an excellent workstream, how do we carry that over into the national picture so we can make an impact? Is that something you, do you have a protocol or a process for doing that? The Centre for Sustainable Delivery tries to work on areas where there's potential improvement and they've got a number of workstreams across a number of different specialities to try and optimise performance in that area. The board chief execs meet every month and will share information. We also use Discovery, which is a national benchmarking tool, which enables you to look at your own performance and your infrastructure against others so you can look at variation and then when you see variation you can try and explore behind it why are things different, what's going on different there versus your own board to try and identify if there's an opportunity for improvement. Do you feel it's effective? Could it be more efficient as there are ways to improve it further? I think there's always opportunities to improve without doubt so I think it's part of the reason it's there is to explore that. I don't think there's any massive steps that could be made but certainly you'll always get incremental improvement. Do you have team to team collaboration at a lower level than the boards across different health boards where you've done something operationally where you can then teach others how to do that well? I'm happy to add to that way so not only do we work as teams, all of the chief executives coming together on a regular basis and we obviously share some of that learning but we also work regionally as well so myself, Callum and our colleague Rafe Roberts from NHS Borders we meet on a regular basis as well so through the three of us but also through our teams come together as well once a month so we share learning in a variety of different areas as well and I'm sure it's the same within the north where Cadline is. I'm happy just to add so we do have a similar setup in the north east and west. I think the ownership if you like and the motivation of our colleagues in all specialties to improve things and move things forward often results in a lot of informal networking but we also have a range of formal networks across Scotland where best practice is shared and just to add to Callum's narrative on CFSD they have in the recent past established specialty clinical groups where specialist clinicians from different specialties come together to do exactly as you're describing which is to make sure that we are doing what we can around sharing best practice in different contexts and I think it's really important to see that despite the pressures that we've described we are hugely proud of our colleagues across health and care who come to work every day and keep the show on the road and do an amazing job but also are genuinely trying to improve and find solutions all the time to make the current system perform more effectively for patients. This obviously touches on financial sustainability as well as performance but fundamentally do you think that there's a need to transform the way in which services are delivered? Do you think that the way of delivering to SNOW is fine it's just the need to have some of the innovation that you've already mentioned? I think undoubtedly I think that it touches on performance, touches on financial sustainability, touches on the fact that health has got an insatiable appetite but the reality is if you look at the demography of the nation we're just not going to have the workforce to provide the services and the format and style that we currently provide them just as you move through the next 10 to 20 years so there is going to have to be a fundamental rethink as to how do we best provide the health services to best meet the population needs I think demography automatically takes you there. I'm happy to add to that so just to support Callum's position absolutely how we transform locally and nationally has to be part of our consideration. The Scottish burden of disease is forecast to increase by 21 per cent in the next 20 years which to specifically relate back to Callum's point if the models of care were to remain extant then we would need an additional approximately 33,000 whole-time equivalents on top of our current workforce which as we know is a challenge so the more that we can work to transform our system to empower communities and provide a better balance of enabling wellness as well as responding to ill health is the sustainable way forward. If I could add to that I think there's something as well around how do we have a slightly different dialogue with the public around what a modern NHS looks like we need to look I think perhaps wider than our traditional approach of looking at what what the services that we're delivering within hospitals and looking more broadly into the third sector into the services within health and social care partnerships but even into primary care or particularly into primary care so the role of community pharmacy is huge and there's a lot that pharmacists can offer that might avoid somebody having to attend their GP or attend hospital we have community optometrists who are linking more closely with our ophthalmology services as well so it's having a different dialogue we all talk about going to see our GP but actually what we really mean is we're going to our local primary care provider and that may well be an advanced nurse practitioner or it might be a physio but we we describe talking about going to see the GP so we maybe need to shift our language and have that engagement and the dialogue with the public as well so that we'll listen to the public but we also communicate around what is that wider role of the primary care practitioner. Thanks James. Thank you. Can I ask you about NHS Lothian's hospital sterilisation and decontamination unit? Obviously you've been talking everyone's been talking about increasing the work that you do within a theatre complex but you can't do anything if you don't have any kit so your specific sterilisation unit is severely over capacity right now. What steps have you taken and are taking to ensure that you can not only meet the demand right now but that of your ambition going forwards? One of the conversations we've had with Scottish Government is the fact that Lothian would like to take forward a capital programme for a national treatment centre. We recognise that the decontamination capacity not just in Lothian but in other boards in Scotland is fragile so one of the things that we've actually proposed as part of that is that we will look to expand the decontamination capacity for the national treatment centre in Lothian which will be at St John's to increase the decontamination capacity not just to meet Lothian's need but also to create some resilience within the Scottish decontamination capacity. You plan to expand it? Yes. What steps have you done already because you need to have you need to have done something already but also one of the questions at the very beginning was about a lack of money and how you've got a deficit going forward so there is a lack of capital to support new things that especially plans to do that so how will you achieve your plans with this deficit? The issue in Lothian is we do have enough decontamination capacity but we don't have any resilience around our decontamination capacity so our decontamination unit went down recently. When that went down there wasn't enough resilience elsewhere in the country to support it. We had to get support from down south while we were moving instruments right around the country so we do currently have enough capacity we are looking at that infrastructure we're trying to protect that infrastructure but there's just not the resilience within it. I don't see a shortcut to being more resilient either in Lothian or nationally without that and that's why one of the reasons we've made our one of our primary capital priorities as additional decontamination capacity I don't see another alternative shortcut to that. I'm now going to move on to the next theme and Emma Harper. Thank you, convener. We've talked a little bit about Covid recovery and the challenges of performance as in pre-pandemic levels and where we are currently so a lot of the responses you've made have touched on Covid as well and I absolutely think that we can ignore that because we've just come coming through a pandemic you know we're still recovering a lot of folk think it's going to be an overnight fix and it's not so I'm interested to to hear your thoughts on on the recent NHS overview audit where Audit Scotland states that the Scottish Government didn't fully engage with NHS boards in the preparation of the recovery plan so I'm interested in what you think about that statement from Audit Scotland but also you know have you made changes to the recovery plan because to adapt and evolve based on knowledge that we've learned from the pandemic? So in Lothian we have a Lothian strategic development framework which we have openly shared with the Scottish Government so that will have informed some of the planning there we are very clear on our capacity both on outpatients and inpatients for each of the services that we can provide and to degree the unknown factors demand that's coming in one of the rate limiting steps needs quite right I think it's going to be a long journey as we find an awful lot of pressure in our social care colleagues that is limiting our flow through our system when the flow is limited then the amount of activity we can get through is diminished and that does affect the recovery period for the system I think you're quite right to flag the the challenge that Covid is presented we had a really good waiting list position we were under pressure pre-pandemic post-pandemic I think it's going to be many years to recover from it. I think prior to the pandemic we were seeing significant challenges anyway my background is as a as a finance director prior to being chief executive and we know we saw the financial challenges before the pandemic we also saw challenges around our emergency unscheduled care and also within within our hospitals in terms of electives so I think to some in some respects the pandemic has exacerbated what was probably you were facing before then I think the challenge we have is that if a talk specifically around recovery of waiting times so there is a challenge around that I guess the financials associated with that and the cost involved but equally we are looking at a range of opportunities to increase the throughput of our elective capacity in terms of that recovery so we're looking as I mentioned earlier about improving and removing all any barriers to procedures that we could be recommended for day surgery we've spoken this morning about digital solutions how can we support our patients in that regard we're using an app for patients in terms of pre-assessment ahead of surgery teams as carline has touched on our clinicians that our teams continue to review how they can work differently and they're very very committed to doing everything they can for their for their patients we have a range of improvement actions that we've described that the centre for sustainable delivery have outlined and that we're working collaboratively and together with but really despite all of that we have got workforce challenges which I know is an area of interest of the committee and that is a limiting factor and our capacity is struggling to meet to to keep up with the demand and that I think is prevalent across across all areas so we have all got very robust and detailed forward plans of our ability to address our waiting times going forward both the length of the weight and the size of the waiting list but the challenges do remain and as we've outlined already there are a number of particular specialties that are particularly stretched and that can be for a variety of reasons some of which is available workforce in those particular areas. If you had some key asks for things that would really help to curtail to prevent the I guess the shortening of the recovery or enhancing the recovery what would your key ask be? I think the biggest rate living step is social care flow I think our colleagues in social clear are under significant pressure that is limiting the capacity within the NHS and I think we have to accept that health and social care are so fundamentally linked so I think if we could ease the burden on social care I think that would be certainly from my perspective with the biggest ask. I think from my perspective the continued support of our colleagues across health and care and Carol's already mentioned how do we engage effectively we'll be doing it locally through routes such as our community planning partnerships and our locality networks but how do we truly harness the empowerment of local communities as we did during the pandemic in designing our NHS and social care going forward because they are inextricably linked and actually being able to work with our local populations as locally as possible to support citizens as well as be supported nationally with some of the things that would help us so conversations that are engaging and truly listening at all levels locally regionally and nationally with the public to help us move forward as quickly as we can in relation to recovery. Thank you, thanks. Thank you. I'm going to move now to David Torrance who's joining us remotely. Thank you, convener, and good morning to witnesses around the recovery plan and the progress that NHS boards have made. How accurate is Audit Scotland's assessment that of October 2022 progress updates does not fully reflect the scale of the challenges boards have faced and the extent to which this has hampered progress towards recovery by many individual boards? I'll go to Carol first. I think Audit Scotland has a unique opportunity in terms of seeing that overall picture across NHS Scotland and triangulating all of the different data and metrics that they look at. I think it would be remiss of me to counter what they are saying around the challenges that are facing all boards. As we mentioned earlier on, recovery is not, there is no single solution to recovery. The short term focus on addressing our waiting times and also dealing with the pressures around the front door of our hospitals, but we also need to be focusing on the longer term. We talk about the horizon 3. We have lots of conversations amongst chief executives in that regard, so we need to be looking at the same time as balancing the priorities for recovery immediately. We also need to be looking at the longer term at the health and wellbeing of the population more generally and all of the factors associated with people's life circumstances. We know that housing and education, lots of other metrics affect somebody's longer term health prospects. It's a reasonable assessment. As a former accountant, I'm not going to challenge Audit Scotland on their perception, but I certainly recognise the comments that they have made. Just expanding what Carol was saying, I think that in Lothian I was saying that basically the sites are very full most of the time, but on top of that, the thing that will dictate the pace is the workforce that we've got. There is a significant workforce challenge. I think that, going back to March, there was about 4,200 registered nurse vacancies in Scotland. You touched on the point about agency staffing. With the sites full, we do read the workforce. There was about 1,500 non-registered nurse vacancies in Scotland, so trying to get the workforce there is back to the point about demography. We need the workforce to deliver the performance, workforce equally cost money, trying to get the balance between them. Audit Scotland quite rightly highlights what a significant challenge this is going to be. I agree with both Carol and Calum. For our system, the evidence that was presented in Audit Scotland report, although specific for Scotland, reflects a growing body of evidence globally in relation to how we manage, effectively, the interdependencies of our risks associated with further infectious diseases, the cost of living crisis, a very fragile health and care system, and climate fragility. The work that was presented there and the work that we are doing as individual boards through our delivery plans to move towards recovery will start to address that, but it has been in relation specifically to what has changed in Grampian. We have absolutely noticed a change in our demand profile, similar to Calum. Our bed occupancy in Aberdeen Royal Infirmary, which is our main tertiary secondary care site in the last week of May, was sitting at 106 per cent. An optimal system should be sitting at 87 per cent bed occupancy. The ability for us to take a step back, to take our learning from the pandemic, to look at the evidence in the UK and globally around sustainable health and care systems, and clearly within that our workforce is a key component. Our workforce numbers have increased in the last year, however that has not been across all domains and applied uniformly, and we have definitely in Grampian some highly specialist areas, which are fragile. We have improvement work around that, but specifically I would cite psychiatry as a very fragile professional specialty at the moment, and pediatric anesthetics. Where we have a small number of specialists coming through, so we are working with Ness and others around the pipeline, if you like. That is very specific around our medical profession, but the demand profile on workforce would be key to our recovery. Thank you for that. Are there any particular areas that witnesses would highlight with good progress as we made, and what are the reasons for this? I will go to you as well, Carol, first. So without apologies for a bit of repetition, I would go back to the ability that we had during the pandemic in Fife to essentially protect the capacity within the D surgery unit at Queen Margaret hospital, and that certainly was key to us enabling us to sustain an elective programme, and it is absolutely fundamental to the post recovery plan as well, and we are expanding that further. So it is the ability, I think, to, as I say, to ensure that we are maintaining that balance of demand, so that we are balancing the need to address the challenges that Caroline described around capacity, around unscheduled care, and the emergency demands on our services at the same time as balancing that with the need to have a throughput of patients who have been waiting too long for elective procedures. So it is something about how we are using our infrastructure in a very planned way, and I know that Callum mentioned some work earlier on at the Royal Infirmary around protecting beds as well, so I think that is what is going to be really key. I'm happy to add. I think that for Grampian, one of the key things that we have done well and continue to do well is to work as a much more integrated system. I've reflected several times in this conversation today about the interdependencies, and we now have teams that are absolutely working together. We are challenged, as you will know, around the majority of our performance metrics. The relationship between unscheduled care and planned care and cancer are very apparent. In relation to the work that we are doing with our primary care colleagues, Grampian has one of the lowest attendances from primary care into the front door services at hospital per head of the population. Our primary care colleagues, despite the challenges, are continuing to do a very good role around that. We also have one of the lowest admission rates. Of course, our social care sector is challenged, but our work to manage flow across the system has meant that our delayed discharges have been pretty constant and they benchmark reasonably well across Scotland. There are other aspects of care that we have focused on around improving issues that remain challenged, such as psychological therapies. We made a commitment to not have any citizens in Grampian waiting more than 52 weeks for their appointment, and we now have achieved that. That feels that it is still too long in relation to the target that the population deserves and expects, but we are incrementally improving that. Cams in Grampian remains high-performing in relation to the first appointment. The national target is 18 weeks, and a young adult in Grampian should get access to their first appointment between six and eight weeks. That is great. However, it is also creating a follow-up challenge for us in regard to secondary appointments, so that is a good news story as well as a challenge that is creating. We are seeing incremental improvements, but, as we have discussed in previous parts of this conversation, the recovery is going to be slow and requires transformation as well as improvements. I also mentioned the innovations relating to artificial intelligence and imaging. Similarly, our ability to do a one-stop radiotherapy piece of work for cancer patients has been significant and very positive for patients who are suffering from cancer and require radiotherapy. I wonder if I could add. Caroline mentioned some work with the partnerships. I think that one of the areas that the question was around where we have seen success. What I would like to highlight is that one of the successes that we have had that I have really noticed has shone through has largely been about how we have worked as opposed to what we have been doing. How we have worked in terms of—we use the term team-fife in a lot of conversations around how we are approaching the challenges facing us, but there has been a relentless commitment from colleagues across all areas, whether it is health and safety partnership, or acute service, or leadership teams as well, to focus on the expression of being complete, not compete, so get to the end point. What is the end point or the intention that we are working towards and whether that has been around the challenge around delayed discharges, whether it has been redesigned around the front door of the hospital. All of these programmes of work have been successful where the teams have worked together in a really collaborative way. It is about the relationships and not necessarily what they are doing. It is how they are approaching that and that is single focus. We have a tool that we have mentioned in the briefing that is our operational escalation framework, our OPAL tool, and that is a language that is used across the organisation. Again, that shared language and shared approach and common purpose. We had success during the pandemic. We all recognised that when we came together to work collectively, collegiately, collaboratively, whether that was with the public, our teams and others across the community planning partnership, that is where we saw success. That is something that we need to really build on and develop further. Thank you, convener. I have no further questions. Thank you, David. I am going to now move to Sandesh Gulkhani. Thank you, Karen. Can I turn to you? I would like to ask you about audiology. The families failed by Lothian Audiology Action Group flag. They have said quite a few things in public. I would like to raise them directly with you to get a response, please. They feel that there is a lack of access to produce sign language tutors, a lack of access for speech and language therapy and appropriately qualified professional support deaf children. The question is what support are you putting in place for families that are affected and what would you say in response to flag? I apologise that the whole issue started off in the first place. I think that the Ombudsman's report, the work that we had through the review, was quite a wake-up call in Lothian. We are grateful for the efforts that went in around that. Jackie Taylor, the independent chair, made a number of recommendations. NHS Lothian has followed every one of those recommendations. We have communicated widely across speech and language therapy. Health visitors and the five local authorities have been very open around the challenges. We have tried to contact every single family—I will come back to one particular point in a second. We do not just use British Sign Language as one point that I would make. Our speech and language therapists will say that there are other forums that we use. We make available British Sign Language, but it is not the only forum of Sign Language. I am not aware that we have limited in any way speech and language therapy. We have met a group of MSPs less than a month ago. The same comment that we have made is that we have put additional resources into speech and language therapy. There is a balance, I accept, that some families might want more, but we believe that there is a need that speech and language therapy is there. We have not limited it. We have significantly invested in there. There are challenges for us. It has been a long journey. We have retrained all our staff. We believe that we have got to everybody, but we can never be positive around that. One of the MSPs flagged one person that we think we have missed. We have reached out to say that we think we have missed you. Please come forward and we will check. We think that we have done everything reasonably that we can to do it. We have tried to make available British Sign Language, although we make the point that there are other forums of Sign Language there. We have communicated extensively. We have had a telephone line available throughout the period. We have 24 calls to it throughout that period. We will follow MD up. If any MSP councillor flags MD to us, we will follow them up to make sure that if we catch everybody from this. Obviously, the thing that is very concerning is that the development of speech occurs between birth and three. That is when you become really fluent when your speech. The average age of identification is about four and a half. From my understanding, the cut-off has been 2018. So what is happening to potential families? The cut-off, the original review from the British Society of Audiologists was about 2009 to 2018. That was the first review. There have been two subsequent reviews. All children from 2018 up to now, who we have at any concern around ABR, have been back. We have been back and checked. We have been back the way and checked. They are all been checked out. The 2018 cut-off was the first cohort. That was the review when two subsequent reviews have been carried out. We have tried to be as extensive as we can in addressing that. To be clear from what you have said, do you feel that you have identified everyone who has been affected? I would caveat it for the fact that I did meet some MSPs a month ago who flagged the thought that there was one family that we had missed and said, please let us know who that is and we will follow them up. We do believe that we have, but I do need to caveat that. You have increased your resources into getting speech and language and audiology, and you do not feel that there is a lack of access to the British Sign Language shooters for those who want it? Within the NHS, I believe, if somebody requires a British Sign Language support, I would be able to get it within the NHS. I could not talk broader than the NHS. In written evidence from NHS loading, you noted that there are no low-secure forensic units in the health boards and no female high-secure beds in Scotland more broadly, with people being managed in units that are not suitable. How are your health board managing this lack of forensic mental health capacity and what could the Government do to improve that situation? I think that mental health, as we all know, is sometimes a bit of a Cinderella service. We are having to use our medium-secure unit both for some patients who actually could cope well in low-secure, and we are having to have a high-secure female patient in our medium-secure unit as well. Effectively, what that is doing is squeezing us. We are losing 25 per cent of our medium-secure capacity because there are either low-secure individuals in there or we are accommodating a high-secure female in there. We do have business cases together to try and expand our capacity, but it is a need to get the balance between psychiatric wards, IPCUs, low-secure, medium-secure capacity across Scotland and set a high-secure for females. I want to touch on more broadly. As CAMHS referrals being rejected, I have noted that there has been a significant increase in this pattern across Scotland in the last five or six years. In 2017-2018 11 people were re-referred in Fife, but last year it was 46. In Grampian over the same period it was 161. Now it is 260. In Lothian it was 287. Now it is up to 416. I just want to understand more about what the reasons might be behind GPs having to try more than once to get successful CAMHS referrals. What might be the case? Is it due to capacity? Is it thresholds being higher than what GPs are assessing is appropriate? Is it just the interest to get your insights as to what might be going on there with that trend? I was relatively quiet earlier on when we were talking about improvements. One of the challenges that Lothian had pre-pandemic was in both her CAMHS and psychological therapies waiting lists. We were escalated for them. We have seen over the last two and a half years a continued reduction within those waiting lists. One of the things that we have developed in Lothian is that we are working with partners around what we call tier 2 CAMHS, because too many young children are getting referred into tier 3 CAMHS, community CAMHS, where other support services, if we are not medicalising it so much at level 2, will be more appropriate. We have worked hard to develop those services, and that is where we believe that quite a high percentage of those patients can be there. They will be considered, but they will then be directed to the appropriate place for them, depending on their clinical presentation and need. So we are seeing an increasing referral rate, not just in childhood mental health also in adult, but specifically for CAMHS, the triage. We use the CAPA model as well, so choice and partnership. The triage and redirection of patients will be about the most appropriate place, so there will be no child or young adult that is referred into our system that is not signposted to the appropriate service for their level, as assessed by clinicians in Grampian. We are using the national framework for decision making around CAMHS and embedding that. As well as the planned appointments, we will also provide an emergency service, so all emergency referrals are seen within seven days in Grampian. If I can build on that as well, I think what we have certainly seen that is over the last few years, the complexity and the mix, if you like, of referrals has increased so prior to 2021. It is about 50 per cent of young people who would be classified as high priority now that that has shifted to about 80 per cent. What we are seeing is that earlier redirection into other areas of support, so there is support coming through school and online tools as well. We have now got mental health nurses being rolled out into GP practices as well, so that is certainly helping and are real. I think that it has been an area of focus across Scotland in terms of innovation, different ways of looking at pathways and adapting the CAMHS service to more appropriately support the spectrum of needs of our young people, whether that is initial treatment all the way through to we have got a test of change at the moment with our education colleagues that are supporting those with complex mental health needs as they turn 18, and they are starting to move into adult services. How can we support them further with self-help tools and other aspects as well as supporting them in that face-to-face way? A slightly different approach, but, as colleagues have also mentioned, our performance has improved and the long waits have been reduced significantly, but it is a complex area and I think it is a growing area. The last few years have been extremely difficult for our young people across Scotland. Do you be confident that this metric—I know that it might just be a narrow metric—about wee referrals? Do you expect, given the measures that you have put in place to start falling, because GPs are now aware of a more appropriate referral pathway? Is that what you are saying? We would hope so. Again, it is back to that communication between the multidisciplinary teams working with our general practitioners and colleagues around the appropriateness of referrals. That is great. Can I just refer members to my register of interests here? Is there a case perhaps for some change of language or change of measurement when we talk about rejected referrals, which sounds a very hard thing about not being seen, to a redirected referral that comes into an inappropriate service because of level of need or complexity or whatever, and that could be at either end of the care spectrum, whether that be limited intervention or very high-intensity intervention, that that referral is then redirected to a service that is more clinically appropriate for that person? I am going to now move on to Gillian Mackay. Thank you, convener, and good morning to the panel. Last week's evidence session, we heard from the state hospital about their use of induction and peer support in regard to recruitment. They said that there has been a focus on the development of a peer support network throughout the organisation and that they now have a number of staff who are trained as peer support workers and that this has proved successful. I am interested to know whether there are similar schemes being developed in your boards, how successful they have been if they are developed, or if you are planning to bring in something similar. Carol Nodding, so I might go to Carol first. We rolled out peer support within the organisation back in 2021. The initiative actually came from a number of our clinicians who had been involved in it in previous roles and also just a general interest. So it is a great example of we listened and we heard we did. So we have a number, I apologise I do not have the details to hand, but we have a large number of staff across the organisation, many with clinical backgrounds who are trained in peer support and that is widely known, widely advertised across the organisation. We have a huge range of staff wellbeing initiatives and it is something we are really proud of. We know we do not always get it right, but we want to listen to staff. We have everything from physical staff hubs on every site within our hospitals. We have been very fortunate to be supported through our health charity in that regard. We have staff hubs, which are available to all. We have held their wellbeing groups, financial wellbeing guides, menopause support, sporting leisure passes, a whole range of initiatives, but also importantly we have a staff listening and counselling service, which I think has been hugely, I was going to say popular, that feels like the wrong term, but there's been a high demand and that's where our spiritual care team have reached into the organisation to provide one-to-one support, reflective practice and staff listening. So really going to the heart of how people are feeling about life in general and the workplace and the peer support, as I say, is one aspect to that. I don't know who wants to come next. Similar, Caroline said earlier on that our staff have been great throughout, but they've had a hard time. So we have tried to do a number of initiatives, not just to try and recruit staff, but also to retain them, and certainly a number of wellbeing initiatives across the organisation. We also have speak-up ambassadors because, as Caroline said, we don't always get it right, so when we get it wrong to try and create the culture where people can speak up early, let's intervene early. We do need to recognise a number of our staff, we've got a significant percentage of our staff that are over the age of 50, so the wellbeing initiatives are actually back to the question that your colleague made earlier on, trying to intervene there, support them early, it helps all the way through. There's a lot of emphasis on our workforce, our culture, to try and get it right, to try and retain our staff and keep them healthy. I mentioned our new strategy and one of the key things was, our strategic intent was to prioritise our workforce's wellbeing in a way that we had never been able to do. We are on a journey with that, and, as Caroline said, we don't get it right every time. We have an overarching wee care programme, which is a number of initiatives that include peer support and investment in wellbeing and capacity to support the wellbeing and culture of colleagues working in Grampian. Not just NHS Grampian, but colleagues in the health and social care partnership who are employees of the council. We are also trying to spread that as broadly as possible. Our peer support model for psychological first aid is now rolled out in 11 different service areas. We have an app that we are using to raise concerns. We have speak-up ambassadors, but we have an app called Trickle, which allows colleagues to use an app to raise questions and have them answered a couple of additional things. However, despite that, the impact on our workforce of the past three years has been significant. I was recently in staff governance, where we reviewed our sickness absence data. We have reasonably benchmark sickness absence data in Grampian with the rest of Scotland. However, short-term absences have gone up, and the highest reason now for long-term absence with our workforce is anxiety, depression and stress. The evidence is there that our workforce continues to be challenged by that. It is important for the retention factor and the demographic of our workforce. Those who will be working for longer to make the working environment the best it possibly can be and specific pieces of work. In Grampian, 82 per cent of our workforce are female, and I cannot remember the percentage, but a proportion of that clearly is at an age where they are experiencing menopausal symptoms. We have had an amazing response to our menopause awareness week and the uptake of over 2,500 employees around understanding what we can offer. It is about responding to our workforce and continually listening for those who are here just now, but also to make sure that, for those who are considering coming into work in the health and care sector, it is seen as somewhere where they will be looked after too. Caroline Brown is very much preempted by my next question about an assessment of sickness rates across the workforce. I wonder if the other two boards could comment on their sickness rates. What action is being taken to support people for their return to work? There is a lot of focus on reducing vacancy rates, and I am concerned about the pressure that that puts on staff to feel like they have to come back. There is always a willingness for staff across the NHS to come back and feel like they are not passing pressure to other colleagues knowing what they have been through in the past few years. If you could particularly comment on that, you have all mentioned counselling and mental health support in particular. Often, in some organisations, there is quite a short-term nature in terms of those counselling sessions. Is that something that is limited within each of your boards, or is it a more long-term approach? In Lothian at the end of March, our sickness absence figures were 5.86 per cent. That is made up of about 3.2 per cent, which is short-term, and 2.65 per cent, which is longer-term. It breaks down that about 86 per cent is to do with physical health, 14 per cent for mental health. That is the short-term, longer-term, 65 per cent for physical health, 35 per cent for mental health. We have questions well asked. We have invested, we are piloting, using our psychological therapies, working with our occupational health service to try and do that. It has been very successful. We believe that it has been successful. The reason I am saying that is how heavily it is used. We are doing a full evaluation of it. We have agreed to fund it again for another year, again funded through the Lothian charity, but if that evaluation comes out positive, we will be looking to bring that in as part of our core occupational health service. I want to repeat what colleagues have said. We currently have an absence of around 6.7 per cent. I do not have the breakdown in front of me in terms of the short-term or long-term absence, but it will be very similar to colleagues elsewhere. Again, the most common cause is the anxiety stress-related. I think what is important is to acknowledge that is not necessarily work-related. It is difficult to get that level of granularity, but we do need to look at staff members holistically and what we are working with our trade unions. We are wanting to do a tailored focus on whether we are providing the right support at the right time for a particular individual. It is not one-size-fits-all. Some members of staff will welcome and seek and ask for the counselling and spiritual care support and some of the softer skills for others that may not be appropriate. We are looking to tailor that appropriately. It is very much linked to our ageing workforce. The other area that we are looking at, which has been typical this week, is the range of support that is available for staff who have long Covid. It is a complex issue across the wider population. I echo what colleagues have said about the actions that are being taken, but there is always more that we can do. That is great. Something that has been raised with me on a couple of occasions by staff, long-term staff who have worked in core services. They have mentioned to me that some of the challenges that they face within their teams is around the way in which more modern funding streams happen. Perhaps specific pieces of work have been undertaken funding for that. It drains some of the really experienced nursing staff, in particular, out into specialties, which are then fixed. The core teams sometimes struggle with experienced staffing, which has a knock-on effect in supporting new staff coming through. Is there any particular area in your own services that seems to be happening? I cannot think of a particular example of what I would say, when we are talking about workforce, as a problem for the recorded sickness absence figures. I think that we need to look at my background historically as a nurse. When I trained originally as a nurse, I was an apprenticeship model. I worked in the wards as a nurse. I think that we need to go back to say, do you really need to go to university full-time to become a nurse? I am not against degrees, honours degrees etc, but you can effectively train nurses, especially when we have a gender for change with bands 2, 3s, 4s. Lothian has been very successful at what we would call modern apprenticeships. Using that approach, we are settling our mental health side. We do over 100 applicants for 20 jobs over the past two years. We are going to pilot it this year for registered nursing, where they are much more present in the ward through an apprenticeship model, but they are not eligible for modern apprenticeship monies. If we were to have an ask of it, it would be to rethink some of that element. I think that a lot of people find it difficult to give up a job to go to university for three plus years, whereas it could be an employment using an apprenticeship model. That would help our workforce. That way, they also come in a bit more experience, more hands-on, than if it is a more academic programme. I think that there is certainly a place for academia. I am not diminishing that, but trying to get a balance could be better. I recognise what you are saying. Very often, priorities will come up. I have mentioned already short-term funding. For the individuals who take up those posts, it is a great opportunity to do something different and to gain more experience in a different area. Obviously, those short-term priorities are a priority, so it is great that we can get those posts filled. To Calum's point, without a different pipeline or redesign of our workforce, all we are doing is moving people around the system and we are leaving gaps. It will be no surprise that there are some specialties that are perceived to be harder work than others and are more attractive to go into, and people have the ability, because of our workforce vacancies, to choose, which again is quite right where they go. There is something about the redesign of our workforce. Calum has given one example around nursing. I know that, in Grampian, I have been asked about Prentice models with an allied healthcare professionals. How do we create career pathways for people that give them that portfolio approach to their career, but that means that we have the right number of colleagues coming through that will have reduced vacancies? I recognise what you are saying, and I think that there are a number of ways that we are trying to deal with it. I recognise the points that colleagues have made in looking at alternative roles, alternative pathways, and I guess the expression, as you learn, which is picking up on Calum's point. Really supporting a number of staff to come into the organisation, or existing members of staff to undertake academic studies whilst working and supporting them through that in a very different way. We are also focusing on apprenticeships and youth employment initiatives as well. We have seen some of that coming through different roles during the pandemic. We had a member of staff who we have used as an example within our strategy, which, similar to colleagues, has got a strong theme around staff wellbeing and recruitment. A member of staff who was furloughed from a media job during the pandemic joined us as a support officer in the vaccination clinic. He was encouraged by the staff there to join the nurse bank and is now a student nurse undertaking mental health nursing. It is a fantastic example of the wider role of the NHS, with an anchor institution as well, but looking at career pathways from a different perspective as well. Emma Harper has a supplementary question. Just a week, quick and subtle. When I did my nurse training, there were two intakes a year, so that meant that there were entry-level nurses and more experienced nurses in training working together. Is that something that we should be thinking about again, is to help peer support mentoring, because then you have students at different levels in the classrooms then on site? Is that something that we should be looking at as well? I would certainly be very supportive of that. I think it stops this at a famine and feast, where it is very good when the new students come out, but it is once a year. If we could level that out in any way, two intakes a year would be a good way of doing that. I am happy just to add a bit to that. I remain a registered nurse, and my role prior to this was the nurse director in Grampian. It was a very live debate that went on between our academic partners and service in relation to the pros and cons around that model. I do not think that we will ever land on one view, but I recognise Callum's viewpoint on that. Along with the intake, whether that is one or output, whether that is one or two, we need to consider the attrition rates and the uptake rates within the nursing profession in regards to the number of places that are within each academic institution and the growing gap in the uptake of those places. It would be one part of the picture, from my perspective. If it is very short, because we have still got another theme to cover. You mentioned earlier about pediatric anesthetists consultants. They might have to work in one NHS board in order to achieve certain competencies or skills. Is it easy for an anesthetist to work across board as far as competency, inclusion or do they have to do the whole infection prevention control and fire safety and move and handle and no matter where they are? My experience is that doctors in training—if a doctor in training wishes to specialise in pediatric anesthesia, they will work across. They may come to the north and they may get all of their places within Grampian or they may go across other boards. I will need to double-check that, but their training is partly with Ness as in their statutory mandatory health and safety and infection prevention controls. They will do components of that through Ness, which should be consistent with TURAS and there will be specifics that they have to do within each board. I think that the reality for substantive consultants and trained doctors working across boards is more complex and you have highlighted one aspect of that, which is the governance around our induction and different policies in local boards to keep clinicians and patients safe. I think that there is improvement that we could do around that. I will move to Karen Malkin for our final theme. Just for the last theme, I am interested in dignity at work. We no longer do the survey, so I wondered if each of the health boards could feedback on how they feel, how they make sure that they do and make sure that staff have that ability to feed into the system, how they think that the overall trend in their boards is. In terms of staff governance, how do you monitor that and then go on to make sure that changes happen should they need to? I am happy to go with that one. We have a range of opportunities for colleagues to raise concerns. We would hope that that does not happen, but the reality of large organisations is that there will always be different perspectives. It is critically important that we create the opportunity for people to feel safe, whether that is in escalating concerns to their line manager and having that level of mediation or discussion or whether that goes through into more formal human resource investigations. I have mentioned already that we have confidential contacts within the organisation. Everyone has whistleblowing as an opportunity if that is the route that people choose to take. We have our HR processes in very strong and positive working relationships with our staff side colleagues. We have mentioned other things that we do around raising concerns as early as possible, so we have a range of question and answer sessions. We are working on our culture and creating the psychological safety for people to challenge poor behaviour when we see it in action and supporting colleagues with education and training to give them confidence to do that. Our evidence of that and how we monitor that is, indeed, through our staff governance committee. We also have our advisory clinical networks that feed in and our Grampian area partnership forum. We have, in relation to the overall reports, had our whistleblowing report, which we considered in committee, and specifically a breakdown of our bullying and harassment cases. I am just trying to find the figures on that, but I think that within this year we have had three cases that have been identified as being escalated by staff being taken through formal process and are under investigation, so that would be our governance processes around that. Can I ask on the whistleblowing, are you confident that people are well supported and feel that they would do that, should it be necessary? So specifically for us, as I say, we have just had our report considered at committee and the feedback that we had from, because we interview every person that has raised a whistleblowing case, and so the feedback that we have had is that colleagues who raised concerns fed back, they felt listened to and well supported during the process, and that is because we have that process in place to do an appraisal of each case individually. That is very similar to Caroline has mentioned around governance through staff governance committee and the reporting through that route. We are also just introducing through our board on a bi-monthly basis, we are going to be introducing staff stories as part of the introduction at board meeting as well to give that increased focus. So in culture, how staff are feeling, whether they are feeling listened to is given the highest level of attention amongst the executive team within Fife, but also at board level. We have similar initiatives through the whistleblowing processes, we have know who to talk to, we have a talking toolkit that we are rolling out as well. We have had a very small number of whistleblowing cases and that makes me slightly curious because it makes me want to dig a little bit deeper just to ensure that is the culture through the organisation in how we would hope it would be at all levels and in all teams and is there more that we can do. We have a range of ways in which I guess we approach all of this. So I certainly have emphasised the importance of visible leadership and I know my colleagues well as well. So I personally do regular walkabouts with the employee director within our health and social care partnership. The director alongside staff side representatives do the same, like my within our acute setting. So that visibility of leadership and giving staff sharing information, written updates. We have mentioned earlier on the team Fife, that sense of belonging. There is a real focus and concerted effort on that across the organisation and we would hope that that would develop and nurture the culture that we would be hoping for within the organisation, but as I say, it is a real priority for us. But again, always more we can learn and I believe the room. I am going to speak to Caroline a bit trickle, because I would like to hear more about the app. Similarly, we have a small number of whistleblowing cases. They are always dealt with as best we can. We do have speak-up ambassadors who try to take people through the process. The governance structure is the same as colleagues have outlined through the staff governance committee. I settled myself and the employee director, both co-chair of the partnership forum and all the other partnership forums linked into that. I think that one of the things that I would cite is that we are finding that a lot of our staff are coming back. We are finding that 25 per cent of our staff are retiring and returning now certainly nursing. I think that that is a good indicator. We do also have supportive staff networks and some of those networks, our BME network, are driven by our staff and that is to provide peer support there. I am a big advocate of those, so they are there to support the staff throughout. I think that it is one of those things that you are never going to be finished with. It is the fourth road bridge and you are going to have to keep going round it. I do not think that we always get it right, but we do try to get it right. I thank the panel for their attendance today and for your time. We will have a short break while we change over to the next panel of witnesses. The next item on our agenda is the final oral evidence session as part of our inquiry into female participation in sport and physical activity. I welcome to the committee Marie Todd, Minister for Social Care, Mental Well-being and Sport, and Andrew Sinclair, head of Active Scotland, the Scottish Government. We are going to move straight to questions. What progress has been made towards introducing a national approach to increasing female participation in sport leadership and governance, as recommended by the Leveling the Playing Field report? There has been a great deal of progress over the years. I am very pleased that recent data from the Scottish Health Survey shows a significant 4 percentage point increase for women in meeting UK chief medical officers recommended levels of activity. It has gone from 61 per cent up to 65 per cent. The gap between levels of participation between men and women is closing, but, although we are delighted that things are headed in the right direction, I do not think that any of us here would want to be complacent. We have to continue to work to improve that situation. In terms of leadership, there have been some brilliant successes, particularly with younger women taking up opportunities for leadership in sport. I am really delighted to see that progress, but we cannot be complacent. We know that when it comes to sports governing bodies and the organisation of sport in general, while we are seeing more female athletes participating in sport, we are not seeing female participation reflected in the boardroom and nor are we probably seeing the level of participation that we would like to see in the governance of sport in terms of officials. We have more work to do, but we have some good things to report. Some of the things that you have reflected to the minister were issues and concerns that were raised by various stakeholders about women's traditional role in caregiving and how that can become a barrier for them to be able to become coaches or participate in the governance of sport. One of the other areas that the committee has touched on is how women's sport is portrayed in the media and the lack of reporting in print on TV, with some exceptions. I fully accept that there has been some improvement, particularly in women's football in terms of broadcasting. In the 2021-22 programme for government, a Scottish sports media summit was promised. Perhaps he would be able to give us an update on what is happening with that and how the Government is trying to help to promote women's sport to a wider audience, which, realistically, is through the media or through social media. You will be aware that, between the pandemic and the challenges that we faced in balancing the budget last week and last year, some tough decisions were made and we did not progress with some work that we had intended to do. I would still aim to hold a media summit and to try to challenge some of the reporting around female participation in sport. There are challenges. Football is our national sport and everybody loves it, the national game, but it probably gets more coverage than almost all of the other sports put together. I think that you heard some of that in your evidence. The fact that women are playing football and playing football successfully now means that they are gaining some coverage, but that does not help to celebrate the successes of... I know that you had an athlete who was involved in judo giving evidence early, so it does not help with, for example, giving her sport the profile that it deserves. Let me tell you that we are very successful at judo in Scotland. We have some fantastic female athletes participating, so there are real challenges. I think that there is a cultural change of foot. I think that there has been some, particularly with broadcast media, I have to credit BBC Alaba for the work that they have done in terms of bringing women's sport to television. It is phenomenally important. We have a women and girls sport every week every year, and the thing that we are told every time is just how important it is for people to see the roles they want to be. They can't be it if they can't see it, and it's just vitally important. I'm somebody who's absolutely passionate about sport. I haven't found this sport yet. I don't like it. I would like to see coverage of more diversity of sports and absolutely celebration of those female athletes who are challenging some of the stereotypes that are there in society. Sometimes you know I'm a passionate rugby fan. When I see some of the social media films that they bring out about the Scottish women's rugby team, where they are lifting weights and really strong physical role models, that busts a myth about women in general, doesn't it? I think it's really important that more people see those things. Finally on this particular theme, I wonder if any decisions have been made regarding the future of the women and girls and sport advisory board? If that board were to be dissolved, what would take its place and how would the Scottish Government continue to progress towards gender equality and sport? I think that they've had some great contributions to make. There are absolutely some phenomenal leaders and glass ceiling busters in that group. Let me say if I think about, I think, deep liberties in that group, isn't she? So there's a tier one nation, female president of a tier one nation in rugby, which has not been replicated in the rest of the world. Scotland has some very powerful leadership roles who are in that collective. In terms of the future, I don't know if you want to say more about the future of that group, Andy. Yeah, so the group went into slight hibernation during Covid, as much of our work did. However, they made some clear recommendations before Covid hit. Again, we are taking those recommendations forward at the moment. Again, the media summit that the minister mentioned, again, there's been some great progress around broadcasts in women's sport. We've seen a number of highlights. We've seen the Scotland national women's team move the hand in. We've seen record crowds at SWPL games, record crowds at women's six nations, live netball coverage of the Scottish netball team. However, I think that print media is still an issue. I think that the column inches that women's sports get is not good enough. Often, the women's stories focus on not their sporting performance, something in their private life, what they've been up to, who they're married to, that kind of thing. I think that changing that dial is what we're looking to achieve through that media summit, which we hope to have by the end of this year, hopefully. Thank you very much. I'm now going to move to Evelyn Tweed. Thanks, convener. Good morning, minister. Good morning, Andy. We know that socioeconomic status is the biggest factor in whether people are involved in physical activity, but how can we ensure that funding is used where it's most needed and inequalities aren't further entrenched? That's a real focus for the Government, and we've committed this term of Parliament to double the funding for sport and physical activity, and we are determined to focus that extra funding on tackling inequalities. You're absolutely right that there is, at the moment, a pre-existing inequality across the board for participation. Football, again, to give them credit as our national game, is the one sport where there is equal participation across all the socioeconomic groups. Every other sport favours the wealthy, so there is a socioeconomic divide for literally every other sport. How do we tackle that? How do we even prove that? Well, we are speaking to all the sports governing bodies about that. There are some amazing programmes in place. For example, Scottish athletics are doing some great work going into communities where they wouldn't normally be operating, targeting those groups who may not naturally be participating in athletics, and that is gaining participants from those particular areas of socioeconomic deprivation. It's also gaining them a more ethnically diverse participant group. There's some specific work that can go on. I think that the socioeconomic thing shouldn't be ignored. That may be one of the reasons why women experience inequalities generally because of their inequality and wealth, inequality and power, inequality and status. I used to talk about women experiencing health inequalities when I was a women's health minister. That's one of the reasons why they experience inequalities and health in sport as well, because they don't have as much money as men. What can we do? One of the basics that we can do is encourage those sports where money doesn't matter. Things like participation in the daily mile being integral in part of the school day in Scotland is a really important way to target absolutely everyone, so boys and girls can participate in the same way. There's no economic barriers to participating in that activity every day. We've got, I think, 1,000 schools participating, but it's 32 local authority areas, so it's really, really good, but it's still only about half the children in Scotland, about half the children aren't doing the daily mile. The daily mile will, you know, it's just 15 minutes of exercise three times a week. I do my daily mile every day, let me be clear, but the recommendation is 15 minutes of exercise three times a week. For that, you get such a bang for your buck. You get measurable improvements in children's fitness, decreasing BMI, decreasing body fat, so you get all the physical changes, but you also get the cognitive changes. They are more able to learn. They are more confident. They are happier. They are calmer. The mood impacts and the cognitive impacts are huge, for a very small investment in time and no money. It's about the most inclusive programme we have for exercise in Scotland, and we're pretty keen to expand it further. I think that everyone should do their daily mile. I assume at the present time, Minister, that it's very important given we're living through a cost-of-living crisis? Absolutely. There are many barriers to participation in sport, such as needing kit and equipment. Again, I think that you heard that there are not all sports are equal. Cricket, for example, I looked at the evidence that you were given by that young female cricketer in choosing because of the equipment that's required for her sport. It does tend to attract people who are from a wealth-there socioeconomic background, so there are many barriers to getting involved. We as a Government want to bust as many of those as we can. One of the great programmes, and there are so many brilliant programmes, Scottish Sport Futures, collaborated with Sweaty Betty, and they're actually a luxury brand of sportswear. They've provided hundreds and hundreds of bras so that young women who might have been prevented from getting involved in sport and physical activity had the equipment. I mean, a sports bra is a really expensive acquisition. It can be £30 to £60 to buy one decent sports bra. That is an absolute barrier for many young people to get involved in sport, so that collaboration is really phenomenal. I mean, I love it that that particular young group of women were getting the most luxury brand that you could possibly imagine, but they came up and met me in Inverness, and we did some sport and exercise together. It's a fantastic way to open the conversation about what the barriers might be. Now, needing specialist kit isn't the only barrier to participating in sport. Those young women spoke to me, as you have heard, throughout this inquiry about the challenges of being involved in sport while you're menstruating, the challenges of just the general society pressure to look a certain way, to behave a certain way. The fact that women's bodies and young women's bodies are pretty, I would say, past commentables is the phrase I would use, so they face a lot of commentary when they do get involved. So, kit and money isn't the only barrier, but it's certainly a significant one. And just now, in a cost of living crisis, it is absolutely the difference between some women being able to exercise and some women not. I know that the Scottish Government is looking at maybe restricting alcohol advertising. How are you going to do that, but still make sure that it doesn't negatively affect funding for sport? It's really challenging, isn't it? I think that's a really excellent question. So, I am somebody who is absolutely passionate about sport. I want sport to be well-funded, but I want sport to be healthy, and I want sport to be inclusive. In the two groups that we have found who are particularly vulnerable to the sort of sport sponsorship and advertising of alcohol are children who there was a very dismaying study a couple of years ago that looked at the Calcutta cap. I think it was in 2020 and saw that children watching that on television saw an alcohol prompt every 12 seconds as they watched that match. But the other group who are particularly affected are people who are in recovery, and they are particularly susceptible to sports advertising. I believe that we can strike a balance. I think that we have to start from a place where we acknowledge how much alcohol harm there still is in Scotland. So, over a thousand people a year die of alcohol in Scotland. I think that it's 24 people per week die of drinking alcohol in Scotland. It is something that, although we have made progress in recent years, it is absolutely essential that we continue to make progress. There is a perception that the people who are dying of alcohol are a distinct group that you can somehow target with your intervention. There is some truth in that. There is no doubt that the socioeconomic divide appears here as well. If you are living in poverty and drinking excessively, you are more likely to die than somebody who is wealthy and drinking excessively. But alcohol and alcohol misuse and harm from alcohol really does no bounds. We have seen that over the course of just this weekend where a couple of colleagues have spoken up, Miles Briggs and Monica Lennon, both of whom lost parents to alcohol, who spoke very powerfully about the stigma of alcohol dependence and misuse. I think that it is important for us to have these conversations about what we can do at a population level that would shift the curve so that fewer people are finding themselves in the situation where they are drinking hazardously. I think that a discussion around sport sponsorship, sports promotion and advertising is a really important part of that national conversation. I will bring it back to women's sport. The Scottish women's football has made a conscious decision and commitment to only engage in ethical sponsorship, so avoiding alcohol and gambling firms. It is a good model and it brings us back to the inquiry today. It can be done, but I accept that there is a fairly small pool that Scottish sport is fishing in in terms of sponsorship. I will make a small plea then to the Scottish Government if they are looking at reducing alcohol sponsorship, that they take some lessons from what has happened in Ireland, where there has been an alcohol advertising band. However, some companies appear to be trying to get around those rules by advertising low or no alcohol products that share the same or similar names, so they are still getting that brand recognition. Pick up on Evelyn Tweed's questions about alcohol and alcohol advertising. There are two big soft drinks companies, one of them supports the Olympics and the other one seems to be in and about all the mountain biking in America and whether it is soapbox racing or mountain biking. It is a lot of money that helps to support sponsorship for sport, but I have been approached by other people that say that those are health harming products, so we have to consider that when we are supporting sponsorship or advertising or helping to get young women or young anybody into sport. How do you feel about implementing restrictions on advertising for other products that are not just alcohol related that might be soft drinks? It is challenging, in that area. Tobacco or smoking advertising has been restricted. I had the absolute privilege of meeting Billy Dean King last year who talked about the Virginia Masters, which used to be a big tennis tournament in America, which was sponsored by a cigarette company in Virginia. We have made strides in reducing tobacco and smoking's appearance in sport. Usually, in Scotland, we have a sports minister who is part of the health department, so I am a junior health minister. I absolutely recognise the health benefits of sport and physical activity. That is not just for your physical health, it is for your mental health too, which I am sure we will get on to. I think that it is really important that we remember that when we are considering how we fund sport. The challenge is getting that balance correct. As Andy has said, there is a relatively small pool for companies to fish in terms of getting access to sponsorship in Scotland. I think that it is important that we consider those issues. I think that it is really particularly for those groups who, as I said, we are aware, are particularly susceptible to advertising, which would be young people and people in recovery. I have a final question. I know that we are going to come on to children and young people, but I am interested in evidence that we took last week. Basically, there was a plea for our review of the national performance framework to include specific outcomes related to physical, mental and social benefits of sport and physical activity. Would the Government consider making a specific target as part of the national performance framework for that? Is that something that would help then refocus or focus further the importance of physical activity and sport for physical and mental health and wellbeing? I try to make that link all the time when I am talking and very regularly talking about sport and its benefit for physical health, mental health and social health. I think that there is a general population level recognition of the benefits of physical activity and sport for social health since the pandemic, when we were all restricted from participating and found ourselves walking outdoors to socialise because it was the safest way to do it. I absolutely love it if Scotland became a nation that socialises through exercise. Andy, I do not know if you want to come in on the national outcomes particular. Physical activity does feature. Obviously, the NPF talks about being healthy and active. I feel that we are quite well represented in that space. We also have the Active Scotland outcomes framework, which sits below that, which talks about our whole systems approach to physical activity and how we implement things in Scotland. Again, that is recognised by the World Health Organization as an exemplar. Again, probably part of the reason why we are bucking global trends in getting people more active in Scotland. One of the things that came out quite strongly in a previous evidence session was that around 90 per cent of funding for sport in Scotland is channeled through local authorities. It was quite a highly disseminated model of funding. Of that, councils are faced with 80 per cent central government allocations, 20 per cent through council tax and charges. There is a bit of pressure to leased on council finances. Often, the first things to go are what are seen as non-statutory service provisions. The focus would be on things like social work, education, things like sport, which are seen as potentially less severe options when they are looking at making savings or cuts. What is your assessment of the impact on council finances, on the provision of sport, particularly focused on provision for women and girls in that kind of specific facilities, and what can you do to try and ameliorate that impact? I think that everyone would acknowledge that we are in challenging financial times right at the moment. It is challenging for central government, for Scottish government, and it is challenging for local government as well. This particular financial or cost crisis has come in the back of over a decade of austerity politics, which has had an impact on our public services, undoubtedly, over the course of more than 10 years. It is a challenging situation that we face. The Scottish Government has not just maintained funding to local government, but we have increased it in real terms. We are very keen to continue to prioritise local government spending in our budgeting. We recognise how challenging it is, and we are all hearing it in the press at the moment. There is a small number of local authorities around Scotland where they are making decisions on closures of particular individual facilities. We had a debate in Parliament just last week about Perthyn Cynros and the challenging situation that they faced with regard to maintaining dures. Thankfully, they have managed to maintain the funding for the dures facility, and it is secure for the next few months. We are working day in and day out with local government colleagues to try to rise and meet the challenge and to see what we can do to support them. Much of the current challenge is being precipitated by energy costs, so it is the energy dense sports that you are seeing, particularly struggling with things such as swimming pools and ice rinks. I am continuing to put pressure on the UK Government that has many of the levers over the cost of energy. It is an important strand to try to tackle that particular challenge, but in the short term, it is challenging, in the medium term and in the long term. I think that there is work that we can do together to try to improve the estate so that it is less energy consumption going on with those facilities, but that is not an overnight fix. That is something that we have to do. We have to make that transition anyway in order to meet our net zero targets, but that is something that the Government is more than happy to work alongside local government with. I know that, as I can test, it is based around real-terms cuts from COSAL, etc. I will want to get into that sort of debate. The focus is on what we can do to highlight risks in the estate that you mentioned. Could it be things such as investment in district heating networks? Could it be capital investments that are targeted, where councils are making decisions, where there is a risk to the future provision of sport facilities in Scotland? Is there a mechanism by which that can be flagged as a risk and then potential mitigating measures are looked at with the Government around things such as capital investments or targeted investments? Could there be opportunities to look at where there is best practice and other authorities, where they have been able to crowd in maybe some sort of external investment, whether there is sponsorship or whether there is some entrepreneurial activity, which has immediately led to the impact? I am just wondering whether there is potential for a more developed ecosystem, if you like, of feedback between local government dealing with challenging situations on the ground versus sharing that best practice, sharing things that have worked better, and potentially where you say, for example, swimming pools, highly energy-intensive assets. Could there be ways of investing capital into those to reduce the revenue costs, for example, as there is a potential for developing something there? We are doing quite a lot of work in that space already, and Andy will probably want to come in and tell you a little bit more about the work that Sport Scotland is doing with local authority colleagues on the sporting estate nationally and trying to take that strategic view about where investment will have the most impact. We are working very closely with our local authority colleagues on that. I absolutely empathise how tough a situation is, and we are in a tough situation, too. Difficult decisions are being made going forward. It is a difficult time to be in politics, so we have very open and candid channels of communication and support available. What we do not have is a limitless pot of money to help out in those situations. I think that that is challenging for all of us. There are not easy short-term solutions in the situation that we face longer term. We can certainly work to get the estate on to a better footing. Sorry, Andy, do you want to come in? To give some comfort, we speak regularly with local authorities and community leisure UK, who are the umbrella body for leisure trusts. To understand the position and recognise it is incredibly challenging. As the minister mentioned, Sport Scotland is at the start of commencing a full facilities review for Scotland to understand the condition of the estate in terms of physical activity infrastructure. The pressure on local authorities means three things that they need to think about doing. That could be reducing opening hours to cut costs and putting up prices for people. We have spoken about the challenges that we present in terms of inequalities and closing facilities. There will be cases where swimming pools are a prime example. The swimming pools that were built in the 70s will never be energy efficient. If a local authority does a proper consultation process, there are facilities that could be used in a different way. As we know, local authorities have a requirement to provide adequate facilities. That is the only requirement on local authorities. Again, there is no clear definition on what adequate means. As long as there is genuine engagement with local authorities and the people who live in those areas, they will hopefully come up with a solution. When we had our witnesses in last week at Kingston, it was clear that local authorities are held accountable for their investment in sport. Given that, as Paul Sweeney says, quite a substantial amount of money that is put out by the Scottish Government for sport goes through local authorities, I have seen the price increase in my own area, which caused a huge outcry—a 114 per cent increase for children and young people in terms of changing the discount that they had to access sport facilities. I appreciate that we want local authorities to be as autonomous as possible, and it is a very fine line that the Scottish Government walks on. Given that the impact that some of the price increases and closures might have on children and young people, is there more that the Scottish Government can do in ensuring that that money gets to where it should be going? It is a really difficult and challenging area. Local Government is democratically accountable to the populations that they serve. It is not the Scottish Government's role to oversee their spending decisions. It has to be a locally accountable decision making. Paul Sweeney mentioned just how much of the budget is already ring-fenced. Ring-fencing more of it would not be welcome. If I am honest, over the course of the pandemic, we have worked really closely together with local authority partners. We rose to face that incredibly challenging time for our nation together, and we navigated the challenges together. I think that there is a keenness on both sides between the Scottish Government and COSLA to try to continue that positive working relationship. Although everybody acknowledges that there will be challenging decisions that are made on either side, local authority might contest some of the spending decisions that we make. We might also contest some of the spending decisions that they make. There is room for respect on both sides and working together on both sides to try to collaboratively find a way forward in this really challenging time. I am now going to move to James Dornan, who is joining us remotely. Thank you very much, convener. Good morning, minister, and Andrew. It is 10 years since Maureen MacDonald, Alison Walker and myself began Scottish Women in Sport under the leadership of Maureen MacDonald. One of the things that was of real interest at that point was how girls, at a certain age, dropped off in physical activity. I am seeing pretty much the same as still the case. How do you address that drop-off? What actions can you take to ensure that girls feel safe and welcome to participate in physical activity in school play areas? You are absolutely correct, James, that that drop-off at puberty is well recognised, long-established, and it is a challenging one to shift. I suppose that, through the life course, we see a difference between, so for children, we see a difference in participation. It only becomes statistically significant between the ages of 13 and 15, so although boys participate more than girls, it only becomes statistically significant that difference at puberty. We see that difference continue right throughout life, but it is not permanent. Girls drop off at puberty and boys drop off at puberty. They do re-engage again at future points. I think that there are challenges at puberty. For women and girls, from a very early age, there will be expectations around caring roles. There are challenges when girls hit puberty, the changes in their body that give them—I was reflecting on my daily mile this morning, one of the things that I was thinking about was the difference in my body confidence aged 50 compared to age 15. I think that everyone would recognise that difference. Now, there are challenges for girls coming of age in a gendered society, such as we live in at the moment the expectations of body confirmation. There is discomfort about menstruation. I heard an athlete this morning on the radio, a triathlete Emma—let me remember her name—Emma Palant-Brown talking about a photograph that she posted of herself running with a bloodstained swimsuit. Menstruation is still taboo, body hair is still taboo. There are all sorts of reasons why, as we hit puberty, girls stop exercising and it is a challenging one to get into. I do think that we are in a healthier space now than we have ever been. In terms of the debate that is occurring, there are particular programmes that will help. Women and girls only spaces will help. In terms of communal changing spaces, women tend to have a preference for privacy, so changing the changing rooms so that it is possible for women and girls to change privately, rather than in a communal space. All those things will help, but it will take time. There is massive societal pressure. Do not underestimate the societal pressure on women and girls to look a certain way in which we feel strongest at that 11 to 15 stage of life. Having been a grandfather of a granddaughter is now beyond that stage, not having to go through all those worries, but I understand what it is like at that age. I am talking about what was 10 years ago when this came up as an issue for us. 10 years on, we still have almost exactly the same issues. What is it that society needs to do, that the Government needs to do, that sport needs to do, that education needs to try to ease that burden for young women at that age? I agree that it is frustrating that that has been 10 years, but if you think about the taboo on menstrual blood, that has been millennia that has been in place. The idea that we could overturn some of the taboos and the challenges that women face in participation overnight is, frankly, wrong, I would say. I think that we are having some really good conversations now. I have never known a time in my life where elite athletes are talking openly about issues such as menstruation, contraception, pregnancy and sport, menopause and sport, and it is really healthy that this debate is finally happening. In the same way as we have seen women's health studied, we have seen women's participation in sport and understanding of the influence that our different physiology has on performance sport and things. Hasn't historically been looked at. Firstly, women have participated less in sport, and secondly, we've been studied less as we are in medicine. There's a great deal more understanding going on in those issues, and Sport Scotland has some particular work in the elite performance athlete field, which is really helpful. There's better conversations going on, there's more understanding of the barriers, there's more tackling of the barriers, but I think it would be foolish to imagine that there was just one thing that unlocked sport and physical activity for women and girls. There's multiple barriers. As I said, a sports bra costing £30 to £60 and being a pretty essential piece of kit is a barrier that many women and girls will not be able to overcome as they hit puberty. Well, I look forward to a further report in the future to see how well we're getting on with this. Thank you. Thanks, convener. Just picking up again on the sports bra issue, I visited Wallshall academy yesterday, and I spoke to five young women, Mika, Fern, Zena, Mikaela and Daisy. They were all six-year students or their abouts, and they all participated in rugby and running and loved all sports. They were absolutely confident and informed and empowered, but they did recognise that not all young women their age were confident and empowered to speak up about their periods or about the need for a sports bra. One thing that they did see was that the school purchased for year one students a specific sports PE uniform. That was a bit of an equality in a leveler because all these kids were coming from different primary schools and it was a way to engage them all at a literal level playing field. That was something that was interesting. I would be interested to know, minister, if you think that we do need to look at uniforms and availability for sports bras, for instance, and sporting uniforms as part of the uniform policy for government? Absolutely. That would be a really good idea. During this Parliament, we have committed to introducing statutory guidelines for school, increasing the use of generic items of uniform and reducing the cost of the school day. We are consulting or we have consulted and guidelines on school uniform and clothing. We engaged with pupils and undertook a public consultation. We are in the process of analysing that and a report summarising the funding that will be published sometime soon. I would have thought sometime pretty much around now. The cost of school uniform and clothing and equipment for PE, physical activity and sport come into it. There will definitely be a focus on trying to reduce costs for families. Looking at breast care is an important part of that. It is definitely one of the reasons why there is a drop-off in participation. As we have said, there are lots and lots of reasons, but that is one of the reasons why there is a drop-off in participation. Seeing what we can do to engage in that and to improve that situation is really important. One other thing that the young women raised was that sometimes the boys that they played rugby with or played sports with, or if they were in the field at the same time, the boys were a bit sexist and misogynistic. When I mentioned to the principal teacher that don't be that guy campaign, which is a bit more hard-hitting, because it is about harassment and sexual assault and sexual violence, Barry Graham, the principal, is going to take a look at don't be that guy, but is there maybe a room for something maybe not as hard-hitting but maybe a don't be that guy equivalent for teenage lads as well? There is definitely an important area to acknowledge. We live in a gender stereotype world where girls and women are expected to look a certain way, behave a certain way and conform to certain roles. There is no doubt at all that as children grow up and reach puberty, they are experimenting and finding out who their tribe is and testing out the world that they live in and exploring it. Part of that can be absolutely thinking that women's bodies are, as I say at the term, passed commentable, but it's okay to just say, and we face it all the time. Each and every single female in this room will have had times where people have passed commented on their appearances. I think it's particularly difficult for teenage girls and I hear all the time about boys' comments being a barrier to their participation. I think that education can help to tackle that, but we have to recognise the same as with other societal challenges like racism, sexism, misogyny, sport reflect society. We live in a world where things are a reality, so there will be some of that reflected in sport. I firmly believe that sport can lead the way in changing culture. I really believe that there are some positives that sport can lead on in terms of shifting that culture. I think that it's important that we harness the power of sport to tackle some of these societal ills, as well as looking at education in schools. We can look at role models within sport. We can look at grassroots projects that might tackle some of those issues, but I think that it is really important. It is a really important part of work. Final question about the variety of sport. One of the other things that came up in conversation was during the summer sporting, there's shop hut javelin, there's 400m relay that's mixed genders and tug-of-war, because not everybody wants to win a gold medal, some folk just want to participate and actually have a bit of fun. That was something that this particular school, Wallace Hall Academy, have implemented. Is there something that the Scottish Government could do to increase the more wide variety of sports and take on board really good practice in some schools and get everybody not just competing but participating as well? I think that I'll let Andy speak a little bit about this as well, but there's always that tension, isn't there? There's a difference between elite sport and social sport and recreational sport. As a Government, we want to encourage participation right across the board. We want everyone, I mean I could sing the praises of sport morning, noon and night in terms of the benefits for your physical health, mental health and social health. We want everyone to have access to that. If it were a pill it would be worth billions, wouldn't it? So we want to increase participation. One of the ways to increase participation is to take away barriers. One of the things is to offer a diversity of experience, so that's a diversity of different sports. Sometimes there may be a gendered difference in this, although I'm not totally sure sometimes it's a perception there's a gendered difference in this, but there might be different levels of appetite for competition. There are definitely occasions where just participating for the joy of it is really important. Gymnastics, Scottish Gymnastics, sees themselves as very much a feeder for all other sports. There are particularly gendered participation, a very high number of girls and women participating in that sport. They very often go on to other sports and gymnastics is where they gain their physical literacy. Only a small number of people participating in gymnastics go on to compete as gymnasts, but they are very often using the skills that they picked up as youngsters in that sport, in other sports going forward. We watched the Olympics with a lot of interest. The last time it was on, there were really brand new cycling events which really captured the imagination of the world of BMX events and things. I think there's really exciting innovations happening in sport. There are new kinds of competition coming along. We're going to host the UCI Worlds in Scotland this year. I can't wait to see football on a bike and gymnastics on a bike. There are really interesting innovations going on, but I suppose what I'm saying is that we need to think. I passionately believe that there's a sport out there for everyone. I joke that I got into rugby because I was a bit clumsy and I had to bang into people and fall over quite easily. I found a sport where those characteristics were an asset to me. I admittedly have always participated in social sports. I was never going to be an elite athlete. I trained hard and I played hard, but it was only ever going to be a social or recreational experience for me. I think that everybody should have that. When I was talking this morning about my daily mile and reflecting on that journey to body confidence that I have now as a 50-year-old participating in rugby was a big part of that, recognising that my body could do things that I never imagined it could do. It was really strong. I could knock down people who were much faster than me. I could be. I'm just recognising that there are sports out there with a role for every single body shape. It's really powerful stuff. We need to broaden everyone's horizons. We need to get everyone participating and give them loads of opportunities. I think that a number of you might have been at the 150th celebration of football in Parliament last week, where we heard from Sam Milne, who talked about starting a recreational football group, and Alassie, who talked about a particular individual, Farah MacKenzie, who had come along. Recreational football is not competitive at all. It's just social. Women come along and they play together, and they talked so powerfully about the camaraderie that gave them the social benefits, but also about the physical health benefits and mental health benefits. Farah spoke about losing, I think that she said, six stone in weight. She had been a type 2 diabetic who was on the brink of going on to insulin, and participating in recreational football pushed all that back for her. My thing would be, let's make sure that there are as many opportunities for absolutely everybody to participate in sport and physical activity. We do need some competitive opportunities. I'm not dismissing the elite athletes amongst us. They need competition. They were saying about that recreational football that even they, some of them, were beginning to enjoy having competition. They were gathering together to have recreational football games once a month now, so there is that opportunity for competition, but I want participation. I want us to move more. I want us to enjoy our bodies. I want us to be fitter, stronger physically, mentally and get all the social benefit that it brings. We also have around 200 community sport hubs across the country. Many of which are based in schools and offer a range of activities. Sports have become really good over the past few years at sharing participants. There's not really as much competition between sports, so if football is not for you, Abammenting Club is also housed here, you try that. Again, it's giving young people in particular a range of activities to try out, which is really positive. Just as an aside, Tug of War is our smallest governing body in Scotland that we invest into, so they do some good work. I think that one of the other things that's happened is that active schools coordinators are really good at collaborating with the assets that are in the community already, so making those links between the sports clubs in each locality—I mean, I know that you're part of the country, they're big on curling and ice sports, my part of the country, they're very big on shinty—so trying to make those links with the sport that is already happening in the community to give children and young people opportunities to join with assets that are already there, I think that's an important part of getting it right. And the curling is also good for people in wheelchairs as well? Oh, the curling is just spectacular. I had the most marvellous visit to Inverness Ice Rink, where I met a group of curlers—I mean, it nearly finished me off curling, I have to remember I said it was a bit clumsy. I didn't find it easy, but oh my goodness, what a supportive bunch, and there were so many of them with stories to tell. Some had participated lifelong in the sport, some had come to it very late, so it seemed to be a sport that was really easy for a particularly older woman to get involved with. A couple of women there spoke about having been widowed, and friends invited them along, and it just became—it's an unbelievably social sport, and the advantages of that are endless, but oh my goodness, those women were pretty competitive as well. So you get all the advantages, and it was a workout, I was sore for days afterwards. We've touched a wee bit on community sport already with the leisure centre discussion. I'm interested in some of the questions that we were asked from our other witnesses, and it really is about trying to engage women, but the themes that come through that are difficult, and there's three things. Safety around going to and from venues, particularly if there's not things very local for young women in particular. Then for women as they go through childcare facilities at sports and leisure centres, whether they've had any thoughts around those. Then the third thing that's been raised with us recently, but in the longer term, when we've done another activity around sport, is about the use of the school estate. It's an important point that keeps coming back to us again and again, so I'd be interested to know what work you have done or intend to do around that. I think that these are challenges to women's participation in sport. The issue of safety, the issue of safe transport to and from sporting venues particularly. We have long dark winters in Scotland, and not everybody feels comfortable out and about at night. Some environments, frankly, aren't safe for women. Again, it's something that every woman makes decisions on every day. It's just a reality of our lives, isn't it? We make decisions and compromises about how much risk we're willing to take. I think that designing communities where there is good active transport links to sporting hamsmena just a couple of weeks ago. I opened the West Lothian cycle link track, and it was just phenomenal. It was linked by active transport routes while it beautifully made that you could cycle basically to this cycle track from many parts of the community around it. I think that thinking about these things is really important. Thinking about public transport, meaning in my part of the country, public transport doesn't really, well, so where I live now, public transport barely exists at all, but where I used to live in the east of the highlands, public transport tended to stop at a certain time of night. Those are undoubtedly challenges and barriers for women. We need to think about that. We think about it by designing public transport systems that are accessible to women, that are safe for women, and designing communities that are well lit and well designed. I saw the evidence given by one of your earlier people who came and gave evidence to the committee talking about how women feel more comfortable walking in a place that's overlooked. Where there are lots of windows looking out onto the path for people, women will feel safer walking there. It's not always obvious what makes the difference, but we need to do more research and make sure that our communities are safe for women. The childcare and caring in general is a really important one. One of the things that I have been encouraging many sports to do is to think about opportunities to link up. Women do a lot of the children's activities and organise a lot of the children's lives, so giving opportunities for women to participate in sport while their children are participating in sport. I remember very well the first captain of the Orkney ladies rugby team who talked about her journey into rugby through being a rugby mum who had a hangabout for her wee boy who was training and just thought, well, how about we start training ourselves? Within two or three years, that club, that women's team, were picking up silver where they were pretty phenomenal at it. I think that's giving opportunities for women to train while their children are training. Jog Scotland do a lot of that, so they all have groups. I certainly used to participate in a Jog Scotland group when my kids were really tiny. I could drop my children off at nursery and then go for a jog with an inspirational group. It's mixed gender, but it was mainly women because it was during the day. There were some outstanding older women in that group who gave me as a young mum who was feeling very out of condition, a lot of inspiration about the potential for lifelong participation. I think that there are some real opportunities for collaboration that we can help. In that first postnatal year, more opportunities for yoga and exercises that might be focused on pelvic health, that would be a win-win. Just encouraging more of that with babies along too would be a really important way to encourage women with exercising. The school estate, again, has lots of policy in place that enables the use of the school estate. There is lots of use of the school estate. It's more that could happen and further we could go, but we've made a great deal of progress in the last few years. We've had a challenging few years with the pandemic, where safety and protection against infectious diseases has been at the forefront of people's minds and trying to limit the number of people who access the school estate in a day has been challenging and it's been slow to recover post-pandemic, but I think that we're making progress there. Nothing too much to add, as the minister said. The general principle of the learning estate strategy from the Scottish Government is that those community facilities should be open for the community. Again, it's been a while since we've done any research into that. I think that 2014 was the last time Sportscotland did a formal study into that, but Sportscotland speaks regularly to local authorities and raises the school estate as a continual issue. Again, in many cases it is down to scheduling and more so than facilities not being open. Again, it's just about working through all those challenges. I think that that was well made before that, that it's open but it's not being accessed. I don't know if you've got any insight into why that might be. Has there been feedback to Government about why that might be? It's definitely a difficult one because on the face of it the estate does seem like it's open, gates are unlocked, but again it's just about working with local authorities and governing bodies in particular to make sure that scheduling is right. The school quite rightly uses the facilities during the day, but then as soon as the school day finishes then it should be available for the community, so it's just about working through those issues. I'm going to now move to Gillian Mackay on our next theme. Thanks, convener. How do we ensure that an intersectional approach is taken with regards to improving participation in sport and physical activity, including people with disabilities, the LGBTQ community, and other marginalised and underrepresented groups? I think that you're absolutely right, while there's a general concern around each of those groups and women and girls who fall into the individual categories, undoubtedly the barriers are greater for those who are in more than one group. I think that disability is one that particularly challenges me. I would love to see more participation across the board and more opportunities for participation. I went to a disability sport festival in Dingwall and I was so impressed by the work that was going on to target inclusion. This was probably over a year ago, so it was at a time when we were still feeling pretty cautious about the pandemic. Many of that particular group had spent a lot of the pandemic very isolated and very vulnerable. It was really joyous to see them participating in sport and participating sometimes with siblings, so brothers and sisters who never get a chance to play the games together or do the sports together in the way that other siblings do. There's some really important work going on. It is bearing some fruit, but we could do more. Last year, one of the young people sports panel did a very powerful course in challenging all of us to reflect on how we could make adaptations to encourage participation of people with disabilities. When I speak to athletes or people who are participating in sport who have disabilities, I almost always talk about how challenging it was to get involved in school and how they will have been told to sit at the side in PE classes. As her education session amply demonstrated, it is really easy to make adaptations, which means that everybody can be included. That is what I would absolutely play for. Every opportunity to encourage inclusion and participation to be made. There are some great examples. I went recently to a badminton club that was run by a coach called Rajani Tyagi, who won a prize at Sportscotland Community Coach of the Year. I probably got the title wrong. I apologise, Rajani, but she had done some fabulous work in encouraging participation in the BAME community. It is just basic. As you would expect, she did it with word of mouth. She targeted people. She made sure that it was a safe environment for them to come along to. She held it at times and suited them. It was at 8 o'clock at night, which I personally felt was quite late for me to be running around playing badminton, but it worked, because many of them had caring responsibilities. It was a time of night that people could get out free of their caring responsibilities and participate. It is basic. Ask the community that you are targeting what would work for them and then do that and reach out. She had a really thriving badminton club. She had also done quite a lot of work in cricket, in targeting BAME participation. Some really powerful work is going on. In terms of LGBTQ plus community, you have heard this from some of your earlier commentators. In terms of homophobia in sport, women's sport has traditionally been quite a safe space. It has been inclusive and has been welcoming to everyone. I think that is something that we really need to be proud of and hang on to going forward. I think that there is clearly a debate to be had about trans participation in sport, and there are some challenging conversations on that issue being had, but we absolutely need to have to play again that we focus on inclusion, where possible, recognising just how important the benefits are that everyone gets from participating in sport. For some communities and each of the communities we have talked about, we will face marginalisation and challenging health outcomes. Sport can be part of the answer, so we really need to make sure that we consider inclusion where possible. As I said, women's sport has had a relatively healthy attitude in previous times to earlier discussions. I think that we need to hang on to that. Absolutely. Is someone very much like yourself who found rugby because it is easier to stop things than it is to run quickly? I am quite interested in how we include people with hidden disabilities who might not end up qualifying for the disability sport side of things and end up in more mainstream sporting activities, as someone who has misjudged how quickly an opponent was coming at them and missed several tackles due to my hidden disability. It is how we make those environments welcoming and change some of that culture. You mentioned PE as well, the ridicule of how many times you miss catching a ball and things for children with hidden disabilities is something that we need to tackle as well. What work is Government undertaking to improve the visibility of disabled people in sport, including people with hidden disabilities? Many of the sports are doing a lot of work themselves on that, so rugby is an excellent example. There is a club, and I am pretty certain that the Parliament team, Sandish Galhany, may be able to contribute here as a fellow participant in the Parliament rugby team, but we play an inclusive team each year. Some of the people playing in that team have hidden disabilities, some of them have less hidden disabilities and the roles are adapted so that everybody can play together. It is absolutely fantastic. I think that wheelchair rugby is hugely inclusive. It is a game that men and women can play together often in our mixed teams. I have a Twitter pal who has very severe... I have met her in real life, but mainly we are friends on social media. She is desperately trying to get me to go along on a Wednesday night training wheelchair rugby. It has been a revelation for her. She has very severe asthma and has been prohibited from participating in conventional sport, but wheelchair rugby has given her the opportunity to participate again. There are absolutely ways of adapting sports so that everybody can be included. I think that one of the people who got a coaching prize in last year's award ceremony was a lady from the north-east, I do not know if you remember her name, who did the inclusive swimming coaching. She was just phenomenal at absolute power, who reached out to people who, to get them involved in her sport and made sure that they could achieve absolutely the best of their potential. There is some incredible work going on out there. There are loads and loads of challenges and barriers, but there is some really good work. I go back to default setting inclusion. We have to try and make sure that everybody is able to experience the benefits of participating. I am going to move to Sandish Gullhane, who might want to comment on the rugby. I tell you all the one thing that I would never be brave enough to do is to wheelchair rugby. That is quite scary. I would like to ask questions around ethnicity in women's sport. We have spoken already about how participation drops off, but that is even more acute when it comes to ethnicity. You gave a very good example of badminton, of a way to engage with the community. My first question is about information and data, because every single time we have had someone in front of us, I have asked them what data do they have around ethnicity? Very few have come back and said that we have good data around it. Is that an issue? It has certainly been a challenge in the past. I think that we have improved our data collection over the past few years and I will let Andy give you a fuller answer on how we have gone about that. From a Government perspective in our household survey, we are looking for ethnicity data as well as physical activity data. In terms of sports governing bodies, the data that they collect, we are doing a little bit better. I think that in the past the data has not been there and we saw that in health as well as in physical activity. It was not really until the pandemic that we actually went out and collected data routinely that gave us the level of detail that we would like about ethnicity, and then we really could see, whilst anecdotally there were lots of concerns about particular ethnic groups participating or not participating in the vaccine programme, we did not know until we got the data. I think that data is really important. There is a balance to be struck. I will let Andy tell you a little bit more. So, as the minister said, we have quite good national data through our national surveys, health survey and household survey provide us a good level of understanding around ethnicity and participation. Sportscotland collect a lot of good information particularly around their major programmes like active schools, which used to really just look at participation stats, but now it looks a lot more deeply about participants who they are, where they come from, what they are getting out of the experience of active schools. So, again, the data is a lot better, probably incomplete in some places, but a lot better. Again, the balancing act is always around, you will have heard in previous evidence sessions, that sport relies on a lot of volunteers. Again, there is only so much you can ask them to do in a participant session. As soon as you start creating false barriers, almost when you are asking for too much data to be collected, both for the volunteer coach but also for the participant who may not be keen to share that information. So, there is definitely a bit of a barrier there around data, especially when you are dealing with volunteers who are just looking to put on a sport session, not filling 10 forms. So, I understand that the data that we collect through our national programmes through us and through Sport Scotland is not bad, it is pretty good, but again, some of that community-led, volunteer-led activity, there are some gaps, and we appreciate that. So, certainly, at that community level it is difficult to gather data and I appreciate that, but when you are on organisation and you are putting on organised events, I feel that you need to think about data, you need to think about what you have got. The reason I asked this question is because if you do not have good data and you have got a huge drop-off with ethnicity, well, why? And if you do not know why, then how could you possibly fix it? So, once you have got the data, so you spoke about the Household Survey, you spoke about other ways that you are gathering data, also our organisations have also, they are looking to improve it. So, now, once we get this data, will you centralise it? And then, there is no point in having it if it is not going to undergo some form of research. So, what research are we going to put into place to really try to drill down and find out why people with ethnicity are not participating further, as we would hope that they would want to? So, I think that individual sports governing bodies are looking at that in varying degrees, and they are, it is absolutely in their, they want more participation, so it is absolutely in their interest to ask those questions and to pursue the answers to those questions. I do not think that the answer will be the same for every sport, nor will it, you know, it is also difficult to generalise about different ethnicities. So, you know, we saw that, Rajani, the badminton coach initially, I think, or largely, was targeting Muslim women's participation, but actually, there is a whole variety of different ethnicities coming along. What she done was created a safe space for people of all different ethnicities to participate in sport. Now, is that about, you know, there are all sorts of barriers in terms of whom, you know, certain religions might have roles around modesty or clothing, but not all of them have. So, I think that once you get the data, you need to go asking, sensitively, questioning what the barriers are and trying to take them away for people. You know, as I said, participation is key, we're dead keen to improve participation, and all the sports governing bodies will be trying to do that. So, just back to, you know, when we get data from sports governing bodies, because a lot of those who appear in front of us don't have the data and said they are looking for it. So, once we've got that, will it be centralised or will you be able to access it at least, not to have an entire database? Would you be able to access it and then start to do research in it? We certainly will be able to interrogate it to an extent with the individual sports governing bodies. As I said, though, it's a bit, you know, it's a challenging area to coalesce all of that data, I would have said, and to make, to draw conclusions, because there are so many individual aspects to the sport and to the ethnicity that, you know, it's really important that we don't make assumptions, but absolutely open to having conversations about how we improve beam participation. There are all sorts of immense programmes around the country trying to do that, and I think it's really important that we have the data to support that and to support investment in that, to try to tackle some of the exclusion that is apparent. I would just add that, as part of our national governing structures, we have our data and evidence group that has main partners from across Scotland on that. So, again, it's something that we can definitely take away and look at in more detail. I think that it's come up in many previous sessions as income inequality and that preventing access to sports particularly, as was mentioned earlier on, where there are particularly expensive tax and term transport facilities, costs and equipment. What active steps is the Government taking to provide support in that regard, whether it's in the form of grants or loans for equipment or potentially even looking at things like kit libraries? Is there any measures that the Government is particularly looking to promote to try and address income inequality as a measure of access? I guess that the Government has, as one of its core missions at the moment, tackling poverty, particularly child poverty, as you recognise. Poverty impacts all of your life opportunities. Participation in sport and physical activity is just one of the areas that it will impact on. It's really important that we don't lose sight of that sort of whole system approach and thinking about, instead of finding ways to fix the problem like getting access to people for young people to sports, but as we also think about the bigger picture on how on earth can we tackle poverty and how can we make a difference? That is a really important thing for us to do. There are really good programmes as well in terms of kit libraries. Again, the young people sports panel came up with some brilliant work that is led by young people. They are young people who volunteer for leadership roles in sport and are supported by Sport Scotland to develop ideas and projects. One of the projects that they were working on was the kit library that people could access and share good quality items of kit. We need that work to happen at scale all around the country because there is absolutely no doubt that it is a barrier for participation. Recognising the challenge for participation in sport is one of the challenges. If you are working three jobs and struggling to keep your head above water, it is very hard to get involved in leisure and recreation activities. It is not just about the costs, it is about how tough people's lives are as they battle day in, day out with an acute cost of living crisis, which is what we are experiencing right now and how hard that makes life for them. I really think that the big challenge to Government—we are seeing huge efforts across the board on that. Yesterday, we saw some statistics that showed that, in Scotland, the level of poverty that children experience was 24 per cent, 29 per cent in the rest of the UK, so we are seeing some huge efforts and some benefit, but it is not good enough. We need to do more because living and poverty is all-consuming. It is hard to think about anything else if you are struggling to get access to food and heat and shelter. That is a fair point. One of the other challenging backgrounds—certainly, I came from a low-income background and one of the things that I did as a kid was to do swimming lessons, and that was because it was free, so I was able to take me along to local swimming baths. We mentioned earlier on about the cost pressures being faced. Free swimming is increasingly a scarce opportunity for young people, but it is certainly some of the statistics that have been put forward by Scottish Swimming. Around 60 per cent of swimmers are female, and it is the top participation sport for people with disability. Clearly, it is one of the obvious community-based facilities that is accessible at relatively low cost in terms of equipment and so on. However, the cost pressures—some of the council have reported that there is a 90 per cent increase in electricity and a 200 per cent increase in gas costs. I do know in England that they have introduced a swimming pool support fund. It is to the tune of £60 million, which is £40 million capital, £20 million revenue. Is there plans to introduce a similar relief measure in Scotland in trying to maintain access to swimming pools, perhaps conditional on things such as providing free access to young people in particular? As I said, those conversations are going on between ourselves and local authority partners on how we can ensure that the estate is able to invest in the estate in a strategic way to ensure that participation is maximised. The challenge with the allocation is that we will have consequentials from that, so we get about 6 million consequentials from the spend that came from that Westminster decision for England. It goes into the block grant, though, and it is in the general allocation of our budget, so it does not, just because it was spent on swimming and swimming pools in England, does not mean that it will necessarily be spent on swimming and swimming pools in Scotland. We make all sorts of different decisions, not least in this space, on the decision to fund the Scottish child payment, which is a uniquely Scottish benefit, which is game-changing, as commentators tell us, and is clearly having an impact on the level of poverty experienced by children and young people in Scotland. I will be working hard with local authority colleagues to try to see what can be done, but it is certainly not automatic that, because that decision in Westminster was made to invest in swimming pools, we would make the same decision in Scotland. The Scottish child payment is a classic example of a different decision that we make in Scotland that is making a difference in exactly the same area. There are opportunities to do things differently, and it might not be specifically that it is not automatically necessary to read it across, but there is a reasonable and pretty decent business case here to make sure that there is targeted, discrete support for, I am just saying this instance, swimming pools, because it is an obvious opportunity. Whether it is designed in the same way, that is a secondary consideration, but identifying that particular issue about the threats to those facilities and addressing it specifically. Absolutely, and as I said, there is lots of work going on already in terms of collaboration across the board with Sport Scotland and local government colleagues to try to look at those issues and try to ensure that the sporting estate has adequate investment to ensure that we can continue to support. Swimming is a fantastic example of a very inclusive sport, brilliant life-skill, pure educational. Learning to swim, learning to do something that is so frightening and succeeding at it is a brilliant educational experience, I absolutely would not argue against investment in swimming. We have lots of work going on to ensure that children at school can experience swimming lessons, but it is difficult financial times at the moment. We are just going to have to keep working together at ensuring the security for the future. Thank you very much, minister, and to yourself, Mr Sinclair, for your participation this morning. I am very much appreciated. At our next meeting next week, we will be holding stage two proceedings for the Patient Safety Commissioner for Scotland Bill, and that concludes the public part of your meeting today.