 Welcome everyone to the 11th meeting of the Health, Social Care and Sport Committee in 2022. I've received no apologies for today's meeting. The first item on our agenda is to decide whether to have items 3 and 4 in private. Are members agreed? We're agreed. Thank you. And our second item today is two evidence sessions as part of our inquiry into alternative pathways to primary care. We'll hear from two panels of witnesses comprising organisations representing a combination of NHS primary care services and community settings and multidisciplinary teams in GP practices. All our witnesses are participating remotely, as well as a good number of our colleagues, MSP colleagues, are also remote as well. I welcome to the committee Claire Morrison, director for Scotland of Royal Pharmaceutical Society, Julie Muzzgrove, vice chair of Optometry Scotland, Harjeet Sandu, managing director for the National Community Hearing Association in Scotland and Jess Sismon, policy lead for the Royal College of Psychiatrists in Scotland. Welcome to you all and good morning. First of all, one of the reasons why we decided on this inquiry was to draw attention to some of the services that were out there, which people could be directed to or self-directed to in order to get specific primary care. We wanted to have—certainly anecdotally we're hearing that there wasn't particularly a lot of public awareness about what was out there. That's my first line of questioning. I really want to know from all of you how difficult it is or how difficult it has been or how successful it has been in shifting that traditional view of you go to your GP for absolutely everything. From your perspective, I would be interested to hear what you think that this has been in train for quite a few years now, this sort of pathways system. How successful has it been and what's the public awareness of it like? If I may just go down in the way that I introduced you to Claire Morrison first of all. Thanks very much. First of all, just to say that I'm here on behalf of the Royal Pharmaceutical Society. We are Pharmacy's professional leadership body. We have members in all sectors of the pharmacy, including community pharmacists, pharmacists working in GP practices and pharmacists working in the wider NHS and education. There are around 5,000 registered pharmacists in Scotland who are a large professional group and the third biggest health professional after doctors and nurses. As a professional leadership body, we really represent the individual pharmacists in their professional practice, so we don't represent commercial companies or contractual matters. To develop our written statement to the inquiry, we held focus groups together, our members' views and we also met with pharmacy leaders across Scotland, so we are representing a wider view. To start off with an answer to your question, I think it's really clear that pharmacy already provides a number of alternative pathways to GP care and primary care, and that's through community pharmacy services, through pharmacists working in GP practices, and also through specialist services and community settings. Pharmacists certainly have the professional ability to deliver more, but to achieve that and then capacity within pharmacy needs to be improved. Some key enablers there are around better skill mix, around developing the pharmacy's workforce, specifically around independent prescribing and around better digital technology. To answer your specific question about awareness, I think that both public and professional awareness of pharmacy is mixed. Certainly awareness of community pharmacies is high, but awareness of the professional roles and services that community pharmacists have is lower. Awareness of other pharmacists such as those working in GP practices is very low. When you say pharmacy, people tend to think that pharmacist roles are very much about supplying medicines, but pharmacy is already much wider than that. A third of pharmacists across NHS Scotland are actively prescribing medicines as independent prescribers, and that number is increasing all the time. I think that there is a lot of work to improve the understanding of pharmacy roles right now and indeed the further extension to them. Hi, I'm Julie Mosgroff, vice-chair of Optometry Scotland. We're a non-profit organisation representing optical sectors, so that can be practices and it can also be the optometrists within the practice, dispensing opticians and other staff there as well. We've got over 900 providers across Scotland, so I'm just representing. Much like my colleague Optometry, generally we are on the high street. We are very well known. You can't walk down a local high street without seeing an optometry practice, much like a pharmacy practice. However, despite that, there were 2 million people attended for an eye exam in 2019. There's still a lot of uptake that could be done there. Eye exams, traditionally, a lot of people think that it's just to get your eyes tested. If you've got a problem with your vision, you go and see an optician then, but there's still quite a lot of work to be done on the awareness of what exactly can be picked up during a routine eye examination. Another thing is that, as well as optometry, we begin with the first port of call for all eye emergencies. That is something, even with our other colleagues at Edgstry Pharmacy, they're still building the awareness between that. For any eye problem at all, rather than seeing a GP, it should be attending the optometry practice. There's been quite a lot of work that's been done over the years to try and build relationships with that and also get that message across, specifically in NHS Grampian. We did a campaign, which is a know-who to turn to, and that's been going on since 2009, trying to raise awareness. The posters were put up publicly. They were in GP practices, pharmacies, and just reaching out to try and advise where to turn to for the first kind of eye problems. There's certainly still a lot of work that could be done from that side of things. We also provide domiciliary eye care, so that's something that, since 55,000, attended for a domiciliary eye appointment in 2019. There's still a lot of work that could be done to raise awareness from that side for people at home who are unable to access the service. On that, we have many optometrists coming through the ranks that are becoming independently prescribed. They are able to prescribe a certain range of medication that are specific to their level of competency for patients. We could be seeing more. We do have capacity at something that we had prior to the pandemic, and it's something that we continue to have availability. We don't have a backlog, like in secondary care, so it's something that we are on the high street and easily accessible, and we could just be promoting that more. Thank you, and I'll come to Harjeet Sandhu. It's a pleasure to be here today. Thank you for inviting us. I'm Harjeet Sandhu, representing audiology providers that work in primary care science throughout Scotland, and they work out over 150 locations and provide home care. To answer the question, awareness is generally very limited for a lot of primary care professions, largely because primary care is still very much framed as GPs rather than the wider primary care professions. With respect to hearing care, general awareness about acting on hearing problems is relatively limited or poor in general society. Lot of people accept that hearing problems are something that just happens with time. Therefore, there is a huge opportunity there to tackle what is a growing public health challenge. Just raising awareness of alternatives to GPs as primary care will also bring major benefits for the population of public health, but in order to tackle that general awareness, there has to be more of a communications strategy around removing that kind of concept that the GPs are a single point of access. The committee's evidence that it's got from the general public shows what the public really want is confidence that those alternative routes are planned routes rather than diversion routes or avoidance routes, and giving them the confidence that these are planned for their benefit and that they're in the right place at the right time will be a key enabler. That's all that I have to say. I'm a consultant psychiatrist and today I'm representing the Royal College of Psychiatrists in Scotland. The psychiatry profession are experts at providing specialist potentially life-saving care for mental illness within a clear ethical framework. Our focus is on delivering the best care and outcomes for patients. When looking to this consultation, we wanted to ensure that those with severe mental illness, those likeliest to need our care, are better able to access support and care in their communities. While recognising the importance of meeting the needs of all Scots, we believe that that should involve our most vulnerable citizens and that support should not cater simply to the majority of people who may have poor mental wellbeing and or mild to moderate mental health. While recognising that those with need of clinical interventions can and should be engaged in health services, we also recognise that there are those in our community who found traditional methods of accessing healthcare services uncomfortable, meaning that they didn't present until their mental ill health had reached a severe stage. Our previous campaign focused on the need for there to be no wrong door to access the right care in the right place and at the right time for mental ill health. Ensuring that pathways into care from our communities are as accessible as possible is a critical aspect of delivering on this vision. We welcome the opportunity to discuss how we can better meet the needs of all those who may interact with our primary care and community support, and how those pathways can be adapted to the needs of all Scots, including those with severe mental illness. To answer your first question, we felt that there was a varying level of knowledge amongst practitioners. For patients, it was felt that many access using traditional methods and that is their decision to access that way is defined by factors such as their culture, geography, health awareness and the availability of signposting information. However, we also recognise the need for alternative pathways. As I said earlier, there are those in our community who feel very uncomfortable accessing traditional pathways and so did not present until they were very unwell with their mental health needs. We have long-standing examples of those from the past and so it is critical that we find other ways to help those individuals to come into the service and get the support that they needed at an earlier stage. In relation to alternative settings, we felt that there were many that you could engage with alongside. Traditional ones and religious settings were cited as an example with some community seeking religion as an avenue to get mental health support. We also felt that community resources were worth considering for this purpose, including social capital assets such as youth groups. However, our concerns from a practitioner perspective were the lack of the ability of funding for community and social supports, meaning that the landscape is constantly changing. I cite examples in Hoik of a wonderful art group that, when the funding ceased, it collapsed and we did not know what resources were available that would be equivalent to that in the local community. It is about having a constant ear to the ground and having to maintain a knowledge of quite a flexible and fluctuating setting. You have individually raised some points that I was interested to follow up a little bit about. First of all, you said about home care. That is something that I hear from constituents that traditionally have been able to have home visits in the distant past from GPs. It was fairly irregular. It is a very irregular thing. It has to be quite a serious situation. You mentioned home visits as something that has been part of your normal practice. I do not think that people are aware of that, that they could have those alternative pathways coming to their home. Could you expand on that? I am happy to go first. Most of the significant, most severe here problems occur in older age, so people are more likely to have, by hearing problem, a greater severity of light to be 80 and over. Therefore, some of the most unmet need in our society is in care homes and in populations whereby people are finding it difficult to travel with mobility. Unfortunately, there is a large offering in Scotland, mainly from the independent sector private sector, to deliver that home care service, where you can have hearing diagnostics and testing and care and after care at home. There is that inequality, and it is something that really needs to be addressed, but it is available, and it is readily available. If I hand over where I have been optometry, it is a little bit different in the NHS, but they might explain that to you, because Julie also mentioned home care. She did. I will come to Julie on that. Herjie, you are saying that at the moment that it is mainly in the private sector, but it is something that could be expanded. Absolutely. I understand that. I will come to Julie now from the optometry point of view. With optometry, it is available now. It is not across every optical provider, but it is something that specialised practitioners are doing across that. Is it difficult? The biggest barrier is the funding for it. It is keeping it a viable service, making sure that it is accessing with a lot of travel. It is not just visiting care homes, it is also visiting individuals in their homes scattered across Scotland. Specifically, remote and rural will be a lot more difficult if you are driving to someone's house. That is the barrier of it, but we do certainly offer the service across different providers. In 2019, out of the 2.1 i exams, there were only 55,000 who accessed the home service. It comes down to communication from the point of view of Optometry Scotland, but in audiology there is another issue there about the funding. Emma Harper wants to come in and pick up on particular the points that are made around geography and rural. Before I hang on over to Emma, I have got the chat box in the platform that you are on open. If anyone wants to come in on anything and specifically go to the chat box and put an hour in it, I can see it and make sure that I bring you in. Just to pick up on what Julie Harper said about remote and rural, as far as optometries are, we have places in our small towns and large villages to access optometry, for instance. However, in the remote and rural areas, there will be additional challenges. Julie, can you outline what the challenges are for remote and rural areas if we are going to look at delivering alternative pathways or having people access to alternative pathways? In optometry at the moment, it is well placed. There is a good network. When you look at the Highlands as an example, it is over about 60,000 people who travel to the Rhaigmoor hospital. They live over, say, 30,000 miles away from Rhaigmoor. All those 60,000 people actually have an optometrist within a 30-mile pedagogy of their homes, so it is well placed. However, we need to be able to sustain that going forward. Especially with vacancies that come up, they can be more difficult to fill in these remote and rural locations. At the moment, there are issues with some areas of vacancies, but it is more the on-going community that I care at the moment. It is making sure that a good supply of professional staff is still coming through to fill these positions. Something like future support would definitely help to mitigate this risk. At the moment, if you are looking at putting optometrists into more difficult locations that are harder to fill, often it is higher salaries that incur with that as well. That makes it a more difficult service. Another wee question. Previously, we have talked about additional skills to deliver additional services. For instance, in one of our member's debates, we spoke about how optometrists are often the first people that would detect type 2 diabetes. That would then lead to our referral to get blood glucose check. Is that something that could be potentially delivered in an optometry setting, but that would require additional skill, training and competence, for instance? Diabetes at the early stages can be picked up by any optometrist right now. There are certain signs with diabetes that we can be looking for at the back of the eye. I have had patients that I have seen in practice who have come in with no symptoms at all. I have noticed changes at the back of the eye. It suggests that they have diabetes or high blood pressure. I have advised them to go and see their GP and show them signs. Many of them have been quite shocked because they have come in for a routine and did not know that they had symptoms. They have sometimes been a bit dubious until they have seen their GP and then come back and said that they have been diagnosed with diabetes or blood pressure. That is something that can already be picked up. Once someone has been diagnosed with diabetes, it is to follow on care that they need. They get regular eye exams, and a lot of that is in secondary care environments at the moment. There are areas such as Ayrshire and Arran that do diabetic screening that they were seen in a community by an optometrist. That is with additional training so that someone is able to monitor and look for changes there. It does require a little bit more equipment and a bit of training, but that is something that is happening in different pockets across Scotland. Unfortunately, it is not everywhere. It is in just certain areas. Can I bring in Claire Morrison, who wants to pick up on your question about remote and rural? To add, remote and rural communities are very much in our communities right across Scotland. That includes remote and rural communities. Indeed, the accessibility of community pharmacies is something that I think the public is really aware of, particularly during the COVID pandemic, when community pharmacies did indeed keep their doors open and were one of the services that was very much there. I have lived and worked in the Highlands for the past 17 years, both in terms of community pharmacy coverage, but also in terms of some of the more innovative practice that has taken place in the pharmacy around pharmacies working in and with GP practices across rural areas. We see all but seven GP practices across the country having input from pharmacists through the pharmacotherapy service, so that again covers all the rural practices. That includes both in-person but also use of remote support as well. Finally, I would just like to highlight some data from a recent Ipsos Moray survey, which was a survey of 1,107 adults in Scotland. They were asked about methods of accessing pharmacy services. What was really interesting was that 87 per cent said that they wanted to access pharmacy services in person, so that is great, because we have that coverage there already. There were a lot of people who said that they wanted to access pharmacy services in other ways, so 59 per cent were talking about telephone consultations, 42 per cent were talking about video consultations and 38 per cent were talking about other digital services such as online messaging. I think that all those ways enable improving access to people in remote and rural areas, alongside having people travel and provide services in the location. Harjeet Sandhu, do you want to come in on that? Just to build on Claire's point, one is that today we also have innovative technologies in healthcare where you can fine-tune remotely people's digital hearing aids to help them to hear better, so that they do not have to travel as far for every single visit. There is also this quite large primary care infrastructure across Scotland, which is not yet mobilised always by the NHS commission services in quite the same way as the primary care professions. There is a huge opportunity to tackle those inequalities and access that exist in rural communities, reducing the cost on individuals who are travelling by long distances sometimes to access care. I just want to mention the opportunities here in terms of reducing inequalities and access. I am going to bring in a couple of my colleagues. Stephanie, you wanted to come in on the diabetes aspect that Emma mentioned. Can I bring in Stephanie Callaghan and then I will come to Sandesh Gohani. Thanks very much, convener. I have a quick follow-up with Julie. I have just been speaking about diabetes and have been able to spot it early on. She spoke about referring to GPs and I am wondering whether she would also refer directly to other primary care pathways or to specialists or whether that would be appropriate. I am just trying to figure out how it fits together and whether it always has to go back to the GP or whether it can be onward referral. That actually kind of skips that step if it is unnecessary. Thanks Stephanie. I suppose that it depends on the conditions of the diabetes. It would actually probably be the nurse that we would refer to for it to get blood pressure checked, so it would probably be actually the nurse that we go to with that. There are other conditions that we can pick up as well. I suppose that it is, and if we are suspecting that the patient has had a stroke, then we would be referring through the GP, but if it has affected the eyes as well, it would also be contact in the hospital. We also referred to pharmacy for certain conditions as well. It depends on the condition, but we tend—the majority of our referrals would either go to a GP or direct to the hospital. That is probably the majority. There are other things that we can do as well with our sectoral organisations. That is great. It is actually helpful to know that those referral pathways work actually within family care services and beyond that as well. That is great. Thanks very much. Thank you. I want to talk a bit about innovative practice that we heard a bit earlier, especially in rural areas. I know of some amazing work that has been done in NHS Grampian, and I really like Julie Mosgrove to tell us a little bit more about it. Barriers to rolling this out Scotland-wide and whether anyone else has any examples of innovative work around rural areas makes life better for our patients. We will go to Julie first of all, since she mentioned Julie. Perfect, thank you. I am based up in Grampian and I have worked within the system for over 10 years now. The Grampian and I Health Network set up a set-up that was ahead of the rest of Scotland being the first port of call for all eye emergencies. The reason it was set up was the fact that, when it did an audit on the eye-out patient department, it found that less than 10 per cent of walk-ins actually required to see an ophthalmologist. It was finding that ophthalmologists were seeing all sorts of conditions that we could have seen in primary care. The model was built up around four main conditions that were eye-related emergencies, but it has grown in collaboration with working with secondary care and GP practices. There are optometrists out there within Grampian who have a network where we can prescribe for a range of conditions. That is something that we do not need to be an independent prescriber for. From 2007, we were able to prescribe certain medication for patients, take them in practice, monitor them in practice and then get them back for review appointments, whereas those patients would have originally gone up to the hospital to be seen. Some of the conditions are simple, such as foreign body removal, and optometrists would be trained in Grampian to remove that. Whereas, if you are in Tayside, you would potentially be going into the hospital in Tayside to get something removed from your eyes in an A&E department. There are things like that, but likewise there are some medical conditions that have been working in support with the GP. With more and more independent prescribers, we can prescribe that ourselves without having to co-prescribe for the GP. In Grampian, any optometrist is able to do that. I know that there are pockets across Scotland, especially in remote and rural areas, where they have that good network with the GP and also at the hospital, because it requires the ophthalmology support there as well to help us to support the patient in the best way. There are different networks, but that is probably one of the best ones there. Claire Morrison wants to come in on this, Sandesh. One of the services that I would draw attention to is the consultancy service, which is the very early pilot of which was placed in pharmacy services in NHS Highland and, indeed, in other pockets across the country. One of the reasons for that was around an ability to provide remote pharmacists and support into really rural areas where there was not a community pharmacy. There are really isolated communities in North West Sutherland, for example, and some island populations as well. What those services enabled using NEMI, which is obviously now during the pandemic, was scaled up significantly and is available right across NHS Scotland. That service enabled patients to have complex medication reviews remotely. One of the great things is that you can hold up your tablets on a video camera, so that you do not have to be able to pronounce the names, which can be a barrier for some people, and also to be able to see into people's homes and support them with taking their medicines effectively. Definitely, we have seen innovation with technology in rural areas like that. Before I move on to more questions from my colleagues, I wanted to ask Jess Susman on something, because we hear, as constituents say, regional MSPs about long waiting times to access mental health care. From your perspective as a psychiatrist, there may be people watching this and listening to what you have said before saying, well, I thought that I always would have to be referred to any kind of mental health care. Can you give us an idea of how the public would access the services that you are talking about? You have mentioned the outreach stuff that you have been doing, but could you maybe give us a flavour about, just for the public out there, where is the self-referral, or where is that doorway into services that you describe? A great example is the primary care mental health teams in Glasgow, where you can self-referral, and now I understand that about 46 per cent of referrals are self-referrals. That would be for an assessment of your wellbeing and whether or not you have a mild to moderate mental health problem. If they felt that there was something more serious going on, they would refer to secondary care. That is a good example of a primary care setting. In Glasgow, that is another example of good practice, but it is obviously not rolled out nationwide. It depends on the issues around signposting and understanding of the options related to how severe illness is. We want to ensure that there is a straightforward pathway when you are severely unwell through the GP to get to the appropriate specialist psychiatric care. However, when the condition is different and it is maybe mild to moderate, there should be a variety of options available in the community that people could choose between to maximise their health and their wellbeing and to improve on anxiety management style, relaxation opportunities for improving access to other people, to peer support, and so on. It is very postcode lottery at the moment about what is available, where and how those things are sustained. I do not want to interrupt you. I was going to give a good example of a resource that has been wonderful in the borders. That is where I work. NHS Borders is the men's shed, which is an example of an organisation for men. At the moment, it is mainly older men who choose to access it. It is peer support, it is woodwork. They do all sorts of interesting things, depending on the area and depending on what the individual groups want to achieve. That is about wellbeing and maintaining health, and it is possibly mild to moderate when you are not feeling fantastic going there and talking it through with peers and getting that kind of support. It is a different level to the level of needing to see the GEP and the needing onward referral to psychiatric services. I know that you wanted to join in on the responses to Sandesh's question, which brought up near me. Yes, my point about near me was more. I am also a rehabilitation psychiatrist, so my main job is looking after people with chronic schizophrenia, people who are never entirely recovered from their illness in terms of symptoms and onward difficulties. While near me is a fantastic resource for many, I would say that none. I cannot think of a single patient in my rehabilitation service who would feel comfortable using an online service to access any support. They all have wanted all the way through Covid. They have wanted and needed face-to-face contact. Those who have chosen not to have it through anxiety around Covid have become unwell, and we have had to reinstate face-to-face contact. Thank you, convener, and good morning to the panel. Is the panel concerned that the NHS will be able to recruit sufficient staff to fulfil the ambition set out in the NHS recovery plan and the national workforce strategy for health and social care? How likely is it that staff will be redeployed or recruited from elsewhere to fill gaps? Who would you like to direct that to first? Will we go to Clare Morrison first, Gillian? I think that that would be a good idea. Like every other profession, pharmacy is at the moment in difficulty in terms of total workforce capacity, but there are some things that could be done to improve our capacity and our culture in our workforce that could lead to an increased capacity of staff. Some of the things that we need to do are things like making our processes more efficient in all settings. Right now, we have poor information flow in and out of community pharmacy, which has an awful lot of work of time into professional days. We have the pharmacotherapy service in GP practices, where there is real variation, for example, in terms of dealing with acute request prescriptions, and again, improving some of that could create capacity within the system. We have a lack of digital tools, so introducing an electronic single-shared patient record to improve capacity, quality and safety and underpin all the referrals that we have talked about already would create significant time savings in both community pharmacy and in general practice pharmacy as well. We could also do more to invest in skill mix in pharmacy, so investing in more pharmacy technicians and more pharmacy support workers in order to release pharmacist capacity. We could do more to modernise the dispensing process in pharmacy, and we could look at digital tools such as electronic prescribing as well. There is work going on in all of those areas, but we need to accelerate all of that, and we need much better workforce planning. One of our concerns is that pharmacy needs workforce planning by government in the way that it is done for doctors and nurses, and it is not done for pharmacists and pharmacy technicians in the same way at the moment. We are very aware that we cannot create an additional workforce because it takes many years to train a pharmacist, so what are some of the things that we can do right now? Focusing on some of those capacity issues would be really beneficial now. Focusing on workforce planning and while we look at training more people in the longer term. I will bring in Julie Musgrove. With us for workforce planning and optometry, a lot of optical businesses have been having to do that in order to attract optometrists dispensing optitions to the practices. One of the things that we do is attend local schools for careers events, talking about optometry. I personally found myself when I decided to become an optometrist, it was only because I got my eyes tested and naturally needed glasses and that completely shifted my thought. I had not thought of it as a career choice, it was more medical. I looked at doctors, dentists and things like that, so optometrists are reasonably aware of us at school level to attract more people to university. In Scotland now, we have only had Glasgow Caledonian University up until very recently, and now we have University of Highlands and Islands to start optometry as well, but those graduates have not come out yet, so there are two universities now offering optometry. When people come out of university, they tend to stay closer to the university that they studied in, so there is a hope that the United Nations will help to keep optometrists in that sector. Overall, there is an increase in patient volumes, the same as every sector with the ageing population. I suppose that a barrier with it is that investment in staff is becoming greater over the years. That is going to be something that is the funding stream going forward, to ensure that we can protect the workforce going forward. However, there is certainly a lot more that can be done and a lot more raising awareness that it is starting young and working up to get people into the sector. Thank you for the question. The NHS recovery plan specifically mentions audiology and making it evolving it to be on par with the rest of primary care, and that means greatly expanding access. In order to do that, the current NHS workforce, which is a predominantly hospital-based, will not be able to meet that need, but, fortunately, you can double the workforce by using other primary care professions in the same way as optometrists, GPs and pharmacists are using. In fact, many hundreds of audiologists work in the same practices as optometrists and pharmacists today throughout Scotland, so there is definitely both the workforce and the infrastructure to deliver that part of the NHS recovery plan. That is the audiology perspective. I will come to Jess Sussman. Thank you for the question. From our perspective, I think that, as everyone else is saying, that there are crises of staffing within mental health and nursing staff, social workers, pretty much across the board, we have problems at the moment filling all the necessary roles, but we really welcome the expansion of link workers into primary care settings and in the borders. We also have local area coordinators to help folk with mental health problems to be able to navigate within their local communities the resources that are available, so having someone there who can spend time with them and understand, which requires a real set of skills to engage with folk with difficulties with their mental health and then to be able to signpost them and support them to access different resources in the community and alternate pathways is very much welcomed, but we are also concerned that, unless there is a real look at the workforce and how you plan for it, it is going to be taking skilled staff from within other settings and just moving them across, creating other gaps. The public knows that the NHS has been under extreme pressure for the last two years and, as we hear more about the impact that this is taking on staff, is there a risk that this will impact recruitment? How do we persuade people that the NHS, primary care and the sectors that you all work in and represent are still great places to work and continue to attract people into health professions? I think that it's important that times are changing and a lot of people are looking for more of a work-life balance as well, so that is certainly going to create a challenge from a recruitment point of view, making sure that there's more people coming through. I'm certainly an optometry who have found that people have looked at changing their working hours and doing less days than dropping to four days compared to five. It's something that we have to be mindful of, as we are just recruiting generally, but also putting people through the courses. The university has been more open to that as well, because we need to be flexible and not trying to keep people set in the role that it maybe was. That will help to keep the balance better and attract people to stay in the roles, but it's just providing that support. Employers are generally one of those things to look after the staff and make sure that everyone has made sure that they've got the support that they have. Certainly, there's different mental health support out there as well, and the pandemic has taken its toll on a lot of people. It's having those access to services, and it's something that has come out of the pandemic, because people have and employers are accessing those services more and letting them available to employees to better support their staff. It's important that we modify how we look at recruiting and what we're willing to offer as well. I'm not seeing anyone else who wants to come in on that particular question. Have you got a follow-up at all, Gillian? There's a couple of ours just popped into the chat box. My heavy head has worked. I'll go to Clare Morrison first. First, I think that pharmacy can be a bit of a hidden profession, so it would be a fantastic thing if we could have a recruitment drive in order to promote careers in pharmacy. I'm not just about pharmacists but also some of the other really important roles there are around pharmacy technicians and pharmacy support workers as well, so that would be fantastic. I think that there is very much something about talking about an increase in public awareness of the types of roles that exist in pharmacy as well, so thinking about things like the NHS pharmacy first service and community pharmacy, thinking about the pharmacotherapy service developments in GP practices, and how educating and giving awareness to people about those types of services is almost certainly would make pharmacy seem more a captive proposition. The other thing is that I think that we do need to work with pharmacy employers to improve some of the culture around things like flexible working opportunities and certainly having a rest break during the working day, and that still is a really important issue in community pharmacy in particular, where there can be an expectation to work from eight in the morning to six at night without a single rest break at all, and that is a challenge for us, so I think that there's lots that could be done by working with pharmacy employers, and then finally is a professional leadership body, and part of our role is around creating a positive vision for the future, and we recently published pharmacy 2030, which is our professional vision, and that is really about maximising and making the absolute best of what makes pharmacy unique, which is our expertise in medicines, and so being able to describe an exciting career prospect for people in that way, I hope, that it will attract more people into the profession. I think that this question goes to the heart of the inquiry as well. At the moment, the public very much appreciate GPs to the point that they're very upset clearly in the service user view back when they can't access the GP, and it builds on what Claire said. People just don't recognise sometimes just how valuable the primary care family is, and by raising the profile of those at the professions, I think that we'll naturally see more people interested in those careers, for example in an audiology, where audiologists can do ever more extended services, wax management, supporting people with counselling for tinnitus, and really helping people with that long-term hearing loss. I think that the more awareness we raise, the more exciting and fulfilling these careers will be, and not only hopefully will we attract people, but we'll keep them in the professions for longer, so I think that hopefully this will be part of the solution. I want to echo what everybody else has said, but I also think that the value of a person-centred helping career is so important to people and the connection with others, and that we've lost some of that with the isolation of the digital model at the moment. I appreciate that we're getting back into it, thank God, but there'll be more hybrid working, but I think that working remotely has really harmed people's relationships and their sense of being part of a team and part of a group, and we need to recover from that a little bit. Also, the development of the career, whether it's nursing, whether it's audiology or other careers, the opportunity to develop and different roles and specialisms is vital to recruitment. I think that people feel that they can move in a direction positively over their lifetime of their career. Those are the things that I wanted to add. Gillian, are you happy for me to move on to Sue's follow-up question? Yes, I'm happy to move on, convener. Thank you. Thank you, Gillian. Sue, I'll just go over to Sue. There we are. We don't appear to be able to hear Sue. I wonder if I can't see that Sue is muted, so I'm wondering if there's an issue there. Maybe just give it a wee minute for broadcasting to switch it off, switch it on again, type thing. No, I think that Sue has frozen. Maybe if Sue wants to rejoin, maybe. And I'll come back to you, Sue. Don't worry about that. If you want to rejoin or broadcasting can get in touch with Sue and sort out those technical problems. Right, we'll move on and I'll come back to Sue's question on workforce planning once she's back. David Torrance, over to you. Thank you, convener, and good morning to panel members. Does the primary care system enable a holistic and preventive approach to keeping people well? I'll go to Claire first, please. So I think a really important role of pharmacists is that they do provide person-centred care and they do provide a holistic approach. So rather than looking at someone in terms of just a specific clinical condition, they are looking at the medicines in an entirety. I think that we need to do more to ensure that that person-centred approach is taken right across primary care, but absolutely. I think that pharmacists play an important part of that. And I'd just like to highlight some data from a public opinion in terms of the recent It's Us Murray survey that I mentioned earlier because their views on the roles of pharmacists included 95 per cent supporting pharmacists advising on medicines, 87 per cent thinking it was important that pharmacists prescribe medicines, 89 per cent thinking pharmacists should be the first call for common clinical conditions, and 81 per cent thinking that pharmacists should be monitoring, reviewing and adjusting medicines for long-term conditions. So all of that really kind of feeds into the public engaging with pharmacists on providing that holistic care to people's conditions in the entirety. Julie Muscoff. Just to that, optometry practices are welcoming places and they normalise healthcare, so a holistic approach is something that we would take anyway. Patients sit with an optometrist for on average about half an hour, and during that time we're delving to find out what's the reason for them coming in, are they having any issues, and it's delving into different areas of their life as well. You know what they use their eyes for, the working, is it, you know, you're on a computer all day, what's your hobbies and interests, like, you know, it's very dynamic important. It's not just solely focusing on one medical condition, we're looking for a range of conditions, and we're also looking for a range of visual requirements to see, you know, delving into what this patient needs. I think the holistic side is that while we're talking about general health, we're talking about smoking, so there's lots of different areas with that as well. As I say, it's not, it's very similar to pharmacy, it's not pinpointing into a specific thing as such, it's looking at the whole patient. Okay, and I'll go to Harjeet Sandhu. I think it's into, answer your question in two ways. One, it does each of the professions focus on prevention, I think they do a relatively good job. Is the interprofessional communication to maximise the prevention and public health elements? I'm not so sure if we take audiology for example, people with hearing loss at increased risk of depression, dementia, social isolation and other mental health risks, and yet we have hundreds of thousands of people in Scotland going to see their GP who aren't referred for an intervention for hearing loss to prevent those risks. We have hundreds of thousands of people that are seeing pharmacy colleagues where that difficulty in hearing isn't picked up, so I think there's a huge amount of opportunity, if you like, to really benefit from prevention by that interconnectedness across primary care, and hopefully these kind of inquiries really help to interconnectedness in that on-order referral to really benefit from that massive public health game we can get, which I think is at the heart of what the Audit Commission recently said about really putting the NHS on a short footing is really going upstream and doing more out of hospital, and I think so, there's huge opportunities there. Thank you, and Jess Sussman. I think if we're talking about prevention specifically, then we have to look more widely at socioeconomic issues as well, that the community is most likely to develop mental health difficulties and other communities with the most challenging socioeconomic status. But in terms of holistic approach with a mental health professional, I think that we do not just focus clinically on people and their illnesses and their illness models, but we also look more broadly at how they can best integrate into communities, have a better socioeconomic, social occupational and educational opportunities once they're well enough to achieve those, and then it's about the alternative pathways that they can access to best make use of those and the support they need to access those. David, Emma wants to pick up on something that Jess has just said, and I'll come back to you, Emma. Emma Harper, I'll bring your make-up. It doesn't seem to be... Can we bring Emma's microphone up, please? Broadcasting. It does not appear to be coming on. We've got Gremlins today. Oh, there you go. There we are. Great, thank you. It's just to pick up on what Jess said and relating back to what she said earlier about art and supporting that. I had a case where someone was exploring self-directed support and they wanted the money to be used for art, which was going to help them tackle social isolation, but it was refused because it was art and it was seen that it wasn't important. So I suppose in Jess's experience, how would you feel about something that actually would benefit a person to tackle their social isolation or therapies really, really good? I see you shaking your head. What would be your thoughts on that? Absolutely. I'm very surprised. I have patients who have used self-directed support, SDS, to get and have had an art teacher come to their homes, spend time with patients with chronic schizophrenia. I would absolutely support all those resources being used in that way. The difficulty that we had through Covid with self-directed support was that, unlike the council-run led care structures, which kept going to a degree during the early stages of Covid, a lot of the self-directed support just disappeared. That was one of the difficulties. Much as it's a wonderful thing to have the opportunity to choose your supports, that is wonderful. It also needs to be solid and to be present in different circumstances, and that was one of the difficulties that we were aware of. I think that it is a fabulous thing that you can access and organise the supports that you want, and a lot of our patients need help with that, quite a lot of help. Our social workers will help them access SDS through organisations like Encompass, the borders. It's been a problem during times of Covid. I'll come back to David Torrance to follow up on your question, David. Thank you, convener. To what extent are primary healthcare practitioners, other than GPs, able to promote prevention and self-management? Is there a greater focus needed on prevention? I think that pharmacy does apply a lot on prevention, particularly when we look at some of the public health services that are available in community pharmacies. These are contracted services around things like sexual health services, smoking cessation. There are locally agreed services such as injection equipment provision. Indeed, there is prevention in talking to people about their wider health as part of supplying medicines. Pharmacy tries to deliver prevention services where the contractual framework has enabled that community pharmacy. The other thing to pick up on is the pharmacy first service. Again, a really important service in terms of being available from all community pharmacies is where pharmacists are providing advice and treatment for common clinical conditions. Sometimes, some of that kind of management that happens can help to prevent people developing or their condition worsening and them needing GP care as well. I think that there is quite a bit that's happening, but, of course, there's always more that can be done. Thank you, and I'll come to Harjeet Sandu. I would say that audiology is fundamentally a prevention service. When an audiologist sees a service user, what they're really doing is limiting the impact of their hearing loss on communication and then all the benefits that flow from that, such as reducing the risk of social isolation and mental health, the challenge that we really have is that those types of prevention are not what make the headline. Normally, the types of prevention that make the headlines are preventing stop smoking and so on. These very high-level interventions when every look at prevention strategies that come from government, they're always there. However, with an Asian population, what we'd very much like to see is an active Asian strategy. Within that, I think that we see whole new prevention opportunities to help our population age well rather than just preventing the primary preventive public health measures. So, as part of active ageing, there's huge opportunities again. I hope that answers your question. Thank you, and we'll go to Jess Susman. That's sort of rethinking prevention in mental health because our population fluctuates in terms of their illness and actually accessing the right resource at the right time for preventive deterioration that could be long-lasting and have major impacts in their futures. It's about the stability of resources that are available in the community that are the alternative pathways again that need to stand stable. It's about accessing services when you need them at speed and for those services to be well resourced. Finally, on that, I'll come to Julie Musgrove. Thank you. I'll follow on from what hard it's said. Optometry and ideology can be very similar from this perspective. We are predominantly preventive eye care, so routine eye care is generally over half the patients that we're attending for an exam in 2019 were responding to a recall from already being seen one year or two years prior. The eye exam in itself, we're taking photos of the back of the eye, we're documenting what we're seeing, so a lot of it is routine appointments, and then we are monitoring things over time, so it might just be that we're monitoring a healthy eye every two years. We're having discussion around health generally, so whether it's smoking, exercise, affecting your eyes against the UV, eating a well-balanced diet, and also how are people's families' eyes? Is there any conditions that run in the family that can affect the eyes so that it is predominantly preventive? We can often end up being reactive to things, and part of what we do is reactive, but eye care on the whole is predominantly preventive for looking ahead. Jess Smith wants to come back in. I also wanted to thank you about it from the optometrists and audiologist's perspective. With severe mental illness comes a much greater risk of physical health problems, weight issues, diabetes and increased smoking. Those things need specific resources for engagement for our patients specifically who need additional time, additional understanding to build trust with the person supporting them to get the test and to get the support that they need, the input and care that they need. Again, that needs to be thought about in terms of the pathways. We have got Sue Webber back. I want to jump back into the workforce issues theme that we had been discussing when we had issues. I'm just double checking your ear, Sue. Over to you. Oh dear, we still can't hear you. My goodness. In that case, Sandesh Gohani has said that he will be your wingman on this occasion and will ask your question. Always convenient. It's about MDT and it's really looking at talking about in terms of data to drive decisions. With all members of allied healthcare professionals to be included fully in the workforce plan, what would need to happen for you to get appropriate data for you to get the right things? Obviously, in terms of training and financial support, a lot of groups are different businesses, but you need access to patient data to be able to perform the function. Right. I think we'll just go down the list. If we may go to Claire Morrison, first of all. If anyone else wants to come in, please use the chat box. The thing that could be absolutely transformational in terms of enabling that multidisciplinary team working is a single shared electronic patient record. Right now, information is held in silos right across health and care and all professionals waste time tracing information. There's a safety risk of not having the relevant information when you're making a clinical decision, and there is an enormous duplication of effort when we think about things like medicines reconciliation, that process of every time someone, a patient moves between care settings such as on admission to hospital or discharge back to primary care, then the professionals have to check multiple sources of information to ensure they've got the right list of patients' medicines, they have to update the records that they keep, and if we had a single shared record where every professional entered information and every professional read the information, it would eliminate all of that work, it would make care safer, and the kind of shared record that we're talking about is an appropriate view. So everyone writes in and everyone can read what is appropriate to their role, so we're not talking about a record that is with all information available to every profession, but actually about what's the relevant information for this professional to have in order to be able to provide that safe and effective care for the patient. So I think it would be transformational, and I think to really enable that working in terms of both having the information but also the communication as well. So if you see a patient in a community pharmacy setting, you prescribe a medicine for that patient, and then it could be that the patient then goes in and has a consultation with their GP a few days later. Actually the GP needs to know what medicine has been prescribed in the community pharmacy, having that information on that single shared record would mean that they would have that information to hand immediately. So it would be transformational, and it's very much what I think we need across Scotland. Thank you, and a couple of other people want to come in on this. Jess Rusman. I'm to totally share what Claire has said and reiterate it. Even at the moment, we cannot see the records from other GP practices into mental health, so we can't be clear about what tests have been done for patients, what current medications are on things like that without contacting directly. In addition, I would say that the digital strategy across nationally would be important for this, that actually patients do move around, and it would be incredibly helpful if that patient record travelled across Scotland rather than just within an NHS board. Thank you, and I'll come to Julie Musgrove. It's just again to reiterate exactly what Claire has already said. It's really frustrating not being able to access certain information for a patient. So from a prescribing point of view, we're looking to prescribe medication at the same barriers that pharmacy have having to contact the GP practice. We're hoping that the patient has a list of their medications speaking to family members. It doesn't build confidence, but it takes a lot of time to try and get the access to the information, and likewise we could be seeing a patient ourselves, and the patient attends the GP the next day, or the pharmacist the next day, and they won't know what treatment we've already started as well, so it's both sides. It's us referring to others and others referring into us as well, so it's just to reiterate everything Claire said, completely agree. Thank you, Julie. I'll go to Harjeet on that as well. I agree with the colleagues that Claire is right. I think connectivity, interconnectivity, is key to sort of getting the actual patient benefit gains from MDT working. In audiology, also what we're quite good at is epidemiological work, looking at population needs, and then looking at the type of workforce that's required to meet that need. I think if each profession contributes to this overall, we might be able to develop a rather comprehensive way of matching workforce to need, and whilst building in MDT working. Thank you. Sandesh, do you have a quick follow-up? Yes, Sue has a follow-up question that I will say. Okay, but you're speaking on behalf of Sue. I'm speaking on behalf of Sue. On this topic about the workforce plan, we, it's rather GP NHS centric, and we're concerned that it doesn't include all of you about how you can feed into the workforce plan. I was wondering if you are able to give us what feed-in feedback you gave, and what needs to happen for you to be included in this on what you feel you need. As I said earlier, and as we've said a number of times to Government, we are concerned that effective workforce planning for pharmacists and pharmacy technicians is not done in the same way as it is done for other professions such as doctors and nurses. It is a significant gap and it needs to be addressed, and linked to that, we have to consider the Health and Care Staffing Act to ensure safe levels of staffing right across pharmacy. We also think it needs to be, effective workforce planning needs to be looking to the future, so it isn't just about an analysis of the numbers of pharmacists and pharmacy technicians that we have right now, but actually really looking to what's the future need and have we understood what the roles are going to be in the future and have we considered the difference that digital technology can make and the different shaping of services. Then workforce planning around that is needed and it hasn't been done yet and it really needs to be. I think on workforce planning there's kind of two areas in particular that I'd like to draw out for the different areas we're talking about today, so from a community pharmacy perspective, I've mentioned the pharmacy first service, which is a really important service for improving accessibility to careful patients. There is an extension to that service, pharmacy first class. It is a service that involves pharmacist prescribers and it's only available in community pharmacists where the pharmacist is a prescriber and that means that if a patient regularly goes to a pharmacy and that they know well and their pharmacist is a prescriber, they've got access to that service and they understand that if perhaps they go to a different pharmacy where the pharmacist isn't a prescriber then it can lead to a frustration that the service isn't there, so we absolutely need more investment in training in pharmacists and independent prescribing. There are training places now, there's been a recent increase, but my understanding is that the courses are significantly over-subscribed, so there's a potential to expand that further. The other area is turning to the GP practice side of things and the pharmacotherapy service, which is part of the GMS contract. Again, we've got all GP practices bar 7 in Scotland, we've got some level of pharmacist support, which is really good, but we worked with the BMA last year around identifying areas for improvement that are linked with workforce. We know at the moment that pharmacist clinical skills aren't being fully maximised in practices and one of the reasons for that is a lack of the rest of the pharmacy team, so the pharmacy technicians and the pharmacy support workers to undertake particularly the level one level of the service and by having that staff mix in place that would enable pharmacist clinical skills to be used more effectively at the higher level three of the pharmacotherapy service, which is really where they should be working. Skill mix and the workforce planning around that needs to happen alongside some of the other things, like improved IT and improved effective team working. A lot to do, I think. Julie Mosgrove wants to come into this before we move on to talk about self-referral. Julie? Thank you. Optometry has capacity, and we're not a profession that's in crisis with workforce planning, but certainly more can be done. I think that it was hard that Sandy earlier had said that raising awareness of the profession, generally discussing, I think that it probably works within all the health professions that we're talking about, but it's showing it as a career pathway and also the other jobs that are available within that sector, so there's different levels, and that will help with sustainability of the service, but certainly with the ageing population in the future to sustain that service, we're going to have to keep that pipeline going, but certainly in the moment, we have capacity agencies, we're not in. Thank you. Can we move on to talking about self-referral questions led by Paul Cain? Thank you, convener, and good morning to the panel. I think we've started to touch through the conversation this morning about self-referral pathways. I suppose I'm interested in terms of the public's awareness of self-referral. I think that what we know is that there are initiatives out there, for example, Pharmacy First, which we've talked about a bit, and NHS GGC, for example, Right Care Right Places, a web resource that tells people when and where they should go. What we found in terms of some of the research that's been done around this inquiry is that public awareness isn't always high around some of those, particularly around when to go in self-refer, outwith, particularly Pharmacy. I think that a lot of people are aware of Pharmacy, particularly, but perhaps not other avenues. My first broad question is, how do we raise that awareness of people's knowledge of self-referral and their ability to self-referral? As I mentioned, I'll maybe ask Claire first. I think that it's a mixed bag in terms of awareness. To start off with community pharmacy, and you've mentioned Pharmacy First, I think that there is a high awareness of people's ability to self-refer into that service. However, we do have some concerns that awareness is more mixed in certain populations, particularly in some deprived groups, those with lower health literacy and potentially people in care settings as well. I don't think that it's completely there, but I think that there is a good general population awareness of the ability to self-refer into that service. However, when we look at other parts of Pharmacy in primary care, for the pharmacists that work in GP practices, the awareness of self-referral there is very, very low, and that's really linked to that public awareness of the roles of pharmacists in GP practices being low. We have never had a national public awareness campaign about the roles of pharmacists in GP practices, despite it being a contractual change when it's in the GMS contract around pharmacists having a role in practices. The service is new, it's taken a little work to establish and so on, but it's established now and actually now's the time for that national public awareness so that the patients and people are aware of the roles that pharmacists have and that ability to self-refer into them. At the same time, we could look at some of the awareness of services like Pharmacy First. I think that some of the awareness campaigns have tended to be around a kind of a focus of don't go to A&E services but go to here instead rather than actually, these are all the fantastic services that are available in Pharmacy. So, some more positive public awareness and messaging would be really useful. Thank you. And Harjeet Sandhu wants to come in on this, Paul. In terms of self-referral, unfortunately, a lot of NHS audiology services is nonexistent. You have to go to your GP for a referral but it's not a medically necessary appointment. Everybody in Scotland that has the ability to pay can directly self-refer to audiologists on the high screen. So, there's this huge inequality in access to self-referral, which when we talked earlier on about prevention and public health benefits, leads to health inequality because of that unequal access and I think that's a key thing as well. And then because of inquiries talk about GPs, when we don't allow people to self-refer things like impacted wax or hearing loss, it also creates bottleneck for GP services. So, there's a whole lot of system effects when we're not promoting self-referral. I think historically it does come down to this idea that the GP is the gatekeeper, but services moved on, the professions have advanced and there's these huge opportunities where innovation in care is not really executed well. And I think that that promoting self-referral, sustainable models of self-referral would be a great thing for the system and service users in particular. Thank you. And Jess Sussman. I would again reiterate what's been said already. I think that those are more connected to health services. We'll know more about what is available and where and when they can self-refer. And so, in some ways it's for the organisation. A national campaign would be brilliant but it's also for the organisations that people do access like pharmacies have information about other routes to self-referral to other things. So, where do people already access? How can they then learn more in those spaces to lead to other resources as well? But national campaigns would be excellent. Julie Musgroff. National campaigns would be the best to mean that, from an opportunity point of view, the majority of the patients who are easy are self-referred or responding to a reminder, but I think that better signposting everywhere. So whether it's within our primary care professions as well as we're all signposting to the right place in general practices as well, it's also going into the kind of targeted promotions in key areas. So health centres, community centres, people that are accessing, that are not accessing healthcare at the moment that's looking at the areas that they would attend, whether it's cafes, just general community centres as well, because that would help to promote just the health services and people who haven't accessed the service before who then know what to turn to from that point of view. Thank you, Paul. Thank you, convener, and thank you to the panel for those responses. I heard what Hurgit said about the GP traditionally being the gatekeeper and I think people trying to almost find different avenues. I think that in some of the written submissions we've had, particularly from HSCPs, I think that there's still a nervousness around people who can't self-refer or who end up in a self-referral pathway and end up kind of going from pillar to post slightly and ending up in an emergency setting because there isn't the same relationship with that kind of direct point of contact that would be the GP. So, I mean, is there an acceptance that we probably do need to drill down in that in terms of understanding who has to kind of perhaps go through the GP route as a first point of contact to then access other services and perhaps for other people it's easier? I think some of the answers already have kind of referred to that, that it's easier for other people to self-refer, but I think we do need to kind of look at individuals and their individual needs. I mean, is there a kind of acceptance that's acceptable? Harji, you'd like to come back in on this? I think that's absolutely right. I think if we look at what's already been established today, we have pharmacists and we have a normalisation of when patients access that and we have optometrists and we have a normalisation of people know when to go and I think there are some conditions in society that's at such large scale and in so many people that naturally the professions are well aligned to be the first point of contact and audiology is one of them. Audiology, if you have a hearing problem, going to audiologist, they can add more equipment, we've got the infrastructure and it's not because they're more qualified than the GP, GP's are a highly qualified staff, it's just that they're specialist in the hearing problems and they are going to be a better first point of contact. That's not going to be universally true so I think you've hit on an important point, it's about again the right person for the right at the right time in the right place and I think it's for us really to make representation to say we believe this particular service is very well suited to be in primary care because it's the first point of contact so I think audiology is unique in that sense, it aligns with eye care and pharmacy but I agree with you, not all professions will be the same and not all clinical needs will be the same. And Claire Morrison, what did you comment on this? So I think there are some fantastic examples of GP practice staff and really effectively triaging patients and signposting them on to other services such as pharmacy first and such as the pharmacist working on the GP practice and in particular I just wanted to draw attention to the work of healthcare improvement Scotland's practice administration collaborative because they worked with practice staff around the triaging and referral to a number of different services including pharmacy and there is still variation across practices and actually looking at some of that work and seeing whether that work could be replicated right across Scotland could be a really effective way of improving some of that signposting. Thank you and follow-up question from Stephanie Callaghan, Stephanie. Thank you very much, convener. I suppose just dig in a wee bit more under the questions that Paul's already raised there. Obviously the big picture really really matters and the GP relationship is established over many years and is really key to a lot of patients. The GPs get the knowledge of their patient, their circumstances and that relationship with them allows them to have those kind of sensitive discussions that patients might otherwise be unwilling to have there. So, you know, we've talked about the fact that there should be no wrong door and what I'm really interested in in this, maybe a question for Claire and Jess initially, is it realistic for a whole variety of organisations to have someone that becomes that key person, that kind of trusted person to the individual patient who offers that continuity and kind of helps them get access to all the primary care services? Thanks. So, will we go to Jess first on this? Are you suggesting that the individual that could be the key person for a patient, a client, would not necessarily be the GP? Is that the nature of the question? I think what I'm suggesting is that, obviously, I'm not undermining the GP's place at all, but what you tend to find is that the individuals, and especially as they get older, there'll be a particular person that they connect with and that's their go-to person, you know, for advice that would say to them, oh, you really need to see your GP about that, or actually it'd be a really good idea to go to your pharmacist. So, you know, we've talked about link workers, we don't have them everywhere just now, and maybe that's part of it too, but as well, realistically, what patients will do is probably choose their own key person, their own go-to person that they trust and they feel they can rely on. So, it's just about, you know, how realistic is it for that to happen? Is that something that is understood and is part of the system? Or, you know, we do see no wrong door, or is there this kind of push to get patients to go in the right direction, either on their own or through specifically just a link worker? I think it would be fabulous if people felt that they had enough training and experience to be that person for any individual, you know, so people who are ancillary and, you know, appropriate setting within an appropriate setting could be that person, doesn't need to be the GP, it doesn't need to be, you know, the practice nurse, absolutely, so long as they have the confidence to know where to guide the person and when and to have that training and if they've got the engagement, that's probably, to me, someone in mental health the most important thing is the engagement and the relationship and the trust, the ability to build trust with an individual, and so the training bit is additional to that, and it should be something that we can provide, you know. And Hargey wants to know your... Sorry, Jess, I spoke over you there, didn't mean to. I'll bring in Hargey and then Claire. I think it's right. I think the GP will remain one of the key, if not the key, person in a person's overall integrated care in the future, I think where the difference is, for example in audiology, the audiologist helps that person here, so all their healthcare interventions are that much easier to go through, but also because audiology normally look after a long-term condition, that relationship has an opportunity to build up, the audiologist are more likely to be the kind of person because they're seeing the people regularly, the service user shares more with them, and that's why that connectivity that we talked about earlier on about enabling people to move seamlessly through the system will be key as well, a joint patient record and so on, and that integrated care, but I think that, following on what Jess said, it would be great to have more healthcare professionals that service users trust in to share that information and for all of us to work together to get person to the right place at the right time. And another thing that we have here just listening to Hargey is that the patient's not having to tell their story multiple times as well has come up on quite a lot of, not just this inquiry but many inquiries that we've done. Claire, can I bring you in? Yes, so really just to reiterate how important it is to take that person's entered approach because where a person has a relationship with someone and wants to have to use that particular health professional as their first point of contact into the service, then we should really try and enable that. What we saw during the Covid pandemic was where community pharmacists continued to have their doors open. We saw an enormous increase in the number of people who were coming in and making requests about how to access different services. Many pharmacists already have those good relationships with people. They may not be able to provide the care but they can signpost people on to the care that they need. That really brings in one of the other key enablers that we need. I've mentioned the single-shared patient record already. That is the most translational thing that we could have in place but we could also have a referral mechanism. One of the barriers sometimes to signposting and moving people around between different members in the multidisciplinary team is a fear that it will add time into the patient's journey and a fear that what happens if a referral is made and the patient needs to go somewhere else. If we had a really clear mechanism, a direct referral mechanism from pharmacy to GPs, for example, that would enable the patient's journey to be really smooth so that if the practice, for example, was to triage and the patient said, actually, you'd be better off in your community pharmacy, community pharmacies, in this particular case, my professional opinion is that they need to see a GP. There needs to be a really fast and smooth method to enable that to happen so that the patient hasn't waited an extra day, for example, as a result. I think that that could be achieved through a single-shared record but I think it could be achieved in other mechanisms as well. Emma, you had a question picking up on something that Clare said there. Yes, thanks, convener. Just directly clear to you, there's a system called ALIS, which is the local information system for Scotland that is used to signpost to local services, for instance. Is that something that pharmacists use? I am not aware of pharmacists using that, but I can check and come back to you. It would be interesting to know if any of the other people on our panel are aware of ALIS and what it provides as well. Maybe Julie wants to come in anyway on Stephanie's question. Can you bring in Julie on that and you can let us know whether or not ALIS is something that's on your radar? Unfortunately, I'm not aware of ALIS. I just want to agree with Clare on the referral mechanism. It would definitely avoid patients repeating themselves. It's also making sure that the information is passed accurately between what kind of a patient is given information and advice to go and see an optometrist. It's then lost on translating the information that they were going to be passing across. That would ensure that information is consistent and accurate between health professionals. Also, just to reiterate what Clare said, it's not delaying the treatment either. That would be another bonus with having the referral mechanism. It was about ALIS. One of our social workers referred to ALIS on one occasion, and when we tried to use it, I think that it was either something that had shut down or things that we were aware of in the local community were not on the system. It was about how useful those resources are if they're not centralised consistent and consistently updated. If they're not updated, you'll never go back and use it again. We have talked about the single electronic patient record, but do you have a follow-up on that issue for our panel? Yes, I do. It's very clear that everyone across the panel agrees that it would be transformational, but it would be a massive benefit. Where are we right now, as far as patient record sharing is concerned, and what progress do you see in plans to improve patient record sharing? What plans do you see coming along in the future? What do you know is coming so far? Do you want to direct that to anyone in particular? Not anyone in particular, but just whoever feels it. In the chat box we've got you prompted there. Jess Smith wants to come in on that. At least I can tell you a little bit about the borders, just from my own working perspective. At the moment, mental health services is using the same system as the GP practices, but it is for individual GP practices to choose to share their data and information with us. However, in other boards, the system that is being used by GPs is different from the system that is being used by mental health services, and crazily in the borders, the IT system that is being used for patient notes for mental health services is not the same as the one that is being used for medicine and surgical services. It is not very joined up at the moment, and it would be very hard to share electronic records across different platforms. Is there any sign of that abating then, Jess? Are there any plans in place to rectify it that you're aware of? Well, within mental health, we have a national digital leads group, so there are individual clinicians within each board who have been identified. Some are being given time in their job plan to do that, most people are not, and they meet regularly to try to think about how nationally we can unify the digital systems. That's within mental health care, that's not GP and then medicine and surgery. I think that what we'd all like, as I said before, is a national platform that meant that everybody was on the same platform, speaking the same language, and then you can say yes and no to whichever groups are relevant at the time to that individual patient. Can I come to Julie Mosgrove? Great. Hi, so within optometry, we can access the last eye examination date within other optometry practices. That's the only information that we can even share between optometry practices. It doesn't even tell you where the person is tested, it just gives you the date that they were tested. There is a system in Grampian where we're trialling an electronic record alongside secondary care ophthalmology, so the idea is that if we see an emergency appointment, we can enter information on the record card and it can be shared with ophthalmology, and likewise, ophthalmology can share information back. That has been trialled in Grampian at the moment. Just to reiterate what Jess said, the biggest barrier is system to system linking. At the moment, with so many different systems and then adding in different referral mechanisms, we're just repeating information, which is time consuming. You're copying and pasting different systems as well. That is a barrier, and it's time consuming and costly with that. There's still a lot of work to be done, but there are some trials going on in different health boards around that. I'll bring in Claire, and then I'll need to move on to our final line of question. Oh, sorry, Sandesh, who wants to come in. Sorry, I'm getting a little bit beyond myself. I'll come to Claire, and then we have a follow-up question from Sandesh, and then we can move on to our final theme. So, Claire, over to you. So, community officers don't have access to emergency case summary, although there are issues with logins, so different logins in each health board, and if you are allowed to move around, you can often end up with many, many different logins. I think that's a number of professions. In, I think, three boards, two or three NHS boards, pharmacists can have access to the clinical portal as well, which gives some wider access. Again, an issue with logins, but actually the fact that that isn't available across Scotland means patchy information, and then, in addition, there are a small number of GP practices who have enabled remote access into their clinical systems for their local pharmacy teams as well. In all of these issues could be overcome with a single-shared record. Just to pick up on the earlier points, one of the issues, I think, with achieving a single-shared electronic record in the past has really focused on trying to get systems to talk to each other. If you think about all the many, many different clinical systems that are out there across all of health and care, it was really difficult to enable them all to speak to each other. So, if we look at a cloud-based system where each of the individual clinical systems writes into a cloud-based system so that they're only writing into one place, and then equally each profession reads from within its own platform, its own system as well, so rather than getting hundreds of systems to talk to each other, you're getting every system to talk to one thing and one central platform. I think that is almost certainly the way that we can make some progress in the area in the way that we've just spent years not being able to achieve this in the past. Thank you. Sadesh, you have a follow-up question for Jess. Thank you, convener. Yes, directly to Jess. Just on your point about mental health systems in Glasgow, our CAMHS service has a different system to our general psychiatric service. So that means when I was covering CAMHS, I couldn't see patient records. I needed my nurses to open the records so that I could read them, and I needed my nurses to type my notes into it, because I didn't have the ability to do that. Worse still, GPs can't read what psychiatry has written, and obviously you can appreciate the importance of GPs and psychiatrists being able to read our notes. I feel that this is dangerous, so what can we do quickly to overcome this? It appears to me that some of the—at least in the board, as I know—so the system in Glasgow's EMIS, we use the same system in the board as we got it after Glasgow got it, so we can benefit kindly from Glasgow supporting us to use some of their additional platforms. It's a nightmare system at the moment for everybody involved. My understanding from the reason that we can't read some of the—we don't share some of our records with the GPs in the boarders is because of GPs being concerned about confidentiality issues, and that there's a minefield out there, and I would want, as you do, all those records to be available to everyone at the points at which they need to access them, confidentially, as you'd expect. I don't know exactly what the answer is except to say that we need to re-look at the whole thing, because, of course, again, boards are buying these platforms individually as well and then adapting them individually. It doesn't make any sense to me, especially in mental health care where people move around quite a lot, especially when unwell. My patient recently ends up in Aberdeen, and they didn't have any records for the patient. Those kinds of things happen a lot. I think that it's a national issue and needs a national answer. Just as you're saying about child psychiatry versus general adult and your systems, our social workers are using a totally different system to us as well, so they have to write twice if they want to give us information. The whole system is not working, it is broken and it's not efficient. I agree with you. We must move on to our final theme, which is around inequalities. It's already been mentioned a few times by a number of you, so we're going to drill deeper into that, and those questions are led by Evelyn Tweed. Thanks, convener, and good morning, panel, and thanks for your answers to the previous questions. It's been very helpful. Questions are around inequalities, and I know that you've all touched on that theme already. Is there a risk that increased use of alternative pathways to primary care could exacerbate health inequalities? I know that you've all touched on it, but I would like to pause the question to clear for us, if anybody else wants to come in. I'd start by talking about communities in particular being in communities right across the country, and how important that is in terms of accessibility to all populations. It's a service that helps to address health inequalities in many ways. I think that we need to address some of the information that we provide, so it's one of our concerns around the pharmacy first service, for example, whereby we don't have the guarantees that we are reaching all populations of particular people with lower health literacy, for example. If they have the information that they understand about the service that they can access in a pharmacy, having said that, people, when they walk into a pharmacy, will be told about services as well. Hopefully, if they are coming into the community pharmacy because it's in their locality, then hopefully that's a way of tackling health inequalities. I think that you also have to look at the range of services that are available as well, and some of the services that pharmacy provides already can help tackle and some of the inequalities that exist, particularly looking at some of the services around drug use, for example, and the public health services that are available on community pharmacies as well. Community pharmacies are a way to improve accessibility rather than to add to health inequalities, but we must just ensure that the information is there and it's available to everyone. Finally, I'm supposed to touch on digital inequalities because that's become increasingly important over the past few years. We know that there are a lot of people who really embrace digital services and how that is improving access to services, particularly for people in really remote areas, people who are housebound, for example, people who've got caring responsibilities. We have examples of people who are at home with young children and are finding it difficult to get out to a pharmacy and are able to access the service remotely and how beneficial that is, but, on the other hand, we also have to ensure that we don't create new inequalities for people who cannot access digital services. The most important thing is around enabling choice, providing services in a number of different ways and enabling individual people to access the service in the way that they want, rather than putting a label that any particular service type or way of accessing it is either good or not good, and saying that these are the range of opportunities that you have and what's the best way of accessing it for you as an individual. Thank you. How do you decide who wants to come in? Fully support what Claire said, especially about that, giving people choice and individualised care. Any system that's designed really focuses on how we reduce inequalities and access and health outcomes. To your question, this is a huge opportunity to address inequalities. GPs don't have the capacity to see the growing population need, they simply don't have it, and if we carry on the way we are, one thing we're going to be almost certain of is that inequalities will increase or worsen. I think that this is just a massive opportunity to tackle those. We talked to them about these at the beginning of the call, home care for people with hearing loss, allowing people the same right and access to hearing care services based on the clinical need and the ability to pay. There's just huge opportunities out there. Thank you. I'll come to Julie Mosgroff. Just to reiterate what Claire said as well, I'm not concerned about it coming into primary care in the community. Practices, optometry practices, are accessible. Every community has the access to the service and it's something that's welcoming at an atmosphere and it's normalising in healthcare as well. When we look at the eye exams that were done in 2019, looking across all communities, the uptake was at the lowest at 26 per cent and the highest at 30 per cent. This is actually quite a good uptake considering everyone gets an eye exam every two years. Although there is a gap between the lowest areas at 30 per cent and the highest at 26 per cent, that is a relatively small gap. The biggest thing is making sure that there's an awareness out there that the NHS funds eye examinations and also that support can be available towards glasses depending on your circumstances. I think that it's the awareness of it, but I wouldn't be concerned about it coming into the community. It's just making sure that we get the messaging out there that it is funded and that there is help there if you need it. Hi, our members talked about the economic aspects impacts of Covid on wellbeing and cited the Scottish Government's Covid mental health tracker that showed that the key indicators of whether you're experiencing depressive symptoms, thoughts of suicide and higher psychological distress as Covid were related to whether you'd experienced a change in working circumstances, although those who'd been furloughed or lost their jobs had higher symptom rates in all of those areas. That needs to be looked at. The other points that I wanted to make were about challenging stigma. Those with mental illness at more than two thirds of people, 71 per cent, with mental health problems served by CME, still experience stigma or discrimination with work colleagues cited as one of the key groups. When we're thinking about alternative pathways and access, we need to include those with the most severe mental illnesses in those groups, so they're not always separated and having specialist resources that are in the distance and happening somewhere else to them. The experience that I have generally with my patients is that we have to create additional resources and structures for them because they can't be catered for within the standard set of options. That concerns me a lot. For instance, something like smoking cessation, which our patients usually benefit from. Your average smoking cessation plan would be maybe six sessions sat down with somebody specialist to talk you through the options. For our patients, it would take months of engagement and time spent building a trusting relationship before the actual piece of work on reducing your smoking can take place, with an understanding that those might miss a few appointments due to their mental health problems. Things like that need to be accounted for to reduce the stigma and reduce the fact that they have to be somewhere else or treated in a different place. The final bit was on parity of esteem. When we talk about health inequalities, we need to bear in mind that those with severe mental health or ill health have one of the lowest life expectancies and the lowest rates of employment of any group, and alternative pathways need to be supplemented by wider socioeconomic support to enable people to build the stability in their lives that can secure a prolonged recovery for those things to be thought about in terms of inequalities. Thank you. Thank you. Evelyn, do you have any follow-up questions for our panel? Convener, I've actually covered off the second question. Yep, I thought that might be the case. Sandesh, you wanted to come in and... Yes, please, convener. I'd like to ask what assessment that's been made of the link between access to alternative pathways and digital exclusion. I'm just checking who you're addressing it to. Oh, everyone. It would be quite important, but I suppose I'd like to start with Jess. Thank you. So, within the team I work in, one of the teams I work in, the rehabilitation team, looking after people with chronic schizophrenia, we surveyed, at the beginning of Covid, we surveyed all our patients, there are 120 patients in the service, and while 40 to 50% of them actually had a smart device, none of them were willing to use it to talk to us or to access other services, they wanted face-to-face contact. They did not feel comfortable or confident, probably due to the nature of their illness, to use those devices for that purpose, and they wanted direct input from physical contact with us, the body language, the other aspects to engagement that are so vital for people, as most of your communication is not through verbal communication, but through body language. For those groups especially, it's really important. Accessing other digital resources has been very difficult for that group of patients, and they would much prefer all their contact to be face-to-face. I hope that answers the question, but if there's a follow-up, I'll happily take it. I mentioned briefly earlier, but I think that it's important that the recent Ipsos Moray data that we surveyed—Ipsos Moray surveyed—1,107 adults in Scotland just very recently. They asked them to tick all the ways that they applied that they wanted to access services. That isn't about saying that they always want to access a service digitally, but that they want it there as an option. It really goes back to what I said before about options. While the highest figure was for sure, 87 per cent wanted it in person, although interestingly, that's 13 per cent of people who didn't want it in person, you've also got a 59 per cent wanting telephone consultation and 42 per cent wanting video and 38 other digital services. I really think that it's about enabling choice and ensuring that all of our services are available whenever it's currently appropriate in a variety of different ways. I suppose that the other thing that I'll draw attention to is the public consultation that took place in the summer of 2020, which was a Scottish Government consultation around public opinion on using video consulting. That was a survey of over 5,000 people. The data on that is worth reflecting on, rather than the smaller data set that I've just provided around 1,000 people, for example. To reiterate what Jess and Claire said about choice but also making sure that it's appropriate to the service, if we look at telephone consultations during Covid, we know that the people who depend on British Sign Language itself have done that, it doesn't work. At the same time, Scotland's led in providing a BSL service, which actually improves inclusion and accessibility to health, so it's really about tailoring it for appropriate care. In terms of audiology and innovation, because it's chronic condition, lots of people also don't want to go on with their lives for certain conditions, and they're very much welcome remote fine-tuning of hearing aids, moat follow-up using Wi-Fi, etc. Whereas some people really want their human interaction, they struggle to hear on the phone or moat, so it's all about that choice and tailoring care to the individual. I don't think that digital has to enhance, but it's against the inequalities test along as we, before we implement a model of care, we tested it against some key thresholds of enhancing access and reducing inequalities. I think we can limit the impacts of digital exclusion. Sandesh, have you got anything that you want to follow up on? Thank you very much. We have really enjoyed listening to you this morning and thank you for everything that you've told us, lots for us to think about and really interesting to see that there's really common themes running throughout all your services and disciplines. We're going to suspend till our next panel to onboard and we're going to take a 10 minute break. Thank you. Thank you. We now come to our second panel of witnesses, given evidence this morning as part of our inquiry into alternative pathways to primary care. I'd like to welcome to the committee joining us remotely. We have got Alison Kerr, the professional practice leader of allied health professionals federation Scotland, and Dr Graham Marshall, the clinical director of Glasgow City Health and Social Care Partnership. Good morning to you both. I don't know how much you heard of the panel beforehand, but some of the issues that we're in questioning that we put to them will be put into you. I guess I'll start off where I started at nine o'clock when talking about public awareness, public perception, that shift in that traditional mindset that is there, that going to your GP is the only way to access primary care. I guess I want to know your thoughts on that. Where are we on that? Are we beginning to see a shift? Is there still some issues there in terms of public awareness and what do we do to address them? Big questions to start with and probably a theme that will go throughout our time this morning. Good morning, and good morning, committee. My title is not quite right, so I'm here today in my capacity as chair of the allied health professionals federation Scotland. I'm the professional practice leader of the Royal College of Occupational Therapists. We've got merged together. We've made you into a hybrid rail case. Apologies for that. Thanks for putting us right. I'm here today on behalf of the allied health professionals federation Scotland, which is a group of 12 professional allied health professional bodies, and the EHPFS is there to provide collective leadership and representation on issues that are common to EHPs. I listened to the previous debate. It's interesting around our perception of access to primary care and GPs. The world is changing, but we live in a patchy world at the moment. For example, if you were to contact NHS 111 and ask around back pain, they would refer you back to a GP at the moment because there isn't physiotherapy coverage in 100 per cent of GP practices in Scotland. Where there is GP coverage in the practices, that would be appropriate, but often the call has to go back through a GP because there isn't coverage in all of those areas. What we know around perception is that the people who see the physiotherapists are really happy. Recent figures from Glasgow show that 92 per cent of people who saw a physiotherapist would recommend them to somebody else, and they were happy or satisfied that they saw a GP physio as the first point of person that they saw. The other issues from your committee inquiry are that there is a quote that says that you may only be aware of the practitioners when your family needs them. I think that that is some of the issues, so people don't know what else and who else does other things if you've never experienced them before. If we add that to our patchy picture around Scotland, where you might see a physiotherapist in one practice, you might see an occupational therapist. In another practice, you might see a podiatrist or a speech therapist in a different practice, but that isn't consistent across Scotland. It becomes hard for us to get our messaging together because people don't experience the same thing across the country. Thank you, Alison. I'll come to Dr Marshall. Although I'm a CEO of Glasgow City, I'm mainly here as a drawing GP. I'm a GP in Gordon's Health Centre in Glasgow for nearly 30 years now. I suppose that I'm an example of what happened to me recently. I was asked to talk to a relative of a lady who was struggling at home. She hadn't followed me, but was at risk of doing so, and she was struggling with her as I'm in her home. I've got a rehabilitation team in Glasgow that's full of physiotherapists, occupational therapists, nurses, dieticians who can come out and see her and get her back in her feet and try her best with her. She says, no, I want you to visit. I said, well, why is that said? Because they're not doctors. There's that perception out there, and that's a wrong perception, but it's genuinely there. I work close with the physiotherapist as my own Irish responsibilities in Glasgow City. I know the figures that Alison was talking about, and I see them, and I know how valued physios are. By the patients when they get older, I'm back up for Alison's head, but the public perception is changing. It is slow. People, then, in other examples, are optometry. The experience that my patients get from optometrists in Glasgow City is excellent. My colleague Frank Monogh will work closely with and see my patients in person, but I'm massively in better service than I do. He knows much more about eyes than I would ever could. I had a 10-week course nearly 30 years ago, and I have a small light in my wall. He's got slow lenses, computers, he's got years of expertise, and he's much better saying the correct profession than just going through the JP. How do we change that? There's got a few ideas, but I'll let you ask the next question. I'm quite happy for you to talk about the ideas, because that really is my next question. We all are nodding along as you're saying that there are certain people who will think that the GP is it, and I demand to see a doctor, and I want to see a doctor. Looking upon perhaps those other specialists as being a lesser option or being fobbed off, and you're always, I suppose, going to have that with maybe even a certain demographic, even particularly older people, who have had that traditional the way that they've lived their lives, throughout their lives, has always been access to a GP. However, given the public confidence that alternative pathways don't mean a lesser service, what do you think more could be done while we're on the subject, Dr Marshall? Okay, so I hear a lot of my colleagues saying, no, we need to advertise this more, and we need to advertise that more. I don't think that would work. I don't think that your national ads on TV or radio, whatever you're saying, or we're going to see a year of launches that are better options. I don't think that's overly convincing. I think that multi-distributory working is what we do. Now, we used to have a good context about when I started a minute 30 years ago, we saw up there on our silos, practice nurses were just starting. There wasn't really an option outside of the GPs. Now, even 10 years ago we were quite siloed. I did my work, my nurse did her work, the district nurse did their work, pharmacists worked in their surgeries. Now, there's lots of different professionals who tend to work together, and it's not just numeral to this, where the team meetings is working as well. I work with close to a pharmacist and CPNs, and I already have a team of my district nurses and my practice nurses and my Scottish ambulance service ANPs. We all work together, and that's almost an gradual response to our learning and working together so that we can get patients seen by the correct person on a day-to-day basis as a way forward. Patients are introduced to the whole concept of a team rather than just an individual running a service as a way forward. I certainly got experience of that in a change to a GP service that I had locally. It was one of the most difficult public meetings I ever had, but ever since people have generally got a good feeling about it because they know that they get that service when they go to see a nurse practitioner or a physio within the practice that they're getting that specialist care. The nervousness about that kind of different strands has abated somewhat. Can I come to you, Alison Kerr, from your perspective on the question that I just asked about? What can we do to have better public understanding of the options but also confidence in the options that are out there? I absolutely agree with Graham that MDT working is key. It's about different members of the team being seen as appropriate different pathways. They're the right people to see, so we're not an alternative to a GP but we're the right person in the right place with the right skillset to help you. That is about experiencing that and for the team to be confident in that, to share that experience with our service users. It's also an understanding that health is not all about medical needs, so the social determinants of health impact hugely on people's general health. A wider MDT will have a knowledge of housing, the importance of working or the economic benefits of working or volunteering and how those wider things really impact on your health and how different members of your team can impact on your whole life, which impacts on your health in a more general sense. A good springboard to talking in more depth about multi disciplinary teams. We have some questions from Gillian Mackay. Thank you, convener, and good morning to both of the panel. Does the panel feel that the Government has undertaken sufficient workforce planning to ensure that the multi disciplinary team will be in place to allow delivery of the GP contract? Could I maybe pick on Alison first? I think that we're on a journey with workforce planning, and I'm delighted that the Scottish Government now has a specific commitment to improve HP workforce planning. Work has now started on that. We need to find a swift and efficient way to plan our future workforce, because our workforce is going to look different for the future. Historically, we were perhaps more in secondary care, but we know increasingly that our offer is in primary care, and we need to grow our workforce and develop our workforce to meet that need. That includes planning who we are, where we are and what that means in terms of education and placements. However, it's also really important to not look at that around team members, but to understand it from a population health need. So what is it that our population in Scotland needs, and who can meet that need and then to workforce plan from that point? I'm not saying that we need X numbers of physiotherapists, occupational therapists and riotations. I think that it's important for us to collectively understand what our population needs are and to then work out who in the MDT has the skillset to best meet those needs and therefore to workforce plan on that basis going forward. The GP contract was originally set up with the premise that there weren't enough GPs, and I think that's correct. It's not enough for us to go around, so we thought that we could bring another value to professionals, pharmacists, physios, mental health workers, links workers, etc, to take some of this work from our hands. Hundreds of them are not pharmacists or physios or riotations or mental health workers either. There's a workforce out there to plan as it's just false. There has to be a workforce plan to bring those people in that it can't be tomorrow, because these are highly trained people who require years and years of training and then lots and lots of work is being used to get to the standard you require to meet the service requirements, so it's not tomorrow that can come along. Although the GP contract was in general a good idea, I thought that maybe we should have looked at who was available to take on those roles that might have been useful at the time. Has the Government undertaken sufficient planning with regard to how infrastructure will need to change to accommodate an expanded multidisciplinary team and do practices have the physical capacity as well as IT infrastructure to accommodate the multidisciplinary team? I suppose that some of that leans into some of the data sharing that we discussed with the last panel as well. I'll go the opposite way this time. So the IT is okay, the IT in general practice is fine. I've got a role of a secondary care as well and the IT is much better than primary care. I think that there is a planning. There's planning to recruit more medical students to work in the university as well. I know that we're getting more doctors to talk to my pharmacy colleagues to say that the more pharmacists are being trained. I'm also going to be much better to talk about work force planning for AAPs, but I think that there is planning to increase the numbers of all those professions, whether they all want to go into general practice is another matter of the day. One of the problems that we have in primary care is the pretension of staff, so a lot of people come into the roles that think that it's great. They get a better offer, they want to move and work near their home, they have family commitments, but they have good reasons for moving away, so people who become employed soon move on. There are other more work force concerns that I want to worry about, but it's hard to retain people as well as recruit them into primary care. I think that in terms of work force for primary care for MDTs, we're probably looking at locality working rather than practice-based working, because often there are not enough AAPs to meet their practice, so we will need to move forward in a locality-based model, so we're covering several practices around population needs. I think that our experience of data sharing is patchy, particularly where we work in integrated teams. If we're working across health and social care as many AAPs do, we're often working with different systems, so we might need to input information more than once. We might need to move between seats and offices to different days, because different computers link to different systems. It's not an efficient way of working, and I think that there's definitely work to be done across that health and care integration information. For data, we need to get better around our data and understanding of allied health professionals, and we are starting to work on that. Our systems, historically, log very little information about who our AAPs are in Scotland, so you might know which profession you are and which bands you are, but we don't know where our specialties are, and doctors and nurses can pull much more information than AAPs can. We are in discussion with Ness about how we can look to prove better data to prove who our AAPs are and where we work, and therefore evidence of where we make a difference. Thank you. Gillian, have you got any follow-up on that? No, that's me. Thanks, convener. Sandesh, you have some questions in this area. Yes, it's on behalf of Sue. Directly to Dr Marshall to start with, but then I'll open up the question a bit wider. In December, the BMA weren't happy about the shortage of doctors in Scotland, and the new workforce strategy seems to talk about 800 new GPs by 2027. Audit Scotland in 2019 weren't very happy with that and threw that into doubt. What assessment do you make of the workforce strategy, Dr Marshall, and then to open it up to everyone else? As far as your roles are concerned, how can we workforce plan better to ensure that we get what we need? On a spot that is above IP grade, I don't take part of day-to-day workforce planning, but I know that, as I said, I want to come to the University of Leicester. The teaching, the element of Glasgow, and we have trained a lot more during the doctors just now, where there's a lot more people coming through. In fact, the Leicester Theatre in Glasgow University isn't big enough to accommodate them now, so when we're struggling to get tutors, because there are so many people who just come through, that's a great thing. I'm more than happy with that. With where they go, I don't know, no doubt that primary care is seen to be a bit of a secondary health service by medical students, and this is perhaps even encouraged by their peers. It's a great fresh and deviant, and I think that the general practice is that I like working in it. I think that it's an enjoyable thing. I think that it's got the priorities, so people coming through will be able to see that, and people like myself can encourage them to work in primary care. I think that the doctors will come through and populate our surgeries, but it won't be tomorrow. It's the same as with our ASP colleagues. We're going to require years of training to get to being in the school 10 years, 12 years before you become a GP, so it won't be tomorrow before that comes through. I think that it will come through, and I think that people have thought about this and are training the doctors appropriately. Can we get the allied health professions perspective from Alison? I think that the 800gp figure is an interesting figure that's been around over a few years, and previously there was discussion around whether that could be complemented by part of a wider MDT, and I think that it comes back to the right person in the right place. I know from—to give you two examples—first contact practitioners, physiotherapists doing MSK work in Four Valley have certainly contributed to the GPs being able to offer a longer appointment time, so they've been able to change their appointment time from 10 minutes to 15 minutes because the first point of contact practitioners have been doing different things to free up GP time. In Lanarkshire, occupational therapists seeing people with frailty and mild to moderate mental health problems have reduced return appointments to GPs for that population by 52 per cent, so by widening your MDT in the GP practice, it gives a different focus, a different skillset to help people, which also helps our GPs because other people have different skillsets to help our population. Emma Harper Thank you. We've set up on that regard in general practice. We've got the SCOTGEM programme now that's been established by the Scottish Government as a four-year training programme to help to support GP practice for rural areas. Is that something that you're aware of that you have experience in with SCOTGEM? I work in Gorgol's Health Centre in Central Glasgow, which could be any less rural if you try to be right in the middle of it, so I don't have experience in working with it. I apologise for that. I've heard of it. That's the best I can do for you, but I don't have experience in working with it. I'm sorry. Emma Harper We have put Dr Marshall on the spot somewhat. Did you have any other follow-up questions on this theme? We now have questions from Paul O'Kane. Paul O'Kane Thank you very much, convener, and good morning to the panel. I want to focus on the signposting journey, if you like. I think that we have heard throughout the evidence that we've taken so far that one of the barriers to signposting is perhaps the constant changing landscape of providers of service. I think that barriers are also about understanding what's available and communication for patients. My opening question is how can we improve people's understanding of what's available and the communication that exists to let people know? If we maybe start with Alison MacDonald. Alison MacDonald I think that that's a tricky problem that's been on forever and ever. How do we tackle that? I know that Graham Ford mentioned that he wasn't on public campaigns, but I think that there's a role for that at the same time, because we need the population to understand that there's a wider workforce who are the right people for you to see alongside the work with our MDT that increases our confidence in each other to work differently. As professionals, we need to be confident in how we work in a new world that lets us talk about a wider group of people that will help you. Alongside that, we need to prepare the population for seeing a bigger group of people. There's also a challenge around systems at the moment where people will often wait for a long time for an allied health professional. If we could shift to earlier intervention so that people are seeing an earlier point in their journey, that changes how effectively, in a good way, we can help people. In children's services in Scotland, we've changed the language from referral to request for assistance. Referral is quite a medical dependent type theorem, whereas request for assistance is a much more enabling approach. How do we get to that model where it might be a phone call and we direct you to the right person rather than it's a phone call and you end up on a waiting list perhaps for some time to see the right person, and then it might not be the right person after all? How do we change our systems to have earlier and more supportive conversations with people so that they can get the right help or seek their own solutions sooner in their journey? As far as accessing the people, I think that my receptionists are critical in admins on care navigators or signposts or whatever they like, because if they are in public correct, people will still contact their GP's first protocol, and then what happens? People have to have a trust in what when they phone up GPs. I don't like for a long message that you get at the start of a lot of people, I've phoned a lot of practices in my CD role and you get, if you have a chest being called this way, if you have, and I problem call this, I don't like that, but when you come through to a practice receptionist, they have to be trusted to be confidential, professional, because they are trained. We have had recent training to our practice staff on signposts and they get people to the right places. Now, in strong practices that might be like mine, I've only seen half a thousand patients, so it might be easier to do because there's not that many people to have signposts too, but in the larger practices, although it may be complicated, there may be more fruitful because you can get an advanced nurse practitioner, an advanced physiopratician, a health support pharmacist, somebody who is able to deal with your inquiry and going through them and having the trust in your call and your care navigator on your first phone call is the best place to go, I think. Is your sense, Graham, that that is working effectively as well, that the people when you are signposted, someone goes on that journey with that HP or whoever, or do you see that sometimes people kind of maybe go round the houses for want of a better expression and end up back at the GP? Is there a kind of effect of that? Yeah, it's only a personal view, but they don't come back to me. If they go and see them, we've got links worker recently, it's great, everything goes to her, stays with her. It doesn't get pumped to back to my flat sport pharmacist, although they keep changing our excellent. Again, if they were medication, if I was at a place to go, they'd know much more of medicine than I do, and when they go there, they don't come back. So my sense is they don't come back to me. If hope must have been the correct professional, they could take care of it because honestly, I'm nothing compared to you, they're better than I am, so why would they? That's very helpful. Thank you. David Tollans, do you have some questions around receptionists, since they've been mentioned already? Can I come to you? Thank you, convener, and good morning to panellists. To what extent do you public recognise the increasingly complex of the GP's receptionist role? Graham, please. I get a sense that people learn more understanding, and just on a personal, they may have a platform now, an IT platform, where patients can contain their phone us, but if they want to, they can then mischief via a website or a website to ask us questions, and then we can, from that, navigate them to the correct place. It's not usually me that does it, and it's usually my receptionist that I care enough for them to do it, so if they have a question about their medicines, it does go to my pharmacist that have got social problems or monetary problems, and money advisers are on board as well, so they can be directed properly. I think that the service that they get, the outcome allows them to be satisfied, or if they want to be dissatisfied, that's fine, but I haven't had negative feedback, and the data that was seen so far is that the patients are very satisfied, but the IT fixes have got it. The professionalism of our receptionist should be respected, and their level of confidentiality and their level of training is high, and I've listened to any consultant who has gone up recently, because he said that he's fed up with listening to a highly trained receptionist, but they are highly trained, and they are valued by me. It's a different job. 30 years ago, they were busy bodies at a desk writing down the names of people in chat, and now they don't know what they do. They're always working hard, and they're always on computers and doing things, and they're extremely highly trained and very professional, and they're worthwhile listening to what their opinions are. How could between receptionists and patients that whole work be improved? The reason I'm saying this is that I have a practice in my constituency that, because of the lack of support from the GPs and the level of abuse from the public, all four receptionists have resigned and they will have none by the end of this month. How can we support receptionists and how can we have patient reaction with receptionists? How can we improve that? An easy answer is training, and as part of the answer, in any training as good, we put ourselves routinely through training. I don't think that it would make any use to still do it, because I think that when I'm not at their values, it's terribly important. Are you still going to abuse, perhaps, to say that these long necessary to start making the time that it's difficult to get through to the GPs or just because it is difficult to get through, I can't deny that, as it would reduce the frustration, some kind of response to it. Now that I've said this in public to Glasgow GPs, you should make your semester shorter so that it's easier to get through or press one for this and then get cut off is not going to increase the frustration. So, on our side, there are problems being made on how easy or how relatively easy it is to contact your practice, but the abuse side is unacceptable, is that fair? You can abuse folk. Thank you. Stephanie Callaghan has some questions around the rule of the receptionist. Let's bring in Stephanie. I could be wrong. I'm not seeing Stephanie coming up on my computer. Oh, thank you. Oh, you're there. Good. Yes, I have. I was still on mute and my camera was still off, but that's me on now there. I want to ask about the GIS practice and administrative staff collaborative and the fact that it really seemed to improve triage and referral to the appropriate professionals. I'm just wondering what comments would have them possibly rolling that out at a wider level. Yes, I think that it would be valued. We took a private half way down that way because there wasn't the standard out-of-ight to training to be employed at a private company to train our navigators up to do what they do. I think that any training, as I said earlier, any training is good, but having a high-quality training is ideal, so we're rolling that out as I've seen it. I think that doing something like that would be excellent. I'm wondering what Allison's comments would be on that. Yes, it was more, I wanted to come back in around the receptionist being that first point of contact in a time of change. We're expecting the population to know all of those changes and the receptionist is the first person that they speak to, so it goes back to that messaging to the public around what they can expect. That supports our GP receptions in a different way. We need to get the public to have a greater awareness that it's good to see different people. It's the right person, so the GP isn't on the receiving end of unhappy people who are still expecting to always see a GP. It's not so much about the training, it's about the messaging. That's really important because that's unacceptable for our GP receptions, but I wonder if that's the first point of frustration for a population who are not fully aware of a world that's changing around about them and how do we help them to understand that a bit more? On that, Allison, I think that patients see very often the receptionist that GP is being the gatekeepers, but gatekeepers who are determined not to keep them out, if you like, on occasion. How is it that we go about improving the public perception of GP receptionists and support staff there as the HIRS, that is administration staff, collaborative? Is that in a route towards that, or is there something else that you would suggest changes? I'm not hugely familiar with staff collaborative, so I don't feel like I can comment on that particularly, but I think that there is an MDT role around supporting our receptionists. The receptions are a key member of that MDT, and how do we, as a wider team who are doing different things in the practice than we did two, five, ten years ago, how do we work with our receptionists to help them to understand what it looks like to give them confidence in making different offers to people who phone up? Paul, you had a question. We heard some evidence last week about the requirement for protected learning time for everyone who is involved in a practice, and that includes reception staff. Other people have talked about how we protect that time properly. I don't know if Dr Marshall has had experience of, for example, NHS 24 covering phone lines and things like that in his practice, or if there are other methods where people can feel that they are getting a service from their practice, but that protected learning time can be put in place for everyone who works in the practice? Yes, we used to have a protected learning event in Glasgow. It was a smile, kind of smile stood for, protected learning event, Eric. It wasn't NHS 24, but they did the phone calls. It was the GP of our service that covered it, so all staff and receptions included, and we went along to an event that was a handgun for the foot south, and we went and we all trained on different things, and there were different packages set up for receptions. We went to one meeting now, went to another, and it was enjoyable and it was valued, and then it became impossible practically because there weren't doctors or there weren't staff to cover us, so we ended up just not being able to do it because there weren't practically that people to cover us. It was a service that we didn't want to stop at, but the service couldn't cover us. I think that going forward, multi-risk learning should be as good as much as it's different, because currently, I thought it was a thing of cardiology. I'd go to that if there was a thing on how to get phone calls better to the receptions, and we'd go to that. I think that we should be trained together. I think that there's no harm in all the professions that would learn each other's roles, not only to see what strengths we have, but also what deficiencies we have. I think that it would be very useful to allow a discussion to take place afterwards, allow us to see what we can and can't do, and I reckon that to work as many as much as 80 per cent of patient contact could be dealt with by anyone in the professional team. I think that there's no harm in such a business. However, if we train together, we're nearly able to learn together, so I would value the return of multi-risk learning rather than just protected training. We should do it all at all. I want to learn what we each other do, and I think that patients will benefit from that. On the receptionist theme, Sandesh. Thank you, convener. I just wanted to pick up a little bit about what David Torrance was asking about the abuse that our reception staff take. I, too, am a jobbing GP, and receptionists allow us to do our job without them. We simply couldn't function. I remember coming through to reception and seeing one of my receptionists in absolute floods of tears over what was said to her, and I hear every time I'm at work things that have been said to my reception staff where they are feeling hurt and upset. Demond and frustration are leading to this, and, as you rightly said, abuse is completely unacceptable. However, I'd like to know what more can be done in a concrete way to protect our receptionists and to maybe ensure that this is completely unacceptable. Yeah, because current practices, usually, if someone says something unacceptable to our receptionist, they get sent a letter saying, you can't do this. In the future, if you use it again, you'll be removed from the practice list. If it happens again, which is quite that common, it really isn't, but it does happen. You could put off the list, but I don't think that that's learned from. I think that they move on to the next practice. I don't think that it's a massive determinant. There are people who become recurrently and are removed from their CVRS or patient service, where people can only see a certain GP under certain circumstances. That's pretty rare, again. Most of my patients are nice, they are respectful, they are decent. The problem that I see is that they pick out the bad apples so that you can see somebody behaving badly and you think, oh, they're all like that, and they're not. Most of my patients are absolutely fine. It's an occurrence that happens and they don't like it, and receptionists don't like it, and they should be perhaps up by their doctors. The majority of my patients are fine, but the ones that do behave badly, they certainly shouldn't be allowed to do it, and they certainly should be sanctioned in some way. Removal from the lists and referral to the CVRS seems to be the only thing that happens just now. I can't think of another pathway. Emma, do you want to ask a quick question on this? Thanks, convener. Just a quick question about whoever's taken the phone calls in order to triage people. It is the receptionist that's the primary person, but in my local work, I've heard that there are GPs that have answered the phone to triage and identified themselves as Dr X answering the phone. Their experience has been different and not traumatic, for instance. Is there somewhere where we could be measuring that, as far as not requiring GPs to be the triagers? Just to look at that kind of different experience, where is it the perception that the receptionist who's answering the phone isn't going to have a clue about how to triage, when they're really pretty specialist themselves? Should we maybe measure that and look at the different attitudes depending on who's answering the phone? Is that to Dr Marshall? Yes. I don't know how you are. You would measure that other than a paper audit. I'll go back to what I said earlier on about the electronic ability to contact. Now that doesn't suit everyone, and I get that up to the health of the deprived patients. However, if you own our platform and contact the practice about a subject that you will get me, or you will get someone that is in the receptionist to contact you, you might say, and if you want to talk to someone about your health problem, I will be contacting you in either remotely or via video confidence or through telephone or face-to-face if it's appropriate to come and see me about it. That's a way of directly getting a doctor. I don't know how you would measure it. However, alternatively, it seems to be a wee forward, and I would back up using that platform or that pathway. Thank you. Evelyn Tweed, do you want to ask a question around link workers? Sorry, I apologise. I've just noticed that Alison Kerr wants to come in off the back of Emma's question or possibly Sandesh's question. Alison, I'll come to you, and I'll come to Evelyn. Thank you. It was just to follow on from Graham talking about training together, and I can't emphasise the importance of that enough, and that must include our receptionists. We are all part of a primary care MDT going forwards, so we support people differently. We give equal value to all members of that team. I think that shared training is really key to how we support and consider the wellbeing of all of the staff in our newly formed and created primary care teams going forwards. Thank you, and I apologise for nearly missing you there. That's the juggling act of the hybrid meeting for you. Evelyn Tweed. Yes, thanks, convener. I wanted to ask Dr Marshall about his comments about link workers. Dr Marshall spoke very positively about years, and I had a wee look online when you were speaking about the numbers between different health boards. I see that it is quite patchy. Do you see the link worker as quite a key role in your practice to make things work? Yes, I do now and now experience it. I just like patients experiencing the best service that I use, too. The way that GP contract works is that the money is separated, so it is around friends' money to these people in and out. It is around friends to try practices, because they are the people who are going to be less social. It is harder for them to access services, because they are no less social than they are doing it. I think that it might work across the board. I think that it might be the sort of ease that they take and how much time they have got and how much expertise they have got. I was so surprised at how good mental health, housing and benefits my link worker was that I am very confident in referring on as many people as I can to see them as it is almost at. It is public and almost at a sensible central adult who my people can link on to and be directed to the correct type of service. I think that they are really valuable in my experience of them. If I haven't seen the numbers on how they are directed from GP workforce, they probably might take some of my work away, but they more appropriately take my work away. They are the ones who know that system. I don't know if they will phone up and say that they are having trouble with their employer or can't access this. I wouldn't know how to do that, but she does. It is an excellent service for my patients. Thank you. Alison Wood, do you want to come in on link workers? Absolutely. I am a very valuable member of our new-shaped teams, but it is also important to consider how they can link with our allied health professionals in teams. That might be an occupational therapist. It might be working on a specific treatment plan to help somebody to use public transport again. How can the AHP and the link worker work jointly on those objectives for people? It might be a physiotherapist to set an exercise programme for somebody that the person needs to get to the local health centre. Again, there is a really nice link between the AHP and the link workers, and how, together, we can get the best outcomes for people with their everyday licensing tasks going forward. Can I bring in Stephanie Callan? Stephanie wanted to pick up on something from the previous panel line of questioning around patient data and records. I know that we touched upon the single electronic patient record during Gillian Mackay's questions. There was just a further question on that going back. Clare Morrison on the last panel and all the others agreed with her that having a single electronic patient record would really be transformational, with everyone being able to all different health professionals being able to access things at the same time. She also made the suggestion that there was a single cloud system that all the other different systems talked to, so that that information was available to everyone. My first question is, would you guys agree that that would be transformational to have that single electronic patient record? Secondly, does it sound realistic that an integrated cloud-based system that all the different systems can talk to would be really helpful as well? I suppose that it does pull in just the previous question, the link workers, and everyone having access to all the information. I think that the single patient record is a great idea. It is empowering. It lets the individual be absolutely at the heart of the things that are important to them. My knowledge about a single cloud system is not good enough to comment on that. I think that a system that brings things together into one place can only be better for the individual and a safe place where that can be retrieved, because some people will have more trouble managing their own records than others, some people will find it easy, some people will find it hard. We need a safe backup and perhaps a cloud is our new solution to do that. However, if we are thinking about empowering self-management and helping people to think about their own health, a single patient record is certainly a part of that journey, I believe. Can I go to Grem now? You'd be mad not to think that it's a good idea. There is quite a lot of transfer of information. I can go on clinical portal and see what happens to secondary care. When we talk to patients who are being referred to our money masters, our link workers or our HB colleagues, we tell them that we are going to share this information. Is that okay? Sometimes that is drifting down and sometimes it is verbal, but there is a good sharing of information within primary care. Would I like to see what is happening in care first in social care? Yes, absolutely. I think that we have used a lot of disparate meetings. I would love to have access to care first or not of access to social care, but if that was not available, I would have been able to agree, because if someone is only at home, they would need to know what is happening, and if someone has child protection issues, they would need to know what is happening, and that is to make appropriate decisions. A football team would be playing in one pitch and they would say that social care is used to go to charity, so they would play in a dense park. I can't access the area across the road, so some access to the whole system would be fantastic. That's great. Thanks very much. I think that we all know the joys of copying and pasting stuff as well, and we'd rather avoid it. Thanks very much, convener. Thank you, Stephanie. Now some questions from Emma Harper. I'm interested in social prescribing, also known as community prescribing, and we did an inquiry in the previous parliamentary session, both David Torrance and I were members of the health and sport committee as part of that inquiry. It was talking about social prescribing being an investment and not a cost, so I'm interested to hear whether you think there's scope for wider use of social prescribing. Will we go to Alison Kerr first of all? Thank you. I'm absolutely interested in social prescribing around how we offer different solutions to people to help them to achieve good health and wellbeing. Whether that is community walking groups, leisure centres, cooking classes—these are all the things that we need to do in our general life but also the things that keep us well. Thinking about health in a much broader sense rather than just traditional medicines prescribing, it's been able to access that wider selection of things that we need to do and want to do, but actually let us be living the best life that we possibly can. So I think that social prescribing is important, highly appropriate and good for people going forward. We'll go to Graeme now. Yes, it's the might. The answer to this is via a health improvement net colleagues who introduced a social prescribing element to their piece of hospitality and improvement plan in Glasgow. There was a pilot, but it was excellently welcomed by the UKGPs to then, at least, put you on board and ran with some of this, and I think that the good outcomes, as far as pieces of that fashion, were again whether it reduced what load or whether it definitely improved care and it definitely improved the satisfaction of people to availability. Of course, the link-link workers would be felt as if we were making these referrals or making these prescription issues because they know the service. Because in Gorbos is a huge number of third sector things available to us, we're just scheduling this to know better. My son went to a music session down in Gorbos and I've even heard of the place and I've been there for 30 years and I just don't know it, so having people who have their knowledge out there to prescribe is an important burden. I can ask someone else to do that. To go back to Graham, the link workers, if they're the ones that are signposting people, are they using the ALIS system, which is the national government-funded local information system for Scotland? I'm aware of that, so there might be issues of keeping it up to date, so that's my first question. Are the link workers directing people through ALIS or using it themselves? In Dumfries and Galloway, they basically dingied ALIS and set up their own DG locator so that it was updated at a regional level rather than national. Any thoughts about how we direct people and is the link workers' job to link into the ALIS system or other systems? The issue with ALIS is that it's massive, it's a worker. It needs a trip advisor, but it needs people to know what's the good part about it, and what's the bad part about it, and that's done through local knowledge. I know that frequent meetings are very well coordinated with the link workers through Cathy, and they talk to each other and find out what's best in the area. There are more than one link worker in his postcode and they find out what's the most appropriate service and what's the worst best and what's the most effective service in doing it to the local. I think that they're doing it through ALIS, which I understand is a massive piece of work and a massive resource, and they need to know local knowledge of what's best, so I think that it's something like what's happened in Dumfries and Galloway, but even on a postcode basis, it's going to work best. I think that the use of ALIS is there, but it's patchy. Some people use it, some people don't use it, sometimes it's up to date, sometimes it's not. However, I think that it's how do we think about empowering people? It might not be that we use people to access services on their behalf. How do we help people to have the skills to access services in their own right? That's often where goal-setting through an intervention from an allied health professional can help you to regain skills that perhaps you've lost. So there's two levels. There's somebody who will do it for you, and actually there's also a need where we help to work with people, help them to do it themselves, and that's absolutely a role of EHPs who work on a real asset-based approach, helping people to work on the things that are easy for them to regain their productivity and be active participants in their life again. Okay, just another question. I'll just put them both together. We know that social prescribing, so whether it's singing in a choir for pulmonary rehabilitation, we know that works and it helps people feel good, as well as walking football and things like that. So we know that it works, but are we measuring the benefits accurately enough, and is there a risk that social prescribing will then be seen as a replacement for what's perceived as more appropriate care? We had a very interesting response in our survey that someone said that they would be offended if they were given any social prescribing, so that's always in the back of our mind. How come to Alison first? I think that the important thing is an outcome-focused approach to anything that we do. So what matters to you as the individual must be the starting point of any intervention, and for some people, the most important thing will be singing in the choir, it might be reading their child a bedtime story, it might be going to work. So it's understanding that that is what drives the person and then working out how we meet that need, and that might be done in part through social prescribing to help them achieve an interest, but it's also about the whole wider team taking that whole premise of what matters to you, so that comes through everything and every discussion that we have. So it's seen as not an alternative but a true listening that we're there to help you achieve the things that are important to you, right place, right person, right time, so that's the important approach to take going forwards. And can I come to Graham? Yeah, we're kind of what Alison said, but what the provider that experience makes a difference, and I've already said that in this column that my experience of having come across services and realising how good they are would equally apply to patients when they come across it and realise that pulmonary rehabilitation is great. I used to coach others first at MCM for Glasgow and Clyde, and I found out, and I didn't really know about pulmonary rehabilitation, and I found out how good it is and the outcomes of how much difference it makes since one of the only things in COPD that keeps you alive, living longer, and understand that, and realising that is so important. I think that patients, although that has to be patient-centered as Alison says, if they come across how good these services are, then they might come to accept it more. Thank you, Emma. We're now going to go to Evelyn. She's going to leave in some questions on self-referral, Evelyn. Thanks, convener. Yes, we've heard much about the public maybe not knowing much about self-referral, how-to, et cetera. Really, the question is around how do we do it better, how do we get the message out, and I would like to ask maybe Alison first. Thank you. I think that that's a challenge when our system still somehow stop us, encouraging people to self-referral. I'll go back to what I talked about at the very beginning about NHS 111. It will encourage people to go to a GP because the services are not the same in every GP practice. There's sometimes a default for people who are encouraged to go back to the GP because they will know what is there locally. That's a bit disabling for people. Until we have less patchy provision, that's a challenge. But the self-referral is really difficult for people to navigate through a complicated system that often health professionals don't fully understand. If you're a person at a point of need, it can be really hard to work your way through that system. We need clear messaging, we need that development of our MDT, so we are confident of our offer and of our offer of each other within that team. That comes back to our receptionist, so the conversation has started to change. We are at the beginning of a journey that should be much more about self-referral, but it's not as easy as we should just encourage people to phone up and ask for something, because they don't quite know yet what to ask. If they ask for it in Glasgow, they might get it, but they might not get it in Dumfries. Our teams are still developing in a new shape compared to what they used to be, so we need to continue to develop that, so we are all confident in what our offer is and how we help people. In a much better way, the vision for the future with these extended MDTs is much better for service users, but we are at the beginning of that journey. Some people are further on that journey than others, but it's hard to give a consistent message when the picture at the other side is not consistent with what that looks like. There is self-referral for some things in Glasgow City, but there is self-referral for some mental health services. The theory being that if patients will access that themselves, if they go through the process, then they are much longer to attend from the plastic case, but that would be the area behind it. If they are also right to dispatch, some practices do it, others don't, even within the health force, it's not a universal thing. Some services like knowing the background to the patient, so if you self-referral, you won't know that they are passing through history, drug histories, etc. We can do it if you get a formal referral such as Skygate Way, you know a lot more about the patient in the background. Although self-referral is budden, it probably won't encourage attendance and will be proficient in that as well. Just to follow up on that, convener, if the self-referral is maybe not the best pathway for some people and it's maybe leading them down the wrong avenue, how can we make sure that they access the most appropriate health practitioner for their needs and maybe to Dr Marshall again? I'll go back to that. The navigation point, whether it's through our train research and the source, through some electronic means where we can see what people get. I'm not plugging this, I'm not on or selling it, but when I get a message from a patient, I'm not getting it over the phone, I'm not getting it. Someone else has interpreted what they said, I get a written off in a paragraph or two paragraphs about what exactly they want and what exactly the needs are and if there's got time to do it and they're not nervous speaking to me, they get the opportunity to write down exactly what they want and I can ascertain from that a much better idea of what they need and can put them on to the appropriate service, whether it's me or someone else to try to solve the health or social care issue. There's somewhere that would be a better avenue to really what they actually mean and what they actually want, although I was to direct it better. Thank you. It's how we have these requests for assistance conversations to how we give people an opportunity to explain what their need is in loathe and the use of three conversations approach. The first point is to try and unpick what people are asking for and then to help direct them in the right journey rather than they get on a waiting list. We have an early conversation trying to help people to get the right people quickly. Evelyn, I've got a follow-up question to your line of question and it's very specific because it's one area of a woman's experience that happens to pretty much every woman and that's menopause and at the moment that seems like an ideal aspect of women's healthcare that could be self-fulfiled. It's very, it could be quite obvious, you fit the age profile, you're getting the symptoms and at the moment the pathway is through a GP and it's quite a long time until they can actually get any kind of treatment yet you know you're pretty much perimenopausal when it happens to you. In the same way that we've had, you know, we've got, you can say, self-affirtening family planning clinics, whatever, do you think that the women's health plan and some of the things that are happening around menopause could be an opportunity for a real step change in self-affirthal for menopause care. I'm not quite sure who would like to come in on that, I'll maybe go to Dr Marshall first of all. Yeah, yeah, that sounds very menopause. It's not quite as simple, I think, because there are a lot of statistics and difficulties. When I talk to someone about HRT, I mention risk of breast cancer, I mention osteoporosis benefits, I mention cardiovascular benefits, I mention, oh, there's loss. It's not a simple conversation, it's not quite the menopause of HRT then, it's you've got to weigh the frozen cons, you've got to have an understanding to the patient of what they're going to be dealing with. So, oh, at the end of that conversation I often say, and when you need to take on board what I've said, here's the round of information, hold me back, because I don't want a single conversation about something that's very important to someone's life and might have different frozen cons, whether what their family history is, whether it's not quite as simple as, here's a quick self-referro to someone, it's good. It may be to me as a man to find a harder older man, but I do find it a complicated conversation. But I guess what I'm coming from is that I've anecdotally heard from a lot of women that they feel that, because it's a complex situation, that they feel that they have to have that specialist care and often will, that comes back to that health inequalities, will opt to pay privately to go to a menopause clinic, but that doesn't seem to be an offer that's out there for everyone. I'm speaking for Glasgow and Clyde, but our excellent Sandie Ford service, when you get there, run by Becky, Metcalf is very good, but it's under a lot of pressure, under a lot of pressure with numbers, under a pressure with signatures, under a lot of pressure, and I think we're almost lucky to have it at all, given what she tells me, because that's what Metcalf tells me. It's hard, and to put more pressure on my servers would be difficult, and as HRT can be done in primary care with student practitioners, there would be more to be ditching elsewhere, unless a new service can be funded and brought up, which would be fine. Putting on existing services might be quite hard. Thank you. I don't know if Alison's got anything to add to that. I suppose just around including allied health professionals in the women's health plan work, which we are doing, but there are statistics around a lot of women fall out of employment at that time. Things are just really hard for them, and perhaps with intervention from a different group of professionals, that might not have happened. So to think about the scope of help that could be there from a wider group of professionals. Thank you. We have one final theme of questioning led by Sandesh. I want to touch on inequalities that we have. I think that it's very pertinent to Dr Marshall as you are working in government. I asked this in the first panel. I'd like to ask this to you directly. What assessment do you think, or what worries do you have around the link between alternative pathways and digital exclusion? It's got what's working. I wonder how precious I know you're knowing that I'm up as well. I'm very lucky in the other factors to have the junior planners, the John O'Dowd, who used to be a public health consultant and has a special interest in inequalities. He talks to me about this. It's an exclusion. Most folk have a phone these days. It's a mighty access. However, the people who are in the health study get the service first. The public health doctors Helen Irvine used to say that most of the money that's put into extra money that's put in health is picked up by the high-SSND. That's who's able to access it. They're unworried, unwelder, out there. They need to be accessed. How do you do that? I'm not entirely sure. Most of my time, as a GP, is taken up with either the worried well or the frail elderly who definitely need that care. By the unworried unwel, the undiagnosed diabetics, the hypertensors who won't convict in the pub all day and are not accessing me, need to access them in some way. It's possible, but having some kind of campaign to try to get these people in to see us is what is important and appropriate. I think that, around the question of health inequalities, having a bigger MDT in a practice is a huge asset to tackle that. We go back to thinking about the social determinants of health and the wider issues that cause ill health. Employment and economic factors work. The allied health professionals are really skilled in helping people in those areas, looking at housing, helping people to consider how they get back to work or stay in work, helping them to think about how they fill their time—all of the things that keep us well. On health inequalities, I think that having a wider group in your primary care team is really, really important. For digital inequalities, that is a challenge. I agree with Graham that lots of people do it before, and we need to remember that. There is the cost of digital access, and then there is the whole infrastructure. If you are in Glasgow City, that is fine, but you do not have to go very far outside Glasgow before you will not get broadband. There are pockets of no access, and we cannot move entirely to digital solutions as to be all because not everybody can access them. Some people just need to see people, so we need to consider a wider range of options to support people and not be channeled more and more into a digital offer because one size does not fit everybody. How do we do things differently in our localities? How do we use our local libraries and infrastructure that is there to offer different access to people that might not be through GP, but it is also not a digital offer? It is different ways to get to the people who are harder to reach. How do we go where people can find us so that we become more accessible and more part of the population? I know that it is seen as that people healthcare professionals are there in bad times, but we are there as part of the community to help people to keep well. Thank you. Just to pick up a little bit on that, I recently visited the Citizens Advice Bureau in Glasgow and they told me that they are embedding themselves in some GP practices and they have actually found that the engagement, so if they see a health professional, a health professional says what, you need to go along and see the Citizens Advice Bureau, their engagement and the work that they do is actually better than when citizens turn up and ask for help in their offices. So I wonder if we expanded that, put Citizens Advice in GP practices, especially ones like Dr Marshall's, whether that would free up time for not just the GPs but also for our health professionals, because the social aspect is being catered to by a specialist service. Alison? Yeah, absolutely. So it's who's in that team to support people and where are the best place to support them. My other experience is carer support services in GP practices and people might not have gone to carer centres, but actually if there's somebody with a pop-up stand in the GP practice, it's really opportunistic to pick up people at the right time. So thinking about where do people find it most comfortable to access those services, they might not go there otherwise, so how do we take them to people and use it to access them this way because that's better for everybody. Good to Dr Marshall. We have a recent experience of money matters coming in and being embedded in general practice and previously in north-east we had GMAP services in north-east practices and they work extremely well. The numbers, I can't quote them, are the numbers I've seen from our health improvement colleagues. An enormous number of money they've gained for patients and like it or not, money helps your health. They make a huge amount and they benefit to the patients that they're trusted. If you're sitting in a GP surgery, you're much more trusted than going 200 yards down the road to an emergency visual even. What we used to have in Gorbells was a separate path for all five practices to access. It does not work as well as it is in the health centre. Some are sitting in a room down the corridor where you can directly access. Someone mentioned that the start of the early on meeting is a room for all those people and there isn't, but if they had room for them to be sitting in my surgery, and then seeing my patients because as soon as someone mentions harness of security, my mind turns right, I've got someone who can do that because having never accessed it, I don't know where I'm really going, so someone is sitting in my practice and is trusted and has access to the patient's medical records is great. We have a couple of members wanting to put forward some follow-up questions. Emma Harper first. Thanks, convener. It's just a quick supplementary about digital exclusion and pop-up health checks, for instance. I'm aware that the local national farmers union in Dumfries and Galloway went to the auction mart and did like blood pressure, vital signs, blood glucose type checks for people. Is that something that we should be looking at pursuing and measuring and seeing if something like little pop-up health checks in the town centre in the empty shops or at the auction mart? Is that something that we could be pursuing? I'll go to Alison on that. It's about making health accessible to people. I know for occupational therapy in Ayrshire, they had pop-up shops, so if you wanted advice about your, you know, a gravel or a ramp, you could go and ask somebody not being a waiting list. So it's being there when people need us, rather than putting people on lists to see us, and that's the whole thing about being preventative. If we can be there more quickly, we can pick up problems, rather than if we're not around, people don't access us, and potentially the problems can become bigger than they need to. I guess that that's a good idea. I'm not an academic, but the evidence that I've seen in this is obviously screening, to the screening that that has not the evidence behind it that everything that I have seen. Screening has to be evidenced and proven to work. We had a system in Glasgow, we were in the poor areas, we were off with people to come in, the ones that needed to didn't access it, the ones that the baby stayed at home and the ones that were health-heavy access to it. So everything that I've seen and I've just been screening, as it doesn't work bad out to my health, public health colleagues who will know much more about this than I have. Thank you. I've found the questions from Calum Ockham. Thank you, convener. Can I just make the point that I thought Dr Marshall made a really good point when he talked about people having access to money and how it's linked to health? That was an excellent point there. What I'm really interested in in terms of asking a question is to the allied health professionals. I think that the evidence that we've taken from today and other days is that there is clear evidence that it can help in terms of inequality in health. I wonder if we have enough information about which allied health professionals are in primary care and whether there is a waiting towards areas that may need much more of that support or whether there is any work that is needed on that matter. That's a question for Alison Kerr. Alison Kerr, please. Thank you, Carol. I think that there is absolutely more work that is needed done on that matter. How do we link that to our population health needs? It goes back to the point that I made about it. It's not X number of physios or occupational therapists or dieticians that we're asking for. It's understanding what our population need is and then working out who has the skills to help meet that population need. That definitely needs more work to make sure that that fits with whether it's a greater need or a lower need, but we're not quite there yet. I think that it's something that we absolutely want to develop going forward. It's better for our populations. If we understand them better, we're able to meet people's needs better. Carol, do you want to follow up on any of that? Just very quickly. I know that we're time for time. I'm just wondering if you could direct us to—if there's something as a committee somewhere that we could ask for that work to be done, would it be Nes or what would be your sense of where we could get some of that work progressed? I think that Nes would be really helpful to progress this work around our social deprivation and our population figures. Absolutely, Nes would be a good point of contact. That's lovely. Thank you very much, thank you, convener. Thank you. That brings us to the end of our second panel. I want to thank Dr Graeme Marshall and Alison Here for all their time this morning and for all the information that they've given us. It's been very helpful. At our next meeting on 22 March, the committee will continue to take evidence as part of our inquiry into alternative pathways to primary care. That concludes the public part of our meeting today. Thank you all.