 Gwelwch i chi gweithio y 30 wrth y hwnnw oedden nhw'n gweithio. Er oedden nhw'n gweithio y twmleriniaeth lleoeddau i'w ddefnyddio'r gyrch, byddwn gwirionedd, i ddim i'n meddylion i gyd, a ddim wneud i rhywbeth i gynnwys i unrhyw oherwydd cyntafo'r chi ddarparu ydyn nhw'n gwirionedd. Mae hynny'n gweithio yr rhai ochr�odd mynd yn y cyfолот rhagor. Dw i chi'n ddwyll Prayol er mwyn i gynnwys i'r cyfotodau Instead of the hard copies of the paper here this morning. The first item on the agenda today is a round table on e-cigarettes. The committee has been waiting some time to hold this exploratory session, which is first we have had on this subject. As usual with a round table, I am going to ask everyone to introduce themselves. Firstly, I should introduce myself as Uncle McNeill, MSP for Goodland and McLeid and Convener of the Health and Sport Committee. I'm Andrew Thomson, I'm a GP in Angus and a member of the BMA's Board of Science, UK and a member of the BMA Scottish Council. Bob Doris, MSP for Glasgow and deputy convener of the committee. I'm Jeremy Main from the Department of Health in England. Richard Simpson, MSP for Mid Scotland and Fife, my apologies for being late due to trains. The Net and Mill and MSP for North East Scotland. John Britton, I'm a respiratory consultant in Nottingham and I'm directly from the UK centre of its back on alcohol studies. Little Earl, MSP for Central Region. Eileen McLeid, MSP for South Scotland. Claire McDarmid, tobacco policy team at Scottish Government. I'm leading on the consultation on e-cigarettes and tobacco control. Colin Kear, MSP for Edinburgh Western. Catherine Devlin, president of Eceda, the electronic cigarette industry trade association. Gil Paterson, MSP for Clive Bank and Mulgae. Sheila Duffey from Ash Scotland. Rhoda Grant, MSP for the Highlands and Islands. Thank you for that, everyone. Richard Lyle, you asked the first question and I know I'm not. I should say to the panel that we don't do a question now, but we don't intend just to ask questions. All the times it's a break in the conversation and I will look to the panel members in preference to committee members for contributions at all stages through this session. Richard, please. Thank you, Gideon. I also thank the committee for granting my request for this session on e-cigarettes. E-cigarettes are a new invention which has come on in the last number of years and there are concerns about what is in e-cigarettes and also what they are. There are a number of organisations who have made comments about e-cigarettes, in particular the committee to Young Scots supporting a smoke-free generation by 2034. They actually suggest, and I'll read it out to be on the record, that we want to see a ban on all the sale of e-cigarettes in shops and retail outlets. The product must be regulated and distributed as a medicinal product only. I'd like to turn to the question in regards to the Scottish Government's position in regards to e-cigarettes and possibly I could ask Claire McDermott to explain. It is my understanding that there is no law against selling this to children, but it is self-regulating. As we know, if anyone walks into a shop, they may purchase something. It concerns me that children could walk into a shop and purchase an e-cigarette. I know that the Scottish Government is considering a ban on the sale and is doing a consultation. Could Claire tell us where we are in regards to consultation? The consultation was launched on 10 October and will run until 2 January. We await a programme for government in terms of what a timetable might be for that, but we will seek to consider the consultation responses as soon as possible. The minister has made clear that this is one area that he is committed to bringing legislation forward on. Thank you for that. Can I ask Louisa, on the panel? She even got a response to some of the other things, Richard. You mentioned the recommendation to ban e-cigarettes. I think that some UK legislation is already in place for that. Can we have some comment and feedback to Richard's general questions at the beginning? I think that a number of questions arise out of that. Would there be any question? Catherine Devlin. I feel like I ought to respond on this one, representing the industry as I do. Just in the broadest possible terms, if I may, though, I think with the precautionary principle, as expressed by the concerns that you've raised and the suggestions that you've raised, we have to be enormously careful that we don't do more harm than good. We've been very pleased to see the Scottish Parliament's approach to this, which is to consult widely and bring forward very few ideas initially and take time to gather further evidence before doing anything too drastic. The risk, if we were to remove everything from the market, is that we will see all those people who've made the switch to electronic cigarettes potentially returning to tobacco smoking, which would clearly not be good for public health on a population level or for those individuals. I would agree with Catherine. I have no, I should say upfront, I have no financial or any other conflict of interest or interest in what the industry has to say on this. But electronic cigarettes offer a huge potential benefit to public health by helping smokers to shift to an alternative source of nicotine. And if all smokers in Britain were to do that, we would be talking of hundreds of thousands, if not millions, of premature deaths avoided. So it's very important, I think, when legislating and controlling the inevitable abuses of the market that will come with electronic cigarettes and the inherent risks in the products, which we know relatively little about still, though we do know that they're much less hazardous than tobacco. It's important to manage those risks, but not in a way that throws the baby out with the bathwater because there is a huge potential public health prize in these products. Thanks. Thank you, Chairman. I would agree with what John has said in the context that UK Government has taken an approach which is as evidence-based as possible, recognising that there isn't as much of an evidence base as we would like to make good decisions in relation to this category of products. But what we have tried to do is to think about the risks and the benefits. Rather than banning a product which, as John says, has great potential, we've taken a more measured approach thinking about what regulatory framework and structure is necessary to enable these products to be made available. Thinking about risks and benefits, the position that the Department of Health has taken, is that continuing to smoke is the riskiest thing that anyone can do and costs 80,000 lives a year in the UK. So anything that can help to manage those risks are important that we evaluate carefully and think about the potential for benefits. As John said, the market is such that we can't be confident that the range of products available are safe and therefore can't recommend their use to people. But what we don't want to do is to remove from the market something that has potentially a great value if the regulatory framework is such that we can be confident that the products are of quality and will help people to cut down, to quit and to reduce the harm of smoking. Do we, yes? Clement Dymut? Hi. Probably likewise recognise and develop in the consultation paper the potential for e-cigarettes to act as a cessation tool. However, we do, as Catherine said, we don't feel that there's enough evidence yet to make a decision on electronic cigarettes. That's why we asked the question in the consultation document where we're still seeking people's views to inform future policy development. Just to highlight, one of the reasons we didn't take action just now is in recognition that individual organisations, service providers can act on their own policies if there is felt that there was an urgent need to have e-cigarettes banned in their premises. I think that Richard made the point about the sale of this to children and young people. I think that we're clear on the effects of nicotine on that group, aren't we not? Or a younger group? Jim, if I could just make a point picking up on that. First to say that in the UK we will be consulting very shortly on an age of sale restriction of 18 and a proxy purchase prohibition for adults buying these products for younger people. Those regulations, if passed, will be in place next year. That's the intention in the UK. I think that John is probably better placed to talk about the impact of these products on younger people. I think that none of us would want any of our own children or anybody else's children to start using nicotine for no good reason, which includes electronic cigarette use and, of course, includes smoking. I don't know what the figures are for Scotland, but, certainly across Britain, by the age of 25, 40% of people have been smokers and 25% still are. We have the dilemma in young people's use of electronic cigarettes. If it's young people using electronic cigarettes who would never have become smokers, then that's a negative step for their health and for population health. If the use is predominantly among young people who would otherwise smoke or are already smokers, then the same potential benefits come to them as come to adults who make the switch. I think that it's a very difficult balance to make. At the moment, the evidence from the Robert West smoking... No, he doesn't look at children. Sorry, from the Ash surveys carried out by... surveys based on, I think, carried out by YouGov, the evidence from young people is that use among never smokers is extremely low of the order of one or 2%. I just wanted to make it very clear to the committee that we've always asked for a mandated age restriction. We introduced the voluntary code in 2010. We're very pleased to have seen that it's gone wider than our membership, but we absolutely support the mandating of an age restriction for this. The difficulty that we're hearing from enforcement officers and, indeed, retail colleagues who are out there in the marketplace selling these products is that, without it being mandated, the voluntary code is not enforceable because retail outlets into which members or sellers' products are placed, they will not necessarily respect it unless it's a mandated age restriction, so we do support that while, obviously, completely agreeing with Professor Britton's perspective on the potential benefits to children who are already smoking. That said, I think it's really important that the committee recognises that there should be or they should seek to be no difference between the treatment of the nicotine-containing electronic cigarettes and those that don't contain any nicotine. To date, all of the regulatory proposals and frameworks that we've seen from pretty much anywhere in the world unfortunately failed to make that clear at all, so that the products that don't contain any nicotine are left frequently outside of regulatory discussions. We think that's a significant mistake because, at the end of the day, these are products for inhalation, and just as with the nicotine-containing ones, we would not like to see children being sold non-nicotine-containing electronic cigarettes either. Thank you. Yes, Richard. Can I make crystal clear that I'm not attacking e-cigarettes? I know a number of smokers within this building who have actually given up and have been on e-cigarettes. I'm not one of them. That's a confession I've got to make. But the basic situation, I turn to Professor Brinton's comment. I hope I wrote it down right. We know little of what is in the cigarette. Can you explain to us what is in the cigarette? That's a concern that people have. What is within the liquids? I know you can get licorice, strawberry, raspberry or whatever flavours you want. What else is in that liquid? The basic recipe, if you like, is that it's predominantly propylene glycol, which is well understood. It's been studied for many years, and Professor Brinton's perhaps more in a position to talk to that than I am. Vegetable glycerin, or glycerol, which again is fairly well understood. These are both grass, generally recognised as safe. You have a very, very small concentration of nicotine. I use quite a high concentration at 2.4%, so very low nicotine. You have flavourings. These are usually food flavourings, although in the case of tobacco flavours, there are sometimes flavourings from tobacco absolute, which obviously falls outside of food flavouring standards. There can be food colourings in some of them, and we're in the process at the moment, as the committee may be aware of creating a pre-standard, a publicly available specification with the British Standards Institute, which seeks to include emissions gathering and analysis, so that we can not only know and understand fully what's actually there in the liquid, but also far more importantly, what's delivered to the user in the vapour that you inhale. So we're looking at gathering the emissions, analysing the analytes that are present in that emission, and then also doing a full toxicological health risk assessment on that, so that we will have a better understanding of the impact on the human body from using the products. It is with a certain amount of shame that I can't provide that data to you today, before the products went on sale. That is an error, that is a mistake. We should have done this already, but it's been a process of growth for this industry. Many of the businesses in the sector are not professional businesses. They're often created by vapours who just got really excited about the products and then decided to create a business, and now it's necessary to try and push some standards on them to force the standards up, so that they can know exactly what went into the product, what comes out of it, and what effect that's going to have on the human body. Part of the problem with this debate is that we're not talking about one standard product, we're talking about up to 500 brands and well over 7,000 flavourings. Some of those flavourings, although approved for food use, work quite differently in the body when heated and inhaled. Our position has been that we would love to see people who are addicted to tobacco being able to use those products instead of tobacco or to quit a tobacco addiction, but there are so many unknowns. The little evidence that we have supports both an optimistic and a cautious approach at the moment, so we believe that regulation needs to look at maximising the potential benefits and minimising the potential harm, and those products must work towards our vision for a generation free from tobacco in 2034. Under. Thank you. It's very heartening as a GP to hear the view of the industry that you want also to make sure that these are not available to our children. Certainly my interest as a clinician was first sparked in this when I had a parent come in with a primary school child who'd been found in the playground with an e-cigarette, and that's just wrong on so many different levels. So, I'm very keen for this to be removed. I'm very keen not to see in shops and displays this at a sort of a children's height to be able to take these sort of primary coloured products and take it off the shelf and find out what they are. Also to move to actually get the capsules, the actual nicotine containing liquid into a child's safe form so there's no risk to our children that they may accidentally get hold of this and ingest this, because although, yes, nicotine can cause vomiting and things in overdose, it's not guaranteed that actually the child will bring this up and may suffer harm, excuse me, due to nicotine. It's also heartening to hear that the industry are keen to do a full health study on industry. My concern as a clinician is that not after the horse has bolted. The huge use of this and yet we don't have good evidence as to the safety of these. I absolutely accept that e-cigarettes will do less harm than continued tobacco use, but I'm concerned that this doesn't always take someone who is using tobacco and take them down the path to either 100% e-cigarette usage or quitting nicotine altogether as an addiction. There's emerging evidence certainly that e-cigarettes are being used to reduce someone's reliance on tobacco, but actually possibly then maintaining that tobacco used longer, and the evidence certainly in terms of clinical harm is that the length of period of using tobacco is actually potentially more harmful than the intensity of using tobacco, and therefore that's a significant concern. There is a need and certainly the BMA is very keen to see a quick development or as quick as research ever allows more evidence around this to the point that I as a GP can feel confident to recommend this product to my patients as part of a nicotine replacement therapy and as part of smoking cessation, but that has to be as part of the whole gambit. The evidence on all other nicotine replacement therapies is that they're more effective when they're combined with behavioural therapies rather than just being able to be taken off the supermarket shelf. So we need to actually use this as a product to help reduce the impact of tobacco and not take our eyes off the fact that actually there's a huge amount of harm as you've demonstrated of tobacco use in the UK. So I want to see a state where the evidence is there, but that evidence is going to take a very long time to develop and I think we need to be brave and move forward faster than that. Catherine Devil and Professor Platton. Thank you. Sorry, I didn't mean to cut across your job. Several points raised there. Thank you, Andrew. First of all, child resistance. That's actually been required by law up until July this year when we found that actually it's not for the products that are under 2.5%, but in our code and in our standard we are insisting on that still. So there should be no product containing nicotine out there that is not child resistant. And indeed for our members we do actually verify that. We check that with a government expert to make sure that it is. There's a significant difference between quitting smoking and quitting nicotine use. Nicotine, as I'm sure Professor Britton would agree, is very similar to caffeine in terms of its dependence potential and its effect on the body. So actually quitting smoking is essential for the health benefits. Quitting nicotine, not such a big issue in our view. And then also the notion of continuing tobacco use. Of course using an entrant of cigarettes is not tobacco use. Tobacco use is where you've got the potential sort of health risks and so forth. But the continued use of e-cigarettes removes the harms associated with smoking of tobacco. So it's not quite the same issue. And then finally the behavioural support point just very quickly, I'm sorry. Louise Ross at the Leicester Stop Smoking Service has seen some very significant success with recommending electronic cigarettes. We're not so much recommending but educating her clients about electronic cigarettes and making it possible for them to access these products. But I totally agree with you that we need more research and we need to move fast on it. Thank you. Just one point of clarification on the caffeine point. I would agree that nicotine is probably about as hazardous as caffeine in terms of harm to the body. It's in the same order of magnitude. I think nicotine addiction is harder to break. I suspect. I would just pick up on two points from Andrew. One was the dual use concern and the other the behavioural support issue. On dual use, that's an argument which has been advanced very widely against electronic cigarettes that they are encouraging people to continue to smoke but just use the electronic cigarette at times or it's difficult to smoke. But on the other hand, we actually actively recommend and encourage dual use of licensed nicotine products for use in exactly the same way. A nice guidance on harm reduction, pH 45 which came out at the beginning of last year, I think, does the same. And the argument is that whilst cutting down on smoking I agree probably has trivial impact on health outcomes because it's the first cigarette of the day that does most of the damage. It's more complex than that, but there's a certain truth in that. What we do know is that people who dual use are far more likely to proceed to quit smoking than people who don't. So I think it's just the learning that if I can go for four hours through a meeting, say a morning here, and not smoke by using an electronic cigarette then why can't I do all day? So there's a learning process in that and we encourage it with NRT and it seems to me completely wrong to call it a bad thing for electronic cigarettes. The other issue is behavioural support. I entirely agree with Andrew that if you want to give up smoking you are most likely to succeed if you use proper pharmacological support which in my view can include electronic cigarettes and as a clinician I do recommend them for people who have tried nicotine products medicinal products before and haven't found them satisfactory. Or other medication plus behavioural support but the fact is that each year only about 8 or 9% of our smokers go into those services. The other 90% struggle on their own. What electronic cigarettes do is make that first step towards substituting cigarettes possible for people without engaging with medical services. Now I agree, the more that we could persuade to go through the full monty of NHS support, the better. But I would much rather that smokers who are not otherwise going to engage with that try an electronic cigarette and realise maybe there is a way out of smoking here than not at all. Robert West has described smoking as being like in a nightclub when the fire breaks out. You just need a way out, it doesn't matter what it is. An electronic cigarette could well be a way out for many smokers who would not otherwise find an exit. Andrew, you want to sit and then... I think John has clarified my point in terms of the dual use I think perhaps a sort of misunderstanding on the point I was making there. I absolutely recognise that dual use is something that we've promoted and is promoted in the nice recommendations for nicotine replacement therapies currently. But that's in conjunction with behavioural therapy with an aim to reach a tobacco cessation date. So it's far more a pathway to quitting any use of tobacco whereas that's I feel less in place with e-cigarette use. And I think it is a learning process as you say it's a learning process that while I've managed to go four hours without tobacco then actually I can go a bit longer and perhaps I can move to e-cigarettes. But part of that learning process is, as you agree with me, the behavioural support that's built into that to actually help you gain that learning as opposed to just this happening by default. In terms of me as a clinician recommending, I mean I'm very much the sort of first do no harm and at the moment I still have a lack of confidence about the absolute safety of e-cigarettes to take me to the point that I will actually be recommending to my patients to use an e-cigarette. Of course if a patient comes to me and says they are currently using an e-cigarette because they've found no other way to do it, I'm not going to turn around and say, well actually no, you should stop that and start increasing your tobacco use again. Of course I'm not. But actually I think it's a step further for me to actually come out and as a GP recommend to my patients that they should be using e-cigarettes because there is a lack of evidence in terms of being absolutely sure in my mind that they're not causing any harm. Thank you, gentlemen. Just perhaps picking up on that point about harm and how to proceed whether a cautious approach or a sense of urgency to take action. The evidence base isn't as clear as we would like and certainly if there was clear evidence it would be easy and we would be able to take decisions rapidly. But in fact we don't know enough about the safety of the product. We don't know enough about their long-term impact. We don't know whether dual use is the same as nicotine replacement therapy. So that's why we've taken a cautious approach to regulation. We have defined areas where we think it is important to take action in terms of age of sale and in terms of advertising restrictions. The code of advertising practice has just been brought in a new regime to ensure that advertising for these products is targeted towards adult smokers not bringing people or young people into use of the products. But we do need to proceed with some caution. It might be just worth flagging that the tobacco products directive which is due to be implemented across the UK in 2016 will have a range of measures in place which will give greater reassurance about this variability and the range of products on the market. It will have standards for the contents of the products for notification, for labelling, for packaging, for electrical safety, for enforcement arrangements. We're hoping that that regime will allow healthcare professionals to be able to recommend trying these products. I think that an important point is that with the smoking population still at around 8 million people in the UK one size doesn't fit all and we need a range of measures out of smoking so that we can look forward to a tobacco-free generation. I think that one of the very harmful forces within this whole debate is the tobacco industry which has been buying up these companies and technologies as if they were sweeties. We have boots retailing an imperial tobacco brand. We have Lloyd's Pharmacy retailing a British American tobacco brand. We have Rangers and Celtic being sponsored by Elites, which was bought up with 98 per cent of their profits coming from lit-smoked tobacco in the foreseeable future. We have to be very conscious about how this deceitful manipulative industry operates and watch very closely what their long-term strategy is for these products. On the question of big tobaccos involvement in our sector this is something that we've been watching very closely and with a certain amount of trepidation. But it's very important to remember that there are at the moment a handful of e-cigarette brands that are owned by big tobacco companies and hundreds and hundreds approaching 500 different brands that are totally independent of the tobacco industry. So really this is their CODAC moment. They've recognised the threat but they are the few, we are the many and I think it's highly unlikely that the tobacco industry is going to have control over this sector into the future. What we can all hope for though as part of a move towards a tobacco regeneration that hopefully goes a bit further than Scotland and the UK is that big tobacco recognises the need to move away from selling combustible products at all and moves fully into harm reduction products and nicotine delivery in a clean way so that they can change their business model for the future and stop doing so much harm. What's the market that they've got rather than the number of companies that's against them? I don't have data on that but I can see if I can find out for you and submit this to the committee afterwards. I feel that you want to come back to that. Yes, just to say, there is a very good page on the website Tobacco Tactics that makes clear which tobacco companies own which brands. The guy in charge of the Scottish Arm which was SkySig was bought over by Laura Lard by this tobacco giant and is being taken over by Imperial Tobacco UK has made very clear that he intends to reduce the number of brands to about 10 in the foreseeable future and he intends his brand as he put it in the Guardian to be the Starbucks. In a market so big and if electronic cigarettes are effective products and many of them clearly are it's inevitable that big players the market is going to consolidate into far fewer brands and it's clear that tobacco industry will own many if not ultimately all of them but I think it is important irrespective of what we think of the tobacco industry and I'm certainly not here to stand up for it I think what we need to prevent is people smoking tobacco our target is that our target is not the tobacco industry Richard On the issue of children it's interesting that the trading standards institute report which we got in SPICE indicated that between 23 per cent and 80 per cent of retailers were selling to children so despite the the rules self-regulating rules this is not really applying that the industry may be saying it but the retailers are not pulling that and I think the fact that Boots and Lloyd's pharmacy are selling these products when we don't yet know I think questionable I would say can I take it that first of all that everybody's agreed that we actually need to have an effective European wide research programme funded into the potential for short term harm because this is an addictive product and I slightly to agree with John Britain I think Nicotine is substantially more addictive than caffeine and we don't know what its long term harm is in terms of potential for possibly dementia has been suggested that we need to have research do we need to have research into the pathways in other words is it taking people onto smoking or is it taking them off smoking and we need to have long term research into things is that something that everybody would be in agreement with so that's my first question can we have some responses please Catherine Professor Britton and then Shirley Duff thank you purely on the question of research research is always good we always want more research however I think especially if it's going to be some sort of Europe wide research programme it would need to be very carefully constructed because what we've seen so far from the European institutions is terribly impressive to be fair so we need to make sure that it was shaped properly I am a researcher and primarily I'm not going to disagree with anybody who says we need more money for research however I fully agree that we need to watch very carefully patterns of use because if we see disturbing trends in the way that young people are using these products we need to act on that unless you have regular almost monthly certainly three monthly monitoring systems in place that will be missed but on the long term effects of nicotine we know a great deal from the long term effects of oral tobacco use in Scandinavia where people have used oral tobacco which still delivers nitrosamines and is not a harmless product by any stretch of the imagination to the body for many decades we know a lot about the risk potential or the pattern of risk in lifetime users as opposed to non lifetime users and whilst I can't say there is no risk the risk is very very low I agree certainly we do need the research there are a lot of long term unknowns I think we also need to be clear about the funding for the research because there is a long well documented history of tobacco industry funded research which doesn't hold to the body of all science when tested I think mine was just a word of caution we have been considering quite a lot of evidence in developing the consultation document and whilst always more research would be great it's what can be achieved in a short period of time some of the research that's required around cessation and health impacts can't be we won't get anything with us in the short term so that we're going to push to come forward Andrew I mean obviously I support increasing research European research very welcomed with all the caveats that others have included but very much support the on-going monitoring and also not sort of selling ourselves down a European research line that's going to take a very long period of time to do if we're able to mobilise good quality research in the UK and in Scotland faster that's what we should get behind in parallel with pushing for European-wide research and certainly any trends, especially if it's any trends towards seeing this as a gateway product is absolutely something that we need to seize and seize very quickly just to stop that as a potential trend I know that the evidence is weak there at the moment but certainly that is a potential risk of a gateway product or indeed normalising the image of smoking again On that point also about the importance of monitoring and also research based in the UK Stan Glance who was a very eminent public health and outspoken public health specialist from California once and I think intentionally disparagingly described the UK as a natural it has allowed itself to become a natural experiment in tobacco harm reduction I think he meant that to be an insult but it's actually I think a great tribute to the fact that we've taken a much more open mind about electronic cigarettes than most other countries and we are therefore in a position to do research here that just can't be done anywhere else because we are so far advanced down the line of trying to realise the potential of these products so I would endorse the priority for research is national Robert West runs an excellent survey facility of a rolling survey of smokers including electronic cigarette use it's called smoking in England and of course it does only relate to England but that kind of survey work can tell you patterns of use very very quickly and I think it's vital that all of the components of the United Kingdom do that Very brief question that we agreed a timetable Yeah, brief supplementary I understand that from one of the questions that 50 per cent of 15-year-olds have tried e-cigarettes so my supplementary question is will salsas the Scottish survey of adolescent lifestyle does it now include an e-cigarette question and how soon will we get information on that Sorry it's probably more one for Claire to answer but yes it does include a question on e-cigarette use and I believe it's coming out very shortly Is it moving on the back of what Richard was saying about young people buying e-cigarettes I'm a little bit worried about the flavourings of these things because I can remember being put off cigarettes for life by one puff when I was a child because the taste was so awful but if there's something being produced that's got a pleasant taste I can foresee children wanting to dabble in it and find out which flavour they like best and so on and thereby developing the habit of doing that I believe that these are perfectly set up to be a starter product for children because they are smooth the flavourings some of them seem to be tailor made for children they're high tech, they're glitzy so I think there are real concerns there I think we haven't solved the question of whether they could be a gateway in smoked tobacco particularly if the higher strength nicotine e-cigarettes are more restricted I think we must not forget the tobacco epidemic which is claiming some 13,000 lives in Scotland every year and that is an epidemic that this committee should not be distracted from and e-cigarettes should not be allowed to be a distraction from that tackling that and tackling the availability and the supply of the more harmful product There you go, I think we've got a few hands up there the e-cigarettes are a distraction Catherine Devlin, Professor I John is far better qualified than I to discuss the relative merits of flavourings but I would just like to make the point that adult smokers who switch to using electronic cigarettes and switch away from tobacco flavoured e-liquids find that it is much much harder to relapse to smoking and relapse to smoking is one of the biggest drivers I believe of these tenaciously stubborn smokers that we continue to have it's all too easy for them to relapse back to smoking whereas once you've made the switch and you've switched away from tobacco flavours to something that's fruity or sweet or totally different when you get your taste buds back you can't go back to smoking I've tried, it doesn't work, it's revolting so you stay off the smoking which is the ultimate goal Professor Devlin I don't know what's best about the flavours what Catherine has said to me by some of my patients too but at the same time I agree with Sheila that these things look to be set up to be attractive to young kids and none of us wants primary school children using electronic cigarettes we would be interested to know where that child got the cigarette from but I think that's why we need monitoring in place and an annual survey isn't enough particularly if we so we'd be treading a very difficult path in how unless you prohibit all advertising which isn't the case at the moment is the advertising that's recently been allowed does the CAP guidance apply for Scotland too so it happened here last week as well as in England is that going to appeal to young people or not we only find that by monitoring very carefully and very frequently the behaviour and use of these products so I just don't know on flavouring but I think the answer is to measure who's using it and at what age there's a couple of things that I would like to ask in terms of the cessation policies that we've got in for to help people to stop smoking apart from the support that supposedly goes alongside that they're all based in nicotine replacement on the level of what's the difference between that nicotine getting into someone's body through a patch or vaporising it is there I think I can answer that nicotine is if you swallow nicotine it's absorbed into the blood stream passes through the liver and most of it's destroyed so it gives you heartburn and it makes you feel a bit queasy but it doesn't get in high levels into the blood if you inhale nicotine it's absorbed across the lung surfaces into directly into the blood stream and straight to the brain so you get a hit very quickly to avoid we don't have a medicinal inhalation product to avoid the yet to avoid the breakdown in the liver you have to give medicinal nicotine through roots that involve absorption to blood supply or blood circulation that doesn't track through the liver which means skin or the nose or the mouth or the other end of the GI tract and all of them are absorbed very slowly much more slowly than something that you inhale yes so apart from the speed it's the entry system apart from the speed but the nicotine levels that you would get through vaporising or patches are very similar there are two key things that cigarettes do but nicotine to the brain extremely quickly and the second is that they deliver very high doses if you take out the cigarette and compare vaporising with nicotine patches the early generation cigarettes were all pretty hopeless I think and delivered fairly little nicotine best on a par with the nicarette inhalator which is an oral thing supposedly an inhalation device by delivering nicotine into the mouth the second generation electronic cigarettes, the vaporisers the ones that look less like cigarettes not at all like cigarettes do deliver higher doses and it's a mixture of mouth and upper airway and probably some lung absorption but I haven't seen evidence yet to show that electronic cigarettes any of them have achieved the sort of lung absorption that a cigarette does so there's still a long way to go but these products are going to get a lot better I think on Sheila's point around the potential for a distraction in these products but put that slightly differently my responsibility in the department of health is for tobacco control and actually there's a whole range of things that we can do to impact on smoking so some of that is around nicotine replacement therapy it's also around other central nervous system drugs that are already developed or are in development it's about cognitive behavioural therapy it's about the environment so standardised packaging of tobacco products advertising, availability all these things impact on the smoking epidemic and our tools to help us to reduce the population that still smokes now we could think of electronic cigarettes as a distraction or we could think of them as an opportunity different levers will work for different people we need as many tools as possible in the toolkit to help and that's why we've taken a cautious approach in England to recognise that there is an opportunity it needs to be managed and the risks need to be managed as best they can but it is an opportunity rather than something that we need to do it was really just to add to what Professor Britain was saying about the comparable nicotine between NRT licence medication products and electronic cigarettes I think it's important for the committee to recognise that the nicotine is the same grade so it's pharmaceutical grade nicotine that's used in both electronic cigarettes and in NRT products and that's built into our standard but that's already pretty much standardised thank you I'm going to ask other MSPs who have not spoken yet if they want to ask any questions and then if there's time I'll let other people in again one of the questions I was going to ask if we haven't covered it what justifies then ban in the use of e-cigarettes in public places given that if I've got to leave a public place and a pump or something to go outside and sport an e-cigarette, why wouldn't I just go and have a cigarette? Yes please Professor I think it is electronic cigarettes the legislation we have for cigarette smoking in enclosed public places was brought in primarily to protect people who work in those environments and the evidence on electronic cigarette use in indoor public places is that it does release nicotine into the atmosphere it may well release some other substances some of which may be toxic into the atmosphere and therefore it's not a completely clean innocuous product however the levels of those things are extremely low personally I think it's a matter of courtesy not to use an electronic cigarette in this room for example as we speak but I think to use law to say you cannot use an electronic cigarette indoors does engender exactly the process that you've just described if you're treated like a smoker you might as well be a smoker and also there are circumstances controversial all of them but potentially in patient settings in general hospitals my patients smoke electronic cigarettes under the sheets because they're not allowed to use them openly some of them do in mental health settings where the prevalence of smoking is incredibly high and has not shifted over the last 20 years prisons even again prevalence of smoking is extremely high and very difficult to control going smoke free I'm sure it can be done but electronic cigarettes may be part of the solution and so I would be very cautious about a legislative prohibition of electronic cigarettes in enclosed public places though I would accept that the courteous thing for all electronic cigarettes to do is not to use them indoors any way I'll cut in devil couldn't agree more John hence mine's in my bag and not in use I think the prison population example is a very good one we've actually got a working example of that in Guernsey they rolled out e-cigarettes being made available to the prisoners in Guernsey's prison there's been a lot of party and behavioural support being offered to the prisoners there and it's been very successful they've been able to go completely smoke free when it comes to mental health institutions as well there is quite a significant body of evidence to supporting the fact that mental health patients particularly schizophrenics but all mental health disorders find nicotine enormously helpful which is why we tend to see these much higher prevalences of smoking in mental health patients there are doctors here who I'm sure could attest to that far better than I can when it comes to public spaces bans however I think we need to be very careful about our obligations to every citizen's human rights because if you have someone who wants to use an electronic cigarette and you say to them okay you can't use it in the building you're going to need to go outside to the smoking shelter to use it you're putting them in harm's way because you're effectively telling them to go and stand with the smokers with the known risks of passive smoking I agree with John it shouldn't be mandated it should be left to courtesy and for public policy decisions within each of the businesses or buildings owners or whoever to make that decision but I think if you are going to suggest that you shouldn't have vaping in the building you need to offer separate spaces for the smokers and the vapors thank you anyone else see if there's any other person in the panel watching to respond to that Andrew certainly the BMA were very keen to see this included in the Smoke Free Public Place legislation we think that currently there isn't evidence that these aren't harmful there is the imagery and the normalisation of this image of someone puffing albeit a vapour but these vapours are becoming more and more visible as people are using e-cigarettes and therefore actually telling the difference that's partly why companies like weatherspins have come out and banned this because it's very difficult for their staff to ascertain who is someone breaching Smoke Free legislation or is someone using an e-cigarette that potentially puts them in harm's way and challenging someone we'd be very keen understanding absolutely the potential risks of putting someone in harm's way in terms of passive smoking but we're not suggesting that that's a solution that's a implementation of this of actually having people to have a space that they're able to use e-cigarettes away from the risks of passive smoking but we think very much that currently having a dual standard here for two forms of both tobacco use and e-cigarettes potentially undermines the current legislation on smoking in enclosed public places and we'd be very keen for this to be included the industry certainly purport to say that they're very much providing these products only as tools to help decrease tobacco use so they shouldn't be afraid of having these products treated in a similar way to tobacco and certainly the idea of going back to the flavourings indeed Bluetooth connectivity of e-cigarettes and linking so you can play music and things like that these are clearly designed to capture a young audience and not there as a tool to help reduce the impact of tobacco on society there's no science to say that there's a risk but why does BMAC come to think why do you come off the fence and say we can't prove that they're bad but we can't prove they're good but why did you fall on one side or the other? because we always fall on the side of first do no harm that's our prime directive if you like as a doctor we can't prove that these are safe to those around it and those working within environments that you may have a lot of people using e-cigarettes and therefore we wouldn't want to be sitting on the side where there is potentially harm so the benefit there is moving towards the safest option and the safest option in our view is to include e-cigarettes in the enclosed public places legislation chairman thank you chairman the converse of that argument is that the riskiest thing to do is to continue to smoke so anything that can help to bring people away from continuing to smoke tobacco is potentially helpful in England there is no current plans to extend the ban on smoke free public places e-cigarettes the products are different the risk associated with second hand smoke is very clear very evidence based and there certainly isn't the evidence to support treating two products the same in the context of the level of risk of exposure to them so there are no plans in England to extend the ban we do however support the right of companies to take action and there are a range of reasons they might wish to do so including for ease of enforcement of the smoke free legislation I've also heard the arguments that there are different risks in different places we heard about prisons and mental health institutions they are examples of places where the normalisation argument for example around children seeing products which look like a cigarette being used don't apply so there may well be different arguments for different settings no other panel members go paterson that's not very point the one thing that's coming over clear to me is that no one so far has said that these products are safe nobody knows so the idea that you would not put a ban in place similar to smoking for me would send a signal that they are safe that we do know that they're okay and rather than being proactive on it particularly to in regards to children that if it becomes commonplace then being a person that's never ever smoked my life but never really worried about someone else smoking other than to encourage them to encourage them not to so I've got a weird attitude in these things what people do drinking and smoking but certainly signals to me are very important don't go somewhere is a message don't go somewhere and if you don't have the message you're allowed to go I think the important point that I would wish to stress is the UK Government is not the Department of Health in England is not recommending their use in fact the chief medical officer for England has expressed concern about particularly children and young people and the potential for gateway but the reason we've taken a cautious approach is tobacco is so harmful killing 80,000 people a year in the UK that's something like 200 people each and every day it's more harmful than alcohol than obesity than lack of exercise than any other public health objective it is the singest, biggest killer and for that reason we need to do all we can to support tobacco control and if this is potentially helpful we need to take a cautious approach to enable it rather than to ban something without sufficient evidence can I clear a question up a convener convener before anyone else sorry is that we considered and developed in the consultation paper but I would echo Jeremy's point that the smoke free legislation was brought in on the grounds of really robust evidence on the harms of second time smoke which is why our consultation focuses on the points that you make about young people protecting young people among smokers trying to achieve that balance reducing young people's access to them reducing the appeal for young people and non smokers and how the questions and their about how the products marketed to those groups no other panel members yes certainly sorry I misrepresented what was really meaning myself I didn't mean ban I wanted to get in earlier when we were talking about banning in public places that's the ban I'm talking about I don't think it's logical so it's not the actual banning of the product but treat it the same when it comes to in use in public places Has there been any work done on the cost benefits of the cost benefits of of health reduced deaths has there been any work done on that at all there's been a number of indirect claim we've got 80,000 deaths a year this is going to reduce the harm so by what extent is it going to reduce the harm what health benefits are being claimed here for this as there any Professor Bryn The best analogy or the closest analogy to answer that question would be the pattern of health harms from oral tobacco use in Sweden Sweden has the lowest lung cancer rates in Europe alongside the lowest smoking rates in Europe but tobacco prevalence use is the same in Sweden as elsewhere it's just that many more tobacco users use oral tobacco and that's partly because smokers have switched to oral tobacco as smokers have switched to electronic cigarettes in this country and partly because a whole cohort of smokers are going to become smokers have become oral tobacco users and are growing through without the risk and we know from that experience that in terms of loss of life lifelong use of smoked tobacco in this country takes about 10 years off your life expectancy and lifelong use of oral tobacco probably takes a couple of months or so it's of that order of magnitude so it's a fairly trivial risk on that point no, no, I'm going to take the panel members always first Sheila Duffie you might get in with it if you don't delay the proceedings of the committee Sheila Duffie I think the health gains from people stopping using lit smoke tobacco are huge and the savings are huge what we don't know yet is whether for the whole body of smokers these will perpetuate dual use with lit smoke tobacco we just don't know that yet should just to clarify my point about oral tobacco this is an inhalation product so we don't know the long term risks of inhalation of propylene glycol glycerine or any of the other byproducts of production and there are theoretical risks in that but to my eye those risks are of a similar order of magnitude to the use of oral tobacco which also causes hazards in other ways that electronic cigarettes won't but in response to Sheila I entirely agree we don't know what the long term pattern of use will be and that's why we have to monitor use so carefully, repeatedly frequently and be able to get those figures in days rather than in a year or two as we do in England with many government surveys panel members sorry, yes just to make the point that I completely agree with Sheila and John that we don't know the long term effects yet we can't, it hasn't been around long enough but what we do know is that use of electronic cigarettes as with the use of the oral tobacco products that John was describing completely removes the byproducts of combustion because there's no combustion so there's none of those tar, carbon monoxide all of that sort of stuff, that is completely absent so in the words of Professor West who was presenting last week's summit the risks are residual risks are going to be of such a tiny order compared to the massive risks of continued smoking that it's almost negligible in his view thank you Rhoda Crenant Can I just ask John Britton a question you talked about in the harms in Sweden and the difference is that just comparing it with lung cancer or is that all other cancers because I think some of the arguments were that can enhance tumour growth in the leg I think there is evidence that nicotine can promote tumour growth but there is not evidence that nicotine causes a tumour so I think if you develop cancer and you're a nicotine user it is potentially going to progress more quickly than if you're not a nicotine user that I have never argued that nicotine is safe I have argued that it is not the cause of most of the harm from smoking and in terms of safety it's probably on a par with caffeine which causes heart arrhythmias and other problems I can only speak for the Swedish cancer figures which in men from memory in the sort of 25 to 45 group which is a very good marker of future mortality is about half it's certainly the lowest in Europe for heart disease risk things are slightly different in Sweden but there are many more influences on heart disease risk than just smoking whereas for lung cancer smoking accounts for nearly all of it I don't know if that answers your question I was just keen to know other than lung cancer which was obviously a byproduct of smoking tobacco where other cancers did it appear that they were the same I can't answer that except that I can say that the risks the other known risks of oral tobacco are of potentially of esophageal cancer and pancreatic cancer both of which happen certainly pancreatic cancer slightly more highly in oral tobacco users than never users but less frequently than in smokers so the risks are all relatively low slightly tangential to your question I appreciate it Any other committee members who haven't been in it wish they come in No Richard Lyle spoke about damage to lungs Cunny Any other panel members who have seen the European responsibility society annual congress report in Vienna in September 2012 where a report from researchers from the University of Athens in Greece stated that electronic cigarettes could damage your lungs as they cause less oxygen to be absorbed by the blood Do you have any comments regarding any members Richard Lyle I think I'd specialise in lung disease the lung is a fascinating and very complex organ it's also extremely delicate and inhaling things that you shouldn't inhale probably doesn't make sense but again what matters is the relative perspective against inhaling tobacco smoke and any study that argues and there are reports out there that electronic cigarette inhalation generates as much damage to certain in vitro so laboratory based cellular measures as cigarette smoking I take with a huge pinch of salt there's no question that inhaling toxins into your lung causes the lung to object but whether that translates into lung cancer chronic obstructive pulmonary disease which smoking certainly does we just don't know what the position is that it will a little bit but it will be trivial Carthon I have a fairly intimate working knowledge of that particular set of studies and headlines having been around at the time and had to deal with it on behalf of my industry it was an egregious bit of reporting to be fair what that study actually found was that there was an acute effect that was certainly attributable to PG propylene glycol which is an irritant actually that's why we enjoy it because it gives us a throat hit that makes it feel like smoking but it's an acute effect it's very transitory it doesn't last very long within about 10 minutes of stopping that effect is gone but unfortunately the way that study was reported transmuted those Daily Mail headlines of magnificent proportions suggesting that this can damage your lungs and cause permanent damage and all sorts of nonsense which simply wasn't there in the findings of the study I don't have any bits for any further Richard, go on I don't think in England you have registration of tobacco outlets we have that in Scotland which was one of the moves to actually control illicit sales and it seems to me that it's only a matter of time and I'd like people's comments do people feel that it's likely that actually the criminal fraternity will get on to this area pretty quickly and supply tobacco material to go into these products in some way and if so should we actually limit the sales to registered outlets so that we can make sure that children are not sold as they clearly are being sold everywhere from boot sales at 80% down to I think supermarkets 25% of the best of the trading standards report do you think that we should actually limit it and I don't know if that's in the Government consultation or not but I expect it is OK, thanks for that mention I've got Andrew and I've got Claire Sheila I agree I think it should be limited I think to enable us to have control over the supply of e-cigarettes going forward to avoid the very first thing I said was having a child coming into the surgery and to answer the question that John put is how did that child get it by accident they went in and they bought it I think it was a toy from a news agent that's how they got it, seven years old Claire Yes, just to answer the question that is in the Scottish Government's consultation it's in there that the proposal is to support the age restrictions that we propose to introduce for e-cigarettes so it will help trading standards with their enforcement role at the moment we don't know there's no record of who is selling e-cigarettes so in terms of helping them in that enforcement and identifying who is selling e-cigarettes but also to support them in an educational role much of the work that trading standards do is about supporting an education for retailers and legal sales In terms of registration I can confirm the UK that England doesn't currently have a registration scheme and doesn't have current plans to introduce one however in terms of age of sale we have been working very closely with our colleagues in the trading standards Institute and locally that age-restricted sales are controlled carefully and that these products once they are restricted by the regulations that we will publish shortly are well controlled in terms of the local arrangements The question of illicit trade was also raised and recognising the potential role that registration can play in controlling illicit sales in England the HMRC recently consulted on a range of measures to help control illicit trade what we have seen is that illicit trade tends to fall as prevalence falls so the lower you can get smoking the more illicit trade tends to come down so in our action on tobacco control we should be impacting on illicit trade and that is certainly a priority for the Government in London I think it's clear that smugglers will shift anything that makes money whether it's tobacco, fish or e-cigarettes so we can expect that to come up in the frame The retail register in Scotland has been tremendously helpful in that it's allowed enforcement community to engage with retailers and to offer them education and some counter to the misinformation they've had from the tobacco industry to support those selling e-cigarettes and vaping devices being part of that register but I think we need to go beyond that for tobacco I think we need to start looking at putting it further out of sight, out of mind, out of fashion I think that that brings us to an end to this session I'm sure this debate is going to go on and on and as a committee we look forward to following that debate working with the Scottish Government to address this issue thank you all very much for your attendance here this morning, the evidence provided thanks very much thank you we're suspended at this point we now reconvene and move to agenda item number 2 and continue our scrutiny at stage 1 of the mental health Scotland bill and this week we have another round table and as before we normally introduce ourselves at the round table and let's begin with Sarah no, I should begin, shouldn't I? my name is Duncan McNeill I'm the MSP for Greenock and Inverclyde and convener of the health and sport committee I'm Sarah Cronby I'm acting director of corporate services from Victim Support Scotland Bob Doris MSP for Glasgow and deputy convener of the health committee Karen Kirk I'm a solicitor and partner at legal services agency a mental health project that acts for people with mental health and that's MSP for North East Scotland Kenneth Campbell from the Faculty of Advocates Dr Lionel MSP Central region Cathy Assanti I'm a legal officer at the Scottish Human Rights Commission Colin Keir Edinburgh Western MSP Jules David director of the centre of mental health and incapacity law rights and policy at Edinburgh Napier University I'm also a member of the law society sub-committee on mental health and disability Gil Paterson MSP for Clydebank and Mulgyll I'm Jan Todd I'm a solicitor and I'm here representing the Law Society's sub-committee on mental health and disability Bode Grant MSP for the Highlands and Islands Thanks for that Roder, can you open up please and we'll take it from there and I should say I always look to the panellists first before the committee member Thank you Can I ask about the victim notification scheme and ask the witnesses whether they think the balance is right between the needs of the victim and indeed the needs of somebody who is probably mentally ill at the time of committing a crime Anyone want to pick that up, Sarah? Thank you, convener It's a very complex and complicated area to gain a fairer balance between victims and witnesses and patients Victim support Scotland welcomes the provision of information to victims of mentally disordered offenders and we believe that every victim should be heard voice right throughout the assessment process and also that information should be proactively provided to victims and in a appropriate manner so whether this is by letter telephone call or email in a timely manner and also in plain English what we have found from victims that we have supported through the process is then that there is or there can be duplications there can be gaps and it would be good to streamline this system under one scheme so that victims of mentally disordered offenders do receive that proactive information which is so crucial for them to understand the system as well Anyone else? Jill, did you press your speak button? Yes I would advise everyone to do that not to do that the area you don't need to do it for you Jill, thanks I think that the supply of information is a good thing and the amendments that have been replicated in the current bill as a result of the Scottish Government consultation are welcome. I think we have to be very careful that mentally disordered offenders are not discriminated against relative to the rest of the population offender of population sharing of information obviously is a matter which impacts on someone's private life and that should only be personal information about them should only be shared in a proportionate and legitimate way Can I ask what you mean you don't need to press your button what you mean about personal information Victim notification schemes tend to be about when someone is going to be released a victim knows where they are likely to be released to to allow a victim to prepare themselves for that event what other kinds of information do you envisage being shared as a violence right in the bill and is there something in the bill that you think should not be shared I think it's a matter of discrimination or discernment in each individual case I think sometimes informing where somebody lives the individual concerned is committed a relatively minor crime would not be a proportionate response to the situation I agree and acknowledge the concerns that you make however when it comes to victims and witnesses of crime what they require is the information so that if they choose to release safety plans in place they don't bump into the offender when they're out on temporary release in the community it's this style of information that's required and this type of information that is proactively required by victims and witnesses so they have a choice what they can do with that information Gareth Campbell I think that the important thing from the point of view of discrimination raised by Gill is that the scheme operate in the same useful way irrespective of the character of the offender in other words we shouldn't stigmatise people who are offenders and who were mentally disordered at the time of offending subject to that I think the balance which is struck is proposed in the bill as appropriate I'm so nervous Chan Todd Yes, I would just agree with what my colleague has said that the lost site were concerned that it had to be the same as other types of offenders the victim notification and the one other thing that we've noted was that the bill is going to consider regulations or guidance on what would be exceptional circumstances what the Government would think that would be what would be appropriate for that so further guidance is probably needed on that What would you think would be inappropriate or appropriate indeed in that? What would you be concerned about? I suppose it takes into account the personal circumstances of the situation if somebody is going to be endangered by giving out certain information outweith the need to give the victim's information but you'd have to design guidance around what would be and what would not be exceptional circumstances So just to come in there I think we would agree we would feel that there needs to be a proportionate response on the basis that the tribunal will be looking at a care plan for the care and treatment of the patient so if there was any concerns about releasing information and on that treatment progress then there should be an opportunity to try to stop the provisions taking place Any other comments on that, Cathy? I just to pick up on the comments that we made about the need for parity between mentally disordered offenders and non-mentally disordered offenders we would certainly agree with that and we were pleased to see that the change had been made from the draft bill so that this now applies to offenders who are on compulsion orders but we did note that the bill provides for the Scottish ministers to have the power to amend that so that it applies to people who are not on restriction orders so we would just be on compulsion orders which may only be for minor offences and we were just not certain why that power needed to be there Does anyone else get concerns about that level of Gil Paterson? It's also on a rights issue but this time it's the rights of the patients that I'm going to ask a question on and it's the fact that managers presently have the power to move a patient from one hospital to the other or to the state hospital and presently that's 12 weeks but the suggestion in the bill that it should be cut to 4 weeks, 28 days seems like 28 days so I wondered what the panel thought about that measure, the ups and downs of that canthie We did have some concern around that reduction of time which is quite a dramatic reduction in the timescale A transfer to the state hospital does have a significant impact on individuals autonomy, their right to private and family life and so any restriction on that would need to be justified The justification in the policy memorandum was to bring this timeline that was one of the justifications but we think that there's a reason why the timescale for this type of appeal is longer than others because of the seriousness of the consequences of moving to the state hospital and also the complexity of these cases where someone is that unwell The other justification was that it was not to delay treatment for someone who was unwell and wouldn't be able to be treated in the time that the appeal was going on but the act already has provision to be transferred pending a decision on an appeal if it's necessary so we don't see that as adequate justification either I would just reiterate those comments and we definitely do agree with what's been said There's specific provisions throughout most of the act which relate only to state hospital patients so on the basis that I can see the rationale about bringing the appeal in line with other periods the state hospital is unusual and its extent is treated that way within the act and there are various concerns for patients who are subject to detention in the state hospital that are not relevant to other patient detention we would also note as well for example that a transfer for treatment direction for instance can only be appealed after the first six month period so sometimes the patient's right to challenge has to be at the time or thereafter when the transfer takes place and there is a lot of work that a solicitor might need to do because of the complexity of state hospital transfer and we would regard 12 weeks as being an appropriate period for that appeal to take place No other responses Nanette Millan Yes, sir A number of witnesses have highlighted areas where they consider there would be merit in primary legislation but not included in this bill and one that strikes me is the use of force covered medication and restraint which there is very little about in the 2003 act's code of practice and there have been a number of representations to Parliament people who feel very strongly about this particularly the use of covered medication and I just wondered what the views around the table are on this Do we have any views around the table on that? Yes Raised that as an issue that they would like to see included if there was that possibility we believe that there wasn't sufficient guidance out there at all at the moment and that anything would be useful so yes, we were keen to see that included Anyone else, Cathy? I would just like to echo that we have also raised that in our written evidence it's an area where we think there's quite a lot of confusion in practice and we think it would be beneficial to patients in protecting their rights but also to staff in knowing where they stand if there was more guidance in that area Jill? I'd like to echo what Jan and Cathy have said because we raised that in our response to a call for written evidence as well Richard Simpson I was particularly interested in a comment in one of the bits of evidence that we had that the radical interpretation of article 12.4 CRPD by several human rights experts advocates that legal capacity cannot be denied on the basis of disability and that decision making be supported not substituted and therefore the removal of guardianship and the abolition of laws providing for compulsory treatment of mental disorder now that clearly is a pretty radical view but my question is given that sort of view is out there and the UN apparently has published general comment to this effect in relation to rights of persons with disabilities and I don't know if you read the evidence we had from Steve Robertson last week but it was quite powerful in terms of learning disability I just wonder if anyone has any comments about the act in front of us whether any of it is moving us in the wrong direction relative to that comment I mean given that I don't I personally don't sort of should say I've been a psychiatrist so fellow of the college so you know I don't see us relishing compulsory detention in certain circumstances that's the law at the moment but given those radical views that are out there is what we're now doing with this act this amendment going to move us inappropriately in any way in the wrong direction Jill no you don't need to you don't need to don't listen to me what the general comment what the general comment it gives us the opportunity to do and I appreciate that it is extremely radical and I think most jurisdictions will struggle with abolishing completely non-consensual treatment for mental disorder but what it does provide us with is an opportunity to revisit what we understand as capacity and the extent of capacity and exercising legal capacity and also because the general comment very much promotes supported decision making that we look at existing forms of supported decision making and other forms as well to enable patients to be full partners in a shared decision making process the act as it currently stands does promote with its underlying principles the notion of shared decision making but if patients are additionally supported then there will be more equal players in that so I think it opens that opportunity just to go on very important forms of supported decision making obviously advanced directives and I feel that that should be promoted more and there should be a duty on medical staff to encourage patients to make advanced statements in the act as amended also independent advocacy is a very important aspect of supported decision making and I notice that that really hasn't been covered in the proposed amendments it should be reinforced particularly given the provisions in section 259 of the existing legislation I think that there is a wider challenge out there in terms of responding to this general comment and it is a radical interpretation it's something that we'll need to consider very carefully if we are going to make broader changes to our system of compulsory detention but in the meantime we do think that the issues that Jill has mentioned are very important to take forward to show that we are taking steps to advance supported decision making as much as possible there are opportunities within this bill in relation to advanced statements advocacy and I think also looking carefully at the named person provisions to make sure that they actually do what they set out to I don't think those are the three real opportunities in this bill to at least begin to respond to the general comment I broadly agree with Kathy I think that the structure of this bill taken together with existing provisions in the 2003 act about support for advocacy and the general trend towards patient involvement in decision making is not wholly incompatible with the general comment which certainly is a radical approach the question is the extent to which further primary legislation is the appropriate way forward or whether the case might be for revisiting the code of practice which was issued when the 2003 act was originally passed and it might be that the time is right for revisiting some of these important issues in a systematic way by that means The concern that I wanted to raise having regard to one of the principles of the UN declaration is participation and the proposal to extend the short-term attention period by a period of 10 days is our main concern with regard to the amendments and the question which Dr Simpson raised is quite right on the basis that we are now looking for more participation for patients more effective participation is it right that they have to wait a further period of time before they call before a mental health tribunal for a compulsory treatment order we very much feel that that's not right and we think it does affect their ability to participate in the process itself and if the proposals are to extend the period from 5 days to 10 days as they currently stand it means that it's 10 working days and if you add the time of a short-term attention certificate and emergency attention certificate and the extension of 10 days with the working day element then you may be looking at someone being detained for over 7 weeks before they appear before a mental health tribunal and we would definitely say that that does not comply potentially with the ECHR in article 5 but also doesn't promote participation of the patient Bob, was one to ask some questions about the extension? That was my next question anyway can we nurse off, can we flesh out a bit before we go? It might be worth just saying that I'm delighted that this Parliament is actually bound by the European Convention and human rights and hope that we are on an on-going basis and it's no bad thing that challenges the legislation that we scrutinise that's kind of why it's there We did hear evidence in our first evidence session in relation to the need and obviously people debate whether there is a need to potentially extend it in some cases from 5 to 10 working days was in relation to prepare a variety of reports including a variety of family reports and if there's a named person and that if in some cases and it wouldn't be used as a standard in some cases it may actually be beneficial to individuals so they're not going through for repeated tribunal disposals to decide what's best for them now I'm delighted I'm not a lawyer I'm not a lawyer but the word proportionate I think comes up in relation to the European Convention on Human Rights so I suppose my question would be is there a balance to be struck in terms of exceptional circumstances where there is a proportionate need to prepare all reports for a tribunal to make an informed decision would this be compliant with the human rights of the individual because I was looking at some of the evidence and the evidence does seem to be quite black and white in terms of this contravenes human rights and if it's about the checks and balances in the system the policing of the system and making sure that advocacy groups in the mental welfare commission are taking a view and checking on this so as a matter of course do witnesses have concerns in terms of human rights or do you think there's a way of extending in exceptional circumstances the 5 to 10 working days which would be compliant with the human rights of the irrespective of what they have or have not done and the vulnerable individuals who still have their own human rights needing to be protected by the state I can come back to you, Karen but is there anyone else? Cathy, do you see your hand? Kenneth? Yes Our issue with the proposal as it stands is that the extension is a blanket across the board extension from 5 to 10 days and we absolutely recognise that there are exceptional circumstances and lots of very good reasons that people will need more time to prepare for hearings but I think that the existing provisions to postpone a hearing until such time as people are ready are designed to achieve that and that's entirely compliant with human rights to give people time to be ready to argue their case I'm aware that the mental health tribunal has given evidence that the number of repeated hearings has dropped to somewhere around 20 to 30% and what we would query is whether that is a sufficient justification in a proportionate way for a blanket extension for everybody of the time of the short-term detention certificate we think that if there are circumstances where more time is needed then it may be that a hearing needs to be postponed but doing it in this way where everyone's detention is extended it's not the way to go about it John A lot of society agrees with what Karen was saying and what Cathy is saying that we didn't feel maybe five years ago when McManus report was drafted maybe that was an issue and maybe I should also declare that I sit on the tribunal so I'm a convener of tribunals so I have first-hand experience of this I don't find in recent times that that has been a big issue the patient obviously has a right of appeal during the 28-day short-term detention certificate period if they wish to instruct a lawyer at that point they can appeal so they have that right then and many do appeal during that period and then appeal again when their CTO application is made and the tribunal doesn't always get told whether they've had a previous appeal or not I take on board that some patients are so unwell at the start they may not even be able to instruct a lawyer at that point or seek an appeal so it's very important that they get an early opportunity to have that brought to a tribunal if at the point where within the five days the application for a CTO by the mental health officer has been made and it's brought to a tribunal for a hearing quite often now the patient is ready the solicitor is ready to proceed however I don't know that a blanket extension of five days is going to provide any significant benefit to a patient who has just instructed their lawyer or their lawyer needs to get an independent medical report because it will take longer than five working days usually to get a proper independent medical report before they can have a full hearing at any time the patient's rights are protected because they will be having a full hearing which although the patient maybe can't make full representations based on their own medical evidence that they've sought separately the tribunal will be making clear that they need to be satisfied that all the tests are met at that stage alone for the patient to be detained so their human rights are being protected at that point and any order then would be an interim order to allow that representation to be fully explored and expanded on by getting the independent medical report so we were of the opinion that at the moment there isn't any benefit on a blanket extension of five working days one because we don't think that there's a particular need for it now and there was a secondary point that we made in our written evidence that by extending it and then trying to deduct it from any future detention period that could cause more confusion and uncertainty when dealing with potential reviews from working out how long did the patient extend to and then having to deduct that from a period of time whether it's your 56 days for two interim extension two interim CTOs or the period of six months for a full CTO being granted Can I answer the question directly about exceptional circumstances? It seems to me to be unlikely that if it were decided to introduce a clause which said that in exceptional circumstances a greater period of time might be granted that that of itself would be disproportionate and not convention compliant so I think that the committee could be reassured on that front The whole aim of the involvement of the tribunal in the scheme of the act is to ensure so far as possible that the convention rights of patients are properly addressed If it truly were exceptional circumstances then my view would be that that would be that wouldn't cause a convention problem Can do you want to come back in any of that? Richard, do you want some further questions? I agree with what my fellow panel members have said about it very much we think that the existing provisions do provide the opportunity for a patient to participate and also the time to prepare that is what Mr Doris had said The benefits of an earlier tribunal are quite vast and depend on the individual circumstances of each case but for example a tribunal at a first hearing can direct certain matters to take place for the next hearing and can deal with issues with regards to the named person and the application and how competent the application is in terms of the act itself so there are a number of uses that an earlier hearing can have for a patient not least the practical use that an earlier hearing can have about focusing what the issues are in a patient's case and very much that is invaluable for a patient who is for example opposing a hospital-based order but is not opposing a community-based order and really challenging at the beginning the RMO and the mental health officer as to what they have been thinking why they think hospital-based attention is the least restrictive option in terms of the general principles of the act and very much it can be effective in being able to put that view across so that quite often when you get to a second hearing then really you have a different case at that point, the patient is maybe better because focus has been taken to maybe a community-based order and it's definitely the case that we do definitely feel that if there's two hearings in a case that does not necessarily mean that there's been disadvantage to the patient or certainly that they have been caused upset, they direct that and they instruct their solicitor in most cases so definitely we think there's a benefit to it the only one other point that I would raise is that about instructing an independent report and whether or not practically we could do that in every case in 10 days I've looked at a lot of the cases and I did some research for today and we were generally looking at from the day of instructing an independent doctor about 30 days until we get the written report in yes, these doctors do it over and above their normal patient work and their own local authority area we rely on them to be able to provide an effective system for the patient and it does take for an effective and appropriate report it does take some time for that to be put together so we would not want it to be reduced and then an expectation on doctors to produce a report in an unreasonable amount of time I should also say that in some areas obtaining a specialist psychiatric report on an independent basis for example an adolescent report can be very difficult to identify someone to do that report so again saying that we would be able to do that in 10 days is probably quite unreasonable from a practical point of view Bob I'm probably more confused now than I was at the start I think that Mr Campbell gave me some ideas and Mr Alganff will look over your statement again quite clearly in official reports there was lots in it but I thought you were almost arguing towards the end there that if clients of patients need an independent report to mention then that wouldn't start after 28 days that would start at the beginning of the process wouldn't it? No we may not get instructed until an application for a CTO is lodged in actual fact you have to also be in mind that these patients are unwell so quite often they may not become well enough to instruct a solicitor until 24 to 48 working days so in this process as well I suppose I should have said as well as having to see people that are detained and so obviously can't come into your office you're obviously having to deal with people that have fluctuating mental health as well I thought the reason that was really helpful because we're working teasing our way forward as a committee in relation to this I thought that that might have been the reason why you would need additional time that's why I thought almost you were almost arguing for the extension but Mr Campbell's comment might be the one that would be helpful to tease out a little bit more because I think and this is quite like clarification on might be suggesting that actually it's not about whether there's a blanket extension from 5 to 10 days it's about whether if it's ever used if it can be justified as being proportionate and reasonable on a variety of grounds then it would potentially be compliant with the European Convention on Human Rights so having the the 5 to 10 day extension in itself as a blanket ruling only becomes an issue if it's applied inappropriately so if it's applied appropriately or can it be applied I suppose I want to say if it's applied appropriately is there a breach in the European Convention of Human Rights if it's applied appropriately if that is the case do we need to put greater do we need guidance on when it should or shouldn't be used or whether that's the good judgment of those who are seeking to to extend it I hope that's clear, I know what I'm trying to say Mr Campbell, I'm just not sure I'm articulating it very well I think what I under understand Mr Doris to be saying is that is a provision of which provides for an automatic extension to 10 days as opposed to the existing 5 days problematic in itself or do we look at the way in which an extension might be the reason an extension might be given an existing case perhaps I didn't make myself sufficiently clear when I was answering the question earlier if the existing text were to be changed in such a way that it were to say that the period of 5 days could be extended in exceptional circumstances speaking for myself I don't see a convention difficulty with that there's then a second question about whether a blanket extension from 5 days to 10 days whether that would give rise to a convention problem and there I suppose we are into the issue of proportionality and in thinking about that the committee and no doubt the Scottish Government will be mindful of the evidence which the committee has already had from the tribunal about the number of cases in which this is an issue and the reasons for that and I would have thought that in working out whether a rule is disproportionate one would have to have that in mind I'm not sure that I can be drawn much further on the answer to whether or not it wouldn't be convention compliant to have a blanket extension I suspect it probably would not be unduly problematic from that point of view but I certainly think that the ability to extend in exceptional circumstances from the existing five I don't see a convention problem with that thank you very important one I'm grateful for the evidence we've had so far as I understand it the reason for suggesting an extension from five to ten days is to reduce the number of repeat hearings that was in McManus and the number of repeat hearings has in fact as John Todd has said reduced quite significantly already so the exceptionality rule seems to me to be really important here that if for example is going to save a repeat hearing and the patient their named person the person advocating on their behalf or their legal representation seeks an extension for five or ten days doesn't seem to me to be of critical importance because the individual themselves is seeking an opportunity to prevent having more than one hearing known as exceptionality or if all the ten days was exceptionality would that be okay and then we come to Karen Kirk's evidence which is if a specialist report is required or an independent report is required there's going to be a repeat hearing anyway because it's 30 days and there's no way that can actually be undertaken within what we have been talking about today so that would be a quite different setup can I just check that I'm clear on that comments on the first bit any exceptionality change from the blanket extension which we were opposed to anyway to exceptional circumstances would be that how would they be described and who would be deciding when to have a hearing within the ten day period as opposed to the five day period as Karen said if the patient then needs further time to prepare his case by getting specialist evidence you're going to need a further hearing anyway so that extra five days make a difference to that or you're going to have extra multiple hearings which are not going to be helpful to the patient so I'm not sure I see a great need to have that but that's just my own view the Law Society was consulted on the general view of extending for five days and the consensus around our table was pretty much that we didn't feel that was necessary and that it would be less for the patient's point of view and having a later hearing than an earlier one so I think I'm still of the same view that I would prefer the current situation both from the patient's protection and for the point of not having multiple hearings I don't think it's going to save a lot but I'd be interested in hearing what anybody else thinks exceptional circumstances would merit and who would be deciding the exceptional circumstances would you leave that to the tribunal service themselves so that the applicant would then have to request that here's the exceptional circumstances and here's why we want a hearing set within 10 days instead of within 5 days Anyone else want to come in at this point or respond to any of that? Yes, Kenneth? Or as exceptional circumstances it would be on generally I would expect to be the person who says there are exceptional circumstances they would have to set that show why What would that be? Generally the CTO is the MHO, the mental health officer or what the patient thought I'm going to need longer the patient's solicitor said I need longer it's the practicalities of all that it's how that's actually going to work before you've already got a hearing set up and at the first hearing you find out well actually the patient wanted it to be a few days later because his mum was in person, it's very important couldn't attend, I can just see some practical difficulties As you know there's already plenty of experience of applications for adjournments for exactly those sorts of reasons and I suppose what we're really drilling down into the conflict between the desirability of an early resolution and the desirability of avoiding multiple hearings and it may be that it's impossible to get a complete resolution of that and so what is being sought is the most effective way of reducing the number of cases in which there are multiple hearings to a minimum and I'm not sure whether the committee had a sense from the evidence of the tribunal that they have reached that point yet or whether they think there's still further work which can't be done and the faculty doesn't have a view about that part of the discussion that's taken place is about how the determination is going to be made about whether there are exceptional circumstances and essentially the system that exists at the moment in order to allow you to seek an adjournment of the hearing and have a second hearing allows you to argue that at the first stage there are exceptional circumstances that mean that you need to put it off until a second hearing so I think that there's provision there for a tribunal to decide that in the format of a hearing where they actually hear evidence and discuss some of the things that Karen brought up I think the alternative is that if there were an exceptional circumstances like we're discussing here that you would have essentially a paper hearing where the tribunal service would look at what you're saying, your exceptional circumstances are and make a determination at that stage so I think it's really a question of what the need for assessment of the evidence is what's the preferable way of determining that in my view having the system that we have now where you have a hearing that you go to and the tribunal considers that the time is needed is appropriate No point when we looked at the managed review at that time almost 50 per cent of cases were being continued at the first hearing but that's now being reduced to 20 to 30 per cent and a lot of cases coming for the tribunal will be opposed so how low can that figure go really to allow someone to have effective participation in the system and patients are going to oppose these applications by their very nature and at this stage our view is that the system actually works and as Kathy has said that the first hearing does allow that involvement participation of the patient but also allows the involvement of the mental health tribunal as well to look at the issues and to direct orders and such like that there's a full set of rules for the mental health tribunal that go in addition to the act and it gives them that flexibility to be involved at an earlier stage in the process which in our view benefits the patient most really just about at McManus it looked like the figures were about 50 per cent and is it justified now given that that's been reduced we definitely think it has been reduced on a number of fronts but for example the mental health tribunal does now use video technology for evidence doctors who are busy give evidence on occasion on the telephone so there has been a lot of developments since McManus which we think will have reduced the figures about going from a first hearing but make no mistake they go from a first hearing because by the very nature they're opposed and they're contentious because the patient is not agreeing to be in hospital into the care plan the objective is to reduce that figure below the 20 per cent and it doesn't seem to be a consensus that that will happen with this evidence panel anyway Bob I don't want to prolong it because I'm spending a bit of time really briefly in fact there's no need for witnesses to come back but I think I should be very careful with the words that I use in front of lawyers or those with legal experience because when I asked about compliance with the European Convention of Human Rights, Ms Todd said it was likely to be less compliant and Mr Campbell said it would not be unduly problematic so no clear answer either way which I thought was just fantastic but of course it was myself that said exceptional circumstances what I had in my head was I didn't want an extension to be routinely used just to work to a deadline to unduly prolong so let's not go hung up on exceptional circumstances those were my words convener but I think having heard the evidence and the committee will have to consider but I've heard the evidence I think every case is clearly an individual case with its own unique circumstances so I'm more drawn towards the need for a general power to extend to 10 days been taken to be used routinely or whether it's used appropriately in the individual case but that's just I wanted to clarify the language it was myself that said that here running in terms of exceptional circumstances but I have actually found the exchange helpful so thank you Okay, thanks for that Do any other committee members want to come in at this stage? Richard? I suppose just to finish to defend lawyers here that obviously it wouldn't be challenged past seven weeks certainly I think it would be stateable that there could be a challenge on the compliance of the provisions so I suppose it would be watch the space if that is certainly what happens I mean definitely we feel that the act currently is compliant and there's a question mark if it were still to a more automatic change to 10 days about whether or not it would continue to be so Oh, John's wanting to come in I'll get here a bit Can you stop this Just like to wholeheartedly reinforce what Karen has just said if you give scope for potential for a violation of article 5 for example in the legislation then there is the potential that it will be violated so better to have the legislation watertight in the first place to minimise the ability for that to happen Okay Richard Lyle Richard Simpson This bill is a fairly limited bill and we've heard some indication that cause of conducts might be needed to be reviewed but also I think one of the bits of evidence we've written evidence we got was we need to maybe look at the compatibility between the 2000 incapacity act and the 2003 act and that a wider review was needed and I just, you know a broad topic and I don't want to prolong our discussion unnecessarily but I just wonder you know this act is very limited and we have had some people out there saying you know we need to consider issues such as autism and such as learning disability and where they lie within the act and these are two areas where capacity comes in as an important issue so I just, if people want to put on the record briefly, if there's something they think that we should be recommending to the government in terms of a broader review that goes beyond this act whether that should be happening in the fair and near future or whether it's not something we need to go for at this point in time. I think that it is important that there is a wider review that takes place of our whole system in relation to capacity so that the interrelation between this act, the adults with incapacity act and the adults support and protection act and I think that we need to look at that in the view of the general comment that we were discussing earlier from the UN and really having a more comprehensive system that ties everything together and I believe that Colin Mackay from the Mental Welfare Commission mentioned this in his evidence and I would really endorse his comments I think that there's a bigger challenge to be addressed that we do need to do in early course. Anyone else? We've made written comments about incompatibility with the 2000 act and specifically what powers, guardians and attorneys would have to consent to medical treatment under the 2003 act, that's one area. You've also got the recent law commission report on deprivation of liberty which is making certain recommendations as well that's a whole different area of potential changes to the adults with incapacity act but very important ones. I mean, local authorities are trying to look at what they are doing right now in terms of how they are treating people and how they are moving people and then whether they are being detained in deprivation of liberty situations so I think that a wholesale look at that area as well would be useful in the future. The law commission report in particular on proposals to change the law to adults with incapacity is potentially very important and if it were thought appropriate to have a wider review I don't think the scale of that task should be underestimated. There would be a lot that should be considered there. Okay, okay then. I agree with my colleagues on this. There needs to be major reform and incapacity act in light of Cheshire West this year and deprivation of liberty. It's not being looked at and wasn't looked at in terms of the 2000 act and we would very keenly press that that is very much looked at in relation to article 5 for patients and for those who in most cases are in the community and nursing homes and such like there needs to be provision on that and the provisions on the adults with incapacity act we don't fulfil that need. I don't have very much to add but just to say that I fully endorse what Jan has said in terms of the mismatch between the act particularly section 50 of the adults with incapacity act section 242 of the 2003 act regarding substituted decision makers giving consent on behalf of the person concerned so the deprivation of liberty issue I think we do need to have a sort of major overall of all the legislation in that respect. I haven't had any bids from committee members I don't need any other questions but we've had extensive written evidence of course and your presence here this morning we've got just approximately about 10 minutes left in this session so it's one of those moments that when you get home in the bus you want to say that you've moved on off and on to the panel you know I wish I had said that or I wish I had just given a bit of emphasis to that so we're at that point where those see Cathy's wanting to take that opportunity but just for emphasis and maybe written evidence that you've heard or indeed to anything that you've heard here this morning that you want to leave us with before we consider the evidence and that we've written the evidence I wanted to raise a specific point about appeals against conditions of excessive security we're pleased that the bill does seek to address this to bring in regulations so that people in conditions of medium security are able to appeal against that being a condition of excessive security and it appears to apply to people who are on only criminal orders we think that this provision should be construed much more broadly the conditions of that nature of excessive security do have a significant impact on a person's private and family life and their ability to determine how they live their life so I think it needs to be thought carefully as to who's brought within the category that can bring an appeal it's our opinion that at least those on civil orders in medium secure settings should be entitled to bring an appeal but we also think that people in low secure settings should be able to appeal against their conditions of security we know that the argument is that the move from there is into the community but there are different conditions of security different levels of security in low secure settings so for example the difference between being on a locked ward on an open ward and it's worth noting that the individual in the case that's led to these provisions was actually in a low secure setting but we'd still not be able to bring an appeal under the current provisions in the bill just the other point to note there is that this is a matter that's been outstanding for a while the Supreme Court case found that there was a failure by the Government to bring forward regulations and the bill still requires regulations to be brought forward so we would just encourage the committee to ask for a timetable for when those regulations are going to be brought forward so that it happens as soon as possible Thanks for that Cathy Do you want to say anything in respect to Cathy's statement or any other issue? Thank you It's really for the issue of victims rights for information if I could just say that it's the hope that victims support Scotland that there will be no restrictions on eligibility for receiving information on the release of the offender back into the community and so when it comes to compulsion orders then that would actually bring us into line with the EU directive and that victims of crime will all receive information and finally also as well that when it comes to being supervised in the community then with the planned victim notification scheme covering mental disorders offenders then victims will not be informed therefore there is a risk of them meeting in the community and whether the offender is supervised or non-supervised has really no relation to how the impact that that will have on the victim so we believe that they should be notified in all occasions What Cathy had said that we were concerned that it's section 273 that the new section includes patients subject to civil order so compulsive treatment orders in short-time detention certificates sections 264 and the new proposed amendment of section 273 actually removes those persons on civil order so just includes those in compulsion orders and restriction orders in transfer for treatment directions and we considered that that was discriminatory to those patients who maybe are in the state hospital but under a civil order for treatment that they would have less rights than they currently have under the act and we wondered whether or not that was actually the intention of the bill in the first place so I would just reiterate what Cathy had said but on the basis of that change we think that it might be potentially discriminated to some patients who are on civil orders rather than criminal procedure type orders John No, that's fine Cathy said about the rights of appeal against excessive security and low secure units and hospital wards particularly we don't think that medium secure units extending the rights of appeal to medium secure units would be sufficient in itself so we just wanted to emphasise that Anyone else with their point of response to what John, Cathy, Karen and Sarah has done we're going to leave it at that Can I thank you all very much for your attendance here this morning giving us your valuable time and the evidence both written and oral that you provide Thank you very much indeed As previously agreed our next item we will take in private session Thank you very much