 Welcome everyone to the 23rd meeting of the Health, Social Care and Sport Committee in 2022. I have received apologies from Emma Harper this morning. We have two members joining us online as well. Everyone is here. The first item on our agenda is to decide whether to take items three and four in private. Are members agreed? We are agreed, thank you. Our second item today is a further evidence session as part of our inquiry into health inequalities. During the session today, the committee will be undertaking a round table session and discussion with witnesses to explore possible solutions at a policy level that can sustain focus and action on tackling health inequalities across portfolio. I would like to welcome to the committee Dr Peter Cosson, the principal GP of GPs at the Deep End, Professor Sir Michael Marmot, Professor of Epidemiology at the University of College London, Dr Shirelly McDade, Head of Evidence and Impact for Scotland and Northern Ireland for the Mental Health Foundation and Professor Petra Meyer, the director of the UK PRP-funded Cypher consortium. I believe that all of you have a brief opening statement to make before we start our discussion. I will take you in the order in which I have introduced you and have come to Dr Cosson first. Good morning and thank you very much for inviting me here. I just clarify that I am not the principal GP of GPs at the Deep End, I am a GP principal. I am just one GP amongst many GPs at the Deep End, but thank you. I am a GP at Grosgadenberg Medical Practise Syndrome Chapel. It is one of the so-called Deep End practices, which is the term that was coined by Professor Graham Wat, to describe practices in which the majority of patients live in post-codes classified as highly deprived by the Scottish Index for Multiple Deprivation. There are roughly 100 practices characterised like that, and about 50 per cent of post-codes classified as highly deprived are registered with those practices. I joined my GP practice because I had a deep conviction that general practice and primary care can make a difference to health inequalities. I joined just before my first son was born and he is now 23, so I have been working in and from Chappell for a very long time. The other witnesses here are much better qualified than I am to speak about how health inequalities are defined, but I would just briefly like to speak to what health inequality means at an emotional level. If nothing else, I have spent 23 years witnessing the impact of health inequality on people's lives day in and day out. Health inequalities for me is somewhere between a sense of meaningless and a sense of rage. I think that there is a constant labour of not tipping over into hopeless resignation or angry bitterness. That is something that I have witnessed in my own life over 23 years in my colleagues and also more than anything in the community that I serve. I am not going to speak to individual examples of how health inequalities have impacted on individuals because I do not want to sensationalise people's experiences. However, one of the most soul-destroying things for myself as a health professional has been to witness on a daily basis how the national health service sometimes unwittingly, sometimes deliberately and in many ways widens health inequalities and perpetuates divisions. That is something that I hope that we can discuss today. However, what I want to briefly mention is why I am still idealistic and believe that we can make a difference. I just want to give three examples of things that have kept me hopeful, if not optimistic, after nearly a quarter of a century working in my practice. The first has been seeing the difference that good general practice and primary care and make to health inequalities. That can be through willingness to sit and listen and be an ally and an advocate to people, giving them the time to try to understand what is going on in their lives and to try to help them find a way through. If there is no way of finding a way through of still sitting with them and being willing to listen and not to pretend that they do not exist, the very practical level of taking the time to explain and to allow fears to understand fears and to help people, for example, to go for a test that they are afraid of. Taking the time to support people through bereavement, even when that bereavement is tragically at an early age, is something that is quite helping someone to die who is younger than yourself, something that we have all been working in areas that we might have to do on a regular basis, and that is something that we cannot turn away from and can make a difference in helping people to go through that. In a really practical, nitty-gritty way, through something called safety netting, where we simply make lists of people that we think will not turn up for test, will not go for test x-ray, will not go for appointments to find out whether they have gone and to follow them up and to try and encourage them to go, or responding to letters to saying that people have not attended, not just by finding them away but by phoning up and discussing with them their reasons why they have not attended. All of those little actions feel like little pebbles thrown into a huge sea of inequality, but I believe that, first of all, they help to keep us feeling that we do something meaningful and something worthwhile, but above all, if they are scaled up on a large scale, that primary care and general practice can make a difference to health inequalities. The second example that I would like to give is that my own practice was a lead practice for the community-linked worker pilot programme a number of years ago. One of the transformative effects for us was to try to become a more community-linked practice. Just for example, we had a day when we had a sports day in the practice and what that meant was that we had a treasure hunt around the community where we went to meet all the places in Drumchapel where people can go for physical activity and to learn about how all those little community centres, little gym, boxing clubs, dancing clubs, how much they transformed people's lives. Over the past seven years, we have been trying to become a more community-linked practice to understand that, as medical practitioners, we can make the most difference to people's lives if we work alongside the practice, the community where we work, if we help people to access all the resources that are there. Now, many of those resources are very fragile and many of them have disappeared, but I still believe that strong general practice and primary care supported by community that has a lot of resources for wellbeing can make a huge difference. The community-linked workers in our practice have really helped us to help our patients and individuals to find resources and assets in the community to help them. Just finally, I would like to speak about the third reason why I feel optimistic. Many years ago, one of our practice nurses approached us because she was felt frustrated and disillusioned with years of telling people that they needed to make lifestyle changes, knowing fine well that they did not have the resources or the possibility to make those changes. She asked that she could start a small group to help one another to make changes. That was about five or six years ago and that group was called Chance to Change. Since then, that group has gone on to develop and grow and has had a really transforming effect on the lives of the people that take part in it. There is no longer one of our practice nurses now run by a peer facilitator and that group has now joined with the Scottish Government to try and find solutions to the problems that the inquiry is tackling today. Over the past year, I have been a member of the Scottish Government's short life working group on primary care health inequalities. Chance to Change has been an expert reference group to that work. It has had the opportunity to feed into the recommendations that that work has made and to provide its own reports commenting on the recommendations. It has been a frightening process for me as a GP in that it has put me, most of the members, our patients in our practice and they have not held back in expressing how the last few years have impacted them, including some pretty sharp criticisms of ourselves. We are not holding ourselves out to be any better or any different to the rest of the NHS, but I very much deeply believe that we can find solutions if we work together in this way. I would just like to finally highlight a few things from that process. From the short life working group, there are five P recommendations. One of those is to have a strong process of national leadership, which I believe that this inquiry is helping to provide. Second is around providing the resources for general practice and primary care teams to do the kind of actions that I have already outlined and more in terms of changing how we work and being able to mitigate and change the process of health inequalities. That includes training up people to understand how health inequalities impact on people. More than anything, the recommendations are looking at supporting long-term wellbeing communities around primary care and addressing the barriers that the NHS puts up that widen divisions and perpetuate health inequalities. We need to research and understand what those barriers are and address the structural discrimination and inequality that exists in the NHS. We are from task to change themselves. They have brought forward a project in digital inclusion in helping each other to learn how to use digital technology so that they can access some of the benefits that that will bring in the years ahead. That has to be an important strategy to help people. Digital access is now a determinant of health and there needs to be a strong programme to help people to access digital technology. More than anything, the chance to change has emphasised how relationships are at the heart of health inequalities. In particular, they have spoken to how they so often feel excluded and disrespected and not listened to. They have very strongly spoken to the reality of needing to have a health service that puts them at the centre. I would just like to finish by saying that so often equity has been talked about as if it is a zero-sum game, as if the help people who are excluded have to disadvantage those who are better off or those who already have access to health services. I do not believe that. I think that if we design the health service around people like chance to change so that it is accessible and respectful of them and brings them into the heart of how the health service works, we will have a health service that functions properly and that functions well and that makes a difference to health inequalities. I am very pleased to be here today and I hope that our conversation can help us to find practical policies and approaches to making that a reality. Thank you very much for inviting me. Thank you very much and can I come to Professor Marmot, please? Yes, thank you. It is a pleasure to be able to talk to you this morning. In thinking about health inequalities, much of my analyses have been for England, but all the evidence suggests that what we say about England applies to Scotland and to Wales even more so. I have less evidence from Northern Ireland, but all the evidence suggests that, as I said, what I say about England applies to Scotland even more so. I want to talk about three phases in thinking about health inequalities. The first is what happened after 2010, the second is the pandemic and the third is the cost of living crisis. If we take the first, what happened after 2010? In England, I did the so-called Marmot review, fair society, healthy lives. We had six domains of recommendations of what you need to do to address health inequalities. They were, give every child the best start in life, number two, education and lifelong learning, number three, employment and working conditions, number four, everyone should have at least the minimum income necessary for a healthy life, number five, healthy and sustainable basis. Our review of the evidence suggested that, if those six domains of recommendations were followed, health would improve and health inequalities would diminish. In February 2020, on the 10-year anniversary of my 2010 review, we published Health Equity in England, the Marmot review, 10 years on, just before the pandemic crashed upon us. What we documented was that life expectancy had more or less stopped improving. Inequities, the social gradient, classify people where they live and classify where they live by level of deprivation, there's a social gradient that had got steeper and that was true in Scotland as well as in England. Thirdly, life expectancy for the poorest people had gone down, got worse, and that was true in Scotland as it was in England. Dramatically, if you look at the English data and my colleagues from Glasgow assure me that it's the same in Glasgow, look at the index of multiple deprivation. You see a social gradient, but that gradient is steeper in the north of England than it is in London and the south, and it's steeper in Glasgow than it is in the south of England. In other words, a national index of multiple deprivation has more severe consequences for health in the north of England than in Scotland, and it does in London and the south-east. It's more extreme in parts of Scotland. Then came the pandemic, and the pandemic exposed and amplified the underlying inequalities in society. What we saw—and the Scottish data were identical to the English data—is that the social gradient in mortality from Covid-19 was almost exactly parallel to the social gradient in mortality from all courses. Slightly steeper in Scotland and in England for Covid-19 than for all courses, but what it means is that the causes of inequality in Covid were very similar to the causes of inequalities in health more generally. Yes, we have to control the virus, but we also have to deal with the inequality. When we compare England, Scotland and Northern Ireland and Wales with other countries, the fall in life expectancy in 2020 and 2021 was steeper than in any other country except the United States. When they say that the Prime Minister got the big decisions right, when it comes to Covid, that's not where the evidence shows. Our fall and Scotland's fall in life expectancy was actually slightly steeper than England in 2020 and 2021. For England, and I think that the data is similar for Scotland, in the triannium 2018-19-20 compared with the previous triannium, we saw a fall in life expectancy not just in the poor autumn, and I asked myself why in these islands, why in the United Kingdom did we do so poorly in health-free pandemic and then managed the pandemic so poorly? What's the link? I've suggested the link could act at four levels, poor governance and political culture. The second is increasing social and economic inequalities. The third is the disinvestment from public services. The fourth was that we weren't very healthy coming into the pandemic. Then we have the cost of living crisis. As I'm sure you know well, inflation of 10 per cent has a much bigger impact on households at low income and households at high income, because food and energy make up a higher proportion of the expenditure of low income households. An overall inflation of 10 per cent means something like 8 per cent for households in the top-desire learnings and 14 per cent for households in the bottom-desire learnings. When we look back at why life expectancy failed to improve and health and inequalities got bigger in the decade after 2010, child poverty went up, poverty as a whole went up, inequalities increased, as I said, disinvestment from public services. Looking at my 2010 recommendations, it went pretty well. I've now added two to my six recommendations, the six that I laid out. The two that I've added are to deal with structural racism, discrimination and their consequences and pursue the health and inequalities agenda and the climate emergency at the same time. I would say that we know what to do to reduce health and inequalities. The evidence is quite strong that we could do it if we had the political will and the organisation to do it. The fact that things have been going in the wrong direction is understandable, because policies have been going in the wrong direction. Mental health problems are what I will speak about on behalf of the Mental Health Foundation, whose work focuses on the prevention of mental health problems and our work has embedded in it a strong inequalities lens. We know that mental health problems are not distributed equally across the population and they are not simply a result of genetic or biological factors. The circumstances in which we are born, grow, live and age profoundly affect our risk of developing a mental health problem. And societal risk factors present barriers to many people experiencing good mental health. Fundamentally living in lower socioeconomic conditions, facing financial strain or living in poverty, earning below the real living wage, working in precarious employment, these are key drivers of mental distress and poor mental health, which ends up then resulting in diagnoses of mental health problems. So is living in poor quality housing in unsafe neighbourhoods due to violence, prejudice, discrimination, having limited access to clean, safe and green space. And being at risk of prejudice, bullying and discrimination itself is another key risk factor and this can arise as a result of being identified with a number of social statuses such as being black or person of colour, being a member of the LGBT plus community, being a refugee or asylum seeker, being disabled or other social statuses, which then result in someone being a victim of bullying, harassment or discrimination. Violence against women is another key risk factor for developing a mental health problem on violence against women and girls and living with a long-term physical or mental health condition is also a risk factor. Now we believe that actions to address the risks of developing a mental health condition and to reducing mental health inequalities need to be taken at three levels. We need structural measures, we need to strengthen community assets and we need to increase the resilience of individuals and groups. Structural measures consist of actions to change the social and economic influences and reduce their impact on mental health problems. Things like reducing income inequality, poverty, unemployment and precarious work, preventing domestic violence, preventing discrimination and preventing homelessness. Measures to promote community assets, which we've heard from our deep NGP, are very important, include activities to increase social connectedness, to improve community environments and create community spaces, and to foster participation in community decision-making. Then we do need measures at the individual level as well in terms of educating people about how to look after their own mental health, very importantly about creating peer support opportunities and showing people how they can contribute to their own mental health and other the mental health of communities and families. We need action at all three levels, it's really no good to put up a website that tells us during the pandemic to go for a walk to look after our mental health if we live in a neighbourhood where it's not safe to go for a walk. These are the fundamental interrelationship between the three levels. I would like to note that, from our perspective, we are seeing positive steps by the Scottish Government to reduce mental health inequalities, things like the doubling of the child payment this year and the prioritising of child poverty in the recent spending review, the some new benefits that will support people through the cost of living crisis, though I noted that the low-income winter heating assistance is just £50, so it looks a bit thin compared to what people are going to actually be coping with in their heating bills. Investing in the investment that's been made in increasing supports for women and girls who have experienced violence, I think it was £38 million in 2021-22. This is a significant investment, I think, to support a rapid response to women who have experienced violence and then investing in community action to prevent mental health problems with the £21 million last year and £15 million this year for the community's mental health and well-being fund. What we need to do is to build on these steps, to up the scale, to up the effort to have real impact. I'll give you just a handful of recommendations at this point, ensuring that there is strong cross-departmental involvement in the new mental health strategy. We need concrete commitments from government directorates beyond the health directorate because mental health happens outside of the health system in people's lives, where they live in their communities and environments. We need to ensure that the newly devolved social security service, which is a very important development for Scotland, is non-stigmatising that everyone experiences a trauma-informed, respectful service in which it is sensitive to mental health, as well as, of course, increasing the benefits to provide an adequate minimum income. We need those two together. It's actually not adequate to simply increase the money that people have in their pockets because there is also shame and stigma that comes with being on a lower income, and we need to make sure that the experience of attaining that minimum income is non-stigmatising and is respectful. We need to build the community infrastructure for prevention, so we need to build, rebuild, reinvigorate those community spaces where people can gather, learn and support each other. When I'm thinking about the cost of living in crisis and what has happened in cost of living crisis in the past, one of the first things that gets cut is the library, and yet the public library is a very important social space for supporting people's wellbeing. We need to ensure that those link workers, like what is in place in Drumchappel, that the 1,000 link workers that are being put in place in Scotland have a priority for outreach to disadvantaged groups. That's very important that they're not stuck in GP services and not reaching out to communities that need them. We need to increase and continue to increase that investment in community activity for prevention of mental health problems and to sustain some of the good work that's come out of the Covid response programme in terms of the mental health, human rights and qualities forum, and the Scottish Government's recently established diverse experiences advisory panel, which the foundation is very pleased to be hosting. We know that mental health problems cost the Scottish Government, the Scottish economy, that is £8.8 billion a year, and we know that many of those mental health problems are preventable, so there's a choice now for the government in the context of recovery from the pandemic and in the context of the cost of living crisis. Specific choices can make a difference to preventing mental health problems or to allowing those environmental circumstances to run rampant and leave people unprotected. Professor Mayer, you've now heard from many experts how health inequalities are so strongly linked to inequalities and wealth and influence. You've heard how so many of the systems that impact on health inequalities are failing. Housing systems that don't provide affordable homes, a welfare system that does not prevent poverty, a food system that doesn't guarantee nutritious food at reasonable prices, an education system that doesn't provide equal access to high quality education, and finally our healthcare system, as Peter So rightly pointed out, that is increasingly less accessible to those with the highest level of need, but without the energy to fight for their rights. That has now been aggravated by the public sector austerity of the last 10 years, as Michael pointed out, and then came Brexit, Covid, war in Europe and the cost of living crisis. We seem to be in an era of very fast-paced change. We should not anticipate a return to stability. The climate crisis and increased competition for earth resources are likely to accelerate our economic and social transformation. How do we deal with that uncertainty? How can we get Scotland into a position of more resilience? I would argue that high levels of inequality, poverty and an unhealthy population make Scotland much less resilient to future challenges. We know that poor health affects all aspects of people's lives, whether it is our ability to enjoy life as a private individual, to be creative or to contribute to society through work, caregiving or volunteering our time for the common good. It is a tragedy that so many people spend their 50s and 60s in poor health. It is also a big problem for productivity and for public sector demand. To a large degree, our problem is not an ageing society. It is the premature loss of health. How do we deal with the current challenges is therefore critical. Are we playing whack-a-mole with bits of support for whatever problem that happens to be most urgent right now, whether it is ambulances or food prices or education gaps due to Covid? Or do we attempt to comprehensive change across the large number of systems all at the same time, which would require all Government sectors agreeing to work pretty much flat out, taking every opportunity to reduce inequalities, including sectors that maybe are not currently considering inequalities or wellbeing to be within their portfolios? One way to approach systems changes is to think back. What do we wish we would have put in place 30 years ago? What would have put us into a much better position now? What would have helped us to develop and not lose an equitable education system, access to affordable homes, good work for all, and so on? Importantly, what things are we doing now that we know we are going to be kicking ourselves for in 30 years time? First, we need a frank conversation. If we want to reduce inequalities, we can only do it in two ways. We can redistribute health, wealth and power or we can try to hold the top constant and bring up the rear by levelling up. Levelling up is politically much more palatable. We do not reduce services in better off areas or raise taxes, so we can reallocate resources to disadvantaged communities. The money for levelling up needs to come from somewhere, and that somewhere is really important. It cannot just be some minor shuffling around of public sector budgets. If we have growth or opportunities for more big efficiency savings, then we can use that money strategically, but that is not the situation that we are in. However we do it, inequality reduction cannot happen without sizeable investment. As an example, I am from Germany. Since reunification, over 30 years ago, Germany has invested €2 trillion or €70 billion a year to bridge the east-west inequalities. Much of that is through levelling up, but since 1991 it has also included redistribution in the form of a pretty hefty additional income tax of between 5 and 7 per cent, the so-called solidarity tax. Back to Scotland. I think that if the unfairness in health inequalities and the health outcomes is appalling, there is nothing more precious than life, but we need to have that conversation about how much we really want to reduce health and other inequalities. If we are serious, we need to work out where we want to redistribute and where we want to level up. If we want to redistribute and look across all the ways in which Government influences people's lives and especially the way in which we fund public services, identify inequalities in provision and reprioritise according to the needs of current and future generations. Consider what can be done with taxes, levies, income, profits, wealth, land property, luxury goods and especially goods that damage our health or the environment. For levelling up, where can extra money come from? I am a public health expert, so I am not an economist, and others can talk much more knowledgeably about that, but what is the role of the Scottish National Investment Bank in health inequality? How can we involve businesses? Importantly, what is the role of public sector investment, not just in terms of paying real living wages, but across the board? How can we tweak incentive structures to get the good teachers, doctors, social housing and jobs to those who most need them? We need to make sure that we see the public sector investment not as a burden that needs to be minimised, but as an investment that can be optimised to deliver health, wellbeing and sustainability outcomes. Importantly, we need to take the public with us so that they do not buy into a narrative of low tax and small state without realising the impact on the public services. There are many things that the Scottish Government has control over. Some, of course, can only influence through lobbying Westminster or after independence, and some might well be political suicide, but any conversation needs to start from the enormous social, economic and environmental costs of health inequalities and how we can address them. Thank you. Lots from you there for us to drill deeper on and a really good start for our discussion. What has been very clear to us as we look at health inequalities and we have been taking evidence for a number of weeks now, but we have all had an interest in this for some time as committee members. Health inequalities come up all the time, no matter which inquiry you are doing, no matter which subject you are looking at in this committee. It comes up in other committees as well because of the nature of the causes of health inequalities. Notwithstanding all that you have said about whole systems and cross-portfolio working, I want to drill down on something that Dr Costin said about the NHS and the structures of the NHS perpetuating inequality and widening divisions. That seems to me something that we need to hear more about. I wonder if I can come to Dr Costin for more detail on that. Yes, certainly. I absolutely have found the other contributions fascinating. Obviously, the causes of health inequality and, to a large extent, the really big solutions lie outside the health service. Nevertheless, modern healthcare has now evolved to a stage where it has a significant impact on whether someone develops premature disability and whether someone lives out their life in a healthy state or is disabled or unwell. Access to particularly early intervention in healthcare can have a huge impact on whether someone becomes unwell or disabled in their 50s and 60s, or whether they remain well. Again, that is not to diminish the importance, as others have pointed out, of childhood experiences and income and all the rest of it. Nevertheless, health services have a significant impact. Health services were already struggling before the pandemic. In my view, the pandemic has simply highlighted those weaknesses. In many ways, the systems that are in place across the board—I am including my GP practice in this—are not setting myself apart, but the systems that are in place on the whole tend to be a one-size-fits-all approach, where you have to have a degree of ability to advocate for yourself and have competencies and abilities to navigate through the system in order to be able to access the service. There are many, many small barriers in place that some people find insurmountable. The health service is a bit like the pavements in the 1960s in which everyone has equal access as long as they are able to step up into the pavement, but those who can step up into the pavement have no means of accessing. Just to give small examples, I referred to another service of a patient who had mental health problems and did not open letters. They simply found letters threatening, so they do not read them. The referral that I made asked simply that the service would telephone with an appointment time rather than send a letter, and the referral was rejected on the basis that it was not that kind of service. That is what they did, and that was it. Patients turning up on the wrong day for an urgent suspected cancer chest x-ray referral to be turned away because they had missed their appointment, even though the request was sitting there. The service did operate a walk-in element to it, but because they had not followed the referral procedure exactly, they were turned away. Each individual example can seem to be relatively small, but the overall impact, which occurs literally hundreds—if not thousands—of times a day across the system has an overall effect of producing certain people who have the most need and the most difficulty accessing the service based on the most barriers. The other part of it is in terms of how the health service is resourced and where the priorities lie. First of all, we have a health service that is heavily invested in specialist services and hospital-based services rather than community-based services compared to some other countries. That means that we have access to fantastic technology and that we are not in any way decrying the importance of specialist services—we all need them sometimes. However, we have the balance wrong in terms of how much we invest in healthcare that is close to people and communities. For example, for someone who is travelling to a pain clinic that has three bus journeys away, basically because that is where the investment is in a specialised service, then that presents a barrier to them. Within community spending, certainly in general practice, spending reflects demand rather than need. Those areas of service that have high demand tend to be reflected in figures as attracting and waiting in terms of funding. That means that those that already are demanding of services tend to attract funds. Those who, for whatever reason, are not demanding of services but have high needs perhaps through learned hopelessness, through resignation—that is not captured by the way in which we wait for funding. If you look at how GP practices are funding, for example, there is a flat level of funding across GP practices, regardless of those practices that have high need and low life expectancy and high index of deprivation. In other words, deprivation does not attract resource towards those areas in terms of community-based health funding, but funding tends to be the same a flat across. Professor Mercer and others have produced research that shows that patients consulting the GPs in areas classified as deprived have higher levels of stress and less amount of time per problem because resources do not fall in need. I could go on and on and on, but I hope that that gives a few snapshots of what I mean by the institutional way in which the health service widens the health and equality gap. No, that is very helpful. It is very helpful to have your first-hand experience there. I will bring in Paul Cain. A reminder to all of you remotely that, if you want to add to anything that anyone else says or comes in, please just use the chat box so that I can see that you want to come in and put an R in the chat box and they will bring you in. Otherwise, we will probably direct our questions to individuals. Thank you very much, convener, and thank you to the panel for your insights. It is very helpful. I suppose that what I want to ask is really about progress. Professor Marmot's work and, indeed, a lot of what all panellists referred to very often strikes me as that a lot of this is not new and is not rocket science, perhaps. It is about trying to look at what works in communities and to invest, particularly a lot of that, which is provided already by very often local council services or by third sector. Across the piece, there has been a reduction in funding for those sorts of services. Obviously, we can argue about the politics in here of the source of that, but I really just want to get a sense of, despite that backdrop, has there been progress made in Scotland in terms of implementing many of those strategies and maybe start with Professor Marmot, if that is possible? Yes, of course. Forgive me, but I am going to make the same conditional comment that I made right at the beginning. I have been studying England much more than I have been studying Scotland, but, as I said at the beginning, I think that you can say what applies to England. I just want Scotland to be more in this action. What I described is a really miserable picture at national level, with policies going in an adverse direction from the point of view of health inequalities. The signs of hope come from cities and regions. In 2010, Coventry declared itself a Marmot city. It took my six domains of recommendations and implemented them. This is not a randomized controlled trial, so the evidence of effect is, at best, suggestive. However, that said, they saw improvement in early child development. They saw a reduction in the number of young people, not in education, employment or training. There was an increase in the people earning a real living wage. There was a reduction in crime, so there were indicators suggesting that things were moving in the right direction. Since then, Greater Manchester has said, well, if Coventry can be a Marmot city, we can be a Marmot city region. We produced a report, Bill Backfarer in Greater Manchester. Three weeks ago, we produced a report working with colleagues in Cheshire and Merseyside. We are now working in Lancashire and Cumbria. Yesterday, I was in Newcastle of Fontaine. I am getting closer to Scotland. I was in Newcastle of Fontaine, and we look like we can start a programme of work with the North of Tyne region. Covent wants to be the first Marmot region real estate in regions in acting on the evidence and exactly what Petra laid out. She and I are on the same page, so what she was saying with regard to Scotland is very similar to what I have been saying with regard to England and Wales. There is real interest in action at local level. It does not let national governments off the hook. There is much that they should be doing and are not doing, but there is real interest in taking action. In a way, it is an experiment. If child poverty is going up because of decisions made by the Chancellor of the Exchequer, what can cities and regions do to redress that problem? In a way, it is an experiment, but there is real interest in pursuing it. I want to add a little bit about my fairly recent Scottish experience. I only moved up a year and a half ago. There are significant differences in the way that the Scottish Government talks about inequalities and the way that it does policy, which is very promising. We hear a lot about wellbeing economy approaches, community wealth building, things like thinking about a minimum income guarantee. Although those have not yet had the chance to translate into health inequality impacts, we have been in an extraordinary situation, so it would have been hard for any of those to push through enough in the times of Covid and so on. I think that they are the right things to do. To go for it, to fall out and think about what we need to do to increase the wellbeing of the Scottish population and redress the inequalities is the right thing. I can see a lot of movement in the right direction, and the way that we are concerned about climate change and sustainability is increasingly present in conversations when we talk to someone about mental health or about inequalities and income. The triangle between health, economy and sustainability is, I think, much better understood in the Scottish Government. One would hope that that will translate into real changes. At the moment, maybe the focus is too much on mitigation rather than on the root causes, if you think about the extra child payment. That is really important, and I am not saying to do anything to stop it, but, although that gets some more money into people's poorer households' pockets, it does not, per se, do anything to address income inequalities. What is the thing that you can do with your money that will have the most long-lasting consequences? It is going to be really important. Thank you. I am going to bring in Dr McDade. Yes, just in terms of trying to get a kind of a long-term view, looking at the Scottish Health Survey and the information that we have on say the work in Edinburgh mental wellbeing scores, is very consistent across from 2008 to 2013 to 2019. The score is virtually the same, which is telling us that we are not really, even before the pandemic, we were not making the progress that we might hope for. I do think that we need to redouble efforts. The pandemic has only worsened mental health inequalities. It has introduced new categories of groups of individuals who are being affected by mental health problems that were not necessarily a focus before, including the health workforce itself. We do need to be realistic about the fact that it is a big effort and a long-term effort. As I mentioned before, we have green shoots and we have the signs of the kinds of things that will make a difference. We need, as other speakers have said, to make sure that the magnitude of the effort is equivalent to the disparity that exists. I would like to bring forward three signs of progress. One for me, which has been a shift in thinking, has been to recognise that the health service and the wider factors affecting health inequalities are not two distinct things. There used to be a divide between that approach over the past year. The report on health inequalities in primary care has very much looked at how integrated the wider community factors that affect health and health services are with one another. The community link worker programme, which is now spread across GP parts across Scotland, is the first sign of that sense of possible integration between how communities are vital for health and how healthcare support is there to support communities and not to deliver health. I believe that the pandemic has perhaps hastened along the idea that healthcare services can be there as an asset in the community alongside other assets and that we can grow together to produce wellbeing communities and that we are not somehow distinct things. I would like to emphasise how much I feel that needs to be the way forward through community wealth building, through sustainability and through an assets-based and a wellbeing community-based approach to health that invests in primary care general practice district nursing, community mental health services alongside communities as part of the assets in the community, not somehow in some distinct box. The second sign of hopefulness for me has been the centrality that mental health now has in thinking. Mental health is critical to health inequalities and the choices that we make in our life. The way that we respond to our environment and to our circumstances has a massive impact on our life expectancy and our disability. Helping people to have the resilience within the pressures that they are under is critical. Mental health, the way that it is organised, presents huge barriers to people, particularly people who have addiction problems or the people who are engaging in behaviours that are perhaps adaptive to their circumstances but are damaging to their health. I still think that we have a lot of discrimination and barriers built into mental health. I hope that the mental health strategy is a sign of progress towards making mental health essential to health inequalities. Finally, the inclusion of people in commenting on mental health and in helping to develop mental health policy has to be critical. The involvement of chance to change in the health inequalities report of primary care has to be critical to how we understand and plan. For me, that is a big sign of progress, so that is just the thoughts about how we are making progress, or at least green shoots. Before I hand back to Paul, Professor Marmot wants to come back in. Yes, to pick up the theme that others have mentioned. I remember going to a meeting in Murrayfield. I had no idea what the meeting was about, but I remember that it was in Murrayfield that was memorable. Listening to Scottish ministers speak, I said to colleagues that what the ministers are saying is far more likely to address health inequalities than what I am hearing ministers say in London. I had a similar feeling about Wales. What I have had quite a bit to do with the Welsh Government, I would say that its policies should be far more likely to improve health and reduce health inequalities than the policies that are coming out of Westminster. I looked at Wales and Scotland and the health inequalities are deeper in Scotland and Wales than they are in England. That raises a question of what is going on. Are those policies not being put into place? Are they insufficient to address the deep-seated causes of health inequalities? It is an amazing answer to that question because it relates to what you are going to do next. Have you got the right policies that they have not just been applied deeply enough and for long enough, or are there other things that need to be addressed? I suppose that, on that last point, I wonder if, when we—I think that that is correct—there are lots of aspirational policies that seek to try and alleviate those issues. In terms of the devolution down into local authorities, for me, looking at the six priorities outlined by Professor Marmot, many of them are what local councils do around education, employability in building communities. I wonder if on-going and repeated cuts to local authority budgets have an impact. Maybe if I could just get a sense from Professor Marmot how Coventry or Manchester dealt with what was obviously a reducing picture. Is it in your sense that those things will be hard to achieve unless local government is funded appropriately? Oh, very much so. Again, forgive me for talking about England, but if you look at the funding to local government in the decade after 2010, in the least deprived 20 per cent of areas, the spending per person went down by 16 per cent, and then the greater the deprivation, the greater the reduction, in the most deprived quintile, the spending per person went down by 32 per cent. So, if you're in Greater Manchester, in one of the more deprived local authorities, there are 10 local authorities in GM, action funding in excess of 40 per cent, that makes everything much more challenging. Money is not everything, but it's not nothing. It makes everything much more challenging, and so the context in which we're operating in those regions is what can you do with that reduced level of funding? That's the challenge. It's not that they wouldn't like more money from the centre, but, as Petra said, the levelling up budget for 2021 in the north of England was £33 per person. Over the decade from 2010, the amount of money taken away annually was £413 per person. So, levelling up, you give £33, but you've taken away £413, and that's levelling up. And, by contrast, what happened in Germany, as Petra laid out, is two orders of magnitude greater. So, this isn't serious, and that withdrawal of funding is really serious. So, we're operating with severe headwinds at local level. Yeah, I just wanted to add that what you find is that the local authority model is, obviously, you can do a lot and a lot of these things are under the control of local authorities, but it also introduces a lot of variation and a lot of repetition in learning the same things, trying out the same things. Unless you've got a really strong evaluation framework and people who have the time to do that, I think that it does introduce a lot of redundancy and a lot of extra costs. I do think that cities and local areas are the way forward, but we need to find a way where you do it in a more systems way, where you really think about what are you trying to achieve, what are things that everybody can agree on trying out, rather than letting everybody go away. The other is that local authorities are very differently funded, and some people have got five officers working on economic strategy development and so on. Others have got just the one person who's half-time on it, so it introduces new inequalities in those areas that have got larger resources to do evaluation, to put in funding bids and so on. We need to be careful that with our health in place and localism, we don't make things worse rather than better by having some kind of overarching strategy at the Scottish Government level. I'm a bit worried that what I see is a lot of really, really good ideas and a lot of areas trying out many innovative things, but in a way that maybe isn't as well-coordinated and can lead to quite different experiences for people who live in different areas. We've all heard about postcode lottery and so on, and we shouldn't let it come to that. I just want to go back to something that Dr Costin said earlier on, which really gets to the heart of the issues that we're looking at here. I've talked about the fact that those most in need are often the people who are making less demands and about learned hopelessness. Clearly, those are the people that we really need to be able to reach into those communities and actually touch those people if we want them to be healthy in their 50s or 60s or whatever. I'm really interested in any comments that any of the others have on that there, but mainly, what key recommendations would you like to see this health committee make in its report to address that? Dr Costin? Yes, thank you. Obviously, I echo what has been said about funding, but earlier the comment was made about how stigma and the personal impact of health inequalities are so critical. There is learned hopelessness and resignation among people who are living with health inequalities. There is also learned helplessness in health service providers, which turns into a stigmatisation and a turning back on the individual almost a blaming of people for their own problems. That is toxic within health services and something that we need to recognise. One of the recommendations that the short-life working group on primary care health inequalities has made has been around fellowships for healthcare professionals working in community around understanding trauma, understanding health inequality and understanding the practical skills that are needed to enable people to access preventative healthcare and to access being able to make interventions that will impact on their health. I would like to recommend that as a practical policy suggestion. Coming from a chance to change from the partner group with the short-life working group, they have emphasised how transformative peer support is within communities. Within my own practice, we have had two peer support groups for people that experience loneliness, marginalisation, disability and addiction. Within the community, there are other peer support groups through the Addictions Network, through a group for men. Those groups have a tremendous impact in terms of advocating for people, helping people to develop self-belief, helping people to believe that they matter, that their health is something that matters, that they themselves matter. Second, I would like to ask the committee to support the development of peer support within communities to allow people to use those assets to improve their sense of agency and their sense of being entitled to healthcare and to better health. Part of that has been peer support to become digitally included. We have to recognise that the next 10, 20 years of health services and health itself will be transformed through digital technologies. Digital exclusion is going to become a massive factor in terms of leaving people behind. The peer support for digital inclusion programmes are something else that I would like to ask the committee to consider as being important in helping to be able to access healthcare. Thank you. Can I bring in Dr McDade, who wants to answer your question, Stephanie? Sorry, you've come to me. Have you? My screen froze there for just a second. Oh, yes, I did. Thank you. I suppose two things I would say about this question of why is there lower demand in areas of higher need. One is that it makes me think about the perspective of people who are from a Black or ethnic minority background. What we hear when we talk to representatives of different ethnic minority communities is that they don't, first of all, they don't necessarily name their experience in this Western way of being a mental illness or anxiety or depression, those diagnostic categories. They're not necessarily looking for a mental health service to try and help with their situation. When they do try and seek help, they may be met with a service that is not really at all respectful of and sensitive to and willing to really try to understand how they themselves experience their distress and what it means for them and how it fits in with their culture. We have heard that recently from engagement with ethnic minority communities, you know, minoritized communities. I think we need to see mental health services that are not dependent so much on the family member identifying that they have a child or a relative who has something that might require mental health care because that's an access route that might in itself be a barrier for people. I think the other thing is it just calls to mind that this is, you know, I'll be honest, a bit more speculation than evidence, but I do think that a lot of people who are living with mental distress have a high level of tolerance and, you know, they don't necessarily see their situation as something where they will come forward for help. Particularly when we see in the context of the pandemic that many people experience a time when the health services were not so available and, you know, we know that the health service staff are under huge stress and strain. I'm thinking here particularly, say, of carers. I'm thinking of people with disabilities who are so resourceful and may not see themselves as people who are deserving of receiving a mental health intervention. But these are also people who are at a high risk of isolation, of loneliness and of mental health difficulties because of those factors. So, I do think that we need more outreach and messaging and availability of those low-level and community-based supports that are easy access for people so that they don't see it as a big hurdle that they have to, you know, even that they would have to go to a GP and seek help and then from the GP go on to, you know, a specialist service, which in itself is quite a high bar for getting low-level support. I hear a lot of discussion about poverty of aspirations. My response to poverty of aspirations is that it's a legitimate analysis of the poverty of opportunity and you can't say, well, the problem is young people don't have aspirations if they have no opportunities to do anything with them. Growing up in grinding poverty with little prospects for the future, learned helplessness is a reasonable response to that. So, we in a way can't deal with learned helplessness without improving the prospects, the legitimate prospects of education, employment, services and so on. The second linked comment is that it's incredibly intellectually taxing to be poor. If you're not poor, it's pretty easy to get through the day. You're hungry, you eat something, the fridge is empty, you go shopping, the rent is paid by direct debit or whatever. You don't have to think about any of those things. Being poor is really intellectually taxing. You've got to think about that all day. As one commentator said, if you go into the event, that takes a long time. You've got to tot up the prices and look. It could take 45 minutes. If you come in with £75 to spend, you're in and out in 15 minutes. So, it's incredibly taxing intellectually to be poor. To blame people in that situation that they're not thinking medium and long-term, is there a wawful misunderstanding of the intellectual mental cost of poverty? Thanks very much, convener. I'll be back to a separate question for Professor Mayer. You spoke about the Scottish experience being significantly different, and it being very, very encouraging there. You talked as well about seeing what's a momentum that's going in the right direction. You also mentioned that there was too much mitigation rather than root causes. I'm wondering what can we do in Scotland with the limited powers that are available to us to tackle those root causes, because at times it feels like we're limited to mitigating policy that's coming from the UK Government. I know what you're saying. There are a lot of powers that are not devolved, but there are examples such as council tax, for example, which could be made much more efficient at the moment. A higher proportion of poorer households' budgets are going on things like council tax. Having a look across public sector spending, whether there are things that you can change, education systems are very unequal still in Scotland. There are things that you can practically recommend as being done, things around the green economy, how do you create the kind of jobs that are good jobs, decent pay, decent conditions, and target them at areas where there's the most need? If you look across all functions that the Scottish Government has available, there are a large number of areas around education employment, which would be helpful if they were mindful of the need to reduce inequalities. The gap between health inequalities is one kind of inequality. Economic and social inequalities are something different. That is a barrier at the moment. If you go to sustainability, there isn't always that consideration of how do we multi-solve the different problems that we have and how do you optimise between all the different goals that you have in your national performance framework, which I wholeheartedly agree with. It's a very strong framework, but how do we hit the things that may be on the perfect solution for one thing, but that help us to address three of the things that we also want to again at the same time, and really going for inequality reductions in all that you do is going to be incredibly important? I didn't spot it just before Stephanie asked that second question. I imagine that it's for the first. Yeah, thank you. It's maybe just to reflect a feeling of discomfort around the term that we've been using of learned helplessness and perhaps to echo what Sir Michael said. I think that this isn't to somehow suggest that the kind of locus of failure lies within communities and that they need to be somehow rescued from that situation. I think that the most powerful advocates for enablement and for helping people to feel that they deserve help come from within communities themselves. In many ways, structures, public sector, health service—I speak for specifically—are the barriers to that. I know that in health service planning, the third sector is very much not an equal partner and that peer groups and patient groups and communities within the NHS planning are not equal partners with the health sector. In many ways, we need to take away the barriers to communities and to people advocating from within communities rather than saying that somehow it's a helplessness that they've taken on themselves. In many ways, we create that through our systems. I just really wanted to come back on that phrase. I have found this morning really interesting and learned a lot, so thank you to the panellists. I do have a question, but Dr Cawson talked about creating the systems and summarised to step on to the pavement. There was a general theme talking about local assets and infrastructure. Dr McDade talked about the impact of the loss of local libraries, and Dr Marmot talked about a state of helplessness in developing resilience and the reasonable prices that Dr Mayer talked about. My question is, is there a single practical—I realise that it's really complex—but is there a single practical action that would have a dramatic impact, such as our last meeting where we talked about sport and sport on the agenda? There was this theme about opening up school estates to communities to improve the issue of local health equality. Firstly, the question is, what's your thought about a single action like opening up school estates to the community so that the assets are available? If not that, is there something else that each of the panellists would think would be something better? I think that you're initially wanting to hear from Dr Cawson, is that right? Yes, that would be the one. I guess for me what has driven me throughout my career has been a belief that well-being communities are where health happens. I think that a long-term commitment to communities wrapped around health services as the place where we make the change around health inequalities, I suppose that's not too broad an answer. Many community assets have short-term funding and live very precarious lives. If they had the same level of commitment and support that the public sector does, I think that we could make a huge difference to health inequalities. If that's integrated in with health services and not seen as a separate thing, across all sectors, it's integrated into the community. I'm a system scientist, so coming up with one particular action is always going to be particularly difficult for me because I'm trying to think about what are the systems effects that we need to change what are the key levers, but I think that a fair wage for everyone has to be one of the key things in work poverty is just a real problem. Whatever you can do to increase the national minimum wage or make sure that more people get paid the real living wage, I think that it's going to be a good way out of poverty. Then all the different things that poverty or being on low incomes influences, which I must say would be my one wish list item. In the fortunate position of being able to agree with my two colleagues there who have spoken before, I absolutely agree with Dr Costin that building the community assets, building the spaces where communities can come together and engage in support and ensuring that those spaces are inclusive, so cool spaces might be attractive for some people, but not attract other sections of the community. So I think it's really, really important that we're really taking a community development approach to how we identify which spaces need to be developed and that we're doing that in partnership with the diversity of the communities involved. Then I agree also with Dr Meyer, Professor Meyer, but I'm aware that the Scottish Government is exploring a minimum income guarantee and our own research on the effects of a universal basic income definitely from the evidence there so far is saying that reducing the conditionality on social welfare benefits is key to them boosting people's mental health. It's not enough to just have more money in someone's pocket, but it has to be done in such a way that they don't still have huge hoops to go through to try to get access to that income. I think that introducing that minimum income guarantee in the right way so that it really is reducing as much of the conditionality as possible could be very helpful. Thank you and I'll bring in Professor Marmot. Thank you. It's tempting and it's attractive to ask what's the one thing. It's probably the second most common question I've been doing it. What's the one thing? But please don't go down that route if there are only one thing, we'd all be doing it. If there's one thing, it's to put equity of health and wellbeing at the heart of all policymaking, but not opening up sports facilities or as the one thing. That's why in my own case we had six domains of recommendation, because we didn't think there was only one thing you could do. None of the things that have been said are bad, they're all good, but there's more than one that has to be done. Tess, do you want to follow up on any of that? No, that was very thorough. My question is for Dr Causton. Dr Causton, I say thank you for all your work that you've done in Drumchappel. I used to work there many years ago, so I know that the issues that you deal with and that your patients deal with, and I'm sure that they will very much be feeling the benefit of your commitment. I'm interested in the internal NHS barriers that you talked about, that patients have to navigate through. How can we do this better? What recommendations would you have for us? First of all, I talked earlier about the kind of boundary between hopelessness and rage. Engaging with a chance to change has been actually a process of people uncovering their rage. Coming back to my own practice, we have a sense of grievance and heart at the barriers that we place to them, for example, through difficulties in accessing appointments, difficulties in accessing our services and so on. I'm not speaking as if I'm somehow pointing the finger at other services. It also points towards a shift in the dynamic of power between us, allowing a chance to change a really involved process of questioning the service that we offer is being into position at the moment that feels uncomfortable because they're questioning. To my point, that is where the solution lies, in allowing people to question and to hold up to the barriers that they face. There are almost too many barriers to mention. I've given some examples of them, but I think that there is a shift in which people are able to question those barriers and to have more of a say in how services are redesigned needs to be the way that we're going forward. That is a painful and uncomfortable process. I'm finding it personally uncomfortable because I want to be defensive and say, well, I'm trying my hardest and you should see all the pressures that we're under. I'm going to other services to question how they operate, likewise, elicit or can elicit a defensive reaction in terms of everyone is trying their best, no one is trying to be, but learning to set aside that discomfort and to have very difficult conversations about how we do things, to understand the barriers that people face, to me that feels like a healthier health service. I'm not sure if it's a zero sum game. I think all the barriers that we put up make us inefficient. All the things that we do to try and protect our resources make us inefficient. I suspect that operating in a way that is less defensive of resource and more trusting of people and more willing to bring people in, I suspect, would make a healthier and more efficient health service. The direction of travel has been very much down fragmentation, making services more and more divided, having more and more types of services for mental health, for example. There seem to be dozens of different teams and options for mental health, each of which has its own inclusion and exclusion criteria, each of which has its own hurdles to get through. I think that redesigning services around people would make us more efficient, so I think that it maybe seems a bit utopian, but to me that feels like the way that we need to go as a health service. I think that the past 10 years have been very much focused around living within budgets and defending services and budgets. I suspect that that has actually made us less efficient because each health service is trying to meet its own little part of the budget by defending it against all comers. That is not a healthy way for a health service to run. I do not know if that answers the question, but I am certainly not trying to point fingers at other services. We are all struggling to be inclusive in this way. Perhaps finally, it is also about attitude and about culture and not as health work is getting ground down and just feeling under fire all the time. I think that a lot of people just feel that they are under attack and are just doing their best to get through the day in whatever way possible, and that can be quite discriminatory against the people who feel more challenging or have more need. It is easier to see easy people and much harder to see hard people. If you are going to get through the day in keeping out the people who have got the really complicated, difficult, challenging and unsolvable problems, it can be a way of getting through the day in tact, but that is not the way to go and that just stores out more problems. Evelyn, do you want to get any follow-up? I know that you wanted to ask about intersectionality. Before, I do not know if you announced the time that you wanted to do that, but I am happy to go to another member, if that is not the case. I do not want to put you in the spot. I can go to Sandesh and come back to you. Thank you, convener. I remember reading everything that you were doing at Med School and it is great to be able to see you and speak to you. I have a question for Professor Meyer. I believe that you founded the Sheffield alcohol research group. Alcohol impacts those more deprived the most. We know that through all the work that not only you have done, but we have seen. We have had two reports on alcohol and minimum alcohol pricing in Scotland, including one today. Both present evidence that minimum alcohol pricing is not working with the most vulnerable cutting-back to buy food, especially those of spirits. What is your response to that? How can we ensure that the impact of alcohol is not felt so greatly in those areas of most deprivation? I do not quite agree that the policy is not working. It is working on the whole. There are some very heavy drinkers who may not have the opportunity to cut down their drinking, who then substitute for food spending. I do not think that that is a problem of the price that you put on alcohol. I think that it is a problem on the health services that have not been available. The addiction services have had major cutbacks during Covid, which have been virtually inaccessible unless you were able to join online groups and make do with things like alcoholic, anonymous online and so on. When you get to those very dependent drinkers, we have seen that it has not had many detrimental effects, but there has been some substitution with food purchases. I should say that I was not involved in that particular study. I did not see anything that would make me majorly concerned that the policy was not working as intended, because we have seen alcohol consumption fall, alcohol mortality and hospital admissions fall. It is more about putting protective structures in place and those who have failed during Covid. It is again thinking about what you need in the round for policies to work for all the people that you want to work for. Going back to cheap alcohol is certainly not something that I would advocate. Minimum union pricing is one of the stronger policies that the Scottish Government has come up with. In the absence of having full tax controls, having a sensible duty system is another thing that you would do if you were in an independent country. Failing that minimum pricing and putting up the bottom prices and making sure that it is not pocket money alcohol is very important. It really only affects very high alcohol content spirits, which are very damaging to health. That is what I would say. Let us put health structures in place rather than saying that the policy is not working. With respect, alcohol consumption fell in those who were not deprived. We saw that. We saw alcohol consumption with those who had a problem going up. We also saw alcohol consumption going up in those people who were most vulnerable. A report by Public Health Scotland found no clear evidence of reduction in alcohol consumption among people drinking at harmful levels following the implementation of minimum alcohol pricing. You are absolutely right. There has been a collapse of recovery services, and that is key. Anything that we introduce is key to doing that. We have also found that those who are drinking are just switched what they are drinking. As I said in my first question, looking at the UK Government's policy, where they have increased the taxes at the alcohol based on the alcoholic level, you are seeing spirits with increased tax and those weaker alcohols with lower tax thresholds, so 3.5 per cent for example, and looking at lower no alcohol as well. Is there something that we should be promoting, lower no alcohol, and should we be looking at maybe trying to introduce systems that don't just look at pricing? It's because looking at health inequalities, this is a huge area that doesn't seem to quite be working. I think that, as I said, the duty reforms are very welcome and much overdue. They don't balance out a lot of duty increases over recent years. We had a duty escalator and that seemed to be working well, and then that was abandoned. Now there is that shift in the duty system to penalise some very strong alcohols, which is good and welcome. In terms of what should the Scottish Government do, there is a lot of international evidence on alcohol pricing working in terms of reducing consumption. It also shows that very heavy drinkers reduce their consumption by less on average because there is a dependency factor. There is something to be said about minimum unit pricing, which is a policy that makes alcohol less accessible to young people. It gives a strong message that cheap alcohol is not a good thing to have in your society. Taxation works across the board of alcohol consumption, so having something that is strength linked is very important. As I said, it needs to be as part of a suite of policies that tackle the reasons for heavy alcohol consumption, often linked into mental health issues, having good mental health support, having good alcohol support. However, the evidence on the link between alcohol pricing and alcohol availability and health outcomes is very strong internationally and also in Scotland. It is something that you said earlier about how there is a standard amount of money going into general practice. Am I mistaken in thinking that, initially, GPs who worked in areas of high deprivation actually did get more money, more funding? Following the introduction of the new GP contract, we have seen that there is an element of deprivation, but more money is going into those elderly, those who are living with complex needs. That has thus reduced the money going into areas of deprivation. I really need to qualify my reply. I am not a health economist and I am not an academic in this field, so I am having to quote others on that. The work of Professor Watten and Professor Mercer before the 2018 change in the GP contract did not find that there was a gradient towards deprived areas. Although there was a deprivation waiting factor in how funding was allocated, the actual end product in funding to practices, as I understand it, was flat across practices. There was not a waiting factor. That is my understanding of their research. I may be wrong on that as I say, I am a front-line GP rather than an academic. Since the 2018 contract, the way in which funding was waited changed. I do not know whether that has made the situation worse, but I understand that the Audit and Commission has found that that has not funded towards areas of higher needs so that the funding structure is still flat across GP practices. I am afraid that that is the level of my knowledge on the subject. That is who I have been quoting. I suspect that you probably need someone who has a better understanding of GP funding at a macro level to build down to that in greater depth. Just to come back on alcohol, my understanding—Hetra can correct me if I have not got it up to date—is that if you look globally, there is a clear correlation between mean alcohol consumption and alcohol-associated harm. Secondly, price relates to consumption. That is all to the good. I think that fits what Petra said. In Britain and in general, mean consumption is higher in higher socioeconomic groups. The gradient goes the other way, but alcohol-associated harm goes the expected way, the more deprived, the greater the frequency of hospital admissions and the greater the mortality related to alcohol. It, in a way, is a bit like I was saying with Covid. You need to control the vector alcohol, you need to control the virus, but you also need to deal with inequalities because it is clear that the link between alcohol and alcohol-associated harm is stronger in people of lower socioeconomic position. I go to Gillian Mackay, who is joining us online for some questions. Thanks, convener. Good morning to the panel. To what extent are health services trauma-informed and what improvements need to be made in this area and how do we ensure that all public services take a trauma-informed approach? Can I come to Dr Costin first? Yes, and thank you very much for that question, because I think that it does get to the heart of a lot of what we've been talking about, including the discussion about alcohol. I guess that there's the reason as to why some people suffer greater harm, not only from alcohol consumption, but from consumption of all kinds of addictive substances, including nicotine and other drugs. My experience over my time in John Chappell is that there is a very widespread experience of trauma in communities, both from childhood adverse experiences and from adverse experiences growing up and from day-to-day issues of facing poverty or exclusion or gender-based violence or ethnicity-related discrimination and so on. I'm not sure that health services are very trauma-informed. I think that many of the behaviours that are adaptive that people have learned as a way of coping with trauma and of dealing with the wider world are experienced as difficult and are, in a sense, people are shunned because of those ways of behaving or expressing themselves rather than trying to understand what lies behind the behaviour. I think that to take alcohol, for example, people who are alcohol dependent may present to health services in ways that are very difficult. Ambulances on Saturday nights and attendances at A&E and perhaps behaviour in hospitals that are challenging or behaviour at the front desk and the GP practice that is challenging. What I've been talking about in terms of stigma and in terms of how people are dealt with and how we understand people has to do with every person who works in the health and social care setting, both in community and in specialist level, need to have a better understanding of how trauma impacts throughout the life and how that affects people's behaviour. I think that there has been steps taken towards that. I think that there is more availability from informed training, for example, that we have had in our GP practice at some of our protected learning afternoons, but we still have a very long way to go. Not least understanding the ways in which we re-traumatise people, particularly through the ways in which people try to access health and mental health and the barriers and repeated assessments that they have to go through and being told repeatedly that they do not fit that service and that they do not fit that service as a way of re-traumatising. As well as individual understanding of trauma, it is also how do the systems and barriers in place reinforce trauma for people. I bring in Dr McDade. She has just said that she wants to come in on this and I will come back to her for a follow-up question. Dr McDade? Thank you again for the question around trauma-informed practice. Our view would definitely be that this trauma-informed approach needs to be embedded in health services, definitely, but also extended to other services, public services such as social security services such as housing services. The other aspect of this is, I mean, I'm certainly aware of the government's wider kind of trauma-informed workforce program, but I think the concern is if it ends up being a once-off training around trauma-informed approach, and then someone is supposed to kind of, as we've talked about, kind of go back into their system of working and just carry on trying to remember what they learned in that one-off training session or training program, actually what we need is somewhat of, I think, what Dr Costin was talking about, but we need to embed reflective practice throughout service provision so that it's an ongoing reflection that happens and that that space is provided for public sector professionals, health service staff to be able to reflect on how the experience that they're creating and coming into contact within their services. Embedding reflective practice is the next step, is a step that needs to accompany the kind of training programs in education in trauma-informed approach. Thank you. I'll go back to Gillian. Thanks, convener, and thanks both for your answers there. We've touched on various different factors that might have a stigma attached to them. In what ways, if any, do current working practices in health and other public services entrench stigma? Further to what you've already said, what work needs to be done to address that at the heart of the services that we're talking about, and could I remember going back to Dr Costin to start? Yes. Obviously, at a superficial level, having trauma-informed practice training is absolutely important. It ties in also to the shift in terms of the power structure and the extent to which the third sector and communities are involved in how services are designed and planned. I think that having a much greater voice for people who have lived experience of exclusion or trauma or adverse childhood experiences in helping us to understand how we design health services is critical. Just to give an example for video consultations, which many hospitals are now using and some NTP practices as well, for people who have had to attend court as witnesses for adverse childhood events or for exploitation or abuse, many have had to attend by a video link and video interactions can raise issues around those experiences. They find video consultations quite traumatising. That's something that I've just learned recently from talking to individuals. It's understanding the ways in which we design practices and the only way we can do that is by bringing in people who themselves have lived experience to help us to understand the design services around their needs. Yes, we train individuals, but more than anything, we bring communities into designing services. I'm waiting for the microphone to unmute. This is a bit of an anecdotal experience. I'm supporting Ukrainian refugees at the moment. The way in which you engage with services and sometimes very disrespectful way that services deal with you is just heartbreaking. Having that first-hand experience now of something that I've been studying remotely for a while is really quite powerful to see that you're asked to come to a job centre, which requires an hour and a half round trip on the bus just for you to be told that the person you were supposed to see wasn't there and to come back the next day when you already have an interview and then you say, you've got a job interview, oh no, no, you've got to attend. Things like that are just so, they take away your sense of agency of being able to control your fortunes in a way that is really demoralised. I mean, I know you will have heard many of these experiences from people with lived experience, but it's powerful to see what that constant onslaught of not being believed, of your time not being valued, of you somehow being made to jump through various hoops to, I don't know, register with a dentist and even finding someone who will take you on what that does and how much time and effort, as Michael already said, it is a massive resource strain and if you're already traumatised and have fled from war it just makes life much more difficult and I'm sure if you're in a situation where you're otherwise financially vulnerable or have experienced trauma, as so many Scottish residents have, it's just very, very hard to navigate. The large number of services, I mean, there are great help and support programmes but they're all very bitty and they're not aligned and there's no one-stop shop, so you've got to really be very informed and chase every single bit of support and that is really hard work. You've brought up something that we have heard a lot, Professor Myer, about alignment of services and people not having to retell their story multiple times to multiple different people. I mean, I wonder if any of our other panellists have got reflections on that because we've had some people suggesting solutions to some of that. I wonder if this is a good point to bring in maybe other panellists about that kind of aspect which can compound people's trauma. If you're having to say the same story over and over again to a different person from scratch, not leaving anything out in case it becomes a difficulty in accessing a service, is that something that you must hear a lot, Dr Cousin? Yes, it is. It's something that's a chance to change, have very much brought into their commentary on the short-life working group report. They actually developed a model which they would like to be introduced in primary care, but across the health service, which is, see me, I'm a person with feelings, listen to my opinion matters, be honest, even if you don't know, help me understand, please don't tell me what to do. Remember, I'm an expert in your professional hands 50-50 partnership and consider peer support. People build confidence far more effectively than medication. I think actually going to people and asking them to teach us how to relate in a way that's enabling is absolutely critical to this, and certainly a very strong way that repeated assessments to be told that you don't fit a service is a traumatising experience for people that already face barriers, and we have to find a way to get rid of that. Basically, whatever door you go in, that's the only door you go in. Even if it's another service that you need, the door you end to buy is the single door, and even if you've moved on, the more appropriate service that is the door you end to buy, you don't get kicked out the door until you find another door to get in. I think that has to be a thing of the past. That's very helpful as we think about what we're going to recommend in our report. Evelyn, on the internet sectionality, you want to come in. This will probably be the last theme of questions unless I'll be looking round my colleagues to see if they want to come in, but we really only have about five, ten minutes left. We heard from a lot of people giving evidence that intersectionality is an issue, and that they face multiple barriers because of that. What is being done in policy and practice terms to help and to anyone who would like to come in? We've got Dr McDade offering to start us off. Yes, thank you. I'm not an academic, so I'm not going to try to define the intersectionality, but one of the activities that we recently engaged in the foundation is establishing a diverse experience advisory panel to the Scottish Government to inform the development of mental health policy. This is the first time that there will be a panel who's focus is on mental health policy, but for whom they don't necessarily have to have had a diagnosis of a mental health condition or experience of mental health services to be advising on mental health policy, so it's quite innovative in that way. When we had quite a strong interest in participating in the panel, we had over 180 expressions of interest for a maximum of 30 places on the panel, but one of the things that we found was that many of the people coming forward who we had sought on the basis of have you had any experience of disadvantage or discrimination that might put you at risk of having a mental health problem, we found that lots of people came forward who had experiences that reflected intersectionality, that experiences perhaps they had experienced unemployment, but also had not had a chance to fulfil their education, also had experience of single motherhood. We have people who have been victims of violence but who also come from a refugee status, who have been a witness of violence in Scotland once they have arrived in Scotland. When you ask people about what puts them at risk of a mental health problem, what we found is that they can point to a whole number of different circumstances in their life that have where they have realised that it has caused them stress and distress and perhaps put them at risk. I think that intersectionality is fully alive in individual's experience and as Dr Costin has pointed out, the only thing is that our systems are not designed for rounded human beings, our systems are designed for people who fit a single category and it really needs to shift. Just to note similarly that this was found also with regard to evidence that research on poverty alliance conducted, so we are partners with the poverty alliance project on poverty and mental health and they had done research on people's experience of universal credit, Glasgow-based recipients experience of universal credit, very much saying that what they needed was a much more person-centred service than what they were actually receiving. Yes, thank you. I would like to echo what Professor Marmot said earlier that health inequalities and the climate emergency are the two great emergencies that we are facing in the next 10 years. I think that if those were embedded at the heart of every system and every sector, both in the public and the private sector and the third sector, that we understood that those are the two great emergencies that will make the difference between a good future or a catastrophic future. There was national leadership for that, then I think that at least we would be working towards the same goals and the same aims. I would like to perhaps echo that that they should be embedded in all sectors to help us to work across sectors towards the same aim rather than pulling in different directions. Thank you. That is very helpful. I want to just point out that a lot of the intersectionalities come because things are causally linked and because everything is in a system. If you grow up or you are much less likely to have a good education that has influences on where you live in your adulthood, what kind of job you do, potentially whether you have got help with your childcare or whether you end up as a lone carer who is struggling for money. A lot of those things without that stigmatising life-cost perspective where it is all predetermined, but they are strongly linked. If you grow up in poverty, your chances of overcoming poverty are much, much less likely in future things and health consequences are there. For me, intersectionality is around a web of causes that all stack up against having healthy life outcomes later in life. As Peter said, having thought about it in the round and thinking about how education, employment, housing and everything goes together to create these outcomes is going to be very important. Thank you. That has all been very helpful and a good note to end on because we very much agree with that that the routes of health and the qualities line a lot of different portfolios and you have all made that extremely clear this morning. Thank you very much for that. We have reached the end of our time with you, so I want to thank our four panellists for the time that has spent this morning and for additional information that has been put in our chat box for maybe following up on. Our next meeting on 28 June, the committee will be taking evidence from the Minister for Public Health, Women's Health and Sport as part and the final session on our inquiry into health inequalities. We will be scrutinising an affirmative SSI, but that does conclude the public part of our meeting today. Thank you all.