 Welcome everyone to the ninth meeting of the health social care and sport committee in 2022. I've received no apologies for today's meeting. The first item on our agenda is to decide whether to take item eight in private. Our members agreed. We agree. Thank you. Our second item today is an evidence session on tackling alcohol harms in Scotland and we've got four minutes with us today. They're all joining us remotely. I want to welcome to the committee Alison Douglas, who's a chief executive of alcohol focus Scotland, Professor Neil Fitzgerald, from the Institute of Social Marketing and the University of Stirling, Lucy Giles, the public health intelligence principle for public health Scotland, and Eleanor Jane, director of Scottish health action and alcohol problems. Thank you to you all for your time this morning. I'm going to open things up by asking, really, in terms of the pandemic. There's some figures out there which first look like that consumption of alcohol has gone down, but it's not really the whole picture, is it? I mean, I wonder if you can maybe just go round all of you just to get your views on what the consumption of alcohol and alcohol harms during the last two years, what that really looks like. I'll maybe come to Alison Douglas first. Alison, can you hear me? I'll maybe just move on if I can bring in Neil Fitzgerald. Thank you. I think you're right that that's not the whole story in terms of consumption falling. Some of the work that we've done is to look at ambulance call-outs during the pandemic and alcohol-related ambulance call-outs in particular. What we see is that, although when the bars and pubs were closed, alcohol-related ambulance call-outs were falling, even before bars and pubs reopened, we see a rise in ambulance call-outs to drinking at home, and paramedics and other colleagues in the licensing system have expressed a lot of concern about a rise in home drinking in particular groups. I think that, even as researchers, we were surprised that those call-outs to pubs and bars and to city centres were replaced so quickly by call-outs to people's homes. I suppose that what we're seeing is that, in terms of that indicator of alcohol-related harms through the ambulance service, there's a fairly even split between harms relating to short-term use of alcohol in relation to parties and city centres and chronic long-term use of alcohol where people are drinking heavily on a regular basis and often with alcohol problems. Can I come to Eleanor-Jane? Yes. I think that there's other people on the panel. Lucy, in particular, will be able to speak in detail about the figures and all the data around consumption levels and death rates, etc. during the pandemic due to alcohol. It really was a mixed picture, so, although consumption overall went down, it was a reflection of the fact that pubs and clubs and restaurants in places where you'd go out to drink were closed down. Whilst there was an increase in the amount of alcohol consumed at home, which was a continuation of a trend that had been going on for years, it was a massive acceleration of that trend where people consumed virtually all their alcohol at home. That is a concern in itself, but it didn't quite equate the amount that was the drop in consumption as a result of the closures of pubs, etc. during various different lockdowns. However, that does mask changes in consumption. Whilst there are various bits and pieces going on, we think that, potentially, the heaviest drinkers were at more risk of consuming more alcohol during the lockdowns. What we will potentially see is an increase in health inequalities as a result of that. We will see the difference between more affluent communities who potentially were consuming less alcohol and the heaviest drinkers and, potentially, some of our more disadvantaged communities drinking more. That is a real risk. Obviously, that happened during the pandemic, and we do not know what the long-term implications of that are going to be. However, it means that we need some sort of policy response, and we cannot just accept that. We need to see some sort of response, try and reduce those inequalities and to try and reduce those really harmful levels of consumption. I think that the data that you are referring to in terms of an overall reduction is probably the data that we published last week. We use alcohol retail sales data to monitor alcohol consumption at a population level, but it is important to stress that that is an average for the country. It does mask some of the differences that you would get by different subgroups, as Eleanor has alluded to. We think that what potentially is happening from other sources of data is that some people throughout the pandemic have possibly reduced their consumption, some have not changed their consumption at all and some have increased it. As Eleanor said, it tends to be those who are already drinking at the higher end of the scale that have probably increased their consumption. Essentially, what we have seen is a big shift towards drinking at home. That has already happened over the last couple of decades. We have seen a shift from what we would call on-trade sales through pubs and clubs towards the off-trade, but that has increased quite significantly. Typically, about three quarters of alcohol would be sold through the off-trade in the immediate years before the pandemic, and then that rose up to 90 per cent in 2020 and then increased further in the first part of 2021, because virtually all of the country was in a full lockdown. I think that there is a mixed bag. I think that what we also published, or what is more important, is the actual harms data that we published. At the point of the strictest restrictions, we saw a big decrease in the number of people who were accessing hospital treatment for alcohol-related conditions, and at the same time, we saw an increase in deaths from alcohol-specific conditions. I think that those things have more concern and point towards the polarisation of consumption as well. We saw that that was particularly true among men and those who were aged 45 and older. Those were the primary findings from that work. Lucy, you are looking at the data and the different demographics and what the patterns are there. In terms of rural areas in particular, is there anything notable in statistics there? It is not something that we have specifically looked at. The sales data that we used in terms of monitoring population level consumption, we cannot drill down by demographic group, but the data is not available for us to do that. We would have to look at other data, such as survey data, to be able to look at that. That is not something that we have specifically looked at. Are other panellists anecdotally, in the work that you do, might have something to add in terms of the arbor and versus rural, if there is anything of interest there in terms of alcohol harms and consumption, particularly in the last couple of years? While we have not got any data, in terms of the impact of the pandemic on consumption and harms in rural areas, we know that there is a very different infrastructure and culture around alcohol in rural areas. We have carried out research that has demonstrated that there is very limited access to alcohol free spaces. Because of the reliance of the rural economy quite often on tourism and hospitality, alcohol is quite central to a lot of the social interactions in rural communities. Although we do not have anything in relation to the pandemic at this point in time, it is important to bear the cultural difference in our rural communities in mind if we are going to be talking about different responses and how we build back from the pandemic and address some of the harms that have occurred. When it comes to the data that was published by the Scottish Government last week about isolation and loneliness going up, it is obvious that in rural communities it is going to be even more harshly felt. Those are things that need to be borne in mind that we cannot assume that the problems that are being experienced in rural communities are going to be the same in urban communities. We need to think of different ways in order to build back and make sure that we take action to reduce harm differently in our rural areas. I am now able to bring in Alison Douglas. Alison, I hope that you were able to hear at least some of what has happened there and you can come in from your perspective. Sadly, we cannot hear Alison. You should not have to do anything, Alison. What we will do is get someone from broadcasting to get in touch with you and sort out some of the problems. I am seeing a nod from my broadcasting colleagues. Sorry about that, Alison. Can I just come quickly to Neave before I hand over to my colleague Sandesh Gohani? I was just going to quickly add that if you are interested in geographic differences and differences between urban rural and areas of deprivation, ambulance call-out data could be looked at in more detail. We have not done that yet, but call-outs go to a very specific location. It is good data for making those sorts of comparisons, although it is not something that we were originally funded to do. There are a couple of things that I am really concerning when it comes to alcohol harms in Scotland. It is all borne out by the fact that we need to be absolutely clear that the average is not the average because there are people who are harmful drinking and it is very skewed. The thing that I found really concerning was that even though we have that overall reduction in the amount of alcohol that has been sold that you have spoken about, the average is 18 units per person per week. That is huge. That is over the recommended amounts that we should be drinking, which is 14. I suppose that my question would be what assessment do you think of the effectiveness of what steps we have taken? What is that effectiveness? I will let you answer that before I ask you my second question. I will maybe go to Neave Fitzgerald first and then I will come to Eleanor Jane. I guess in terms of alcohol harm reduction, the three key policies are making alcohol less affordable, making alcohol less available and making alcohol less attractive. Those are the World Health Organization best buys. When you look at what Scotland has done in relation to those, we have addressed price, albeit our minimum price for alcohol is quite low and has stayed low for some time, so that is something that we could look at. I believe that plans are under way to look at the marketing of alcohol and there are other countries that have done more on that and we can learn from them. We know that in other countries, for example, they have found that it is easier to take bigger and broader action on alcohol marketing than it is to take piecemeal action. One of my colleagues has looked at several countries in relation to their regulation recently. On the third one, in terms of alcohol availability, our researchers and practitioners are telling us that the licensing system, as it is currently set up, cannot reduce availability, so it is not possible to take licences away. There is a limit to what can be achieved on availability in relation to reducing alcohol-related harms. That is not to say that there is not good that can be done through that system and there are a lot of people working very hard on that. If you look across those three best buys, while Scotland is very much viewed as a leader in alcohol policy worldwide, there is still a lot that could be done on all three. In response to what you were saying, there is a proportion of the population that does not even drink. There are a lot of people who will be drinking way in excess of the 14 units, which is the minimum risk eye-glines. It is not a safe level to drink. That is just what the CMOs have agreed is the minimum risk limit in terms of what adults should consume maximum each week. That does mask an awful lot. As Neave said, there are the World Health Organization best buys, and the Scottish Government is very supportive and is brought into the World Health Organization's recommendations around alcohol policy. One of the fundamental measures that the Scottish Government has brought in is minimum unit pricing. The whole context of minimum unit pricing is that affordability of alcohol is directly related to consumption of alcohol and consumption of alcohol is directly related to the amount of harms experienced across the population. If you reduce affordability, you reduce consumption and you reduce harms. That is the clear evidence around that. That is what the World Health Organization recommends, which is why the measure has been taken forward in Scotland. When it was introduced at the level of 50p per unit in 2018, it was proposed to be 50p when the legislation was first mooted in 2012 but because of delays, because of the legal challenges to the legislation. When it was finally introduced six years later, it was introduced at that same level that had been proposed six years earlier. While we were supportive of that, we would argue that it should definitely now be increased if we are genuinely going to talk about reducing the affordability of alcohol. In terms of the affordability, alcohol is now, in 2020, 73 per cent more affordable than it was in 1987, which demonstrates why we have seen alcohol harms increase so much in that period. It is our view that, although MEP is a very positive measure, we want it to see it now uprated 65p in order to give it a bit more teeth and to impact on affordability a little bit more. What we would also like to see is for it to be automatically linked to inflation so that we do not have to go through regular reviews and legal processes and to operate it each time, but it should be automatically linked so that it does not have to go through regular reviews and legal processes and to operate it each time. It should be automatically linked so that its level of affordability is maintained. That is one measure that we would like to see taken further. There are lots of other measures that could be taken forward. On marketing and sponsorship, we think that it is a really big area that the Scottish Government is committed to introducing restrictions on that. It is our view that there should be total regulation of all alcohol marketing in Scotland, especially marketing that may affect children and young people and also people who are in recovery from alcohol problems, who are regularly exposed to marketing around alcohol and find this really difficult. What we would particularly like to see is an end to alcohol sponsorship in sports, because we feel that this is totally incongruous to have a healthy participatory activity, to have alcohol, which is intrinsically a harmful product involved in this. For instance, in the 2020 six nations broadcast coverage, alcohol was mentioned every five or six seconds in the broadcast of the Scotland-England match. That is the sort of thing that we would really like to see restricted. Try and make alcohol less like a normal commodity, but the commodity that it is, which is that it does come attached with health risks. There is a whole load of different measures that we think that the Scottish Government should take forward in this regard. Some of my colleagues are going to drill into some of what you have brought up. Can I come to Lucy Gelsen and bring in Alison, who I think has got our technical issues resolved? I was just back to the original question about the sort of effectiveness of the current policy that is in place. I just wanted to reflect on the fact that we have shown in the first year since MEP that that did have an impact of around about 3.5 per cent reduction in total consumption. Again, that is population-level consumption, and that is what the caveat is that that does mask across different groups. We have seen that there has been that reduction of 3.5 per cent in comparison to England and Wales where we saw an increase. We will be publishing data later on this year that looks at the longer-term impact of that, but there is also evidence there from other studies. A group in Newcastle University have published longer-term data looking at what that impact has been. They have shown an impact of around about 7.5 per cent reduction in consumption based on purchasing data, and that has been sustained over the longer term. We will be publishing three years' worth of data later on this year. In terms of how that translates into harms, we have not yet published that data. We will be publishing a study next year that looks at the impact on not just alcohol-specific and directly alcohol attributable conditions, but on a wider range of both holy and partially attributable conditions. We are looking at the impact of MEPs specifically on health harms, but we just do not quite have that data yet. We can hear you perfectly. Brilliant, thank you. Just to sort of build on what others have said, Lucy talked about us seeing the reduction in consumption. We did see in the first full year of implementation a minimum unit price of reduction in alcohol-specific deaths of 10 per cent. Obviously, we cannot take one year's data as evidence of a trend, but I think that that gave all of us hope that we were seeing that effect on consumption starting to translate into a reduction in harms. There is also some evidence that the hospital admissions had reduced slightly. I think that there were some preliminary indications of positive effects on harm, but obviously the pandemic has set us back. That substantial increase in deaths that we saw in 2020 was shocking to all of us. To link to the first question that you had, what deeply concerns all of us are working in this area is that Scotland already has death rates that are 60-70 per cent higher than those in England. If we are seeing a significant impact on heavier drinkers in terms of their drinking patterns as a result of the stress and anxiety of the pandemic, we could be looking at a terrifying trajectory for Scotland and its alcohol problem going forward. We had seen an increase of tripling of deaths from the 1980s. When we have been seeing some reductions over the last number of years or a broader trajectory from the early 2000s, we absolutely have no room for complacency. That is why we need bold policies. We need to follow what the World Health Organization is telling us will have an effect on preventing alcohol harm and reducing alcohol consumption. That is why we need minimum unit price, but as Eleanor has said, we need to think about how we optimise that policy. I think that what I take from the evidence so far and minimum unit price is a cause for confidence that this policy does have the effect and can have the effect that we hoped it would when we implemented it. It is not having any of the unintended consequences that people were concerned about. We are not seeing people driving in their droves to England by their alcohol. We are not seeing people turning to drugs. We are not seeing the industry driven to the wall. We are seeing that we need to increase the price in order to get the more positive effect. Let us not forget that the original modelling showed that a minimum unit price of £60 per unit would deliver double the benefit of £50 per unit and £70 per unit would deliver triple the benefit of £50 per unit. It is both about making good inflation but also about optimising the policy. My colleague Stephanie Callaghan will come back specifically on minimum unit price. Sandesh, do you have a quick follow-up question? We might have to direct it to one person so that we can move on. Did you have a second question? Absolutely, convener. The second question was about the fact that the most deprived parts of Scotland have death rates eight times that of other areas. What I would like to know is, are we doing enough targeted support for those areas? I suppose that the person that I quite like to hear from is Lucy Giles. Absolutely. The data is really stark in that regard. We have much higher rates of alcohol hospital admissions and alcohol deaths in the most deprived areas when we compare those to the least deprived. That is not all down to consumption. That is not straightforward. People in those areas are drinking more. There are more structural elements at play that need to be addressed in order to address inequalities more widely. By addressing those inequalities more widely, you will start to address some of those inequalities that are specific to alcohol. I was heartened by the fact that I have seen that you have a call for evidence specifically around inequalities. I would ask the committee to take heed of what comes out of that call for evidence and start to implement some of those measures specifically around income inequalities, employment housing and all those things. It all plays apart in terms of the more structural elements that sit behind those data. Can we run questions around some of the Scottish Government policies that are in place? Emma Harper. Good morning to everybody in the panel. I think that Dr Gilhoney has covered some of what I was going to ask. I am interested in where we have made the best progress. We have talked about not some of the best progress as far as it relates to health inequalities. I think that you talked about if we affect the affordability that directly relates to consumption. If we reduce consumption, that reduces harm. I am interested in what we should do to continue with implementing the best progress. Where do we need to change tact, especially when it comes to pandemic work? As I said earlier, we want to build on the success of the introduction of minimum unit pricing in Scotland. As Alison was saying, the data suggested that it was having a positive impact in the year after its introduction, but then the pandemic came along and changed absolutely everything in terms of consumption. We saw death, sadly, increase quite dramatically in 2020. I think that, although we saw that initial positive impact, that is why we are now asking for a minimum unit pricing to be operated to direct the impact on affordability once again and therefore reduce harms. That is a particular measure, but the World Health Organization recommends that we take action on attractiveness and availability. Those are areas where there is probably quite a lot that can be done in Scotland now. That is in terms of marketing and restricting alcohol marketing. As I said earlier, in terms of sport, it can be much more generally online, it can be in the street, it can be in various different types of media that we consume. Also, in terms of labelling, labelling could be much clearer and provide health information to consumers. In terms of availability, there are measures such as restricting the hours that alcohol could be sold, so that the hours in which it can be bought could be reduced and therefore availability would be a little bit restricted. We could also follow in the footsteps of, for instance, Ireland, which has introduced what is colloquially known as a booze curtain in shops, but treating alcohol similarly to tobacco products, where it is behind a curtain. Children cannot go in there, and it is not seen as part of your normal shop or everyday shop, but it is seen as a slightly different product that you have to go out of your way to buy and then consume. I think that there are measures across all those areas that could be taken, but I do think that the harms that we are now seeing as a result of the pandemic make all those options more urgent, and we do need to see action across them or the Scottish Government to start to bring forward some proposals quite quickly in order to make sure that we do not see increasing inequalities as a result of the pandemic. Alison Douglas wants to come in. As has been mentioned, there are real structural drivers, as we all know, of inequalities, and it can be quite difficult to identify interventions that can help reduce health inequalities without dealing with some of the fundamental issues around poverty. When it comes to alcohol, interestingly, alcohol interventions reduce health inequalities. We are currently looking at, still unappalling statistics, that you are four times more likely to die an alcohol-specific death if you live in our poorest communities than our richest. That is significantly lower than it was 10 years ago, when you were even more likely to die an alcohol-specific death. When we reduce consumption and harm overall in the population, that has a disproportionately beneficial effect on our poorest communities, those that are suffering the greatest inequalities. That is true of minimum unit price, as a policy is that it will deliver greater benefits to those who are suffering the greatest inequality. I think that that is a positive that we can take from alcohol interventions. Just at build on Eleanor's point about the availability of alcohol, work that we did with the University of Edinburgh showed that there were 40 per cent more places to buy alcohol in our poorest communities than in our more affluent communities, and places with higher density of places to buy alcohol experienced by the level of harm of those with lower levels. Again, we are seeing that inequality playing out, and frankly, in my view, the targeting of our poorest communities by those that are selling and promoting alcohol to the detriment of the health of people in those communities. Availability, as has been discussed, is one of the three best buys for alcohol policy, and yet we have a licensing system in this country that legally does not allow local licensing boards to reduce the number of places to buy alcohol in those areas. We see a year-on-year increase in the number of places that we can buy alcohol in over 16,000 places in Scotland. We have also seen diversification in the types of places. Now our cinemas are licensed, many coffee shops are licensed, we have even got licensed hairdressers. We really have to stop and ask ourselves, why are we allowing this to happen and do we not need a more effective system to grow alcohol availability in Scotland? Just to come back in on the point about availability, I think that the other thing just to add to everything that Alison said there, which was really on point, is that not only can we not address the physical premises that are in communities, but what we are seeing through the pandemic, of course, is also a large increase in online sales. In the work that we are doing in England, what we are also seeing is an increase in rapid delivery services, grocery delivery services, which rely heavily on alcohol for their profits. That has not become really endemic in Scotland the way that it is in London currently. I think that if we want to try to address availability, we are really losing a battle even in terms of containing availability, never mind reducing it when we look at how easy it is to buy alcohol from apps and online. The licensing system currently is locally organised, so you have the situation where very large online retailers can open a very large warehouse and the decision on that warehouse, which is serving the whole of Scotland, can only be made by the local licensing board where the warehouse is located. They cannot take into account any harm to the rest of the country when they are making that decision. The system, as it is currently designed, does not address deliveries from other places, it does not address online remote deliveries, and that is a really key gap. There are gaps in terms of our ability to control physical outlets, but there is potentially a window of opportunity now to close the barn door before the horse bolts if it has not already on online sales. We turn now to alcohol brief interventions. On Public Health Scotland, there are a number of documents to support healthcare professionals to deliver alcohol brief interventions. I know that it is available as an e-learning resource on the TURAS e-learning platform. Are we tracking the uptake of that by healthcare professionals, whether you are a nurse or a doctor or anybody that is participating, especially for primary care people and our A and E professional staff? Is that something that is a good thing where the ABI is something that is working? It is not really my area in terms of Public Health Scotland. I used to work in alcohol and drug partnerships, and as part of working there, we certainly did track ABI at that time. It had a heat target around it, so we certainly tracked it as part of that. It is not an area that I am involved in now, so I am afraid that I cannot directly answer your question, but I can endeavour to find out and get back to you. Beyond that, I am afraid that I am not really able to comment on ABI specifically. Neil Fitzgerald wants to come in. Scotland has made really good progress in the delivery of ABIs. I would say that it is a world leader in terms of that national programme, but the programme has not changed much since it was originally started. It is similar to Minamunir pricing, but we really need to look at how we can build on that success, what else needs to be done. I believe that ABIs are still tracked. There is still annual reporting of the delivery, but there is an issue in terms of the new GP contract. The delivery of brief interventions by general practitioners has fallen in many areas under the new GP contract, where prevention is not as big a priority as it was previously. Care of chronic illness has been more of a priority in that contract. What we know still is that there are many, many people who are attending health services with conditions and problems that are affected by alcohol, maybe caused or worsened by alcohol, who are still not asked about alcohol consumption as part of that. There are issues around how effective those conversations are. We need to do more to understand what the best way to manage those conversations is in order to help people to make change and give people the best opportunity to make change. Some of the research has moved on since the original programme in Scotland could probably be drawn on to help improve that, but there is also a need for more fundamental questions. We definitely need those conversations, but what is the best way to have them to have the best effect? There are still issues that could be addressed. Any programme like that relies on continued momentum, leadership and training, and that is something that is hard to sustain. There were a lot of people trained to train health professionals in the programme. That training for trainers has not continued. There are certainly more than could be done, but it is important to remember that, although people should be informed about alcohol when they are appearing with conditions that are affected by alcohol, the evidence for the effectiveness of alcohol brief interventions in terms of a solution to alcohol-related harms is not as strong as it is for pricing, availability and marketing interventions. Emma, I have a supplementary question from Sue Webber. The number of alcohol brief interventions has declined by 28 per cent between 2013-14 and 2019-20, so we have heard a bit about some of the challenges that you have mentioned and the number of issues that are going on. What value do you attach to those alcohol brief interventions and what are the challenges that are going on? What do you think that the Scottish Government must do to try to reverse that decline in uptake? I think that one of the issues is that that is recorded alcohol brief interventions. Previously, there was greater incentivisation of the delivery, so when people are being paid to deliver, they are more likely to fill out the form that says that they did deliver. I think that we cannot really be sure whether there are fewer conversations about alcohol happening or whether there is less recording of those conversations because people are not receiving a payment every time they deliver to the same extent that they were previously. I would be a bit cautious about the trends. What value do I place on that? I think that that is a really good question. I do not think that we should be viewing reducing one of Scotland's biggest health problems as an either or. Although I did say that interventions on price availability and marketing have stronger evidence for effectiveness, I also feel quite strongly that people are suffering from conditions and visiting health services. For example, people with depression or people who are not sleeping have a right to know that alcohol may actually be playing a part in that depression or may be really affecting their sleep. They are not always told that. I think that that just feels like quite an easy win. It is not terribly difficult to get across to health professionals if we make it simpler. I would say that there are also other advantages of raising the awareness of health professionals in that way and enabling them to have those conversations, which is that you generally create a trickle effect. I was very involved in training health professionals myself back in the day when the programme was first rolled out. What we often found from health professionals is that they would say that not only did the training change their practice but also that when they went back to the surgery or back to their homes, they had lots of conversations with other colleagues, with family members, about what they had learned and how their awareness was raised about alcohol. I think that there is a transformative effect of that sort of level of programme. It is more resource intensive than simply operating minimum unit pricing, which can be done easily. There is a greater resource commitment needed to roll out a big programme of brief interventions and there is to ban marketing or to address pricing. On minimum unit pricing, Stephanie Callaghan, you have picked up some of the issues that have been mentioned. Good morning to the panel today. I picked up the very same point I had there. The mention of affordability directly relates to consumption and that directly relates to harm. That is a really important one there. We have heard quite a lot of different figures as well. Clearly, there has been an issue around Covid and so on with evidence. How effective do we think that the minimum unit pricing policy has been so far in addressing alcohol harms in Scotland and how strong is the case for continuing that beyond the five years? I refer back to the evidence that I have already shared. We have demonstrated that there has been a reduction in population level consumption. In the first year following implementation, we have evidence from other studies outside of the PHS. From Newcastle University, we have essentially triangulated that evidence and demonstrated a sustained impact of MEP on social purchasing at a household level. We have yet to demonstrate the impact on the harms that we have been talking about, such as hospital admissions and deaths. We will be producing that data and that study in approximately a year's time. I will go back to the evidence that Alison was summarising. Some of the more potential unintended consequences have perhaps not been realised as they were expected to be. For example, we have not seen people turning to drugs. None of the studies where we examined that have we seen any evidence of that or people trying to have more harmful substances such as non-veverage alcohol. Not to say that we have not seen any instances at all but where we have been in the minority and not widespread. We have not seen things such as the cross-border purchasing. We have not seen people trying to circumvent the policy by going down to England and purchasing cheaper alcohol there. With the Newcastle data, we have seen essentially a step change. We have seen alcohol consumption at this level and it has fallen to a level and that has been sustained. The evidence suggests that it does not continue to have an on-going effect if you assume that it is just a step change. If you want to see any further improvement in that, action would need to be taken. Alison Douglas Obviously, Lucy is taking a very rigorous view of what we can and can't say about the evidence. You have heard me say earlier about the 10 per cent reduction in deaths in 2020. Quite rightly, Lucy is not putting that forward as proof for a robust basis for thinking that minimum unit price has delivered the reduction in deaths that we saw. It would be accurate to say that we have seen in the past some one-year reductions in deaths that were noise in the system and were not sustained as trends. It is quite right of her to be robust about what she is saying is clear evidence of the impact of MUP. However, it is also fair for those of us who are closely interested in this policy to remind people that that did happen in 2020. Possibly that is an indication that MUP is having an effect on harm, but we will have better evidence on that going forward. So often this is about comparing Scotland to England or Wales as control countries so that we can identify what is likely to be attributable to minimum unit price and what isn't. It is also worth remembering that alcohol causes a wide range of conditions. When the modellers were originally looking at how many lives it would save, they were looking at deaths that would—this is why they talked about the full effect of minimum unit price taking 20 years to show up. Some of the deaths are due to things such as cancers or liver disease, which may take 10 or 20 years to manifest themselves. I think that this is part of the problem that absence of evidence around the harms is not evidence of absence. I think that the fact that we are seeing consumption being significantly reduced gives us all real cause for optimism that we will in time see that reduction in harm. I think that it is important to remember that that fundamental relationship between the price of alcohol and how much people buy hasn't changed since minimum unit pricing was introduced. The case for increasing the price of alcohol through taxation and minimum pricing still stands. It is not that different to many other commodities in that respect when something is more expensive that people purchase less of it. Although the pandemic has made it difficult for us to assess those trends because it is just like putting such a ripple in the data in the trends that we see that makes it more difficult to assess, it doesn't change that fundamental relationship, which is the law of economics that applies worldwide in relation to when prices go up, people tend to purchase less of them. Just in terms of economic impact, it is worth adding in relation to minimum pricing as well that not only did we not see unintended consequences in terms of the collapse of industry, as Alison mentioned, but we also have evidence from a study with smaller retailers and communities that they welcomed the policy and that it had real benefits for them in terms of their ability to survive as businesses. I think that support from perhaps unexpected quarters in terms of the benefits of minimum unit pricing and I'm sure that that would be even greater with a higher level. I think that it was great to have Alison mentioned the longer-term effects over 20 years or so and there's all the ripples that go out as well and impact our children as well and their lifestyles going forward. Going back to the data bit there as well and again it's a question perhaps for Lucy is about are we going to have a strong enough evidence base for this? Is it going to be really difficult to kind of relate improvements back to the minimum unit price and just because of everything that's happened or are you kind of expecting that evidence that's coming through next year in hospitalisation and deaths to be quite supportive of minimum unit pricing? In terms of what the results are going to show, I'm not going to speculate because I'll wait until we've done the work and have the kind of hard evidence there, but certainly in terms of the pandemic happening when it did, that's backbanging in the middle of our post-intervention period. We're looking at the impact on harms in the three years following implementation and obviously the pandemic started in earnest in the UK in March 2020 so that will have an impact but we're implementing measures to try and still be able to confidently say what was the impact of MEP. For example, we will look at just the post-MEP but pre-Covid period so we'll look at data up until the end of February 2020 so that Covid is having no impact there and we'll also then in the longer term taking that data up to the three-year point will apply measures to account and adjust for the fact that the pandemic happened when it did. None of that is perfect. I think that we have to remember that this is essentially what we call a natural experiment so there are a multitude of different things that can impact on how well you can tell what the true impact of an intervention is when it's been implemented in this kind of way at a population level but we are applying the most robust methods that we can to be able to do that. The other thing that we need to bear in mind is that there isn't just one result here. We are looking at the impact across a broad range of outcomes so not just on consumption or harms or health harms specifically but also on crime, children and young people, specific groups within the population and so there isn't just a single answer here that says yes it's effective or no it's not. There are a multitude of different impacts and effects that will have to be weighed up as part of the final report that we will put in front of Parliament in 2023. David Torrance, do you have a question on this? I think that my questions have been answered about the increase in price than it has been in dexlinked. I am interested in the alcohol industry as a big business for Scotland's economy. How do we help the business of Scotland to be supported but also how do we support the alcohol industry to take responsibility or support them in what they need to do to help support alcohol harm reduction? Maybe Alison, you might have some thoughts on that. Yes, and again I think that it's really helpful if we're guided by the World Health Organization in this. In terms of public health policy, the alcohol industry should not have a role in that policy because there is a fundamental conflict of interest there that the industry exists in order to make profits or shareholders We know that a significant proportion of their profits come from people drinking above the low-risk guidelines, particularly from the English figure. We don't have a figure in Scotland, but estimates are that 4 per cent of the people who drink, the heaviest drinkers, are responsible for 30 per cent of the revenue of the alcohol producers. You can see there that, while the industry may say or may say that it wishes to reduce alcohol consumption and to reduce alcohol harm, that that's incredibly a conflicting thing for them to try and do because it would strike at their profitability. We have to be realistic and principled about that and not have the alcohol industry participate in public health policy making and instead route that in the international evidence and independent sources of evidence and advice. Indeed, we haven't touched on what the public wants this morning. When we survey people about their support for the minimum unit price independent survey that Public Health Scotland has published on the data, almost half of Scots support it and another 20 per cent are neutral. There is strong public support and that has built since minimum unit price has been in place. Similarly, when we talk to people who are in recovery, they talk about how they see alcohol everywhere and how, when they are in the early stages of their recovery, they can't even go into shops. They have to get other people to shop for them because alcohol is so present and so attractive. Children and young people are telling us work that we did with the children's parliament, work that Young Scott has done, that they want to see alcohol marketing restricted. They see a lot of it in their lives and they are very aware of sport sponsorship as well and they want that to stop. They don't feel that they should be subjected to that in their daily lives. We need to be prioritising what people in Scotland want and the place that they want alcohol to have and protecting their interests rather than enabling the alcohol industry to influence. As we have seen, they postponed the implementation of minimum unit pricing by almost six years because of the legal action. They will say that they were perfectly entitled to do that, which technically they were, but morally I would question when the Parliament had voted for it, when the public supported it, why were the industry self-seeking in trying to protect their interests and prevent that policy from being implemented. There are a few points around what the alcohol industry does and says that can confuse issues when it comes to public health. One of the main actions that the alcohol industry promotes is education around alcohol, but we know from the World Health Organization that if you are going to improve health, education is one of the less effective interventions that can be made and we should be talking about price availability and attractiveness because they are much more effective in reducing harm. We also know that when the alcohol industry takes voluntary action to try in lieu of any actual regulation from government, for instance, around labelling, they will potentially put information on labels but will portray it in a way that downplays risks or put it in a slightly see-through colour. Although it is on the label, it is very illegible compared to other information that is on the label. Regulation of the industry in terms of labelling and marketing is important because their voluntary approach is not rigorous enough. There is quite a lot of work that has been done in terms of the world of academia that, with peer-reviewed articles, is looking at what the alcohol industry has done and showing how ineffective it is in conveying information to consumers. Finally, there has been an academic review of health information that has been put forward by the alcohol industry and other industries such as tobacco and gambling, which shows that when the industry puts forward messages around risks to do with alcohol and cancer, it can downplay them or confuse them. When a normal person, such as myself, reads them, they will come away thinking that they are not quite sure of the risk, whereas if they were to read information from a health body, they would be quite clear about the risk of alcohol in terms of their health. The public health issues around alcohol need to be kept very separate from the alcohol industry. I was going to say that, removing on to Julie Mackay, I was going to dig into this a little deeper. I completely forgot that Sandesh wants to come in with a question on minimum unit pricing. We have heard a lot about minimum alcohol pricing today and the potential benefits of increasing it and the potential benefits that we have already seen with a lot of things coming out. The WHO had three themes—affordability, advertising and availability. I do not want to touch on advertising because I know that there is a whole theme to go on that. What I want to talk about and ask directly is about availability. I was offered a drink when I got my haircut. I was offered a drink when I went into a cafe and I was offered drinks when I go and try to watch a film. That makes alcohol availability ridiculously easy. It is everywhere. What can we do to reduce this? Do you agree that we need to reduce it? Do you want to direct that in particular, or does anyone particularly want to come in on that? Maybe I can go to Neil Fitzgerald on that. I think that that was something that you mentioned a little bit earlier, Neil. I am happy to take that. We are just in the process of completing a very big review of public health involvement in the licensing system in Scotland and England. We have compared the two systems and looked at whether we can achieve reductions in health and crime harms from alcohol through the licensing systems. Without wanting to pre-empt papers that are not published yet, I will certainly share them with the committee when they come out later this year. It will not be any surprise for people to say that there are huge challenges within the system in addressing availability. However, there are things that could be done and should be done. We do not have a strategic national approach to licensing in Scotland or England. We do not know what the trends and progress are in availability. We do not have a good live accurate register of premises that are selling alcohol with their opening hours, their capacity, when they open, when they are trading or when they close. We cannot even monitor the trends, but we know that availability is increasing, as you say. I would absolutely agree with you on that. We also do not have a routine national analysis of what is happening locally. Alison will be able to say more about alcohol-focused Scotland's work in relation to that, but it is not something that is resourced nationally in terms of comparing local licensing policy statements and licensing data. That is something that is done on a voluntary basis at the moment. We also do not really have sufficient support, I would say, for local public health teams in terms of what they can do. For example, legal advice and legal support to them. One of the barriers to stronger action on licensing is that local authorities and public health teams, if they are making objections, are concerned that, if they take strong decisions, they will be challenged on those decisions. As Alison said in relation to other legal challenges, that is the right of the applicant for a licence to challenge those decisions, but they quite often have access to considerably more resources for legal advice and support than others do. There are other things that I think we could do, so we know that public health teams are engaging and doing well in terms of engaging effectively with local licensing systems to try to make the case around health harms and health data, but really they can only have a realistic expectation that that will slowly change practice. Even within that, it is very difficult for licensing boards in our local authorities to decline licences. The system is set up as a permissive system, so I think that there is more that could be done in terms of guidance, but guidance is not the same as a change in the law. If we really want the licensing system to be able to achieve the licensing objectives, it probably needs to be looked at in a more fundamental way. Just to pick up on what I said earlier, the other thing that it is not even designed or even at all able to deal with is online sales and online availability. That is a small proportion of sales at the moment, but it is going only in one direction. It is much harder to reduce availability once it is already out there than it is to prevent it from increasing. That is something that needs to be looked at probably as a matter of urgency within the system. As things stand, in terms of you being offered a drink when you go to get your hair cut, we cannot take that licence away once it is granted. The system does not allow that to be done. It would be quite a fundamental reform if you were looking to do that, but at the very least we should be looking at strengthening the system to do what it is supposed to be able to do now, which is at least to contain availability in areas where there is existing high availability. I am going to briefly bring in Lucy Giles on your question before I move to Gillian Mackay. Lucy? I just wanted to follow up on what some of what Neave was saying there around data. I am involved in a piece of work at the moment in alcohol surveillance systems, so essentially bringing together lots of data sources, monitoring a range of different indicators at both local and national level. Neave highlighted some of the issues that we have there. If we do not have the data, we cannot tell how we are impacting with different policies and with different local interventions. It would be really supporting what Neave is saying there around trying to ensure that we have good quality data to be able to then monitor where the problems and issues are and then progress against those. The long-trailed Gillian Mackay, over to you Gillian. Thank you, convener. I am aware that we have touched on various other questions and bits of marketing and sponsorships. I am going to try to squish questions into each other to try to cover everything. We have already referenced the SHAP report on alcohol marketing during the Six Nations. Does the panel believe that there should be a full ban on alcohol sponsorship of sport? Given that alcohol sponsorship can be very lucrative and many sports clubs are facing challenging financial circumstances, does the panel have views on how we can encourage clubs to move away from alcohol sponsorship? Does a full ban be better through legislation, or what mechanism should be used for that? Alison Douglas, first. It is interesting, because the prevalence of alcohol sponsorship of, for example, our football clubs has changed over time. There was a time when it was more dominant than it is now. We did some research into premier and first division clubs. What we found was that a small minority of sponsors were alcohol sponsors, but where they were sponsoring clubs, those deals could appear to be significant in terms of the income for the club. It is very difficult to get figures on that. You could tell just by the prominence of the sponsors that that was the case. We need to look at the experience that we had from tobacco. Obviously, tobacco advertising and sport sponsorship have been banned for some time. What tends to happen is that there are other sponsors that come out. I would not want people to rely on betting companies, but betting companies have become more prominent. There are IT companies, finance companies and so on. There is a broad range of sponsors that are sponsoring at the moment. One way of managing the transition would be to phase it out. Another approach that they have looked at in Australia is to create a fund to help clubs out in the short term as they transition. I think that there are ways of doing it. Tobacco gives us a good experience that it does not necessarily mean that clubs will fail because sport sponsorship has been withdrawn. I would like to applaud Scottish Women's Football, which has rejected alcohol sponsorship and gambling, as it happens. It is possible to do it from a purely voluntary basis, but I also recognise the pressures that it puts Scottish Women's Football under compared to their male counterparts. They do not have access to sponsorship money and funding and partnerships in the same way as their male counterparts. I believe that, instead of encouraging sports clubs, leagues and competitions to reject alcohol sponsorship, a ban is a fair way to go about it. As Alison said, we can take the assurance that, when there have been bans of other products such as tobacco, that has not led to any clubs going under our competition suffering, but other industries have stepped into their place. I do not think that there is anything that we need to worry about if we were to introduce a ban, but we should create an independent body to oversee it and take it forward in the round to make sure that it is comprehensive. For instance, in France, there has been a good ban on alcohol sponsorship in sports and marketing. There is a grey area where it has been introduced, but the alcohol industry still gets into competitions and on TV by using alibi marketing. We are, for instance, in the six nations. Instead of having Guinness emblazoned on hoardings and on shirts and such, it uses a different word but clearly uses the Guinness branding. We would need to learn from other countries where restrictions have been taken forward to make sure that we make it as effective as possible if we were to do it in Scotland. Just to follow up on some of the other measures, what is the panel's view on other preventative measures such as a social responsibility levy on retailers? The Scottish Government has stated that it would take action to improve alcohol labelling. What impact could mandatory alcohol labelling have on alcohol harm and what changes would the panel like to see? I think that in terms of the levy on retailers, when you look at who has, I suppose, profited from the pandemic, it is largely shops that have profited at the expense of bars and pubs. So there is a windfall there from the harm that we have been talking to you about in terms of increased deaths during the pandemic due to alcohol. I think that there probably is a strong moral argument for clawing some of that back. If we are to operate the minimum unit pricing, that, of course, does also create additional profit within the system that largely goes to retailers at the moment. I think that there is a strong argument there to look at what we could do with that funding in order to address some of the other measures. Minimum pricing in and of itself does not cost very much to implement it. It uses largely existing systems for enforcement and compliance, but other measures are perhaps more expensive, especially around treatment and beef interventions, as we have discussed. I think that there is a strong argument there in terms of looking at some way of redressing the balance around that. The social responsibility level is currently on the statute books but has not been enacted. In part that was originally motivated by the fact that minimum unit pricing potentially would result in significantly increased revenues. It is something that some people have said, well, aren't you better with tax because tax means that the money comes into the public purse rather than going into the pockets of retailers or producers. I have a lot of sympathy with the fact that we do not want the supply chain to make more money out of selling less alcohol. I think that that is unhelpful because it creates an incentive particularly to retailers to promote the sale of alcohol because they are making more money out of it. That does not help us in our longer term objectives. The Scottish Government is estimated that minimum unit price would result in an increased revenue for the supply chain of £34 million. We do not know how much of that is a pure profit, but a proportion of it will be. What we are advocating for is an alcohol harm prevention tax and that would apply to retailers selling alcohol and it would come into the public purse and be used to offset the harms caused by alcohol and could be used at local level. It is kind of like a version of the public health tax that we had a few years ago and it would be linked preferably to how much alcohol the retailer sold. That relates to a point that Neve was making earlier about availability. A very important opportunity for us is to create a condition on all licence holders in Scotland to provide data on how much alcohol they sell. That would really help inform local licensing decisions and the national strategic approach to controlling availability that we have talked about. On the labelling issue, consumers have a right to know what is in their drinks. At the moment, alcohol is an exception to legislation that requires every other food and drink item to have details on ingredients and nutritional content. That does not apply to alcohol, so we have a carcinogenic product that has less mandatory requirements on labelling than any other food or drink item, which is just ridiculous and unacceptable. We are calling for a comprehensive labelling and that should also include mandatory health warnings. Before I go over to my colleague Sandesh, I have always been surprised that we do not have calorie information on alcohol. Do you think that having that kind of information would have an impact if people knew how many calories were in alcoholic beverages? For people who drink, alcohol represents about 9 per cent of their calorie intake on average. That is really pretty significant. We know that it is a motivating factor for people to cut down on their alcohol consumption when they are trying to lose weight. That absolutely should be on the labels that are required for other food and drink items. Recent research that we did shows that we analysed 30 different types of wine—white wine, red wine, rosé, sparkling, fruit wines—and what we showed was that you have absolutely no idea just based on the type of wine that you are drinking—how many calories it contains or how much sugar it contains. Sometimes those things are inversely related, so you might think that you are making a healthy choice by having a lower alcohol wine, but you might end up drinking significantly more sugar because of the inverse relationship. A bottle of red wine had 600 calories in it, so it can be highly calorific and contain a lot of free sugars. Two glasses of wine of one wine was equivalent to the 30 grams of sugar that should be the maximum that you are consuming in any one day. If people do not have the information, they cannot make informed choices, and that is why it needs to be mandated, because the industry will not do it without being required to do it. I just want to be absolutely clear, because I am staggered by something that you have just said, and I did not realise that this was the case. We have increased the price, say, from 30 people a unit to 50, arbitrary numbers, but we have gone up to 50. The extra cash does not go to, say, the NHS or rehab programmes. The extra cash is going back into the supply chain, maybe going back to the manufacturers. Is that correct? Is that what you said? That is correct. The policy is obviously there to improve public health, and that is what the modelling told us would happen. That is what we think is happening, the early evidence is showing, but absolutely the increased profit from that is going back into the supply chain. The industry, not surprisingly, is not willing to reveal where that money is going, whether the retailers are pocketing it or whether it is wholesalers or whether it is the manufacturers themselves. It is really difficult to get under the skin of that, but companies will be making increased profits as a result of that. That is exactly why we think that there needs to be an alcohol harm prevention tax so that that money comes back into the public purse and is used to prevent and tackle alcohol harm. The UK internal market act has specifically been amended by the UK Government to carve out pricing-type policies in relation to the sale of goods. The act now makes crystal clear that pricing-type policies in relation to the sale of goods, for example, minimum alcohol pricing, are out of the mutual recognition principles. Considering those changes, do you have any further concerns about the bill? I suppose that is directed directly to Alison. We have significant concerns about the impact of the internal market act on public health policies in general. That goes way beyond alcohol. Our colleagues who work on tobacco and unhealthy foods have expressed very similar concerns, and they go wider than that. On public health, there is a very strong risk that the internal market act could curtail the Scottish Parliament's opportunity to take action. The difficulty is that we are dealing with new legislation and an evolving situation. At the moment, work is on going around common framework agreements. I believe that there are three framework agreements in relation to labelling. You can already see that that is pretty complex to navigate in terms of what that means for the Scottish Parliament's opportunity to legislate around alcohol labelling. In relation to minimum unit pricing, it is correct that the UK Government did explicitly exclude minimum unit pricing from the mutual recognition element. However, it is not clear what happens when, for example, as we are asking for, the price increases. As I understand it, the act said that extant legislation would not be affected, but if there is a change to that legislation, as there would have to be to uprate the minimum unit price, what does that mean? It at least opens the possibility of a legal challenge by the industry again. I think that that is a very real risk. We saw the determination of the industry in taking Scottish Government to all the way to the Supreme Court over the initial legislation. It could well challenge it around uprating under the new internal market act, which is a different test and new test compared to the European context in which the original case took place. On labelling, as I understand alcohol supply, it goes from the manufacturers to wholesalers, and the wholesalers supply the shops. A lot of wholesalers are in England and supply Scottish shops. Labelling surely has to have a four-nation approach, because otherwise Scotland might be in danger of not having access to these other wholesalers. One of the big issues with the deposit return scheme was exactly this. Is it not a good thing for labelling to be a four-nation approach that we get it right for everyone? Absolutely, but it is more than 10 years since the Scottish Government recognised that labelling of alcoholic products was inadequate. For two years, we have been waiting for a UK four nations consultation on a narrow improvement to labelling, specifically around calories. I believe that they are also going to consult on putting the chief medical officer's low-risk guidelines on. That is only part of what we would want to see on a more comprehensive labelling regime. As I say, even though we understand that there has been agreement to have a UK-wide consultation, we have been waiting for that for two years and it still has not come out. It is not also the case that when it comes to labelling in terms of the marketing of products, you could have differential labelling for Scotland. For example, when the world cup will be labelled, it can be done in other cases. It is done in other cases in terms of the marketing aspect of things. That is absolutely right. Companies will complain about the cost and the difficulty and the amount of room that they have on labels. Interestingly, products where they see that there is a commercial advantage to talking about how many calories there are or the fact that it does not contain gluten or it is low carb. There are plenty of room on labels for that information when they see a commercial advantage. It needs to be mandated because, to be honest with labelling, the devil is in the detail. For example, at the moment, a lot of products will have an anti or don't drink during pregnancy logo on it. In many cases, it is so tiny that it is almost indecipherable. That is what the public is telling us when research has been undertaken with focus groups. They are saying that they are not surprised that the industry does not provide that information and that the information that is there is barely legible and certainly does not take people's attention. The industry is often saying that we are directing health information to a website that we fund and provides questionable information about alcohol harms or that is represented in a way that plays down the health harms. What we need is independent information that is mandated so that when people are picking up a bottle or a can, they can make an informed choice about whether they want to drink and whether they want to drink this particular product. I think that it is just to observe two things. One is that, across public health measures over the years, we see a pattern whereby when there is an effort to address harms through bringing in the measures prior to implementation, there are all sorts of predictions about how difficult it will be for the industry to implement the measures. When we evaluate the implementation after it has come in, most, if not all, of these difficulties are small or non-existent. There will be a way found if the law changes. In general, we have law-abiding companies in this country who, if the law changes, will find a way to implement it. The second point is that we need to look beyond just the alcohol industry when we are looking at the economic effects of these public health policies. If people are not spending money on alcohol, they are spending money on something else in the economy and quite often something else that benefits their local community more than the tax going on alcohol to the UK Government and not necessarily being reinvested back in those local communities. It is not that people hoard that money, they are still spending it and contributing it to the economy, but perhaps on something that is not harming their health as much as the alcohol is. Around treatment of alcohol harms, we have questions from Sue Webber. A recent study conducted in South Korea revealed that a therapeutic community-orientated day treatment programme resulted in continuous abstinence rates at six months that are nearly eight times higher than those seen in the control group. What was interesting and what I found interesting was that both the treatment group and the control group were women. When it comes to treating alcohol use dependency, what different needs do men and women have and is there more that we can do to address the needs of women specifically? I am not quite sure who might have first insights into that one. I have scribbled down here Eleanor, but if I put you on the spot, I am sorry. I am not sure if there has been a lot of research into the differentiation of services for men and women, but I do know that, in terms of recovery communities, once people have potentially accessed treatment services and embarked on their recovery journey as an individual, those communities are shaped by those people themselves. There are groups in there who will be specifically for men or specifically for women, and that peer support is obviously very well evidenced as crucial in terms of people being successful in having a positive recovery journey. You might be interested in the fact that we are about to publish some research that has been carried out by Glasgow Caledonian University into alcohol treatment services and the LGBT community. Many other minority groups will experience more alcohol harms as a result of stigma that they experience, for instance, because of their sexuality or gender identification. When they experience more alcohol harms than their general population, accessing treatment services can be more difficult for those groups, because they are just not set up or designed to be inclusive of people from different backgrounds. For instance, the research that we have yet to publish will show that people from the LGBT community can feel excluded from treatment services, because sometimes there is a lack of recognition of how important their sexuality or gender identity is to their alcohol problems. Is that the whole artwork that we should be doing in terms of inclusivity? My question is specifically about women, because some of the graphics that we have here show us that after MEPs started, for example, there is a drop-off in the male-related hospital stays, but not women. I am trying to drill down on the women element of things if that was possible. It is important to let our guests finish their sentences, Ms Webber. If any of our other colleagues online have got anything that they want to add to the aspect that Ms Webber wanted to address on male vs female in terms of treatment, could that come to Alison Douglas? I am not really aware of much research in this area, but I guess one thing that I want to mention that can act as a barrier for women accessing support is concerns about their children and worries that their children may be removed from their care if they disclose that they have an alcohol problem. That is something that we need to take seriously and ensure that we are working with and supporting individuals rather than feeling that coming forward for support is going to result in their children being taken into local authority care. We have recently published a right to recovery bill that would ensure that every individual is seeking treatment for addiction or substance misuse. Not the committee, though. No, we, as I am sorry, the Conservative Party. Thank you. That did include alcohol, so I was just wondering what your thoughts were on that bill and have you fed into that consultation process. Would anyone like to come in on that? We very much welcome the intention behind the bill. I think that we absolutely recognise some of the concerns that are driving it, that services are not available there to the degree that they ought to be for people with drug and alcohol problems. The ratio of people who can attain support for an alcohol problem, there hasn't been any estimate made of that in recent years. I think that the most recent data is from 2014 and that showed about one in 14 people with alcohol dependence was able to access a service. We have real concerns that the availability and accessibility of services needs to be addressed. The scale of the problem that we are dealing with is significant. As we heard right at the beginning of this session, there are concerns that those who were drinking most heavily prior to the pandemic are the people who have been at greatest risk of increasing their drinking during it. Absolutely, we need investment in services and we need to tackle stigmatising attitudes and behaviours to ensure that people feel welcome and supported in their recovery. Having said that, Alcohol Focus Scotland thinks that incorporation of the Human Rights Act represents a better opportunity to protect and promote the rights of people with alcohol and drug problems rather than a separate piece of legislation. We think that there could be an inadvertent risk of increasing stigma if we specifically focus on people with alcohol and drugs problems rather than seeing it as part of a wider promotion of human rights. We also worry that it could damage the therapeutic relationship that is so important in recovery between the person providing the support and the individual who is trying to recover by potentially creating a risk of litigation that we think would be unhelpful. We absolutely welcome the intention behind the bill. We just believe that there would be a better way of achieving those ends. Can I bring in Eleanor June? Carry on Eleanor, it was just a wee bit of a time lag to your microphones unmuted to carry on. We would totally understand the motivation behind the bill. People with alcohol problems accessing alcohol treatment services has gone down, which is a strange statistic considering our, generally speaking, increase in alcohol problems. Since 2016-17, over 28,000 people were accessing alcohol treatment support services by 2020-21, and that had gone down to just over 19,000. There is obviously a problem that needs to be addressed, but we would be concerned that introducing a technical legal right like this would serve as a bit of distraction from the most fundamental things that need to happen with the system, which is about resource and direction. We are making sure that we have enough people in our services with the right skills to support people to access our services. Alice Allison said that there is a risk of further stigmatising a group of people who already experience an extensive amount of stigma by introducing a right for this specific group, which will then see them treated slightly differently to other people who access healthcare and treatment services. Although the intentions are laudable, the implications of that could distract from what we need to do, which is to fundamentally increase access to services. We think that the forthcoming UK alcohol treatment guidelines, once they get introduced and have been delayed, if they are introduced and then implemented in Scotland, if they are backed up by some meaningful standards about quality of care and access, that is an opportunity to see some real change in services in Scotland. Emma, do you want to have a quick comment on that? Sure. It is just a quick question on the families and women issue. I know that the Scottish Government has a framework that is being created for families affected by drug and alcohol use in Scotland. It is a framework for a whole family holistic approach to be inclusive for families. That is where the issue of how women need to be supported, because they might have families to support and be carers even for family members. I am interested to hear what your thoughts are on the framework that has been implemented and progress for its delivery. I will throw that out if anybody wants to come in on that specifically. Please just let me know. Perhaps we are going to hear from Alison. I think that it is really welcome that we are taking a whole family approach. We talked about in the past the hidden harm of alcohol. So often people will say that it is an individual's right to choose how much they drink and that they are not harming anyone but themselves. The reality is that many other people are affected by somebody's drinking. In fact, I would guess that most of us in this meeting today have known someone, a friend or a family member who has been affected by alcohol and have seen those consequences directly on those around them. It is not just the drinker who suffers, it is family and friends too. Too often those people around them have been neglected. I think that it is extremely welcome that we recognise that there are those wider impacts but also that those people are really important in supporting the recovery of the person with the alcohol problem that unless somebody has support around them, the potential for them to recover will be much less. I think that it makes a great deal of sense both from tackling that wider impact and harm but also in terms of enabling and supporting recovery. I will pick up on something that Elinor mentioned in terms of the work that you are doing for specific demographics. You mentioned about LGBTQ plus people having specific needs when it comes to treatment. I am interested in that in terms of a lot of people finding it very difficult to even put themselves through the door for treatment and you have mentioned some of the barriers there for that community. Is there any work on going or is there any thought about other cultural demographics as well that you might have particularly people from ethnic minority groups finding the same issue about maybe not having treatment services specifically dedicated towards them? That is something that has come up. We have not been involved in research around minority ethnic groups but I am aware of research that shows that, as a group, they are vastly underrepresented when it comes to alcohol treatment and also recovery communities. There is obviously something going on there. Again, this can be the double level of stigma and shame that people can experience when in a minority group. It is a real difficulty that has a lot more work to be done to try to make treatment services and recovery communities work better for all the different groups that are doubly affected. I think that that is an area worth looking at. What I was wanting to highlight is that when it comes to alcohol treatment and services, it is very important to see people as people and not just a person with an alcohol problem. Obviously, the alcohol problem is going to be tied up with so many other issues. It could be to do with childhood trauma. It could be to do with mental health issues. When we are talking about women, it could be tied up with their relationships. It could be tied up with housing. Alcohol problems could be the cause of some of the other issues in their lives or vice versa. It is important to think of the services that people are accessing as not just about treating an alcohol problem but about them being integrated with all the other services or types of support that someone could need. For instance, there is a really positive model in Aberdeen of whether a specialist alcohol service is provided by the ADP, which links to a vast, huge range of other services, whether it is police, housing or social work. Everyone gets assigned a key worker who can work with all those services. Thinking back to your previous question about the support that women may need, that is a type of service that can work if they are properly integrated and see the person as an individual who may need a vast range of different types of support, some of which may not necessarily be specifically about alcohol but are related to the alcohol problem. That is the approach that we need to see taken more commonly across the country. It is always very helpful when people give examples of good practice that we can maybe further look into. We are going to move on to talking about funding and questions led by Evelyn Tweed. Good morning, panel, and thanks for all your contributions so far. This has been a really helpful session. Can you tell me what are your views on the split of resources between alcohol treatment services and drug services? Do you feel the split of resources is appropriate? Could I maybe pose that to Lucy? It is not an area of funding that I am involved in, so it is not an area that I am heavily ill-versed on. I do not know if anybody else on the panel feels they would want to step in here. We will look for volunteers if anyone wants to come in on the funding issue in particular. I am seeing that Neave Fitzgerald is nodding. You give me the slightest inkling and I am going to single you out. I think that Eleanor and Alison have put a little R in the chat on this. Why do I come to Eleanor? Sorry, I was not doing my job there because I was not looking at my screen. It is not necessarily clear what the funding split is between alcohol and drug services. There are various different ways of looking at it. There is funding to ADPs, which is used for alcohol and drug services. There is also funding that the NHS, for instance, may be using separately for alcohol and drug services, and it is the same for local authorities or IJBs. It is not totally clear what the funding split is, but in terms of resource and emphasis, the Scottish Government said in its budget documents that it published towards the end of last year that it recognises that we have twin public health emergencies of drug deaths and alcohol harm. We are not necessarily seeing that reflected in the focus and attention of alcohol services. We have seen lots of progress in the investment and focus on the services that are provided for people who use drugs, with a particular emphasis on rehabilitation. We have seen lots of other aspects, including the medically assisted treatment standards. We have not seen anything similar for alcohol. As I am sure that we all agree that we know that the data is not good for Scotland, we have seen that deaths went up in 2020 and we know that alcohol harm is a real problem for Scotland. We need to see a bit more urgency and focus, whether that means coming up ahead of the alcohol treatment guidance that I talked about earlier, that we are expecting at a UK level, whether the Scottish Government can do something ahead of that so that we are starting to make inroads and see some investment in services, specifically for people with alcohol problems. That is what we would argue for. We need to see some urgency around that now. I agree with what Eleanor MacDonald said that it can be quite difficult to understand exactly what is going on with budgets, but we have seen this very strong focus for completely legitimate reasons. The drug deaths are tragic and shocking, and we need to respond to that. We also need to recognise that it is about capacity in the system to respond to the challenges that face us. What I am concerned about is that some of what I am hearing from local level is that, because alcohol and drug partnerships cover both alcohol and other drugs, because of all the focus on drugs and all the demands that are being placed on local partnerships from the Scottish Government, the capacity to do anything on alcohol has really been diminished because they are spending so much time and effort addressing the drugs issue. We need to see an overall increase in capacity and not increasing the effort around drugs at the expense of alcohol. I am certainly hearing anecdotally from public health colleagues and from alcohol and drug partnership colleagues that they really do not have capacity to do much on alcohol at the moment. That is really concerning when we may be facing into a period in which we actually have an increased problem to deal with. How can the effectiveness of public spend on alcohol services be assessed? I know that you have touched on that in previous answers. What information is required to allow that assessment to be made? How can we do it better? It is really difficult, because, as Eleanor Brown alluded to, the Scottish Government gives funding specifically to alcohol and drug partnerships, but that is not meant to be the sum total of the investments at local level in alcohol and drug services and related work. In practice, there have been instances in which the health board will top-slice money coming from Scottish Government for statutory NHS services, where the ADP is meant to make decisions as a collective about where that money should be invested. I have to say that somebody who used to work in Scottish Government and was responsible for alcohol services and that investment, is very difficult to understand and detail what is going on at local level. Therefore, it is better to come at it from the other end and look at the outcomes. Rather than trying to follow the money, we should really look at what the impact is at local level and to improve reporting around that. There has been some modelling carried out about the impact of alcohol care teams in England. Alcohol care teams are a broad term that is used to describe specialist nurses and addiction nurses who will work within hospitals when someone has been identified as potentially having an alcohol problem. They will then work with them to either put them in touch with services in the community through a study of outreach or will put in place some sort of support for that person to help address that problem. That model has shown that it both works and also is cost-effective. That is the sort of model that we would like to see implemented more consistently across Scotland. It is done to varying degrees in different places but it could be more consistent. Lucy Giles. Thank you very much. It is really just back to the point that Alison was making around outcomes and focusing on the outcomes and the impact that services are having in an area. I think that that is absolutely the right approach and a call on my experience of having previously worked in an ADP in a local area. That could be difficult for services to do. There are a number of different tools that could be used to measure and monitor outcomes at an individual level. It could be difficult to collate that information. I think that there have also been things like the SDMD, the Scottish Drug and Use Database, that were not necessarily particularly user-friendly for services to use and they found it quite difficult to use. We have now moved on to the DAISY systems. If we can try to maximise the use of things like DAISY, the national systems that are already in place, or implement a single outcome system that all services can use, that would be a real step forward. Can I go to my deputy computer, Paul Cain? I think that it is just to follow on from many of those points that we have made. I think that Kino Alison was talking about the importance of reporting. I think that other colleagues on the panel were talking about knowing what is working. I have asked the minister back in September about alcohol and drug partnership reporting. Previously, we had broken down information for ADPs by IJB in terms of the granular spending. That certainly happened in 2017 and 2018, but we have not had that level of detail. My question is, do we think that there is enough certainty around funding to measure the effectiveness of what is working? Do we have that certainty going forward? Paul, can I just ask for clarification? You mean certainty of what money is going in or how it is being spent? I think that there is certainty that there is funding there and that we are not seeing gradual cuts or more top-slicing, as I think that was referred to. How from that can we then measure the effectiveness of spend, if you like, in terms of the interventions that it pays for? You have been aware that there had been some time back, some cuts to the investment in alcohol and drug funding. We tried, at that point, to do a bit of work with the alcohol and drug partnerships to understand what that meant in practice and how it was affecting services. It is really difficult to get a clear picture of that, because, ultimately, the people who are acting as the co-ordinators and the facilitators for the alcohol and drug partnerships are employed by either the health board or the local authority, usually. It is very difficult for them to necessarily be open and honest about that in public. I think that we found it really difficult to get a handle on that in any systematic way. What we would tend to hear was that a service had gone or a contract was not being renewed. Usually, those were third sector contracts, because statutory services tended to be more protected than the third sector services. I think that that is concerning to me, not just because of loss of services, but because sometimes it is the third sector services that have a more progressive and recovery-oriented approach. That is part of the challenge here. It is not easy to follow the money. The other thing that I would say is about prevention, because alcohol and drug partnerships have a responsibility for trying to prevent, as well as to respond to the existing problems. That would be another concern that I would have. That sort of capacity to look at prevention and to be active in preventing alcohol harm tends to get pushed to the side when you need to be delivering services to those who are in need now. It has been 10 years since Christy, and we still have not made progress in prevention in all sorts of spheres, but we have not made the sort of progress that we would have hoped to have made in the alcohol field. It was just a quick point. It was referring back to what I said earlier about the importance of alcohol treatment services being integrated or linked in with the wide array of other services or supports that someone may need, because you could potentially invest all the money that you wanted in the world to alcohol treatment services to treat the alcohol problem. The other issues in someone's life are not being addressed. If they are not getting their mental health support back to community mental health services or they are living in poverty or they are living in inadequate housing, which is cramped and damp and everything, those are all factors that need to be addressed. We can really isolate alcohol problems from the wider picture and all the other areas that need to be invested in in order to make sure that people have the best support available. We are running out of time a very short question from Emma Harper to round us off. It might not be that we get the answer today. I am aware that there are different models of ADPs who have independent chairs that might only work three days a month versus full-time employees, lots of coordinators, admin support. I am interested in whether we are looking at the best practice examples of ADPs with good outcomes so that we can reflect that practice in other areas in Scotland. Over to our panel for anyone who wants to come in on that. I would urge you to look at the Aberdeen model in Aberdeen City. I do not know enough about all the ADPs across the country, but it is one of the few that has separate drug support to alcohol support. The model that they have taken in terms of being as inclusive and proactive as possible and engaged with all the different services in the area is really positive and is something that potentially other areas could be learning from. I want to thank all four of you for your time this morning. It has been a very useful session and what you have told us has given us a lot of food for thought about what we might do in the future in terms of our targeted work in this area. We are going to suspend for five minutes. Our third and fourth items today are consideration of two affirmative instruments. Those are the Forensic Medical Services Modification of Functions of Healthcare Improvement Scotland and Supplementary Provision Regulations 2022, and Forensic Services Self-referral Evidence Retention Periods Scotland Regulations 2022. We have everything in the session of the Cabinet Secretary for Health and Social Care and officials on the instruments. They are all joining us remotely. Once we have had all our questions answered, we will have formal debates on the motion. I welcome to the committee, Humza Yousaf, the Cabinet Secretary for Health and Social Care. Good morning, Cabinet Secretary. We have Scottish Government officials Vicki Carmichael, who is the CMO task force acting unit head, and Greg Chalmers, the head of the chief medical officer's policy division. Jacqueline Panthenay, the solicitor, and Carol Robinson, the implementation team leader for the Forensic Medical Services Bill team. Good morning to you all Cabinet Secretary. With your agreement, given the underlying subject matter of these regulations, we intend to ask questions on both of these instruments in a single session. I believe that we have already let you know about that. Good morning, and I believe that you have an opening statement to make. Good morning, convener. Absolutely fine with that approach, of course. I thank you and welcome the opportunity to make some opening remarks, first of all, over you and the committee, that are all keeping safe and keeping well. As I said, you are giving me the opportunity to give evidence or a brief opening statement on the two instruments under the Forensic Medical Services, Victims of Sexual Offences Scotland Act 2021. When commenced on 1 April, the act will create a clear statutory basis for health boards to provide forensic medical examinations for victims of sexual crime. Health boards will also be required to provide consistent access to self-referral services. Self-referral will enable someone aged 16 or over to access healthcare and request a forensic medical examination without first having to make a report to the police. I am extremely grateful to the survivors first and foremost, whose courage, bravery and honesty helped to inform the key principles of the act. I know that I can safely speak for my predecessor, Drine Freeman, in saying that it was a moment of tremendous pride when the act was unanimously passed in December 2020. I also thank the chief medical officer, Professor Sir Gregor Smith, for his leadership of the national task force for the improvement of his services and put on record. I also thank his predecessor, Dr Catherine Caldewid, for her efforts to improve forensic medical services across the country. The task force has made significant progress against the five-year high-level work plan that was published in 2017, supported by the Scottish Government funding commitment of 11.7 million over four years. The investment has helped health boards to get ready for the commencement of the act. One of the most significant improvements is that victims no longer need to go to a police station for a forensic medical examination. They now take place in a NHS healthcare setting known as a SARC, a sexual assault response co-ordination service. Healthcare Improvement Scotland has published national standards and quality indicators. Health board performance against those has seen tangible improvement. In the final quarter of 2021, 87 per cent of examinations were carried out by a female doctor, supported by a female forensically trained nurse. Nurse care co-ordinators are in poor post in every health board to help ensure the smooth pathway of onward care and support. National clinical pathways for both adults and for children and young people have been published and are followed by health boards. The national clinical IT system has been developed to ensure the consistent recording and collation of data, which will go live on 1 April. Task Force officials are liaising closely with health boards to ensure that they are all ready to provide self-refero forensic medical services nationally from 1 April and have provided detailed guidance and training, as well as additional funding, to support implementation and readiness. If I can turn to the SSIs turning to the first instrument, section 8, subsection 1B of the Act enables Scottish ministers to set by regulation the length of time that health boards will be required to store evidence gathered during a self-refero examination. This is known as the retention period. Any evidence stored will be destroyed at the end of this period unless, of course, the person has requested destruction of their evidence prior to that period. Or has reported the matter to the police, in which case the police will request that the evidence be transferred to them. The regulations that have been approved will set the retention period at 26 months, time period based on the outcome of the Scottish Government public consultation and on evidence and best practice from across the UK and internationally. Just over half of the responses to the consultation agreed with this time period seeks to strike the right balance between ensuring that evidence is held for a reasonable timescale while taking into account the practical considerations for health boards. The second instrument makes amendments to the National Health Service at Scotland Act 1978, using the powers under sections 13 and 19 of the FMS Act. The technical instrument will give functions similar to those that it currently holds in relation to wider health services. Functions include a general duty of furthering the improvement in the quality of services provided under the FMS Act and also functions of providing information to the public about the availability and quality of those services. The instrument will also extend the inspection power of it to any service that is provided under the FMS Act. The service is a backstop power, which is only likely to be used in the event that a significant issue of continued concern has not been resolved through existing health board governance and assurance processes. The instrument does consider prudent for it and his to have those powers in reserve, as is the case for other health care services. In summary, the CMO task force has made significant progress over the past five years and the Scottish Government officials are working very closely with health boards to ensure that they are ready for commencement of the act. It is an important anchor to that work and it helps to underpin the continued improvements that we plan to deliver without NHS partners. As always, I am happy to take questions. Thank you very much, cabinet secretary. I am just looking to my colleagues to get any questions, Emma. Thank you, convener. Good morning, cabinet secretary. It is just a quick question on the 26 months retention period. I am just going to note that our convener rightly mentioned earlier that this is to do with not contacting survivors on an anniversary associated with a reported assault. That is part of it but the 26 months was a consensus across the evidence that was taken for the consultation. That is something that is based on the feedback from everybody that 26 months was in agreement. That is why we have to that point today. Thank you, Emma Harper, for those important points. She is absolutely right in what she says in relation to why 26 months are not, for example, 24 months. It would seem like the more natural time period, but she is absolutely right. The reason why we avoid 12 or 24 or 36 months, for example, is because they would fall on anniversaries of when that medical examination may have had to happen. Therefore, of course, it is a very traumatic period that I can imagine in a survivor's journey. We avoid those anniversaries for good reason. That is the feedback that we have got from the likes of Great Crisis Scotland and others. She is absolutely right in highlighting that point. In relation to our point about consensus, it would be important for me to say that although the 26 months period was backed by the majority of the consultation just over 50 per cent, there was no consensus among that other group on what the retention period should be. Some thought that it should be shorter than 26 months, some thought that it should be longer. It would be remiss of me not to say that the survivor's reference group favoured a longer retention period, but we wrote to them about the 26 month period and they have not pushed back. I think that they hopefully understand our reasons for trying to balance what are really important factors here, which is retaining the evidence for a suitably long enough period of time, but also, given the sensitivity of that data and evidence that is held, making sure that it is not held for a disproportionate amount of time. The only thing that I have been adding to this is where we have seen some evidence across the UK. For example, if we look at the London service, known as The Havens, we know that the average time between self-referral and police referral was three months. Of course, 26 months is a relatively adequate time, and looking at other UK centres, it tends to be that the average between self-referral and police referral—for those who go on to police referral— is again around that three to six month period, so we think that 26 months is absolutely adequate. I am not seeing any other colleagues who want to ask any questions of the cabinet secretary. We will now move on to agendas 5 and 6, which are the formal debates on the made affirmative instruments on which we have just taken evidence. Are members content to a single debate being held covering both of the instruments together? We are agreed, thank you. I remind the committee that members should not put questions to the minister or the cabinet secretary rather during the formal debate, and officials may not speak in the debate. Cabinet secretary, before I invite you to move the instruments, is there anything further that you want to say in relation to motions S6M-03315 and S6M-03316, both in your name? Nothing further to add, convener. Thank you, cabinet secretary. Would any members like to contribute to the debate? Sandesh. Just to say that I am perfectly happy with what has been proposed. Thank you. I would just like to add a thanks to the previous committee for the work that they did on this in the last session, and I remember it being a very significant moment in the Parliament when we passed the legislation. So thank you to them and all the works, too, from or in this room right now. We do not have anyone else who wants to contribute. I will invite the cabinet secretary for housekeeping reasons if he wants to make any response to anything that he has just heard. No, nothing to respond to, convener. Thank you. Are members content that a single vote will be held on these two motions? Yes. We are content. Can I ask you to formally move motions S6M-03315 and S6M-03316, both in your name? I am content to move the motions in my name, convener. Thank you. The question then is that motions S6M-03315 and S6M-03316 be approved? Are we all agreed? We are all agreed. Thank you very much. That concludes the consideration of those instruments. I thank the cabinet secretary and his officials for attending today's meeting. We will now move on to our next item of business. The seventh item on our agenda is consideration of a negative instrument, and that is the personal injuries NHS charges amount Scotland amendment regulations 2022. That instrument increases the charges recovered from persons who pay compensation in cases where an injured person receives a national health service, hospital treatment or ambulance services. The increase in charges relates to an uplift for hospital and community health service annual inflation. The Delegated Powers and Law Reform Committee considered the instrument and made no recommendations and no motions to and null have been received in relation to this instrument. Can I ask members if they have any comments in relation to this instrument? I would be interested to know how much money has been claimed back using the scheme versus the cost of administrative work here and then we can see the difference that this will make. That is a point of information that you would like to hear back from the Government on, but not in relation to the uplift. No, in relation to the uplift. Any other comments that anybody would like to make? Can I therefore propose that the committee does not want to make any recommendations in relation to this negative instrument other than the point of information that Sandesh Gulhane has raised? Anyone member disagree with this? No, thank you. We will confirm agreement on that. At our next meeting on 8 March, the committee will begin taking evidence as part of our inquiry into alternative pathways to primary care, and that concludes the public part of our meeting today. Thank you all.