 I welcome to the 23rd meeting of the Health, Social Care and Sport Committee in 2023. I've received no apologies for this meeting. The first item on our agenda today is to ask Ivan McKee to declare any interest relevant to the committee's remit. I welcome it, Ivan, and invite him to declare those. No relevant interest to declare, convener. Thank you, Ivan. The second item on our agenda is to decide whether to take items 7 to 10 in private. Are members agreed? Thank you. The third item on our agenda is an evidence session with Public Health Scotland as part of post-legislative scrutiny of the Alcohol Minimum Pricing Scotland Act 2012. For this morning's session, I welcome to the meeting Claire Beeston, Public Health Intelligence Principal, George Dodds, Chief Officer, Lucid Giles, Public Health Intelligence Principal and Tara Shivaji, consultant in Public Health and all from Public Health Scotland. I invite the panel to give an overview of Public Health Scotland's evaluation of minimum unit pricing of alcohol before we open up to questions. Good morning and thank you for the opportunity to come and join the committee this morning. The focus of our work in Public Health Scotland has been to reduce the preventable harm caused by alcohol consumption in Scotland. We know that people in our poorest communities are five times more likely to die from alcohol-related disease than those in the wealthiest. And if alcohol consumption trends continue, convener, then we should expect life expectancy would fall and the cost of providing additional health and care service would increase by an estimated 3% over the next couple of decades or so. So, one of the approaches encouraged by the World Health Organization is to reduce demand on alcohol through pricing mechanisms. That's what Scotland has done, convener, and it remains one of the range of measures that the World Health Organization would continue to advocate in trying to address the harm caused by alcohol. My colleague Dr Shivaji is going to very briefly explain the convention that we've used in public health evaluation, and then we're going to hear from Lucy about the main points of the findings from the report. Thank you. Thank you. So, I just very briefly want to touch on the rationale of the methods used in our approach. Within Public Health Scotland, we follow the recommendations of the WHO on what are the best buys for preventing alcohol-related harm. We recognise that policies should be of a multi-component nature, and as such, these components are interdependent in the act synergistically. So, our evaluation has taken the approach, and it's quite a cutting-edge approach in terms of public health research, of asking a number of questions. Not just does it work, but in what context, what are the unintended consequences, and to set out its strengths and limitations within this context of a multi-component approach? So, I'll now pass you on to Lucy. Thanks, Tara. So, MEP was implemented in Scotland on 1 May 2018, setting a minimum price of 50 pence per unit of alcohol. So, in order for MEP to have the desired impact on alcohol-related health and social harms that we would want to see, applaudable chain of events, what we would call the theory of change, needed to be realised. The theory of change is in itself based on the available evidence prior to the evaluation starting, and is endorsed through consultation with a range of different stakeholders and experts. That is an approach, that theory-based approach is recommended by the Medical Research Council when evaluating the effectiveness of complex policy interventions such as MEP. PHS believes that the evidence shows that, through this plausible chain of events, MEP has had a positive impact on alcohol-related harms, as I'll now outline. So, the evaluation showed that MEP was well complied with by retailers, with some infrequent and isolated instances of non-compliant, but they were not typical and generally associated with sort of teething problems. However, broadly, retailers found the legislation easy to follow and apply, hence why it was so well complied with. Sales of alcohol below 50 pence per unit have actually disappeared compared to the 40-50% being sold below 50 pence per unit prior to the implementation of the policy. The average price of alcohol went through an immediate and sustained increase of around 5 pence per unit, with products such as strong ciders and own brand spirits, more likely to have been sold below 50 pence per unit prior to the policy being implemented increasing in price more. Sales of alcohol per adult decreased by an estimated 3%, and that reduction was entirely driven by sales through the off-trade, particularly by reductions in those same products where we saw the greatest increases in price. We found no impact per adult sales through the on-trade. Alternative data sources showed that household purchasing of alcohol also reduced, with the biggest reductions being estimated for those households that bought the most. One study showed that households in the top 5% in terms of volume purchased reduced their alcohol purchasing by nearly 15%, while those in the lowest 70% did not change their purchasing at all. Self-report survey dated presents a bit of a mixed picture on the impact of consumption amongst different groups, but generally there is consistency of a reduction amongst the heaviest drinkers. MEP has been estimated to reduce alcohol-specific death rates by 13%, or around about 150 deaths annually, compared to what we would have expected to happen had MEP not been implemented. A smaller estimated reduction in alcohol-attributable hospital admissions of around 4%, equating to around 400 admissions per year, was also found. The largest reductions were for chronic conditions such as alcoholic liver disease amongst males and those living in the most deprived areas of Scotland. Conditions such as alcoholic liver disease are only experienced by people who are drinking at levels sufficient to do harm to themselves. Hopefully you'll see that those findings follow a logical sequence of events with one preceding the other. Many of those findings were consistent across a number of different studies and different data sources, and they were importantly specific to the timing of MEP also. PHS are therefore confident that the evaluation provides robust evidence that overall MEP has had a positive impact on population-level health outcomes and alcohol-related health inequalities. Those findings are all from large quantitative studies that use routinely collected data and statistical methods to analyse the data in order to understand and also isolate the impact of MEP at a population level. However, it was also important, as Tara did talk about, to understand the lived experience of MEP and understand some of the strategies that people may adopt to account for it. We did this by including a range of different qualitative studies in the evaluation whereby individuals were asked about their experience. From those qualitative studies we found that some evidence of individuals who would possibly engage in potentially harmful strategies as a consequence of MEP, such as reducing their spend on food and possibly increasing drug use for those who already did use drugs. Whilst those findings are obviously very important, and it's really important to minimise harm for individuals, it's also important not to lose sight of the main findings that there was no evidence of widespread social harm and that we have also seen that population-level improvement in terms of consumption and alcohol-related harms and inequalities. I think just to draw our findings to what we have illustrated is that this is quite a complex nuanced picture. There is a really strong need for a range of interventions, particularly in terms of supporting people with established dependence and those who are affected by alcohol dependence and perhaps other measures to address youth. In the absence of implementing minimum unit pricing as a policy, we estimate that the number of people who died as a direct result of alcohol would have been higher and that the inequalities in health due to alcohol would also have been wider. On that basis, we recommend it as an effective component in terms of the levels of harms that we see in Scotland. The approach on the data, there's a couple of things that I just wanted to dig a wee bit deeper into, if that's okay. First, just to get one thing out of the way, when you talk about a 3% reduction in sales, is that value or volume? Clearly there was some modelling work done in advance of the Sheffield study of 2016 in advance of the implementation, so it'd be useful to get the reference back to that and what was fundamentally different there in how what you believed outcomes were relate to that. I suppose I'm interested in digging a wee bit into this theory of change and the 13% number in terms of reductions in deaths and you're effectively comparing that against the counterfactual, what you think would have happened otherwise. Is that trend upwards or downwards in what is the actual number in terms of the difference in deaths over that period that are alcohol related? Is that a higher or a lower number than it actually was previously? Alcohol specific deaths are, I can't remember the exact numbers but have gone up in 2020 and 2021 and then most recently in 2022 but that was following quite a large dip in Scotland in 2019 after MEP was implemented. So, compared to the latest year compared to the year prior to MEP being implemented, what is the difference? I don't know what the actual absolute difference is but it is higher than it was prior to MEP years. So, the number of deaths now is higher than it was prior to the implementation of MEP but the theory of change is telling you that it was increasing anyway and it would have increased more if you hadn't increased MEP just to be clear. That's essentially what we're saying. I think if you hadn't seen that dip in 2019 then we could assume that we would be at a higher level now had MEP not been implemented. The other thing was going to explore a wee bit more was round about where it has an impact because certainly I would have expected that yes should have seen an impact perhaps to some extent on heavy drinkers, those unfortunately at that stage where they were quite likely to succumb to alcohol related deaths. But I would assume that a big part of the policy objective would be to address people who would be starting drinking and to reduce their access to cheap alcohol perhaps young people. Is there any evidence on that aspect because I think the sad reality is obviously somebody who's going to be drinking excessively, price is an issue but frankly it's an issue that they'll deal with if they need to get a drink whereas a big part of this impact I would imagine would be on an early stage. So is there any data to support any behaviour change at that stage? Cleo, do you want to go in on that? In terms of young people under the age of 18 who were already drinkers, MEP, we did a qualitative study so it's not a quantitative study in terms of generalisable impact but we looked qualitatively and heard their stories about how MEP had impacted on them. I think it's fair to say there wasn't much evidence that price was a big factor in what they chose to drink, it was more driven by peers and trends etc and there wasn't evidence of a substantial impact in terms of young people under the age of 18 saying it had changed what they were drinking. I think in terms of your question there's people starting out on their early drinking career and I suppose we haven't got evidence in terms of how that has changed because I think you'd need to look at that longer term in terms of what people get to. I think it's not a question that we can answer at this stage. And just finally, are there any comments on how the data you've arrived at now in this evaluation compares to the data that was on the table prior to the implementation? From the modelling? Yes indeed, yes. So I think I probably caution against comparing what we have produced with the modelling. I think there are different things. I think the modelling was there to illustrate how different types of policies or different levels would alter those outcomes such as consumption and harm. That said, in terms of consumption, they're actually quite similar. So the 2016 modelling suggested a reduction of 3.5% so that's fairly comparable with what we found. Also a wee bit difficult to compare their findings in relation to harms because they were typically presenting, looking 20 years ahead. I think they, if I recall, they estimated somewhere in the region of 2,000 deaths over 20 years. But again, if we were to sort of assume that, and I don't particularly want to assume that the impact of MEP would continue over time as it's at the level it's set now, but you can see how they're actually broadly comparable in terms of that annual increase. Okay, great. Thanks very much. Thank you. Sandesh Gulhani. Thank you. Just to declare measures of practicing NHS GP. I suppose it's quite important to say that I've met three of the four panellists and we had a discussion about MEP earlier last week. Just from the statement, I was deeply disappointed, Lucy, to not hear you say the 4% reduction in hospitalisation is not significant statistically. That's quite an important statement that you left out there. But you also went on to say that other studies, so can I ask you what studies back up your decision or what you've said, which was 150 deaths annually have been reduced and a 4% reduction in hospitalisations? So I didn't specifically say that there were other studies looking at admissions and harm deaths. That was the study that we performed within Public Health Scotland was the only study that looked specifically at that outcome. There were lots of different studies looking at things like purchasing data, price, consumption. Those generally showed a very consistent picture. In terms of statistical significance, you're absolutely right that the overall admissions figure was not statistically significant based on the p-value. I would tend to now prefer to look towards confidence intervals, which give a much better picture of how likely it is that there will have been a change in one direction or the other. The confidence interval was very largely to the right of zero, indicating that it's much more likely to have been a reduction than it was anything else. Did it cross zero? It did just cross zero, yes. If we look at chronic conditions, which is where we've seen the biggest impact, that was statistically significant, as was the reduction in admissions in males. They were all statistically significant, and three of the four most deprived areas of Scotland were also all statistically significant, if that's the most important thing. Acu as he is. I'm going to stay with you, Mr Gopani, for further questions. Thank you. Tartar, can I ask you for your definition of what a dependent drinker is? A dependent drinker would be somebody who has a physiological and psychological dependence on alcohol. It has less to do with the volumes that people are consuming, but you would expect somebody to be consuming a high volume of alcohol. But when that stops, they would then have experience withdraw symptoms as a result. When you have a dependent drinker looking at the bill, looking at the modelling, what would you have expected and what did you indeed see when it came to the spend of that dependent drinker? The patterns of spend in people who were the heaviest drinkers, you see that their purchasing patterns tend to be for the lowest and strongest alcohols and also tend to be also from the off-sales. So we would have expected minimum unit pricing to have impacted particularly the purchasing decisions in this group. However, what we see in the broader context is that dependence is quite a complex phenomena and we saw reports of individuals prioritising their spend on alcohol. Over other commodities where household budgets were fined out. So they spent less money on food, feeding their kids, things like that. So what mitigations were put into place to help dependent drinkers that we knew would be spending more money on alcohol? I guess that's in some ways out with the scope of the policy evaluation. There's a wider range of interventions that I think are necessary, including support for dependent drinkers and particularly recognising the impact on families and those around them. Those would be key interventions that you would want to see in line with this. There's a concept called, if you like, the prevention paradox where those who particularly are affected by a policy may not benefit the most. Those in the middle we expect benefit substantially, but there's a need therefore to also have targeted focus measures on those at the very, very highest risk and those people would be dependent drinkers and those affected by alcohol dependence. Given that you're a consultant in public health and your specialisation, have we seen a decrease in alcohol brief interventions when it comes to referral rates to people seeking help? And if we have, then surely if a policy is being put into place, which you've just said will be affecting those who possibly need it the most, something should have been put into place to help them. Some extra money may be put in to give help to those who need it the most. I suppose, as part of Public Health Scotland, we produce indicators and statistics on the number of alcohol brief interventions that are delivered. These are short conversations designed to change people's consumption patterns. They're not actually aimed at people with dependence. We also produce statistics on the referrals to treatment. What we've seen over the last 10 years has been that, particularly with the brief intervention programme, it started from a standing start of zero. So there's been quite a substantial increase in the number of recorded and reported brief interventions that have been delivered across the healthcare sector. But we're starting to see that start to tail off over the last five years. Similarly with numbers of referrals to treatment, we're seeing a decline. We don't yet have explanations or an understanding for what is driving that decline in referrals to specialist treatment. That's a piece of work that we're undergoing. At the moment, we would expect it, looking at work that's been done in England, who had a similar problem to be quite multifactorial in nature. It does seem to me from what you said we've supposed to have abandoned all dependent drinkers, but thank you. David Torrance. To panel members, around the consumption of alcohol, around the different types of drinkers in the Sheffield model, can you expand to how many pricing has affected that type of different drinkers in the consumption? Claire, do you want to pick that one up for me? So there's a few different studies that have looked at how different types of groups were found, and there was a bit of a mixed picture, and I think you have to bear in mind that that's from self-report survey data, which does have some limitations. So there were, I can't recall the exact, do you recall the harmful drinkers study, specifically what it said? In terms of, so the harmful drinkers study had four different, well, three different components. So one component was with drinkers recruited through treatment services, who were screened to have probable likely alcohol dependence. And in terms of their consumption, there was no consistent evidence of a reduction in consumption mixed in terms of some people's sense that they reduced consumption, some people said that they hadn't. So there's no consistent evidence in terms of people with probable alcohol dependence recruited through services. In terms of people recruited through the community, again, no consistent evidence one way or another. So some people saying, yeah, that was qualitative. So again, it's not generalizable, but some people saying they had reduced consumption, some people saying they hadn't. There was a study using public, sorry, a market research company called Cantal. They do what's called an alcovision survey. So this is a survey with lots of people drinking and it's very detailed in terms of the evidence that survey collects. That didn't that found no change in consumption. Again, self report. It found that the proportion of people who were drinking at a harmful level didn't change, but the proportion of people drinking at hazardous levels was a significant reduction. Again, the self report. We have to kind of be a bit careful about self report data in terms of this. It's obviously subject to recall bias and how much you remember what you drank and particularly when you're looking retrospectively. So the sales data is a better measure of population change, but obviously sales don't tell us who's changed what. So that was the harmful drinking study in terms of the purchasing data. Again, like Lucy referred to earlier, that found that the households that purchased the most reduced their purchasing the most after MUP. So those heavier drinking households reduced their purchasing the most. Could I ask about moderate drinkers and overall consumption of alcohol? So again, that household purchasing data that Claire is referring to, one of those studies found that 70%, the bottom 70%, so you would call those people, the moderate drinkers, they didn't change their purchasing habits. Emma Harper. Thanks, convener. Good morning to everybody. I'm interested in how do we compare with other countries that have introduced minimum unit pricing? I know Canada has, Wales has, Ireland has and there's a World Health Organisation report that I have in front of me that basically talks about how we are reducing alcohol deaths by introducing minimum unit prices. So I'd be interested in what work Public Health Scotland has done to look at other countries because Canada introduced it in 2014. So is there something that we can learn from other people as well? The way that MUP has been implemented in Scotland is we were the first country to implement it in that fashion in terms of across all alcohol, that MUP does apply to all alcohol. In Canada it's been introduced in different areas in different ways and applying to only certain types of alcohol. So it could be a wee bit difficult to draw comparisons and as yet we don't have a lot coming out of Wales because they were behind us. But broadly in terms of what we are seeing with Wales, where it has been implemented in a very similar way, we're seeing quite a similar picture. I'm interested just to talk a little bit about the variant income groups because we know early on there was concerns about it disproportionately affecting low income groups and then also on the other side people more affluent areas would actually have an impact. So I'm interested just to get clarity on the current pricing and if we think for it to work, do we need to increase that pricing and do we think that it will continue to have the same broad effects on those groups or do we have any concerns around perhaps lower income groups again being disproportionately affected by this in terms of some of the other crises we have in income for people? So in terms of the evidence from the evaluation, there's a much closer link between the increased expenditure or the price that people pay for alcohol is much more closely linked to the volume that they purchase rather than income. So there isn't a systematic patterning from the data that we have that shows that lower income households increase their expenditure more. It's much more closely linked to how much people buy. I suppose just touching on your point about what is the impact of the current cost of living crisis. So that I think is very difficult to answer but I think there are some considerations that are worth sharing. So I suppose that the first is really around, well, in a situation where there's wider economic difficulty, we generally see that alcohol sales and consumption measured by that falls as alcohol becomes less affordable across the population. I think that in this particular context of the cost of living crisis there are really important considerations about inflation and what that means and inflation affects different commodities in different ways. Therefore, what that means for alcohol in particular and how to keep the value of minimum unit pricing such that it continues to have the effects that have been seen are an important consideration. It's somewhat out with the scope of our evaluation to touch on that. I think the final thing worth reflecting on is that impact of cost of living and economic crisis on people's health on their mental health and what we see in other countries is an increase in mental health difficulties and in problematic substances, in problematic alcohol use. So there's a really important, particularly the drivers around that income, the loss of income and the distress around that unemployment. And again, so in that kind of context we need to think about how do we protect those who are most vulnerable to those effects and those would be people particularly with those established dependents and young people who may be more touched by, an economic crisis than others. So I think in that, in thinking about it in that broader context, again there's a need for both a sort of general preventative policy that allows us to address some of these, some of the harms that are associated with alcohol, but also quite targeted interventions that support those at the highest risk of harm. Is it helpful to think about and talk about minimum unit pricing as part of a package of public health measures that can be used to change the direction that we have in this country of alcohol harm? That's exactly the straight line. Thank you very much, thank you. Thank you very much, convener. I just wanted to raise some concerns about how people who have poly substance use, particularly say for example benzodiazepines and using alcohol, whether there's been a substitution effect that you might have observed in people who have problematic substance use generally perhaps where there is a price consideration or substituting for other products that are potentially harmful. In terms of the evidence that we found, we found no evidence that people who didn't use elicit substances started to use elicit substances. What there was evidence of is that some people who already used drugs talked about some substitution. I think that's probably worth saying in terms of a number of those kind of unintended harmful consequences. There were exacerbations of existing tendencies. It wasn't new things that happened. People who already took drugs, people who maybe took more drugs, people who had to make decisions about spending on food had to make more decisions around that. So yes, there was evidence that people who already took drugs on occasions made a different decision in terms of taking drugs instead of alcohol. In terms of the wider impact in terms of what that means, hand over to Tara. I suppose my remit also covers drugs and I think that obviously benzodiazepines are one of the key substances that are contributing to the high level of drugs harms and drugs deaths here in Scotland so they're a very common finding as part of poly substance use amongst people who die and also amongst people who experience overdose. What I think is important to sort of bear in mind is that the drugs market itself is a global market and what we've seen in the last five years are shifts within that market so it's moved from the sort of diazepam and tamazepam which featured quite commonly in the early 2000s through to what we call now, street benzodiazepines, so substances like itizlam and itizlam is currently being replaced by a new substance called bromazalam so we see this shift and that shift has a lot to do with wider market forces globally it has a lot to do with the sort of regulation so as substances are banned and regulated by the United Nations you see this manufacturing of synthetic substances. At the end of the day alcohol and benzodiazepines are depressants, they're commonly used together so I think as Claire says that it's less about substitution effect but actually in terms of our approach to people who use substances we do need to be thinking about them in a much more holistic way and again that our support needs to be much more taking into account the range of substances that people use including alcohol, including benzodiazepines because it doesn't tend to be one or the other. In terms of this policy, if it is influencing behaviour in any sort of way in the substitution sense is there any mitigations you might suggest that could assist in reducing the harms that might be present? I know it's a complex interdependency as you described but is there any specific areas that you might consider? I think first of all that I don't think we did see that substitution effect other than in people who already had established dependence so that brings us back to the need for support and treatment services, outreach services that proactive care that meets people at the point that they're at and deals with the issues because I suppose these issues often occur in the context of other complexities such as homelessness and so on so I suppose that there's a need for again those targeted interventions that sit alongside this. Just also 100% of the additional revenue generated by minimum unit pricing flows to the private sector, not the public sector, do you have a view of how much revenue has been raised as a result of that? One study using our data, we didn't do the study using our sales data, they estimated that compared to, so they looked at the additional revenue in Scotland and compared it to England and assumed that the revenue trends would have been the same in Scotland if MEP had not taken place and they estimated that there was 270 million over four years additional revenue so that equates to 67.5 million each year. Do you think there's any adjustments that could be made to the scheme that would allow for the public sector to capture a share of that as possible? In terms of our, I think that's a good question, a challenging question in terms of our study on the economic impact on the alcohol industry. It was not possible to say how that extra revenue had translated into additional profits and where that had landed in terms of the difference between producers and retailers and large retailers and small retailers so it's not uniform that everybody benefited and it's not uniform that every retailer benefited. Overall there was a net increase in revenue but where that landed we weren't able to say. So in terms of a policy solution to that I don't feel that we can answer that question at this point. I appreciate it, thank you. Ivan McKee, is it on this theme or can you? Specific on that point of the revenue raised by retailers in the private sector is a consequence of this policy. I think what you're saying is that those tax leavers are currently reserved so if those tax leavers were devolved on alcohol duty then clearly Scottish Government would be in a position to benefit from and bring some of that revenue into the public sector. Is that correct? Obviously we're trying to describe for the committee's benefit the approach to an impartial study and I totally respect the question that's coming but I think with respect to the committee that probably takes us into a space that as an independent organisation around levels of taxation who can tax Susie Bale is probably out with the scope if members could respect that response. That would be great. You point noted there Mr Dodds. Gillian Mackay. Thank you convener, I think I'll follow on from the previous two questions. Was there any comparative studies undertaken or any that you've seen or commissioned to compare how the money raised from minimum unit pricing is being used in other countries? Or is that something that you feel should be looked into as a gap? It's not something that was covered specifically. And I'm not aware of any studies looking at that in other countries. Great, thank you. The report says that the three have changed hypothesis size that the alcoholic drinks industry might make changes to product availability such as size. To what extent has this happened as a result of minimum unit pricing? There is evidence that there was some changes to product size. So, for example, large three litre bottles of the very strong cider have largely disappeared from the shells in Scotland and a move towards smaller one and a half litre. So, there is an evidence of that. I think it's important to remember that that was fairly limited because Scotland is a relatively small part of a UK wide industry. And also, a lot of the disentangling the effect of MUP as opposed to other things that might be driving producers to make different types of alcohol, different sizes of alcohol, different strengths of alcohol, disentangling the MUP effect is difficult. So, in terms of strength, we weren't able to say that strength had changed, but there was some evidence that in terms of product size, some products had got smaller, both in terms of single containers, but also in terms of pack size, in terms of number of bottles of beer or cans of beer in a pack size. It was evidence that those had got smaller. That's great, thank you. The report also said that there was no discernible impact positive or negative on the drinks industry as a whole. Are you able to give us some more insight into the effects either way that brought Public Health Scotland to the point where there was no discernible impact one way or another? So, one study looked at quantitative analysis of five performance metrics for economic performance, so things like number of business units, employment turnover, gross value added and output value, I think the five were. And that study was unable to determine any impact from MUP on those measures. In terms of qualitatively speaking to industry, both in terms of people on the evaluation advisory group, but also in terms of respondees, participants in the interviews, kind of the general message was MUP is now business as usual. It's kind of dealt with it. It's what we do now. I think it's probably fair to say that it didn't appear there wasn't clear evidence that any profits that retailers were, so I shouldn't say profits, increased revenue that retailers were accruing from MUP were, there wasn't clear evidence that that was being passed on to producers. There were discussions happening about how that was shared, but it wasn't clear that it was being shared. And in terms of the impact on individual businesses, it depended on what they sold or made in the first place. So a retailer who only ever sold alcohol that was above 50 pp unit, a lot above 50 pp unit, probably didn't see much different because their products weren't affected. A retailer that sold a lot of products that were affected, some of them said, yeah, we've seen a negative impact on our revenue. That's good. Thanks, convener. Thank you. Covered, everything, cover. On theme eight? Yeah, talk with Modlin, yeah, cover Modlin. Thank you, convener. Good morning. Alcohol specific deaths are at their highest level since 2008. How does that fact correspond with your report which shows that MUP reduced deaths by 13%, thank you. So it's about the question that we ask, the question in terms of the impact of MUP, the question that we ask wasn't will death rate so the number of deaths occurring after MUP has been implanted be lower than before. It's comparing to what might have happened had MEP not been implemented in the first place. So we talked earlier about that dip in 2019 that we saw and then we've seen increases since then. Had that dip in 2019 not occurred then we could, we would potentially be at a higher level of deaths now. So it's an estimate? It's an estimate compared to a counterfactual situation. Okay, and you do recognise that the alcohol deaths are the highest since 2008? Yes. Okay, thank you. And you touched upon this earlier, I think Lucy, you touched upon this. So figures for alcohol specific deaths registered in 2022 show that the number of female deaths tragically rose. By 31 to 440. Well the number of male deaths, and that's what you mentioned earlier, the number of male deaths remained unchanged. Why do you think that is? I mean that's out with the bounds of the evaluation of MUP. I wouldn't want to sort of speculate as to what those changes are. I mean I think it's obvious that we've seen where the reduction in deaths has occurred. That has been greater in males from the evaluation work that we've done. And so there's potentially something else going on there. I wouldn't want to speculate, I don't know if Tara you want to add anything to that at all. Just some view Tara if you can. So I think that what we're seeing amongst women for this rise in alcohol specific deaths, if we look at treatment services, women make up about 40% of those accessing treatment services. So I think it has to take us along the lines of thinking about what are the particular risk factors that are affecting women. So stigma is a particularly important one and the stigma of alcohol use particularly in the context of women and being parents in the parental role. That can be a real barrier to accessing support and accessing care and engaging with treatment services. So there are a number of gender specific barriers that I think we do need to focus on and address. And I think so stigma is one the concept of or the experience of domestic violence and coexisting mental health problems as well. So we know that for a lot of people with dependence it follows a sort of series of very previous life traumas. And it's quite common that quite substantial alcohol use, alcohol dependence coexists with serious mental health conditions. And again this is another area where again we need to see a sort of strengthening and improvements. So I would say there are a range of factors in particular with minimum unit pricing I guess that the question would be about the products and the consumption and where women are purchasing alcohol. But again I would return to that point about we need that multi pronged intervention of it's one of a range of measures that we need. Thank you. So more data and then final question convener. There was a PHS report from June 2022 that found no clear evidence that this led to reduced alcohol consumption or levels of alcohol dependence among people drinking at harmful levels. So can you explain how that finding corresponds to the June 2023 report? Thank you. So that finding that you quote is from the harmful drinking study. So that was looking at a particular group of those drinking at harmful levels so people with alcohol dependence predominantly. And I suppose it's the relationship between drinking at harmful levels and alcohol dependence. They're not the same thing. People with alcohol dependence are a subset of people drinking at harmful levels. People drinking at harmful levels is a much wider and in terms of the reduction in deaths and hospitalisations that illustrates that there's been a reduction in harmful drinking because a death is kind of like the ultimate harm from drinking. So they tie up in that way. So again is that an estimate? The first study that you quoted was an estimate of well, an estimate of reduction in the impact of MUP on people drinking, people with alcohol dependence through treatment, recruited through treatment services. Okay, thank you. So one's an estimate and one's a fact and it's difficult to draw comparisons. I'm not sure I've answered that very well because I'm not sure that's what I was meaning to say. All of what we're presenting today is based in evidence and data that has been collected through some form or another. But we're using the terms estimates to convey that there is still some uncertainty around some of that. But all research has assumptions and uncertainty associated with it. So I don't think we should, by using the word estimate, I don't think we should be undermining the results and the findings that we've presented in the evaluation. I would just be slightly concerned about that. Thank you, convener. And Emma Harper. Thanks, convener. Just a quick sup. We went into lockdown on the 23rd of March 2020, just two years after the policy was introduced. What effect did the pandemic have on your research, on alcohol consumption? Tara Shevaigie, you mentioned women based on Tessie's question. So I'm interested in, like we haven't talked about the pandemic, but did that have an impact on your research on alcohol consumption? So I think first we can take consumption, obviously having an impact on consumption because on trade services just cease to operate for at least a number of months. And we saw that off-trade sales went up as a result of that. Overall a population level sales were lower for both Scotland and England and Wales. And I'll come on to why I'm talking about England and Wales in a minute. And at a similar level. So we estimated that in those first three months of lockdown sales were 6% lower in both Scotland and England and Wales during those first three months. In terms of the research, yes it impacted on the research and we dealt with that in a number of different ways. We used a control area for a lot of our studies that was already planned and something that we would have done anyway. Adding a control into studies so we used controls and by control I mean an area where the policy was not implemented and that's why I'm talking about England and Wales. So most of the time we used England or England and Wales as our control area. And that allows us to sort of account for those sort of external factors that we might not have been expecting to happen and they've happened in both areas. And so it's essentially kind of levels of playing field. So that's one way that we've accounted for things. Some of our studies just were in the first year of MEP and so they weren't impacted at all. And then some of those studies we also actually added some data into the modelling that we did to account for the restrictions that were introduced. So yes it absolutely had an impact on consumption. Some people would have some of the sort of lower than population level data shows that different people changed their habits in different ways. So people who potentially were kind of lower or more moderate drinkers prior to the pandemic tended to sort of stay the same or possibly reduce their consumption. And those who were drinking at the higher end tended to probably more likely to increase their consumption. So yes, it definitely has been an impact and we have done our best to account for that within the studies that we've conducted. Okay, thanks. Thank you. Evelyn Tweet. Thanks, convener. Good morning, panel. Tara, you said in your opening remarks that one of the things that was going to be looked at was the unintended consequences of the policy. Can you expand on this? Can you say more? Yes, so I suppose it relates to the nuances in terms of when the policy was implemented, not everybody in the population was impacted in the same way and to the same extent. And I suppose my colleagues either Lucy or Claire can describe that in a bit more detail, but a lot of that refers to the fact that within the population there were subgroups who have different purchasing patterns, different consumption patterns, as well as, you know, if we think about those who drink within the CML, the risk drinking guidance of 14 units, they have a particular as a population purchasing and consumption patterns and they were affected differently to those who drink above the guidelines. And as we've discussed already, people with quite severe dependence were impacted in different ways. So it was that that I was referring to that we set out to try and identify what was the impacts on some of these key groups. I think in hindsight it's really difficult to identify all of the groups that you would want to have this learning from. But I think some of the findings that Claire has alluded to about young people, that they were a key consideration at the start, how would this policy affect them. So that was set out in our protocol for investigation at the start, which were the subgroups of interest. But I think in hindsight and particularly with the impact of the pandemic, we would probably want to broaden that and have a much more thinking about equalities and equalities groups within that. In terms of gaps to be considered and gaps in impact, has there been any gaps in impact between different areas, rural, urban or island and mainland? Urban and rural aren't things that we specifically looked at. Claire, do you have anything that you would want to add to that? The Sheffield study, sorry, the study of howful drinking, those drinking at howful levels did look in terms of their case study areas. They had some rural and urban areas and there was not really any difference. The main difference would be areas close to the border with England in terms of the ease of being able to, people who live near the border with England travel across the border and do shopping, depending on where the nearest supermarket and things, and that continued. And so, I think there was evidence from one study that those living within, I think it's 12 miles of the border, there was less evidence of an impact on purchasing for people living near the border because of the cross-border purchasing. But the cross-border purchasing was very limited to people who lived near the border. It wasn't widespread. Thank you. Lucy, you said that 70% did not change their purchasing habits. Why do you think that was? So that was findings from one study in particular that was looking at the household panel purchasing data. The 70% were the lower purchasing households, the more moderate drinkers. I can only assume that this is in some degree speculation, but based on that pathway, that plausible chain of events, it's probably most likely that they weren't impacted by the change in price. That those products that they were purchasing prior to MEP being implemented were already above 50%. But that is speculation, I don't know, from that specific study. Absolutely. Whilst it is speculation, it does sort of make sense, doesn't it, that most people, everyone in this room isn't affected when it comes to MEP with the type of alcohol purchased that was made. So why 50p, not a pound, 10 pound, 20 pound, 50 pounds? That's not something that I have included in the evaluation at all. We've evaluated the impact at 50p, which is the level that it was set at by Parliament. So I guess that decision sits with you. When MEP was introduced, we saw buckfast sales surged by 40%. We also saw an increase in sales of MADDOB 2020 and DragonSoup. Now, these are all associated with heavier drinking, anti-social behaviour. Why do you think we saw increases in this type of product? I don't think it's necessarily to do with the specific type of product. I think it's to do with the level that they were priced at prior to MEP and whether they were impacted by the policy or not. So people moving into purchasing that then? I think we saw, whilst the sales work that we did can't 100% say that an individual switched from one product to another because we don't have it. That data at an individual level, what we did see was reductions in, particularly, cider, peri and spirits and a smaller reduction in beer and an increase in fortified wine. It makes sense that some people were potentially switching from one product to another. Tyra, earlier you said that MEP needs to be as a part of a package or a range of measures. What are the other range of measures that have come in with MEP? In relation to the other measures that are set out within the Scottish Government's alcohol prevention framework of 2018, I think in terms of what measures I'm alluding to, it would be the WHO best buys and those that are set out by the WHO European framework. They relate to restrictions on availability, perhaps through licensing but also through structural separation of alcohol, there are examples from Ireland on that, restrictions in marketing and from a Public Health Scotland point of view, our focus on restrictions in marketing would be particularly on marketing that targets children and young people. As already discussed, that need to strengthen early access to treatment and the quality of treatment, those would be the broad things. Of those, what has actually been introduced with MEP? Alongside MEP, I guess there's the alcohol licensing legislation and we have a programme of brief interventions and treatment. Those would be out of what's recommended the things that are currently available. I don't know who to direct this to. What has been the impact of a push towards 0% alcohol which we've seen in the last couple of years? I suppose from a Public Health point of view the answer is we don't know yet. It's currently a subject of research. We've seen a growth in what we would call the lower and no alcohol, so 0% but also lower ABVs as well. The current questions that we're asking are does this present an opportunity for Public Health to improve health by reducing consumption? I guess the part that we don't really understand is that are people switching from full strength products to low strength products? Does this present particular opportunities amongst key groups, so in particular for example pregnant women, where the advice is that if women are planning to conceive or if they're pregnant or breastfeeding to abstain from alcohol. Does this offer particular solutions but at the moment we don't have the answers to that yet? One final question if I may. Am I right in saying that MUP is not the panacea or the magic bullet to reduce health harms with alcohol, but your argument is that it should be introduced with a suite and a package of measures? Yes, our approach would be that it would be a package of well calibrated measures in order to respond to the high levels of alcohol related harms that we see in Scotland. Before we move on, can I remind committee members that it's me that's convening the meeting and you speak through the chair and not cross the tables? Tess Wake. The latest Public Health Scotland report states, we therefore cannot completely exclude alcohol treatment as an alternative explanation for the observed impact on alcohol attributable deaths and admissions. My question is, does Public Health Scotland plan on doing any more work on alcohol treatment services in the effect they have on alcohol related hospitalisations and deaths? Thank you. We are currently at the moment conducting a review or an investigation into what led to the decline in referrals to treatment services. In terms of what we need to do to improve access to care, that should help inform that. There's also wider work that across the UK there's a four nations guidance on alcohol treatment and this is the first time we have guidance on the quality of alcohol treatment services. So there will be work that needs to be done to implement this guidance to say to what extent is it improving the care, the experience and that move into recovery for people and we expect to have a role in that but what that is at the moment at this stage we don't know. And just one follow up question to Dr Shivaji. Is MUP in your view being billed as the silver bullet to the detriment of the support and solutions for people with alcohol dependence? So you've highlighted that further work will be done and I suppose my concern here is shouldn't addiction to alcohol be addressed holistically rather than just take one lever? I think I would answer that question by referring to the harms of alcohol that are quite broad and dependence is a particularly serious harm associated with alcohol but it's also related to cancers, hypertension and we project those to increase substantially in the next 20 years. And that is why we're concerned about the 23% of our population that are drinking above the low risk threshold. So of course those who are drinking in the most harmful and risky way people with dependence are at the highest risk of experiencing harm. And what we're saying is there needs to be a mix of measures. What we would say is that these primary prevention measures as we would call them such as minimum unit pricing are often very useful for targeting that the harm that's associated within the wider population that isn't so extremely high risk. It's why you need a mix of the two. So that's how we would sort of frame the problem as in it's very important to have both. I know there's a lot of work going on regarding sales, marketing, advertising. I'm really interested in following what they're doing in Ireland and the evidence for segregating sales as well. But I'm interested to pick up on what Claire said about cross-border purchasing because there needs to be some myth, busting and debunking the fact that folk are driving faecal feccan to Carlyle to pick up whatever alcohol they want because if they did that they would have to buy 33 bottles of vodka to save the five quid on petrol to go the 20 miles faecal feccan to Carlyle. My understanding is that in Hoik and Berwick the price of alcohol is the same. If you lived in Coldstream and you wanted to cross the border you're going for your shop in any way. So it's not these booze cruises that keeps being touted. So I'd be interested to hear about the research that's debunking these cross-border purchases, these myths. Can you tell us about that? So one aspect of what we did, there's a number of aspects to what we did to that. So we looked at, for example, number of licences around the border. If there was lots of booze crews happening you might expect a boost in licences at the border to service those booze groups. We didn't see that. Another important element of what we looked at was looking at the cost associated with driving across the border in terms of the petrol and the time and how much alcohol you would have to buy and what that would cost you to make the savings. On the whole it's not economically. At the time we did the research, which was, I can't remember, 2020 prices, it might have been for the fuel prices. I mean fuel's gone up a lot since then. So that economic argument has got less over time in terms of it's largely not beneficial to cross the border to just to buy alcohol because the savings don't offset the cost. Where it does happen is, like you say, people who already go across the border, that's where they do their shopping, that's where the biggest supermarket is. They work over the border and they're just going into the shops on the way home or whatever. So that's largely where it's happening. Conversely, if I want to get my shopping delivered to Eccl Fecan Fee as done Carlyle, there would then be a price for delivery of the groceries as well. So it doesn't make economic sense to shop across the border, especially as I've just said, the price of alcohol and how it gets the same as the price in Berwick anyway. So I guess debunking this booze cruising myth is something we should be doing. I think, you know, with a lot of these things we can say it's not happening on a large scale and you will be able to find an individual who says, I do that. But on a large scale, yes, I would agree with you. We found no evidence that it was happening on a large scale. OK, thank you. Thank you very much. I thank the panel for their evidence session this morning. I think the committee has certainly learned a lot this morning and I'm sure it will help us in our consideration in our post-legislative scrutiny of MUP. We're going to take a short break till I have to change panels. Thank you. Our fourth item today is consideration of an affirmative instrument, Mental Health, National Secure, Adolescent and Patient Service, Miscellaneous Amendments, Scotland Regulations 2023. The purpose of this instrument is to add the National Secure, Adolescent and Patient Service, Foxgrove, to the list of secure mental health services in the Mental Health, Safety and Security Scotland Regulations 2005. The instrument also adds Foxgrove to the list of qualifying hospitals in the mental health detention in conditions of excessive security Scotland Regulations 2015. The Delegated Powers and Law Reform Committee considered this instrument at its meeting on 3 October 2023 and draws the instrument to the attention of Parliament on the general reporting ground in that the title of the instrument is not in line with standard drafting practice. The committee also draws its correspondence with the Scottish Government to the attention of the Health, Social Care and Sport Committee for its information in relation to the additional material provided by the Scottish Government in its response to the committee. We will have an evidence session with the Minister for Social Care, Mental Well-being and Sport and supporting officials on the instrument and once we've had all our questions answered we will proceed to a formal debate on the motion. I welcome to the committee, Marie Todd, Minister for Social Care, Mental Well-being and Sport, Dr Aileen Bloor, CAMHS psychiatry adviser, Ruth Christie, Head of Children, Young People and Families Unit, Douglas Kerr, Scottish Government Legal Department and Dr Gavin Reid, Principal Medical Officer, Forensic Psychiatry and they are all from Scottish Government. I invite the minister to make a brief opening statement. Thank you, convener. I'd like to thank the committee for asking me to attend today to give evidence on the mental health, national secure, adolescent and patient service, miscellaneous amendments, Scotland regulations 2023. Before we begin the questions, I thought it would be very helpful to provide some short opening comments. I'm very pleased that, after many years of planning and development, the national secure, adolescent and patient service known as Fox Grove is almost ready to admit patients. Fox Grove will be a vital and important addition to children and young people's mental health services in Scotland. Fox Grove will provide services for children and young people aged between 12 and 18 years who are subject to measures for compulsory care and treatment, have a mental disorder, present a significant risk to themselves or other people and require a medium secure level of security in order to meet their needs. Having this facility in Scotland will mean that young people with extremely complex needs can have their needs met in a purpose built and designed facility with expert care delivering high quality mental health care and treatment. You'll hear me speak more about the mental health strategy in the chamber this afternoon, but the opening of this facility supports the vision set out in Scotland's mental health and wellbeing strategy of a Scotland free from stigma and inequality, where everyone fulfills the right to achieve the best mental health and wellbeing possible. One of the outcomes within the strategy is increased availability of timely, effective support care and treatment that promotes and supports people's mental health and wellbeing, meeting individual needs. Fox Grove will play a key part in this by providing a dedicated and appropriately skilled multidisciplinary health care team to deliver the level of care that these young people deserve closer to home. Adding Fox Grove to these regulations will ensure that the service is able to implement a range of safety and security measures to support the therapeutic environment and ensure the safety and security of children and young people as well as staff and visitors. The measures will be applied only when necessary and they'll be applied in a proportionate way, which that is sensitive to the developmental stage of the child or young person. Of course it goes without saying that when these measures are applied they will also uphold and protect the human rights of children and young people. To move on to the specific, the statutory instrument before the committee today, these regulations make amendments to the mental health, safety and security Scotland regulations 2005 and the mental health detention and conditions of excessive security Scotland regulations 2015, so that the same safety and security measures that are available in other medium secure and patient settings can be applied where necessary in Fox Grove. Children and young people detained in Fox Grove will also have the same right of appeal against detention and conditions of excessive security as those detained in other medium secure and patient settings. I consider that a right of appeal is an essential safeguard in the process and the children and young people should have this right when they are detained in Fox Grove. Finally, these regulations do not create any new enforcement or monitoring mechanisms and simply apply the existing mechanisms to Fox Grove. Laying these regulations is an important step in preparing for Fox Grove to admit patients, which it hopes to do early in 2024. They lay the framework for a safe, secure and importantly therapeutic environment where children and young people's human rights are upheld and protected and allowing them to appeal the level of security at which they are detained. I'm happy to answer any questions that the committee may have. Thank you very much Minister and we will now move to questions and Ivan McKee. Thank you, convener. Good morning Minister and panel. My questions are round about the consultation and the process. It's around a fairly short consultation period with a limited number of respondents. Does the Government consider that the period was sufficient enough? And the consultation widely shared enough, given only nine responses were received? Yes, we do think that it was sufficient. Although there were only nine responses received, those were key bodies charged with upholding human rights of children in Scotland. My officials, who are subsequent to their responses to the consultation, have met each of those respondents further to ensure that we have captured any concerns that they have about the legislation. As well as the form of consultation, there has been a good level of engagement with people who are charged with scrutinising the process in this situation. OK, that's helpful, thanks. Just to inquire whether any consultation has been undertaken with children and young people? Yes, so there's a children's panel. I'll ask Ruth to tell you a little bit more about that. There's a children's panel who help us with the development of Fox Grove and have been part of the process of designing the building to ensure that it meets children's needs. And they also engaged in some consultation with children and young people who had been detained in medium secure settings, but I'll let Ruth say a little bit more about that process. During the development of the Fox Grove facility, which has obviously been on going for a number of years, Ayrshire and Arran, who are the health board that are responsible for developing the service, have set up a public patient reference group and they have engaged children and young people a great deal in the development of the facility itself so that the environment itself is in line with what children and young people feel would be beneficial to them. They've carried out quite a lot of consultation throughout the whole process with children and young people, so I would feel confident that that has been taken into account in the design of the service, about how the physical building is going to be, but also how the service will operate. Gillian Mackay. What assessment of this new unit has been undertaken in relation to the UN Convention on the Rights of the Child and the UN Convention on the Rights of Persons with Disabilities? I think I'll probably ask Dr Bloor to tell you a little bit more about how CAMHS operates and in general, as you would expect, our medical services available to children absolutely operate with you and CRC at the heart of them. In Scotland work, we use GERFEC as a framework for all of our public service interaction with children and young people, so you would expect it to be human rights compliant and age appropriate. In terms of the consultation, we haven't done a formal CREA to make assessment between this legislation on how compliant it is, but we have asked a lot of the questions relating to the CREA as we have gone along. The reason for not doing a formal CREA is because of the fact that it is in an amendment to existing regulations, so it's really just about applying. There aren't any new protective measures in here. We would certainly consider doing a formal CREA if that was what the Parliament wanted. The main function of Foxgrove will be to ensure that children and young people are given effective treatment in the care of developmental specialists, so the multidisciplinary team will be able to do that. I mean, the main function of Foxgrove will be to ensure that children and young people are given effective treatment in the care of developmental specialists, so the multidisciplinary team will have a unique role in ensuring that every aspect of care, including the nature of the building, the procedures within it, as well as the more clinical treatment, will be able to do that. The three aspects of care are delivered under the Principles of the Mental Health Act, which includes the principles of meeting the welfare needs of the child, and that's for all under 18-year-olds within the 2003 act. The principles that we met, but also in the everyday care planning, there's attention to GERFEC principles and SHINARI in terms of outcome measures. All of that is looking towards upholding rights, and the purpose of the regulations is to ensure that there are safeguards around the use of particular procedures relating to safety and security. The whole purpose of that is to ensure that there's a level of oversight and scrutiny of all measures used for young people within the facility for the duration of their stay. That's great, thank you. What are the criteria for undertaking a full or partial CRWIA, and will the criteria change of the UNCRC bill does come into force? The reason that we didn't do a full CRWIA wasn't required was because these regulations don't create any new enforcement or monitoring mechanisms, as I said before, they simply apply mechanisms that already exist to a new hospital. I don't think that will change with UNCRC incorporation. We are, and have been for many years as a Government, we try to work according to UNCRC principles and be compliant with UNCRC principles in everything that we do and in all of the public services that we deliver to children anyway. For me, the difference with UNCRC incorporation was that when that didn't happen, it was justiciable. There were consequences to that not happening, but I don't think that it would make any difference in practice as to how we approach these issues. We are very carefully trying to be UNCRC compliant at all times anyway. I am interested to touch on the rights of the child to a family life and, of course, we could all imagine that that could affect that. I am interested to know how the legislation works, ensuring that we make sure that young people, if they are in these situations, have that right. Does the legislation comply in terms of the European Convention of Human Rights and the UN Convention on the Rights of the Child to a Family Life and to support for legal agency? I think I'll let Dr Blore say a little bit more about how it is likely to operate in practice, but yes, all the legislation that comes through the Scottish Parliament is ECHR compliant. We are trying always to develop legislation that's UNCRC compliant even though we haven't yet incorporated fully. The right to the family life is really important. One of the things that Dr Blore was trying to explain and articulate is just how much care is taken of the child's developmental stage and the child's welfare, for all of which family life is really important. There may well be restrictions applied on some occasions very thoughtfully to, for example, use of mobile communications, but the principle will generally be that it's really important for children who are held in this unit to be able to maintain links with family and friends outside of the unit. In general, in CAMHS, family life and family relationships are core. We know that the children and young people will come from all over Scotland to this facility in Ayrshire, which could be quite long distances. The referring team will do the referral in discussion with the family that might be relatives. The child may be in care, but whatever their circumstances, the family will be involved from the beginning in the referral process, in their detention under the act. Under the act, every child under the age of 16 has a default that's called named person, so it's usually a parent who has got a particular role under the Mental Health Act. They're a party, they can make appeals, they have access to all the legal documents as of right. And then the 16 and 17-year-olds can nominate a named person, and often it is a parent or a relative that they trust and they're close to. But all actions within the unit will be discussed with family. There will be provisions for family to visit. Colleagues from a local authority, the mental health officers, will be involved in supporting visits. If families come from a distance, there will be support for them to perhaps stay overnight if that's helpful for them to facilitate contact. Any of the measures under these regulations will have to be, the named person would need to be informed, but as good practice, the parent would be informed. Of the child's progress, the way any hospital would communicate with family about how a young patient's doing, is it also to ask parents advice about everyday things? Just to pick up, so we're quite confident, because obviously the complexities of the young people and the amount of support that would be required to maintain that family contact, we feel that at the moment that it seems quite realistic that that would be able to be maintained. I can say yes, because currently if children are in any of our regional adolescent units in Scotland, the children can still be quite far from home or the national child in patient unit in Glasgow that covers the whole of Scotland. Our services are well used to involving families in the care of even really very young children. A little bit more about some of the safety and safeguards that are in place built in for the safety and security measures that seek to protect rights while also protecting safety. So there are conditions on how the measures can be used, there's record keeping requirements and importantly oversight and scrutiny by the mental welfare commission. So all of those act as safeguards on the rights of children and young people who might be detained in Fox Grove whilst enabling the necessary measures to be taken to ensure that they're safe. What steps have been taken to address the concerns highlighted in the Scottish mental health law of view in relation to appeal rights, particularly in relation to a way in which they apply to children and young people? So there is a right to appeal built into that and as I said in my opening statement I think that that's absolutely crucial. The treatment interventions for children and young people who require this level of security are not brief interventions. Their average length of stay within the NSIIS is about 12 to 18 months. So the appeal process is rigorous and thorough and we consider the time frames suggested within the current regulations to be appropriate and proportionate. There are care and treatment of each individual who is detained, who are managed under the care programme approach, which is a legal framework. There will be a regular review, accountability for RMOs, so there are safeguards built in. But there are appeal processes at certain points during that care planning journey and I think that that's absolutely crucial to upholding children's rights. What consideration has been given to the timescales in which appeals are permitted and is that consideration at a current six month period is appropriate for children and young people? And what consultation have you done on this? So I mean as I said that we think that the timescales are right because these are not short term, they're not likely to be short stay patients, they're likely to be longer term patients and we think that the appeal processes are appropriate. I don't know if it would be reasonable to ask, would you like to give a little bit more information about that and then Ruth, perhaps you can pick up on the question around consultation around the timescales? If I could say that all of the young patients in Fox Grove will have access to independent advocacy, that's a mechanism for discussing their views and feelings and wishes and making sure that they're properly taken account of and communicated. They will all have access to legal representation and if they don't have capacity to instruct, a curator can be appointed at relevant stages. There's lots of opportunities for appeal. They can appeal their detention, they can appeal against excessive security and at each stage legal representation can be sought by the young person. And their safeguards also the young person can contact the mental welfare commission themselves. They can ask for a review of the use of particular measures within safety and security and other specified person. They can ask for the RMO to review it in a timely way and in practice any measure will be reviewed much more frequently than the regulations might indicate. Care planning for young people is a daily thing and certainly by the whole team weekly, at least weekly. That would be done again in discussion with family and the mental health officer would be involved as a link with that. As well as the legal safeguards, there's the practice of ensuring that it's a rights respecting approach that's taken. Because all of that promotes recovery too, the young people are much more likely to have a speedy recovery if they're involved in it as much as possible. Just to add on the point about appeals from the consultation, it's obviously a point that several of the respondents raised and on further discussion with the respondents, I think they were satisfied that we had considered whether the appeal process would be appropriate to be applied to children and that the time scales that are currently set out would still be applicable. I think as well there's a point about making sure that there's time for any appeal to be rigorous and for all the right information to be gathered so that children and young people are detained appropriately at the right level of security. Emma Harper. Thank you, convener. Good morning minister and everyone else. I'm interested in just a couple of questions around the secure care standards and pathways and how the regulations intersect with the secure care pathway and standards. I'm just reading that there's 44 standards describing care that should be delivered with dignity, compassion, sensitivity and respect and they're person centred in the fact that children make their decisions but everybody's involved as well in the team. I'm interested in how do the regulations intersect with the secure care pathway and standards and should the standards be referenced in the regulations? Fox Grove will be working to the secure care standard so obviously when considering how it would operate once the regulations are in place they're looking very carefully at the secure care standards. It's a slightly different environment but clearly there's a lot of learning to be had from looking at how the secure care environment operates. They also look at national standards that apply in England again to pick up on good practice points. To reassure you, Fox Grove will operate to the secure care standards. Fox Grove is intended to be a medium-care facility as well. We talk a lot about helping deliver the aims of the promise and how does that then engage with what would pose in the work of Fox Grove as well because that's in addition to secure care pathway but also delivering the outcomes of the promise. We see this as a real step forward for the care of children with complex problems in Scotland and these regulations will help us to uphold their rights. It will protect their human rights in the situation that they find themselves. I think that it is generally regarded as a really positive step that these children who find themselves in the situation of requiring secure care currently find themselves transferred to England usually for medium secure care so being able to care for them in Scotland and therefore provide continuity in terms of education. There's different education systems operating in the two countries. I think that it will help us to uphold the promise rather than cause any challenge to those principles. The Scottish Government is absolutely committed to delivering on the promise. We made that promise and we intend to uphold that. Fox Grove is aimed at young people between the age of 12 and 18 so we need to make sure that this is care at an age-appropriate level so we're not just transferring care from adult facility lifting and shifting to deliver and provide for young people. This will be targeted at the specific age of the young person that happens to be there. Is that correct? Absolutely correct. The application of the safety and security measurements are to help to protect the safety of children and young people who require to be detained in Fox Grove in conditions of medium security. The measures will only be applied when necessary and they'll be proportionate to the potential risk so they will absolutely take account, as we said before, in a number of previous answers, the way that the service operates will absolutely be UNCRC compliant. They start with the child at the centre and the child's wellbeing is very core to all of the work that they do, maintaining the family links. All of these important pieces of parts will be in place and will operate in order to ensure that it's a child-centred first service as well as being a medium secure service. I've got two questions, Minister. One about staffing and then one about training. My question on staffing is, my colleague actually asked about the consultation and the robust consultation. One submission from the consultation said, I quote, there also needs to be robust consideration of staffing in the community and links with appropriate confident and trained clinicians. Staff are already overstretched to capacity in existing teams. So my question, Minister, is how confident are you that this new unit will be fully and appropriately staffed? Thank you. I'm very confident that it will be fully and appropriately staffed. As I said, it's been many years in the development of this service and we recognise that that particular care needs to be taken of children and young people who find themselves in this situation. It is a specialist and patient service that we haven't had previously, but we do have expertise. For example, Dr Blower in terms of forensic cams, so we do have expertise in Scotland and we are able to look to other examples, for example, the secure care estate and also how the estate operates in England to learn what might be required in terms of training and operational procedures for the unit to work well. We already operate cams in a way that has the child or young person absolutely at the centre of care. The care plan is developed in line with GERFIC and trauma informed practice is a really important part of that. Jigsaw would of course aiming for an entire public service. The work force is trauma informed, but cams is absolutely crucial that they are trauma informed and that training is available to them and most of them will already be trauma informed practitioners. I don't know if Dr Blower, if you want to say more about work force. My second question is around training. Has a children's rights impact assessment taken place? If so, has a training programme for the staff being put in place? I'll let Ruth give a fuller answer, but as I said previously, we haven't done a full career. We have asked many of the questions as we have gone along and been satisfied that we are child rights compliant, but we haven't done a full career. I'll let Ruth answer more fully on that. I can just give a little bit of just a bit of information about, so obviously Ayrshire and Arran are overseeing the recruitment and the staffing and the training of the staff that will work at the facility, so they've already started to recruit the staff that will work in Fox Grove, so that's been a gradual process obviously building up as it gets closer to opening. That has allowed them to recruit staff that might not necessarily have got a forensic mental health background, but there's time there for them to develop and to undertake training in conjunction with NERS and with experts. Like NERS has said, they'll draw on the experience of other units in England. That process is already in place, so by the time it opens, there should be a well-trained, well-informed staff group ready to go and to link in with other local services. It doesn't actually answer my question, so my background is an HR professional, so normally you do a risk assessment and then on the back of that make sure you've got a training programme in place, ideally before the staff start. So what you're saying is the staffing is being done, but the complete risk assessment hasn't yet been done and the training programme hasn't yet been done. I think to be clear, all of these operational details are the responsibility of NHS Ayrshire and Arran and probably that level of detail in terms of a question should be put to Ayrshire and Arran who will be charged with that. It's easy for us to say what we expect to happen, but if you need reassurance on whether a risk assessment has happened and whether training needs were identified during that risk assessment, it's probably best to put that question to NHS Ayrshire and Arran. Thank you minister, thank you convener. Thank you and I'm going to pick up a little bit on that because my question is about operational issues and some of the concerns that have been raised by stakeholders, particularly around technology, mobile phone policy. I accept that we already have very well-established CAMHS services across Scotland who will more than likely already have well-established policies in terms of mobile phones, iPads etc. I wonder if minister you'd be able to tell us what on-going discussions I've been taking place with stakeholders in regard to that and I'll refer members to my register of interests as a registered mental health nurse. As mentioned in answer to a previous question, access to a telephone to maintain contact with family and friends is a pretty crucial matter for any patient in hospital. The FoxGrid team will ensure that young patients can safely use telephones within the unit. Procedures will be developed and again those will be operational procedures developed by NHS Ayrshire and Arran around access to mobile phones for all young patients in the unit and for children and young people as part of their individual care plan. Under separate regulations the use of telephones can be restricted if the RMO determines that a telephone call made to or by the person detained might cause distress to the person detained or to any other person who is not on the staff of the hospital or significant risk to health, safety or welfare of the person detained for the safety of others. It's not a measure that is used lightly or in a blanket way, it's used very proportionately where there are specific care needs that need to be met. The submission from the Children and Young People's Commissioner said that the proposals appear to not address issues such as training for staff. I suppose that that's now a critical consideration for this committee. Given the Children and Young People's Commissioner's response cited the proposal to lack detail and training response from the panel so far has been that that's an operational matter for Ayrshire and Arran NHS Board. There's been discussion around vague ideas of starting to recruit and closer to opening. I understand the openings to be January next year seems to me quite close. How can this committee have any confidence that the concerns raised by the Children and Young People's Commissioner are being addressed? The opening is now scheduled to be mid-March. There's been some building challenges as there often is in the completion of these construction projects, which have meant that there is a slight delay, so the building is now expected to be completed and operational in mid-March. I think that you can have confidence that the health board, as with all of the sites that they operate, is capable of identifying the staffing requirements and training for the people who are going to work in the unit. As we said, that recruitment process has begun already because it's a completely new service. You would expect that to need to begin early to enable the opportunity for any shadowing or networking that might be required on other sites because we don't have anything like this in Scotland as yet. You would expect that process to begin early and to necessarily be a slightly longer lead-in time than if we were just building a hospital such as we already have in Scotland. Given that this is quite a new model, is it not important to have more direct oversight of the detailed training programme and the detailed operational mobilisation for this facility and where it currently stands in terms of vacancies, recruitment and the appropriate training programmes for each person recruited so that we can have more confidence that these concerns raised by pretty serious stakeholders are addressed confidently? I'm confident that I have enough oversight in order to be certain that NHS Ayrshire and Arran are well prepared for the opening of this hospital. I'm confident that they are able to identify the right staff mix and any training needs can be met both through internal training and through courses that are available on Nes and through informal networking. I'm confident that I have enough oversight that it will be successful in opening. It's been, as I said, many years in the planning, many years identified as a need for Scotland. Generally, other than some construction constraints, we are motoring towards opening it healthily. If I may be clear on the fundamental concerns that I have with the National Youth Justice Advisory Group, we don't believe that measures should be authorised as they stand. As children under 18, we have different levels of need and maturity and require appropriate age and developmental stage support. Children's young people's commissioners say that we recommend that alternative proposals be developed using a starting point to secure care standards and pathways. The mental health and capacity law centre, Edinburgh Napier, therefore should be a detailed human rights impact assessment undertaken in addition to this limited consultation. Is the minister's position that this committee should disregard what they have said? As we stated earlier, officials have met each of the stakeholders who contributed to the consultation. They have had detailed discussions and have reassured the stakeholders that the processes are appropriate. We are comfortable that we have the support of stakeholders that we have been able to adequately explain how the service will operate in regard to children's rights and that the service is an important step forward in upholding children's rights. I don't know if you want to say a little bit more about those meetings with stakeholders subsequent to their consultation. Just to add that having those discussions and discussing the concerns that stakeholders had raised is helpful because it's quite a broad framework and being able to discuss how that would be applied in practice to children and young people was helpful. I think we were able to reassure the respondents that we had thought it through and taken proper advice and considered that what we are proposing is the right course of action here. Thank you to the minister and her officials. We now move to agenda item 5, which is the formal debate on the affirmative instrument on which we have just taken evidence. Can I remind the committee that members should not put questions to the minister during the formal debate and that officials may not speak in the debate? I want to make a short comment that this is a brand new facility for Scotland. It is a specialist adolescent inpatient service that will be the only one in Scotland. Currently, I'm looking forward to the progress of this facility. Because it's a completely new facility, I would be interested in the committee continuing to, either by correspondence or face-to-face, get further information as this progresses so that we can inquire as to how operational issues and effectiveness of this new facility is. That is my request only. Thank you, Ms Harper. I have not had any indication from anyone else that they wish to speak. Mr Sweeney. Thank you, convener. I must say that having listened to the statements and evidence from the minister and the other panel members, I do have confidence to support the recommendation of this instrument to Parliament today, given the human rights concerns outlined in submissions to committee. I noted the reassurances received, but until we have documentary confirmation of that, it's hard to come to a firm conclusion on confidence that these stakeholders are critical or content. I would propose that the statutory instrument is deferred with a view to incorporating safeguards that stakeholders feel are absent and allow for a detailed human rights impact assessment, children's rights impact assessment to undertake. The key takeaways for me is that the consultation was too short, spanning just two weeks, and received nine responses. The Children's and Young People's Commission was not included in the initial consultation distribution, so contributed late. There are concerns about whether children and young people in these facilities can consent to the measures authorised under the regulations, including invasive searches and swabbing. Adding a children's facility to the list of regulations used in adult services is on the face of it at odds with the Scottish Government's commitment regarding incorporation of the United Nations Convention on the Rights of the Child into Scots law. I noted the reassurances received by the Minister, but I feel that it needs firmer protocols to ensure that we have confidence in that behaviour. No children's rights impact assessment is undertaken by the Scottish Government, who says that it is not necessary that similar regulations are in place in similar facilities. However, the Children and Young People's Commissioner says that this itself is of concern, noting that we are concerned that these proposals appear to have reached this stage without the creation of a children's rights impact assessment. I think that a CRIA would have brought to light the concerns that we outlined. On that basis, I just don't feel that it's appropriate to recommend approval at this stage. I have no indication that anyone else wishes to speak. Minister, do you wish to sum up? I am keen to proceed with the regulations. I think that I am more than happy to conduct a CRIA and to keep you informed of the outcomes of that. I am more than happy to take on board Ms Harper's suggestion of getting more operational detail from NHS Ayrshire and Arran. Fundamentally, I do not think that the regulations would change. I think that much of what you are seeking assurance on is operational details, which I can by lazing with NHS Ayrshire and Arran reassure you on those operational details. I do not think that fundamentally these concerns would change the legislation, so I am happy to proceed. Can I ask you to formally move motion S6M-10534 lodged by yourself? The question is that motion S6M-10534 be approved. Are we all agreed? Yes. We will have a division and we need to call a vote. Can I suspend briefly please? There is a division on motion S6M-10534. Can I have a show of hands? Those who are for the motion, please. Those against. Do we have any abstentions? The result of the vote on motion S6M-10534 is 4-6 against 4 and the motion passes. That concludes consideration of the instrument. We will proceed to the next item on our agenda, but the minister and our officials are now free to leave. The next item on our agenda is consideration of a negative instrument, national health service general medical services contracts and primary medical services section 17C agreements, miscellaneous amendments, Scotland regulations 2023. The purpose of the instrument is to amend the national health service general medical services contracts, Scotland regulations 2018 and the national health service primary medical services section 17C agreements, Scotland regulations 2018 to enable prisoners to apply to register with the GP prior to their release from a custodial setting. The policy note states that the current regulations enable GPs to refuse an application to join a practice from a prospective patient if that patient does not live in the GP practice area. The effective this for prisoners means that they are unable to register with the GP until after their release from custody, which can present delays to registration and access to healthcare. The policy note further states that allowing prisoners to apply to register with the GP in the community prior to their release safeguards continuity of care during the early stages of their rehabilitation. The Delegated Powers and Law Reform Committee considered this instrument at its meeting on 24 October 2023 and made no recommendations in relation to the instrument. No motion to annul has been received in relation to this instrument and I ask members for comments and Sandesh Gulhane. I think that what happens in prison when it comes to medication, when it comes to treatment is actually quite effective and when prisoners leave often, not always but often they sort of fall through the gap as such and they are no longer receiving that care that really they should get as anyone should in Scotland. My concern though is multiple and one of them is it's all very well saying that a patient, a prisoner will get continuity of care but they won't if the GP doesn't get a summary from the hospital and the number of times I personally have had a prisoner in front of me with absolutely no record of what happened. I would say that it's about three and that is of no use to my patients, it's of no use to me and actually detrimental so that needs to be addressed and we also need to be clear and I would like a response for the following questions because it says that a practice cannot refuse. So what if that practice has a closed list, they are already oversubscribed with patients and they've closed their list, does this mean the practice is forced to take on a patient that comes from the prison service? The next question I have is how can we be sure this person will be living in the area they say they'll be living in because ultimately the reason practices have an area is because you are expected to home visits to that area. So whilst a lot of people want to go back to say a practice when they were children because they feel as though that was a good practice that they had good experiences in, it might not be where that person is living or the nearest practice to them and in that context it might not be appropriate. I just need a little bit of safeguarding to ensure the practice is able to say well actually this might not be the best practice for you rather than blanketly saying you have to take this patient. I would propose that perhaps the committee write to the cabinet secretary and ask for the information that you have answered the questions that you've raised there. Would you be content with that? I have not had an indication that any other member wishes to speak. I propose therefore that the committee does not make any recommendations other than writing to the cabinet secretary in relation to this negative instrument. Does any member disagree with this? Thank you very much. At our next meeting next week we will be holding an evidence session on vaping and e-cigarettes and that concludes the public part of our meeting today.