 Welcome, everyone, to the Health, Social Care and Sport Committee's fifth meeting of 2021. Apologies for this morning's meeting that has been received from Annie Wells. I would like to welcome Sue Weber, who is attending this morning's meeting in Annie's absence. Welcome to Sue. Our first agenda item this morning is to invite Sue Weber to declare any relevant interests to the committee. Sue. Thank you, convener. Yes, I'm a local authority councillor with the city of Edinburgh, but my salary is donated in full via the Give-Us-You-Earn scheme directly through HR payroll. I'm also 100 per cent on the business of Medinborough Limited, which was a company that was involved in healthcare, sales and marketing, albeit at the weekend it was deregistered on the company's house and hasn't traded since May 2021. Thank you. Our second item is to decide whether to take items 6, 7, 8 and 9 in private, and that's to consider evidence heard in our stakeholder sessions this morning, and to consider two legislative consent memorandum. Are members agreed? We're agreed. Thank you. So now on to our third and main item today. It's a round table with stakeholders on public health, and that is intended to inform the committee's future work programme discussions. We've got our panellists joining us online. I'd like to welcome Professor Sir Harry Burns, the Professor of Practice and Special Advisor at the University of Strathclyde, Professor Sir Michael Marmot, the Professor of Epidemiology at the University of College London, and director of the University of College London Institute of Health Equity, and Professor Catherine Smith, who is Professor of Public Health Policy at Strathclyde University. Welcome to you all. I guess I'd like to kick things off and set the agenda for today, because we've called on all of you to help inform where you think the major themes lie in public health, but also where the committee perhaps might want to focus its efforts in terms of scrutiny and adding value on top of what maybe the previous committee did and looking at the landscape in more generally, where we can actually prioritise our work programme, and your advice on that is greatly appreciated. So, if I may come to each of our professors in turn and just ask broadly where you think the committee should be focusing its efforts in terms of scrutiny of the public health agenda, where we might be able to add value and get your advice on that. I'll come to Catherine Smith, Professor Smith, first. Good morning, committee. My particular expertise is on understanding how previous policy approaches to address health and equalities have worked and what shaped those policies, and also understanding pub views on health and equalities in the UK. I would focus my recommendation would be to focus scrutiny on ensuring that the policy making processes to tackle public health problems are being joined up with the range of other policy areas that we know impact on public health for the social determinants. That is something that the Scottish Government has recognised for a very long time, but it is things like asking for wealth and jobs that shape health, but it seems to have been really difficult to join policy making up so that we are thinking about those links adequately, so how policy decisions in other areas are impacting on public health and vice versa. I know that there have been efforts recently with public health reforms in Scotland, but I think that I will be keeping a really close eye on that. Every time it does not work out well, we end up with what we call in public health the downstream drift, where even though policy makers know that things that they are doing are the most effective things, they end up doing that because that is what they have got control over those policy levers. That would be my main recommendation. I want to shout out to broadcasting that Professor Smith's feed is really quite jumpy, and I am wondering whether or not when we take the video off that the sound, the most important part, we were able to hear some of that, but it was quite jumpy, but thank you, we will get that sorted out. Professor Marmot. May I tell you a story about a mythical country that, for purposes of this morning, I will call Norway? Some years ago, the Minister of Foreign Affairs said that I am a health minister because what I do in my day job influences health. He said that every minister is a health minister because what we do in our day job influences health. Then I had a phone call from an official that I knew well in the Ministry of Health in Norway, and she said, you know you have been going around the world saying that our Minister of Foreign Affairs says that he is a health minister. He now is our health minister and he would like to meet you. I met him, I went to Norway to meet him. He now is or will be the Prime Minister, Janas Storra, I am not saying that correctly, but the message that I presume he will take to the Prime Minister's office is that what happens across the whole of government is key for public health and particularly for health inequalities. Yes, the healthcare system is important, yes, organised public health is important, but it is what happens across the whole of government. Indeed, in my build back fairer report for England that I published in December 2020 and for Greater Manchester that I published in June 2021, I said that we need to put equity of health and wellbeing at the heart of all government policy. In other words, it is a whole approach to health equity, to reducing health inequalities. It says that it should be at the heart of all government policy. There is discussion going on at this very moment about energy prices because of shortage of gas. I have heard very little from government ministers about the likely distributional impact of the prices. That will have a huge impact on health inequalities if poor people have to pay more for their heating and we have a cold winter. That is going to have an immediate impact on health inequalities. Putting equity of health and wellbeing at the heart of all government policy is key to the public health and to reducing health inequalities. I am very much in the same sort of scene as Sir Michael. When we talk about health, we tend to think about illness. Absence of health is being ill. In fact, for many years I was a surgeon and I gave up surgery because I wanted to understand how we created wellness as opposed to tackling illness. Sir Michael is absolutely right. It is a very broad agenda. It is what we would call a complex adaptive system creating wellbeing. The problem with policy is that politicians like to do a thing. There is a policy on pachyfoods, a policy on smoking, alcohol and so on. In fact, we create wellbeing through a whole range of different things that are not typically achieved through top-down policy. You can facilitate the creation of wellbeing by policy, but wellbeing to have a large extent is created in the relationships that people have with each other. I speak a lot about the way in which wellbeing is created through early life. It is created in the way that children are born and raised and so on. Creating an environment that allows those children to feel safe, to feel happy, to feel as if they have an opportunity to do well in life is really the thing that I would want my Government to be doing, to be supporting. To give you an example, I have had this kind of conversation with many, many people. The guy who is currently working in a good job started off his adult life in prison. When I spoke to him about his experiences, he said, Well, my mum and dad fought like a cat and dog, and I would always get the blame for the fighting. It was always me that was in trouble. When I went to school, if there was any trouble in school, I would get the blame for it. When I was out in the streets with my mates, if there was anything that happened at all, I would get the blame for it and eventually end up in jail. The thing that transformed his life was a prison officer who took the time to come in and talk to him every day and tell him that he was better than that, that he was a clever guy, that he could do things in life, that he could… Building that trusting relationship with someone allowed this guy to begin to value himself, and when he came out, he now has a full-time job, paying taxes, living well, family, children, but he goes and he helps other people who are in that position. I would like to see a society where the politicians help to support a bottom-up approach to improving wellbeing. Ask front-line staff to go out and find out what people need, rather than telling them what they are going to get is really important. Politicians love a policy that they can fly a flag for, but in fact it is building relationships that support people living in difficult circumstances that we need to be doing. There are lots of examples of organisations that are currently doing that, and we need to be supporting them. Thank you. That is very helpful for starting to think about where our focuses might be. Certainly, one of the themes that we want to ask you about is around the things about life expectancy and some of the factors in there. A few of you in front of us today have been involved in very important reporting on that, which we have all read many reports on. It is a hugely complex area. I would like to move on to my colleagues to have some questions around the issues about life expectancy. I am going to start with questions from Evelyn Tweed. My questions are around the kind of moniker that we have had as the sick man of Europe. In your opinion, is that still a moniker that applies to Scotland? Who would you like to address that first to, Evelyn? It is not a term that I have ever recognised or supported. There is no question that inequalities began to widen dramatically in Scotland around the 1950s. That was the time when industry was collapsing and housing policy shifted to creating new towns where folk did not feel they belonged. We could point to social drivers that created widening inequality in life expectancy. It is unhelpful to label us in those terms. If we are told that, then folk will shrug their shoulders and say, well, that is it. I am going out for another beer and to hell with it. Those are the kind of conversations that I used to have with my patients. While life is not worth living, so the booze is the only pleasure of God in life, so I am just going to keep drinking. I have heard that statement many times. I do not think that we can label ourselves that way. We can be doing a lot better and we should begin to take action to make these things better, but that action is complex and not straightforward. It is not as straightforward as banning smoking in public places. It was a great step forward. It was important. Minimum pricing of alcohol made a difference, but we need to get in and help people to feel more in control of their lives and take positive decisions about their health. That is what we should be focusing on. Would any of our other panellists like to come in, if I can go to Professor Marmot on that? If I may. I am sorry, I did not hear the question very well. I heard Harry very clearly, but I am guessing at the question from Harry's response, so tell me if I am wrong. We have been doing a lot of work in England. I am quite keen to work with Scottish colleagues, I have to say, but we have been doing work in different parts of England. Let me give you some statistics for the moment. I think that Scotland is like England only more so in this respect. If you look at life expectancy by level of deprivation of the area in which people live, it is a gradient. The least deprived have the longest life expectancy, the most deprived, the shortest and it is a gradient. What we see is that if we look at regional differences in England, for the least deprived, the regional differences are tiny. If you are rich, it does not matter much where you live. I am guessing that that applies to Scotland as well. If you are rich, it does not matter much where you live. The more deprived the area in which you live, the bigger the disadvantage of living in the north-east or the north-west. In fact, over the decade from 2010, life expectancy for the poorest 10 per cent improved in London and went down in every other region of England. Things got worse for the poor in terms of health. Their health declined. Now, if you look at the north-east and the north-west, you could say a bit like Harry just described for de-industrialisation in Scotland, you could say that it is hopeless. Growing up north of Tyne, growing up in Cheshire and Merseyside in parts of Greater Manchester, it is hopeless. The future looks grim. That is not the approach that people in those regions are taking. We have been invited into each of the places that I have just mentioned. Cheshire and Merseyside, yesterday, we launched a commission in Lunkish here in South Cumbria. We did a report for Greater Manchester. We have been approached by north of Tyne. The approach that they are taking is that it is not hopeless. We can improve the quality of lives of people who live in these regions. It has to be a partnership. We have to work together. However, we do not start from the assumption that this is all hopeless. It is pretty grim to know that for poor people their health got worse over the last decade. That is quite an indictment of public policy. However, the starting position is that we can improve things. We can really make a difference. It seems to me that that is absolutely right. I mean that launching this commission literally yesterday, last evening, in Lunkish here in South Cumbria, the pride area of the country, huge inequalities within the region, the starting position from local government, the volunteering community sector, from business, from regional government is that we can make a real difference. We can work with our population to improve the quality of lives and improve health. I would say that that has to be the starting position in every region of Scotland. I agree with a lot of what has been said. There are different ways of thinking about Scotland's relative performance with health and health and causes, but I think that it is much better to think. There are lots of examples around Scotland where we can look to for some inspiration, where things are going a bit better and we can look to see what they have done. I would try to frame it that way around. I agree that thinking about Scotland as a sick man of Europe is not particularly helpful framing. Nonetheless, we need to recognise that there are some issues that seem to be particularly bad in Scotland. Drugs and alcohol-related deaths are particular issues that Scotland needs to have a focus on. I also support what my colleagues have just articulated. A key issue is thinking about how we have a public conversation around health and equalities and how we have that bottom-up approach. Even beyond the voluntary sector and the front-line services, we need to have a conversation with members of the public about health and equalities and how to tackle them. That is something that has been quite lacking in research on health and equalities. I am one of the few people who tries to do research on what members of the public think about health and equalities in the UK and in Scotland. That suggests that we are concerned about health and equalities, which is very supportive of a lot of policy proposals to tackle social determinants of health in health and equalities. That should give us lots of reasons to be hopeful in that area. Do the panel feel that we need specific interventions in specific places or more system-wide interventions? For example, air pollution kills 2,500 Scots per year, according to friends there in Scotland. In my region, we have Scotland's biggest polluter. In our papers in particular, I focus on Glasgow. Glasgow is a relatively unique example in Scotland. It is one of our major cities, but it also has a large motorway running through the middle of it. There are, obviously, particular issues in Glasgow with early deaths and things. Does the panel think that we need to make specific place-based interventions or whether there is a wider system change on air pollution and other determinants of poor health that we need to make? We will come to Professor Burns first on that. There is no question that, if we measure things such as air pollution, not just outside but in homes and in schools and so on, those things have become much more important with the advent of Covid when we have been interested in ventilation and so on. Those are things that can help to come back to the point that the major drivers of inequalities in life expectancy in Scotland are not things such as heart attacks and cancers. They are a wide differential in deaths among young working-age people from drugs, alcohol, suicide, violence and accidents. We can look at individual issues and we should do, and things such as air pollution are an important aspect to that. If we are going to achieve success, we are going to have to help to support young people who get themselves into difficulties because they are the ones who will die young because of those difficulties that they get into with drugs and alcohol and so on. I studied in the University of Glasgow some years ago that showed that heart attack deaths were relatively small contributors to health inequalities. The difference in death rates from drugs, alcohol, suicide and violence begin to shoot up in the teenage years. I am keen that the Parliament should focus on the creation of wellbeing in families and support for families in early life. All the other things are important, but if we do not do the early life stuff, the other things are just going to have a relatively minor impact. I could make three points. The first is that I talked to a lot of different disease-specific groups. I was asked to talk to dentists about oral health. I showed them two graphs. The social gradient by deprivation—classify people by where they live, classify where they live by a degree of deprivation—divided into deciles, 10 per cent, and you see a gradient. I did not put labels on the y axis, so I did not say which diseases I was looking at, but there was an identical gradient. One of them, when I did put the labels on, one was Covid-19 mortality and the other was decayed, missing and filled teeth in children. Identical gradient. Then I was giving a talk to some heart disease people, so I got a third graph and I did not label that one either. That was childhood obesity. Identical gradient. We could focus on cardiovascular disease, on oral health, and on Covid-19. Covid-19 is caused by a virus. Dental carries are caused by diet and poor oral hygiene. Childhood obesity is caused by, as you know, your guess is as good as mine. They show identical social gradients. I could show you air pollution in schools in London, identical gradient, the poorer the area, the higher the degree of air pollution in schools in London. Identical gradient. I am very happy for the heart disease people to focus on childhood obesity, and I am very happy for the oral health people to focus on reducing dental carries and infectious disease people to focus on Covid-19, but we have to deal with inequalities that are underlying each of the specific conditions. That is the first thing to say. It is not either or. I recently reviewed Jeremy Farrow's book on spike on Covid-19. Jeremy Farrow is the director of the welcome trust and a member of SAGE. He mentioned inequalities once in the book. I did not pan the book because of that. It was a brilliant book. I enjoyed reading it. I learned a lot. I gave it a very positive review. I did comment that my approach is to deal with inequalities and his approach is to deal with control of the virus. It is not either or. We need both of those. The second point is whether we focus on particularly high-risk areas or whether we need something more general. In my 2010 English review, I coined the rather awkward phrase a proportionate universalism. I did classic British compromise. I was trying to deal with the classic Anglo-Saxon approach to social policy, which is to target the worst off. A more Nordic approach, which is universalist policies. When Harry Burns was chief medical officer of Scotland, he said that I am all for Nordic universalist approaches. I was trying to bring the two together. When you accept that there is a gradient, if you focus only on the worst off, you miss most of the inequalities, which are not confined to the very worst off. However, we need proportionate universalism. That is absolutely right. We need to improve air quality for everybody and we need to work harder to take your example. We need to work harder in the most polluted areas. The third thing that I want to say, particularly in relation to air pollution, but it illustrates the more general point, which is that we need to make common cause between dealing with health inequalities and dealing with the climate crisis. In Glasgow, of all places, in 2021, it is the right time and place to be thinking about that. The big advantage of air pollution in this context is that we make common cause. If we can do something about greenhouse gas emissions and achieve net zero greenhouse gas emissions, we will reduce air pollution and we will improve health. As a result, we are making common cause with dealing with the climate crisis and the reduction of health inequalities is of crucial importance. If Professor Smith would like to come in, I am going in the assumption that if our panellists put an R in the chat box that they want to come in, because my clerks are just feeding that back to me, I will just check ahead of moving on to questions from Sue Webber. Does Professor Smith want to add anything? Very quickly, I will just add. I agree with a lot of what has been said. If you think about an issue like air pollution, you have to take a systemic approach to that, because many of the things that impact on that are systems-wide issues, such as transport infrastructure, where particular factories are lead-painted and things like that. I totally agree that I very much like Professor Michael Marmot's concept of proportionate universalism. I think that it is a really useful concept. If we focus just on places that are sometimes what happens in efforts to address health inequalities, we lose a wider national level outlook and we end up zoning down on policy levers that sit at that local level and are often insufficient. We also lose a focus on that wider issue of national-level health inequalities and we end up focusing on more level improvements in those particular areas. It is important to do those small-level improvements that local areas can offer, but it is really important that we combine that with national-level thinking, that kind of systemic cross-cutting planning that means that when we are making decisions that impact climate change, as Professor Michael Marmot said, we are also thinking about how it impacts on health and that those decisions are linked up. So what I would really encourage people to do is focus on what the Scottish Government is doing to try and make links across those different policy areas. Thank you very much. There is obviously a lot of synergy in what we are hearing in terms of being about tackling the health inequalities. I was really interested in what Professor Burns stated there early doors about how, right now, we are looking at our policy all-focuses on that top-down approach, but we really need to focus on that bottom-up if we are going to capture and really help the young people that are having those early deaths when they are in difficulties through suicide, violence, drug and alcohol. My question is if we were to—we will have a finite set of resources—that is the world we live in—and we know that we want to focus on that bottom-up approach. What do we do with that top-down approach? We cannot be everywhere, because right now our resources are on tackling waiting lists, hip, knee replacements, etc. They are all of the older generation, where, as you are saying, we need to be really focusing in on catching and supporting the young. How do we square that off with the public, I suppose, or how best we might want to do that? Who would like to go first on that? If I come to Professor Burns first, because the microphone has been switched off. Can you give me an example? I guess your sound broke up a wee bit there, but I think what you are asking is how do you square off what politicians and Parliament can do with the bottom-up approach. For me, the most important thing is to give permission to the front line to begin to do stuff. I will give you an example. I was speaking to a group of district nurses in a deprived part of Scotland—very significantly deprived part of Scotland. They were telling me that, when they got together in the Office of our Cups of Tea, they shared stories about families and so on, they thought, look, we know about 30 families here who are really, really struggling. I wonder how often they go to the A&E department at the local hospital. They got the names together and they asked the local hospital and they found that members of those families were going to the local A&E department about once or twice a week. Then one of them happened to be talking to the local community police officer and he said, well, I know who those are. He went away and found out how often those members of those families were dialing 999. Again, it was a very high number. What I take out of stories of those is that, if we were to bring together the different parts of the system and ask the front line staff there, who are struggling and how do we reach out to them? I have never done this because it is difficult to get the data, but if you ask the local education department about the children in those families, I bet you those children are probably only attending school 50 per cent of the time. It is a whole system problem. The most important thing, I think, is for Parliament to give permission to the front line to begin to reach out to those individuals and ask them what do you need, how can we help you, how can we support you in improving control of your lives? We know from our whole range of studies that have been done that that is the most important thing. Hopelessness and helplessness in those families cause them to be troubling. If we give them some hope and some feeling that they can be in control of their lives, then they will find a lot of those things coming about. Create an environment that allows individuals to be helped by front line staff to come up. I have just finished a year as president of the British Medical Association. I do not get involved in the politics of the BMA, but they support me in doing a project. For my project, I have asked all the GPs in Britain to send in stories as to how they help struggling families. We are pulling those together and we are going to have a conference about it next month. It is those stories of how you reach out to an individual and how you can change that individual's life that we need to pull together and we need to share those stories. We begin to build a programme of support for families who are struggling. Professor Burns, you spoke about the data and how difficult it is to get the data. It sounds like, in that one example, you had members of front line staff that were out and did a lot of initiative in digging around themselves. How important would it be that we had systems that spoke and talked to each other about that data sharing? That is very important. I have struggled. I have a research assistant who has been trying for a long time to pull data together to allow us to begin to identify people who need help. I think that I am making progress with the Scottish Government on this. All that data effectively under general data protection regulations rests with the Scottish Government. If we can pull it together, let us say that we took an area of Scotland and we saw that there are 500 people in this area who the data tells us are in difficulty. Let us begin to support them in different ways and follow it. Then, a year later, we find that that 500 has fallen to 100. We know that we are making progress. There are examples. The city of Stoke-on-Trent a few years ago did something like this. We calculated how much the public sector was spending on those individuals who were struggling. It was about £100,000 a year that they found. Once they implemented that kind of bottom-up support, that fell to about £400 a year, £400-500 a year. Those are very soft figures, but it shows that the public sector can do things differently and save a lot of time and effort in the process. Professor Marmot wants to comment on this. It is such an important question about top-down, bottom-up. It is such an important question. In my own research, I put a lot of emphasis on control at work, how much control individuals have, and being in situations without control increases the risk of physical illness and mental illness. When I chaired the WHO commission on social determinants of health, we privileged empowerment, which we thought of as acting at an individual level, but also at a community level and at a national level. Recently, the Commission on Racial and Ethnic Disparities, in its much-maligned report, including by me, said that there is no racism in Britain and there is no structural racism. We think that individuals and communities should be empowered and should take control of their own lives. That gave me real pause. I thought, have I got this wrong? If a group that says that there is no racism and there are no structural causes of inequality says that it is up to individuals and communities to act with themselves, I thought that maybe I have got it all wrong. What I have been saying for decades is completely wrong. I do not think that allowing people to take control of their lives means that the state should have no role. I have written about poor parts of Glasgow based on case histories given to me by John Carnachan, who was a detective superintendent in charge of homicide. He talked about a typical individual growing up in Kelton in Glasgow, who had a single mother. They moved home every 18 months. Mother had a succession of partners, each of whom abused this young fellow. By the time the boy went to school, he had already been labelled as a behaviour problem. As soon as he was old enough, he was involved in gangs, labelled juvenile delinquent. He never had a proper job. He drank and smoked, did drugs, and was thrown out by girlfriends because of violent behaviour. Now we are going to come along and say, yes, take control of your life. Yes, look after you, pull your socks up, stop drinking, eat properly, get a job, stop abusing your girlfriend, look after yourself. We are going to let you take control. That is a parody. It is a grotesque caricature. We need to create the conditions for people to take control of their lives. If that young person that had a stable background had a decent education and chose to do whatever he did, that is up to him. Without creating the conditions for people to take control of their lives, we are not doing our job properly. In other words, my response to the question about top-down or community involvement is yes. We need top-down and community involvement. Ultimately, people should be able to take control of their lives, but we need to address the social determinants of health and health equity that allow them to give them the capabilities to take control of their lives. Professor Burns wants to come back in. Professor Marmot was saying there. This business about people make decisions and some people make good decisions and some people make bad decisions. Some people are in control and some people are not. There is a strong scientific body of evidence that shows that children who experience chaotic early life are less well able to make those decisions. Studies in America show that centres of the brain in children who experience adversity in early life that control emotions, decision making and learning are abnormally developed. We did some studies in Glasgow that showed exactly the same thing. People at the lower end of the social scale had structural abnormalities in the brain. Those structural abnormalities we measured function as well. Those individuals were more emotionally arousable, anxious, aggressive and fearful, less well able to make decisions when faced with difficult choices and less well able to learn at school. That is what happens when you have chaotic and difficult early life. Bruce McEwen, the neuroscientist in New York who showed this, regrettably died last year. Before he died, he told me that he had done a study that showed that those changes could be reversed in later life. An important part of the process of repairing and restoring those problems was mentoring the support of a trusted other person to help that individual to begin to feel in control of their lines. It is a very complex system. He is right that we need top-down support to allow the front line to engage and help those individuals in an appropriate way, and we need very much the ability to pull the data together that demonstrates that we are making change happen. I want to come back to the original point of, if we have limited resources, how do we decide what to focus on? I completely agree with what Sir Harry said about systems and how the different bits of systems interact. We can do that at a local level, as Sir Harry described. We can also do that at national level in terms of how we make national level policy decisions. I am involved in one project that is trying to support the Scottish Government to do that at the moment. There will be others. The project that I am involved in is funded by the UK PRP, and it is called Cypher. It is trying to implement decisions support tools based on systems modelling rather than the more silo-based modelling that we tend to have. It is trying to look at, if you do one thing in the system, one policy decision in the system, how does that impact on the other areas of the system at national level? You need national level systems thinking as well as the local level systems thinking. However, for that kind of modelling and system thinking to work, we need good data. I am also agreeing with what Sir Harry is saying there. A key area that the Covid pandemic has highlighted that Scotland is not doing particularly well on is data around ethnicity. That is really problematic in Scotland, and it would be really good to ensure that more effort is put on ensuring that we have the right data. If you are not even capturing the data that you need, you cannot feed it into that kind of evidence-informed decision-making and modelling and so on. The third thing I would say is that it is really important to bring the public with you. Of course, it is in a democracy, but for me that does not mean only doing things at a grassroots level. We also need to be thinking about what other mechanisms we have in Scotland for bringing the public into conversations about macro-level policy decisions. How are we having those public conversations? Where are they taking place? I really struck me that when I have done research for over many years on how policy makers and researchers have tried to tackle the issue of health inequalities, in the course of that research, many of them told me that members of the public do not support the evidence-informed policy proposals that researchers have put forward. When I explored that via a national survey in citizens' juries, that did not appear to be the case. In fact, members of the public seem to understand the social determinants of health very well, particularly if they have experienced deprivation, as we might expect. They were also very supportive of policy decisions that were trying to address those social determinants of health, things like housing. They gave very clear and persuasive accounts of how changing something like housing has a knock-on impact on so many different aspects of your health and wellbeing. It is really important to think about how we have those public conversations and also research that is trying to better understand what the public actually think about issues such as health inequalities and potential policy interventions. I want to ask Emma Harper. Thanks, convener. Good morning to our panel of experts. The Scottish Government has published public health priorities with a number of items that need to be addressed. We need a Scotland where we flourish in our early years. We need a Scotland where we have good mental wellbeing. We need to reduce the use of and harm from alcohol, tobacco and other drugs. There are six priorities listed. This is the first time that Scotland has had a simple overarching public health strategy. It is the first time that the national public health priorities are aimed at wider determinants of health. For me, I am now the co-convener of the health inequality cross-party group and the improvement of Scotland's health cross-party group and the diabetes cross-party group. I am trying to bring them all together so that we can have everybody around the table having the same conversation instead of conversations in silos, for instance. I am interested to hear from the expert panel whether they agree with the Scottish Government's public health priorities, or do you feel that there is something that needs to be added? Professor Marmot, first of all. Thank you. From what you have just said, I think that it is a pretty good list. In my English review, I had six domains of recommendations to reduce health inequalities. Interestingly, a Swedish commission picked up my six, which I will tell you just now, and added a seventh, which I will also tell you. I think that they apply well in Scotland. The six were, first, early child development, give every child the best start in life, equity from the start, exactly what Harry has been talking about and what you have just said. The second was education and lifelong learning. The third was employment and working conditions. In that, important is the transition from school to work, reducing the proportion of young people not in employment, education or training. The fourth, which is a hot issue this very week in England with the about to take £1,000 a year of universal credit, the fourth is everyone should have at least the minimum income necessary for a healthy life. It took a young footballer to get the Government to do a U-turn on free school meals for people who could not afford to feed their children. Somehow it took a young footballer to shame the Government into saying that it was really not very good if poor kids went to bed hungry. At the fifth, and it relates to the earlier discussion about pollution, the fifth is healthy and sustainable places in which to live and work. That includes housing, but environments, transport, and that relates very much to the climate issue. The sixth is taking a social determinants approach to prevention. Harry talked about drugs and alcohol, and we could add in smoking diet exercise, not simply telling people to eat well or behave properly, but dealing with the social conditions that relate to behaviours. The sixth and the seventh one that the Swedes added to their commission was people having control over their life. Yes, of course, that underpins the others. Those would be my priorities. If you ask me what I would recommend for Scotland, I would recommend those same priorities. Thank you. I will come to our other panellists if we can come to Professor Smith. Thank you. I am very supportive of Scotland's public health priorities. I think that there is a great list of priority areas. I feel that tackling inequalities in wealth and poverty is not as clearly highlighted in the list as it could be and should be for Scotland, but beyond that it is a really good set of goals that Scotland is aiming for. The issue is very much how to achieve them. How we create the policy decisions that are going to achieve those policy priorities and goals and make them realistic. That is where we need the system's thinking. There is a very wide list that is cut across a huge range of policy areas, so you need policy tools that will help you to think about where you get the win-wins and the best returns on your investment in that system. That would be a key thing. The other issue is thinking about how policymaking in the Scottish Government interacts with the wider political system. It is great to see the Scottish Government trying to join up its policymaking around public health. I know that public health reforms have all been centred on that. However, when policymaking interacts with that wider political system, that lobbying and advocacy that goes on where different organisations are for very good reasons trying to influence policy, often pulls things back to the silo-based nature of policymaking. We need to think about how Scotland can maintain that focus on joining things up and not get pulled into focusing on one specific issue because there is lots of advocacy and lobbying, lots of media attention going on around that. As Sir Harry said, it can be very attractive politically to feel like you are fixing one very clear thing and you can see what you are doing in that issue. We need to get on board with the public health reform agenda, but we need to maintain that cross-cutting sense and implement really go with that system's thinking and thinking where you can get your best buys. We have to get in behind it, but the question is how do we deliver it? In fact, Scotland has a good track record on that. When we did the patient safety collaborative about 10 years ago, we reduced surgical mortality and standardised mortality rates in hospitals significantly. Internationally, that was hailed as being a world leader the way in which we had done it. We did it by asking front-line staff to come up with ideas. The early years collaborative tell your story about one thing there. It was decided that one of the things that we needed to do was to make sure that 90 per cent of all children reached all the developmental milestones by the 30-month health visitor assessment. When we started doing it, we discovered to our horror that only 60 per cent of Scottish children actually got a 30-month health visitor assessment and all sorts of heads were being scratched. One health visitor in one clinic and one health board authority thought, I wonder if the parents are not turning up because we sent the appointments out in ground envelopes. Ground envelopes are not being very popular in houses in deprived areas. She started texting the time of the appointments to families. Before we knew it, she was getting 90 per cent of all children being brought for the assessment. She told all the other nurses in that clinic, the health board and, eventually, 90 per cent across Scotland were coming for the assessment. That shows you how one front-line staff member can have a clever idea and a clever insight, and if we spread the learning, we get significant change and improvement. Before we started the early years collaborative, Scotland had the highest infant mortality of the four UK countries. We have the lowest infant mortality of the four UK countries. A big change can take place, but sitting in Holyrood and sitting in academic departments and so on, we can say, yes, this is how we might do it, but doing it requires the involvement of front-line staff to help shape and deliver it. Let's go full pelt with that list of priorities, but let's create a collaborative approach to making it happen. I will be quick. I am thinking about low-hanging fruit. I know that healthcare providers are starting to get more education about adverse childhood experiences. South Ayrshire police are now going through training to recognise ACEs, so that is really important. When I started my vaccination programme training, the e-learning modules, there was nothing about tackling stigma related to alcohol and drugs for healthcare professionals who work outside alcohol and drugs services. If we are thinking about low-hanging fruit and on-the-ground delivery of education, we need to be looking at making sure that healthcare professionals know about adverse childhood experiences, as well as things such as stigma related to alcohol and drugs. You are absolutely right. We need it to be aware. I have been working with Police Scotland, I have been working with Ayrshire councils and so on. I have been working with a number of councils to get them to realise that, and some of them are taking that on board very well. I think that systematic training around adverse experiences would be important. Just while I am talking about adverse experiences, a lot of our learning from that comes from a big study that was carried out in California many years ago. It showed very clearly the link between the number of adverse experiences and the poor health and wellbeing outcomes that you get, but the interesting thing about that clinic, the adverse childhood experiences clinic, started off life as a weight reduction clinic. The clinicians wanted to reduce the weight in people, and they found lots of folk in which they could not get the weight down. By chance, one of them discovered that the patients that he was dealing with had had abuse and neglect as children, and they switched it to anasis clinic. That shows you just how complex a problem like obesity is. When I hear ministers stand up and say that they want to ban advertising of high-calorie foods on television, I think, that will be right. You will get a good result out of that. It is much more complex and much more basic than the whole problem. You are right. Aces' awareness and collecting the data and identifying the people who need help and support and not stigmatising them are as they are because of the situation in which they have been and helping them to take more control of their lives is going to be the way ahead. There are a couple of other members who want to come in on policy priorities, but I believe that Professor Marmot would like to come in on that specific issue. Yes, thank you. I have been to three meetings in Edinburgh about early childhood. The third one was specifically about Aces' adverse childhood experiences. I was very impressed at the level of focus on that issue in Scotland. At the coffee break, there was a group of students from Edinburgh University, public health students, who were buzzing around about me and billing my ear with, yes, it is all very well for practitioners to be concerned with Aces, but what about the economic and social drivers of adverse childhood experiences? That is exactly what Catherine said earlier. We cannot just get practitioners to focus on Aces and ignore the social and economic inequalities that are giving rise to Aces. We know that the data is clear. Aces follow the social gradient. You look at nine specific adverse childhood experiences and they all increase in frequency with deprivation. The greater the deprivation, the greater the frequency of Aces. It is great that practitioners are aware of the issue and are focusing on it, but it illustrates clearly Catherine's point, which is the importance of putting Aces in the context of addressing social and economic inequalities. I have a question from Stephanie Callaghan. Stephanie, you do not have to press your microphones down for me. You have answered a lot of the questions that I had already. I am interested in Aces, which is often on the edges of lots of other things that we are talking about there. I feel that resilience should be shown everywhere. Everybody in the public sector should have a watch at that to understand how toxic stress changes the brain and how that impacts people in later life and affects their health and their wellbeing all the way through. I wonder if there is a case for a specific focus on Aces and whether it is something that we should possibly be working with young people on, that we should be talking about in schools, that we should be considering what impacts Aces are on their own backgrounds. I know that a lot of people who work in, for example, public health and social work, quite often there are positives there, because a lot of those people have suffered quite a lot of Aces in their lives, although clearly they have all the negative impacts from Aces as well. It is not about writing down a list and going to you guys, but about having problems in your life because of the things that have happened to you, but about sitting down and being able to look at it and understanding it. It is about that sense of control, wellbeing and understanding and appreciation. Have you got anyone who wants to direct that to you in particular, or will I just go around? That is fine to go to anyway. If I go to Professor Marmot first, I will go round my other two panellists. I was struck, forgive me, going afield, but I was interested on visits to Australia with the health of Indigenous Australians. The default position of the care services in Australia is not whether to take a child into care because of adverse childhood experiences, but when. The default position is that Aboriginal parents are incompetent, there is drug and alcohol abuse and domestic violence. Children need to be taken into care. Pretty well everybody once speaks to agrees that taking an Aboriginal child into care has disastrous consequences. It costs about $100,000 a year. My question was, for $100,000 a year, couldn't you work with the families to try to do something about the problems of drugs and alcohol and domestic violence? There is a group—this was in Victoria—of community-controlled healthcare organisations. They are controlled by Indigenous Australians, they are community-controlled. In one rural district they said to me, we are doing it. We have taken formal responsibility and we use the money to work with families to deal with the problems of drugs and alcohol and domestic violence. Our default position is that we should keep the families together but to deal with the problems. Indeed, I never make the economic case for doing the right thing. I think that we should do the right thing because it is the right thing to do, but they are making the economic case in addition to dealing with the problems at their source of adverse childhood experiences. It is actually quite cost-efficient because there are such problems down the line, if you do not deal with it, that it is worth spending the money up front. It is a bit like I was saying earlier that it is about top-down or community-controlled, it is both. We need to be dealing with the structural drivers, but we need to have community engagement and professional engagement in dealing with the problems of ACEs where they occur in families and communities. I am reluctant to label families. I am reluctant to say that the problem is all due to ACEs. I think that this is part of the problem that we have had. We have tended to focus on a thing and try to do something about it. There is a great risk. You might find a family where the parents are very loving and very keen to do the best for their children but they just do not have any money. They just do not have any kind of resource to fall back on. The issue therefore becomes support for families, but do not go in and support families because they are bad families. Killing people who are struggling that they are bad and that they may have to take their children away will make them feel even more hopeless. This is a classic example of where you need the front line to go in. In my conversations with Police Scotland, for example, I have shown them to be really understanding about this. They see the consequences of chaotic families and the policemen that I have spoken to say that we do not want to disrupt those families, we want to help them. I think that what we need from Parliament is a positive message that building relationships, trusting relationships with families that are struggling works. A couple of years ago, I was at the National Rural Health Conference in Australia and it was exactly what Michael Russell said was happening. People were going out. There was a really interesting presentation about homelessness from two guys who spoke to homeless folk. One of the things that the homeless people were really anxious about was the fact that their clothes were dirty. Those guys got a van, put a washing machine and a tumble dryer in the van, and what they did was they drove around the city to places where they knew homeless folk were congregating and they washed their clothes for them. Solutions emerge in unexpected ways. That system has now spread to many cities in Australia. Ask people what they need and help them to achieve it and they begin to take control of their lives. Although I talk a lot about ACEs, I do not want people labelled by it and I do not want a national ACEs programme. I want a let's help people who are struggling programme. Thank you. Professor Smith wants to come in on this and then we will move on to talk about Covid-19, Professor Smith. I agree with the importance of having an early years focus. The research literature on the importance of that is very strong and goes back decades, right back to the black report and before. It is very clear that if we want to tackle health inequalities and inequalities generally at a societal level, we need to be thinking about early years. For many of the reasons that Sir Harry has said, I share some concerns about a focus on ACEs when it is explicitly labelled in that way. The first is that it merges lots of different issues under that label that sometimes need to be unpicked a bit. The second is that it becomes a label in itself, which is exactly what Sir Harry was just warning about. That label is potentially quite stigmatising. The third is that some of the literature around ACEs, there was a recent review by David Walsh and colleagues. David Walsh was at the Glasgow Centre for Population Health of the ACEs literature. It found that only a tiny portion of that was exploring the socioeconomic context of ACEs. If you are not making those links, you are really missing a huge amount of the picture there. It is important that if we have a focus on ACEs, it is in the context of a wider conversation and that it in itself does not become a stigmatising tool that makes conversations difficult and people unwilling to engage and so on. I will now lead on questions around Covid-19. Yes, my questions are going to move us on slightly to talk about Covid-19. I think that it is a far and wide-raging impact. It is clear that every day we see the direct impact in terms of what the disease is doing in terms of hospitalisation and death, but I am interested in those longer term effects of, I think, both indirect health issues. I am also particularly interested in long Covid and what impact we think that that will have particularly on people who already suffer poor health or live in areas of deprivation. Perhaps if we take the issue around long Covid first, I am keen to understand what impact—obviously, we do not have a lot of data and information yet—it is something that is emerging. I think that, in terms of interventions around that, there is still a long, long way to go, but I think that it is really just to get a sense from the panel of the impact that we will have and indeed what interventions are required around it. I will go to Professor Smith first. I could say more about the impact that Covid has had on how we think about health and the cause of public health than long Covid specifically, precisely because, as you have said in your question, the data on long Covid and our understanding of long Covid is really quite limited at the moment. There appears to be a gender dimension to it and an age group dimension, but the evidence is rapidly evolving in that area. It is probably too soon to make a call about what the impacts are going to be of long Covid, but we do know that they seem to be, as we would expect and as that has been with Covid more broadly, an unequal impact of long Covid. Generally, the way in which the Covid pandemic has played out is what my colleague Claire Bamber calls a syndemic, in that it is interacted with health inequalities and societal inequalities that already existed. Those inequalities have made the impact of Covid more unequal and worse than the impact, but the impact of Covid is making inequalities worse. It impacts directly on who has been most at risk of getting sick in the first place and who is most at risk of serious complications and illness. If we think about the wider implications of how that impacts on people's ability to work, to care for their families and so on, all of that has been unequal, which is exactly what, unfortunately, people who are working on health inequalities would have predicted at the start. For me, what Covid has done in the context of health inequalities is to draw attention to an issue that has been on the agenda for so long but has not had enough of a policy focus for us to really reduce health inequalities in the way that we would like. On many of the factors that explain why the impact of Covid-19 was so unequal, are precisely the same social determinants factors that we have talked about in the context of health inequalities for so long. Certain people are more vulnerable because they have already got higher burden of other kinds of illnesses, their immune systems are not as effective, they are exposed more, they are more likely to have had to go to work, they are more likely to be living in cramped housing conditions, have less access to nice outdoor space, so then there is increased transmission. All of those reasons explain the unequal impact for the pandemic and, of course, we would expect to see that in the impact of long Covid. What we can do about that now, I would be wary about trying to be too ameliorative, and I think that it really hovers us to think about the more upstream social determinants approaches that have been on the agenda for so long but which we just haven't quite managed to nail in Scotland in the way that I think we've got the potential to. Locusts of control, if you feel pushed around by the circumstances outside you and not able to overcome them, and if you feel rubbish all the time, if you're tired, if you've got chronic headaches and so on, that just worsens your sense of control. It will make people at the lower end of the social scale who have a poor sense of control and it will just make life worse for them. It will do so in a way that's very difficult to detect. There's no test you can do to show that they have become more depressed and more isolated and so on because combination of inequality, poverty and Covid has made a difference. One of the most striking things has been the differential death rates in affluent and deprived individuals. I would love to hear what Professor Marmot thinks about this, but I would speculate that one of the reasons for that—there will be a reason in as much as people at the lower end of the social scale will already have a number of conditions that will make recovery difficult for them. Professor Marmot many years ago described the fact that people at the lower end of the social scale have higher stress hormone levels than people at the higher end of the social scale. One of the things that's been speculated in Covid is the cytokine storm or rush of stress responses that have damaged the body. That may well explain part of the difference. Covid has worsened inequality and will continue to cause problems for people at the lower end of the social scale if they have continuing effects of having antivirus. I would agree with completely that Covid has amplified the underlying inequalities, both Covid and the response to Covid lockdown has amplified them, which means that, because we have controlled the pandemic so poorly, it has increased inequality. Let's take a step back. We know that in the first half of 2020, the first phase of the pandemic, if you look at excess mortality, not just Covid-19, but because there are differences in the way that cause of death are assigned, look at the proportion and look at the number of deaths that you would have predicted in 2020 based on the previous five years and then how many did occur and the differences in the excess. The excess mortality in England was higher than in Scotland. In Scotland, it was higher than in Wales and Northern Ireland. If you take the UK as a whole, the excess mortality was higher than in any other rich country. We look at the US in 2020 and said that their management of the pandemic was a disaster. We were worse. We had higher excess mortality than the United States. The US could be proud that their excess mortality is now higher than the UK's, but we are right up there. When I looked at the Johns Hopkins figures, I think yesterday, where about 45 per 100,000 new cases daily, the US is about the same, where about four times the rate of Germany, of France, of Italy, we managed the pandemic appallingly badly. In fact, I saw a correlation recently that if you look at what happened to life expectancy in the UK from 2010 to 2019, we had the slowest improvement of life expectancy of any rich country by the United States and Iceland. It was only the US that did worse than us. If you look at the excess mortality during the pandemic and the improvement in healthy life expectancy in the decade before the pandemic, the worse the improvement in health before the pandemic, the higher the excess mortality during the pandemic. In asking myself what is the link, why do countries that had a poor health record before the pandemic have a poor record of managing the pandemic? The link potentially works at four levels. The first is the quality of governance and political culture. We really managed the pandemic very badly. When freedom day was declared in July, we had 45,000 new cases that day. In Australia, when they had 1,000 cases, they completely locked down. 45,000 cases were fine for us to declare freedom. We managed the pandemic very badly. Governance and political culture, the second is the increasing social and economic inequalities, the kinds of things that Catherine was referring to. The third was the disinvestment in public services over the previous decade. The fourth was that we were not very healthy coming into the pandemic, which increases risk. Standing back, the pandemic increased inequalities, and part of the reason it increased inequalities was because we managed it so badly. When the management, for example, asked people to isolate, but not giving them the economic resources that made it possible for them twice. It turns out that a study in Liverpool showed that one of the reasons poor people were not coming forward for testing for Covid was because they were scared that if they tested positive, they would have to stop work and starve. We did not make the proper economic arrangements that helped us to control the pandemic. That is quite apart from what Harry was speculating about, and I would agree with his speculation that being lower in the social hierarchy puts you at higher risk of a whole range of disorders because of stress responses. David Torrance, I thank you convener, and good morning to the panel. With the pandemic causing huge backlogs within the NHS and pressure from politicians, and especially in media, do you think that primary prevention will be neglected? I will come to Professor Burns. I am sorry, but I am not quite clear what you are asking about primary prevention of other conditions. I have no insight into that. I think that primary prevention, if you are talking about the increased workload that the health service has been under, then things such as follow-ups to screening tests have been put on hold and we are seeing the consequences of that. What I had been thinking should be done, and there should be an audit. We should look closely at what tests have been delayed, what interventions have been delayed, because there is a chance that things will get worse as we get into the winter. We are trying very hard—I get the sense that the NHS is trying very hard to recover, but if things get worse, as we might expect over the winter, then we might be back to square one again. Therefore, we need to try to understand where the delays are happening just now and why the delays are happening. We had a lot of discussion this week about the shortage of ambulance crews and so on. Are there specific bottlenecks in the process of moving people through the system that we should be tackling? We are only going to know that if we collect the data. I am not sure whether it is being audited at the moment, but it should be and plans should be laid to cope with a worsening situation as we move into winter. I hope that that does not happen. I hope that the third immunisation approach to the over-55s will help that, but things always get worse for flu in winter. Therefore, we need to start preparing for it now. I am very conscious of time. I am going to bring in Gillian Mackay, and then Sandesh Gohani, and then we will have to wrap up. We have talked a bit about people's incomes, particularly during the pandemic. With furlough due to come to an end, universal credit being cut and incomes generally declining for those least able to afford it during the pandemic, would the panel agree that a universal basic income approach could help to tackle some of the economic inequalities to poor health? I would like to have brought in Professor Marmot at this point, but he has had to leave, because he brought this up specifically. If I come to Professor Burns and Professor Smith on this. I am a fan of universal basic income. The evidence that we gather from studies in the US and Canada shows that it does significantly improve health and wellbeing. I was told that America, on the basis of its studies, was prepared to make universal basic income a civil right, but it was suggested that universal basic income led to an increase in the divorce rate in America at the time that it was being tried. People said, or this is what happens when you meet women financially independent from their husbands, they divorce them. In fact, that was complete fabrication. The divorce rate did not go up, but things such as infant mortality fell, engagement with schools increased and so on. There are a number of very significant benefits from UBI and I am a supporter, and I do not understand why the trials that were being proposed never really came to anything. Thank you. I do not know if Professor Smith wants to come in on that. I very much agree with what the Harry said. All I say is that there are lots of different designs for universal basic income, and you can set it at very different rates. Obviously, that has really big implications for how it functions in relation to inequalities, but I agree that it is a shame that the proposed approach for trialling in Scotland does not seem to be progressing. It would be really good to see that re-looked at. We are coming up against the deadline for our session, because we have a second panel, but I bring in Dr Gilhane. Countries with the best fund and best work in primary care seem to have better health outcomes with inequality. With GPs being completely overwhelmed at the moment, do you think that health inequalities and general health will decline? I think that, unfortunately, health inequalities are going to get worse in the context of the pandemic, because of how we have seen the pandemic and societal inequalities interacting. In terms of GPs being overwhelmed, obviously that is a real concern, but I also feel that, if we are thinking about the longer-term impacts of the pandemic on how people think about their health and wellbeing and how they interact with health service, there are some opportunities. Public health is much more in the public and media domain, much more in public and media conversations than it has previously, and that is an opportunity to facilitate better conversations and better interactions. We could try to build on that wider public and media awareness of public health and of the importance of health services and interacting with them, and it would be good to see Scotland do that. Giving them less time to unburden themselves and so on. I have said several times in the course of this, and the most important thing for someone who is struggling is the sense that they have someone who listens to them and they trust and value their time. If GPs are not able to give people that time because they are so overwhelmed, that will cause individual problems. I do not think that there is any doubt about that. The best GPs that I know and speak to regularly are still trying very hard to give the people that they know are struggling in that listening year. It is coming down to individuals who are going out their way in order to do the right thing for their patients. I believe that, in Scotland, we have a very high quality of primary care available to the population in general. Sadly, we are going to have to allow our first panel to go. There is so much in there. I want to thank everyone—Professor Burns, Professor Marmot and Professor Smith—for their time this morning. We are going to take a very short break for where our next panel comes in. Our fourth item today is around table with stakeholders to discuss key themes and issues facing the NHS in Scotland. That is intended to inform the committee's future work programme discussions. I will introduce all our panellists. Welcome to Dr Sue Robertson, the deputy chair of the British Medical Association's Scottish Council. Donald Morrison, the general dental practitioner for the British Dental Association. Ross Barrow, vice convener of allied health professions, Federation Scotland. Graham Henderson, executive director of delivery and strategic development for the Scottish Association for Mental Health. Kate Seymour, head of advocacy for Macmillan. Colin Pullman, director of the Royal College of Nursing. With six panellists—just a little bit of housekeeping—I have asked members to direct their questions to individuals specifically. If any of the panellists want to come in and add to anything, if you could use the chat function and put an R in the chat box, the clerks will relay that back to me and I will try to bring you in as much as possible rather than everyone answering the same question, because we really do not have the time to do that, sadly. I was wanting to open things up, and this is the one exception to that housekeeping rule that I have just said. I would like to go round everybody first off to ask what you want to see prioritised by the Scottish Government within the health social care portfolio. Of course, not just the cabinet secretary but the health ministers in the next five years. If I can go to Dr Robertson first of all. Good morning, everybody. Thank you for having us. What do we do for the next five years? We need to address the vacancy rates in the NHS in Scotland. We need to address the fact that the workforce is exhausted, the vacancy rates are high, demand has gone through the roof and that with the public messaging of the Scottish Government's NHS recovery plan, it is stating that we can increase capacity by 210 per cent, but without any realistic plans to increase the workforce in the short term, it gives us, we think, a perfect storm. We want to engage to try to find solutions. I was struck by Professor Burns in the previous section saying, and I will quote him, that you can create wellbeing by creating an environment where people feel safe and supported and that hopelessness and helplessness creates ill health. I think that you have staff within the NHS in Scotland who feel hopeless and helpless, who are keen to engage but with whom nobody is engaging. There is abundant evidence that workforce stress in healthcare organisations affects quality of care for patients and staff health, so prioritising staff health and wellbeing will retain the staff that you have and make this place a better place to work. I apologise to Dr Zanffar. I stupidly did not read the end of my list of people and I did not include you in the list, so I am going to come to you now, Dr Zanffar, for your asks of the Scottish Government in terms of prioritisation. Yes, we can hear you perfectly. Yes. First of all, thank you for inviting me to this meeting. I am here as the chair of Bapio, the British Association of Physicians of Indian Origin. I have seen the five-year plan and there are a few things that I would like to mention about the issues that affect the black and Asian minority ethnic doctors. I am here to raise the issues that affect this group of medical professionals. I will hopefully come back to Dr Zanffar once we have established the connections. Can I come to Donald Morrison? Hi. Thank you, panel, for letting me speak today. I am just for context by my general test of practitioner, a high-street dentist, for nearly 25 years and I have worked in England for 10 years in the NHS system there. In the last 14 years I worked in Scotland and I currently run in work in a practice that is in Ayrshire. It is a mixed dental practice and we are responsible for nearly 6,000 registered NHS patients. I am speaking today on behalf of the BDA Scotland and just for the record I am feeling really nervous, I have not done much in this before, so I will try not to make a fool of myself. What we would like, I believe, is going to sound like a broken record Prior to the pandemic, it was acknowledged by the Scottish Government that the NHS system that the dentists were working under was broken or was not fit for purpose. We were in conversations to try to find a funding model and find a sustainable forward-moving plan for dentistry. That seems to have been completely dropped. We feel probably that the worst possible thing that has happened is that there is very little or meaningful, timely communication between the profession and the Scottish Government. We would beg the panel to have a look closely at this for us over the next five years so that we could be discussing the needs of our patients and the needs of dentistry in a way that allows us to move forward and come out of the sort of dark ages of dentistry, which it feels a lot like now. Dentists will often talk about treadmill and working deeper item and piecemeal. At the moment, we are in a situation where it was bad before and Covid is really shining a light on that now. It feels particularly dark and difficult just now. We would really want funding looked at, engagement looked at, but the most important thing is that we want the Scottish Government to engage meaningfully with the profession and discuss it with us so that we can help to develop how to look after our patients properly. I thank you very much for inviting me along today. I am here on behalf of the Allied Health Professions Federation for Scotland. We are a multi-professional grouping of 12 professional bodies representing AHPs across Scotland. For a bit of context, AHPs make up the third-largest workforce in NHS Scotland and employ 14,000 staff headcount across a range of settings, including acute care, primary and community care and social care. That is a critical moment for all our professions and everyone who is representing us today. As we look to recover from the pandemic, what we would hope for as an HPFS is that it can be recognised that AHPs have a lot to offer in the current agenda by using their unique skills and training to treat people in all those settings that I have just outlined. That critically includes treating people closer to home in primary community care in order to focus on supporting people in their own community and reducing the burden that was already significant pre-pandemic, which is certainly even more significant now, on things such as acute care and waiting times for surgery, where we think that Allied Health professionals are able to offer solutions in the community. If we could ask for really one thing—I think that it has already been mentioned before, and there is probably no surprise—that the workforce is a key issue that affects all our professions. It affects us in slightly different ways, as we are all a multi-professional grouping, but, effectively, whether it is the fact that there is not enough posts for AHPs in particular settings or whether there is a very high number of vacancies—and maybe we will get a chance to talk about that in today's session—we really need to have integrated Allied Health professional workforce planning, which is something that is really not on the agenda or has not really happened in the way that we would like to. As an HPFS, we would be delighted to be part of that solution in offering what we can to alleviate some of the workforce challenges across Scotland. We will be looking in-depth at issues that have been outlined in terms of workforce and workforce planning. Dr Sanfar is back, so I will come to him to finish off what he was saying before he was thrown out of the meeting. Dr Sanfar, if we can have his microphone unmuted, please. I would like to say hello. Hi, we can hear you. Can you hear me now? Yes. Okay, so I'm sorry, I lost the connection last time. I kept on talking and I don't know where I lost the connection. We really only got a sentence in, so if you maybe just wanted to start from the beginning, that would be fine. Okay, so if you are planning for the next five years, what we would like. I represent the BAPIO, which is the British Association of Physicians of Indian Origin. We would like race equality and race relations to move up the agenda in NHS Scotland. About a third of the medical workforce in Scotland are either international medical graduates or BME doctors, black, Asian and minority ethnic doctors. A significant proportion of this major part of the workforce feel that they do not have a level playing field as far as career progression in the NHS is concerned. This differential attainment starts early off during examinations in medical colleges, during postgraduate examinations and throughout their career as doctors and consultants in the NHS. There's a lot of data from England, but published data from Scottish Government is missing or there's very limited data from Scotland. There was the recent report called the Medical Workforce Race Equality Standard Report, which was published from England. It looks at the different issues affecting the differential attainment, affecting doctors in the NHS and in the academic part of the portions of the NHS. I would suggest to the Scottish Government that there should be a similar report from Scotland as well, because that brings out the great disadvantage that BME doctors face. It's not only in their employment. It's also the regulator of the General Medical Council reference to the GNC by the NHS employers is twice as much for BAME doctors compared to their white counterparts. The GNC processes and outcomes are harsher or appear harsher for the BME doctors. There are many anecdotes and I don't think that this is from Scottish hospitals as well, but this is not the time and place to mention them. In the next five years, as we come out of Covid and as we press the reset button, race equality should come up the agenda. Also, as we catch up with the Covid backlogs, a lot of extra work will need to be done. We would like to see the staff, grade and associate specialist doctors also playing a very important role in this, not just the consultants. I think that I will stop over there. Good morning. I'm muting myself here, getting that you guys are in control. That's a good morning, everyone. From our manifesto, which we shared with probably most members of the committee ahead of the elections, I'm going to come to a fourth thing around social care reform. The first thing that we would be calling for would be that children get help when they ask for it. We've still got upwards of 7,000 young people being rejected from CAMHS referrals. I know that the Government doesn't like the term rejected referrals, but we will continue to use that term until, as there's been a change in the system that prevents people from missing out on services. We'd also like to see an increase in psychological wellbeing support for talking therapies. Still, people are waiting for months when they've been referred for psychological support and we want a more accessible service so that people don't have to go on waiting lists. We'd also like to see more communities supported to prevent suicide and we've been supportive of the Government's suicide prevention action plan and the work of the national suicide prevention leadership group. We'll continue to support that group and work with it. In terms of social care reform, the healing report has made many recommendations and we're very supportive of that report. Just in terms of Dr Robertson and Mr Barrow made the point about the workforce, the social care workforce is under great strain at the moment. We've got high vacancies, high turnover, high burnout. We've got people who are off long-term sick with long Covid and we're really struggling to help our colleagues in the NHS and the local authorities to move people out of hospital. An example would be just the other week there, we're speaking to Glasgow City about 34 people who are in inpatient psychiatric beds who are delayed discharge so there's no social care for them to leave hospital and that is a knock-on effect inside the whole system. We'd like to see the social care reform actually being a reform and not just tinkering around the edges. Thank you. Thank you and can I come to Kate Seymour? Good morning everyone and thank you for the invitation. I think from a cancer perspective we have the immediate challenge caused by the pandemic of the disruption to diagnosis and some treatment and the backlog that needs to be cleared as urgently as possible and that we have we believe up thousands of people who haven't come into the system when we would have expected them to and as those people come through they'll have more complex needs and sadly are likely to be diagnosed later so that's a huge challenge but looking to the five years as well we would really like to see an effective delivery of personalised care so that's looking at the full needs of the individual in terms of their emotional and psychological needs their financial needs practical because if we can do that well then that has a really positive impact not just on the individual but also in reducing pressures on the system and it also will help to reduce inequalities which is a big issue for us in Scotland in terms of health inequalities. We have a programme we're very proud of with the Scottish Government Transforming Cancer Care which is looking to do that in a in a different way working with local authorities and with the NHS and I think we need that radical approach to looking at workforce we recently published a cancer nursing on the line report which was looking at the challenges for specialist cancer nursing in Scotland but we also need to look at it from the point of that whole skills mix and the opportunities that the integration of health and social care in our system gives us in terms of how we can make sure that all the different aspects of the workforce that the other contributors have talked about all work together and are really integrated in terms of planning and delivery. Good morning. Thank you for the opportunity to come before the committee today. I follow colleagues and our members are telling us at the moment that they've never been under greater pressure than in their careers that they've experienced through Covid but obviously we know that Covid is highlighted what is long standing problems in health and social care that's including workforce planning has not been up to what we require it to be. We've been able to guarantee safe staffing levels, we've not been able to do that and there's the elements of payment award which I think are really important as well as the support that we need to put in place or continue to put in place for staff. Workforce pressures are key that we believe that you require to look at over the five years and that covers a huge number of aspects but if we don't have the correct workforce in the correct place we can't deliver what we need to require for the needs of the population. Workforce planning in the past has been financially driven generally and it needs to be driven by the needs of the population. We are at a, colleagues have mentioned, we're at a critical time and I do think that we can look and learn from the past and not make some of the assumptions that were made of what landed us in the place that we are. Recruitment and retention, we mentioned in the same breath that we need to split that and we need to talk about a recruitment strategy that covers us for the medium to long term and we also need to look at retention and we need to look at a retention strategy that's going to be sustainable and allow us to get through what we're going through now and moving on from Covid and when we talk about recovery we might have to have much more detailed plans and considerations and I was very struck from colleagues in the previous session about talking about listening to the clinicians at the front line speaking on behalf of the RCN. You'll have no surprises, I absolutely support that because if we do not engage with our clinicians to come forward with the solutions, we won't get to where we need to be. Thank you. Thank you and that's really helpful to hear from you all on the general priorities. I'm going to pass on to my colleague Paul O'Kane who will direct his question and if anyone wants to come in off the back of it please use the chat function to put an R and I'll come to you Paul. Thank you convener and thank you to panellists for that very helpful introduction and I think we've touched on a number of key themes there particularly around the pressures being experienced in our NHS and I think the real pressure that is on staff and the real challenges I think we're having in terms of staffing. You know I think I'm keen to get a sense around the recovery plan that's been published by Government. I know that there's already been a variety of responses to the publication of this plan for example Dr Lewis Morrison from the BMA saying that it's only a start at best and also hearing other things out of the RCN around I think the pressure on staff, I think the point that was just made around does it do enough essentially to address staff burnout and stress. So I think I would be keen to perhaps hear from Dr Sue Robertson around this. Just what confidence do you have that the recovery plan is actually going to deliver the transformation that is going to be required? Thank you. I mentioned the recovery plan and the public messaging around that that the Scottish Government have told the public that we can increase capacity to 110 per cent but as far as we can see there isn't anything realistic to deliver that to increase the workforce in the short term. We talked about new treatment centres but new treatment centres need new staff we can't just move the deck chairs you can't just take the staff from one place and put them in another place because then you have no staff in the first place. We don't have enough medical staff and we don't have enough nursing staff, we don't have enough HPs, we don't have enough social care staff. Without that being addressed in the short and medium term you can't deliver even what we're trying to deliver now in our mind increased capacity and the public messaging makes it hard to be a front-line member of staff. A recent dignity of work survey and that's even before the pandemic a third of doctors were suffering emotional verbal abuse from members of the public and that comes from the public not being told what's really happening and what they could really expect from the service. The people within the service are all working to their maximum and possibly past their maximum capacity and they're tired, they're exhausted, they feel they have little control over their work environment and often the culture within which they're working is not ideal. I would suggest to panel members that they might consider reading the GMC publication from November 2019 caring for doctors caring for patients and I think you could put caring for healthcare and social care staff in that but the GMC obviously looks at doctors. Eight key recommendations if you'd only read the eight key recommendations they're all based around three themes, autonomy and control, belonging and competence so ABC so that's having a voice, having work conditions that are appropriate for you, being able to work as a team, having the culture that allows you to feel your voice is valued, managing workload and being allowed to learn, trick and develop, being allowed to be part of the solutions and working together as a team to do that. You can't do any of that without having enough staff on the ground to do it and so longer term yes this plan talks about recruiting from overseas that's a long term thing the most important thing we can do now is retain the valuable staff that we have in place give them place that's better to work within and a system that's better to work within and then you will recruit easily if you retain your present staff your short term and medium term is you're able to deliver the service that we have now I'm not sure that we can deliver any more than we're doing at present and that obviously needs to be addressed but if you can retain your short and medium term staff then recruitment will much easier because this will be a better place to work so again it goes all the way back to the report for example 2019 looking at workplace culture proper workforce planning you know there's still a lack of clarity over the plans for GP recruitment we were told 800 more GPs by 2027 but we have no clarity on how that is to happen we still don't know what the plan is and if we don't know what the plan is I'm not sure anybody knows what the plan is but I'd love to know if somebody else on this round table is aware so it's not just sound bites we need action we need consideration of culture we need to retain the workforce that are here and we need to involve them in finding solutions thank you I think that is really key and I think retention has identified identified across the board as being so important and I think it is about culture in terms of how do you encourage people to stay within the profession but I wondered if the Royal College of Nursing wanted to add anything perhaps at this stage just in particularly in terms of those comments about burn out within the nursing profession. Colin Pullman, I'll just wait for broadcasting to unmute you. Thank you. Speaking to oneself, never good. In respect of following up from Dr Robertson, she's absolutely right. At the moment we need to really look at what we need to do to retain staff and we need to allow staff time to rest and recuperate. They've been through our end of time and we're already working on a pressure service. I know that this might seem basic but we do need to get back to basics for the staff. We need to look at what is safe staffing levels, eating simple things like ensuring people have rest breaks, their work in their contracted hours and offering them a good work-life balance as well as the support systems that we need to put in place. We are improving the support systems and I have to recognise that but we need to do more and it does come back to looking at what we can do from a retention plan that is sustainable. We talk about recruitment retention in one breath and we pass it over and I think that there are two completely different things and I think that we need to look at specifically how we do that and keep people in the nursing workforce at the moment and has nearly 5,000 vacancies. How do we keep the people who may be looking at potential flexible retirement and retaining them within the service? Those are things that we need to look at. I come from a professional organisation in Tragenian and you won't be surprised to know that pay is a major element that we also need to look at. All healthcare workers have not kept up with inflation over the past 10 years and those are things that we need to look at. I agree with Dr Robertson that we need to work at making the NHS and social care in Scotland, a place that people want to not only come to work in but to stay to work in. Graham Henderson, I would like to come in. Thank you, convener. Just following on from the points that were made about social care workforce, I have been in social care for just over 30 years. I registered nurse, I came from the NHS and when I joined the social care at SamH, we had parity of conditions with the NHS or local authority. Our salaries were all tied to, typically, the local authority bandings. Over the years, the last 30 years, that has been eroded. Competition has been allowed to run wildfire through the social care sector and we are now mostly paying people on the Scottish living wage. We can't compete and we often lose people to go into social work or back to education or into nursing. We have very few nurses who work in SamH. We have about 600 staff. When I joined, we had many nurses who were on equal pay to their colleagues in the NHS. While we are not in it for money, when you have been in your salary conditions eroded over time, then it becomes difficult to feel valued as an equal partner when you are doing the same work. It is really important that individuals in the social care world are given equal value to their colleagues. I think that Sue and Ross had made the points earlier about that we are all in it together and we are all interdependent, so we all have to work together. I think that that is a really important point about valuing the social care workforce. Ross Barrow would like to come in. I just want to come in on the mobilisation recovery plan. I just wanted to totally agree with what other panellists have said. Of course, we need a mobilisation recovery plan. No one would deny that, but there is an element, sadly, of putting a cart before the horse when it comes to this. What we need is a workforce plan, which is what everyone has commented on. I think that the challenge around the mobilisation recovery plan is really around the mismatch between patient expectation and the reality of what is happening on the ground. I hope that you do not mind if I just run through some of the examples of that. I am sure that we are familiar with them, but just to highlight, there are people who have gone without treatment during the pandemic because their need was not classified as high risk. There are people who have developed complications during the pandemic as a result of shielding on all being able to get out and about, and then there are people who are experiencing long Covid and are suffering with the challenges of that. A mobilisation recovery plan is great, but at the heart of that has to be a workforce plan not only for the HPs but for all the professions and services that are represented around the table. I identify where I will get the right person in the right place at the right time to tackle each of those three challenges. The mobilisation recovery plan is great, but it needs to be fully integrated into understanding where the workforce pressures and needs are. From an HBFS perspective, that is where we would like to start. Thank you. I will come to Dr Sandesh Gohani. He has some questions on this, and if he can direct your questions, that would be great. We heard from Sir Upton the whole panel about the difficulty that we have in staffing. Adding race equality or inequality on top of that makes life of bain staff worse. My question is, what can we do to improve race equality in our NHS? I would like to start with Dr Zanver. I think that we should talk about it. We should acknowledge that there is a problem or at least acknowledge that there is a perception of a problem. That would be the first step. I do not know how many of you have seen the medical workforce race equality standard report that came from NHS England just last month. There is a race equality report for all NHS staff, but the report focuses on the medical workforce. It has really brought out the stark inequalities that bain doctors face. We should, as a first step, do something similar in Scotland as well. That would go a long way. At least we will know what the problem is so that we can start addressing it. The second thing that I would like to suggest is to look at why, from the NHS employers, it is more often that the bain doctors get referred to the GMC. Is there anything that can be done to solve the problem at a trust level rather than having to go to the GMC regulator? Those are some of my suggestions that will help to address the problem. I will move the conversation on to around Covid-19 and the backlogs, unless you want to come to any more. Emma Harper, could you lead on that? I will bring in other members as we go. We have heard, over the past few weeks since the recovery plan was published, that there is obviously going to be a need to address backlogs of cancer diagnosis, breast cancer, bowel cancer and cervical smear tests. There are going to be issues of addressing ophthalmic surgery, so cataracts, hip and knee replacements and all of that. I wonder how we are going to address that demand, because we have, during the pandemic, basically stopped the elective approaches. Even now, we are seeing the ICUs filled with Covid patients rather than the elective bowel surgery patients, for instance. Where do you see the need to tackle the backlog of surgery requirements, for instance, and diagnostic testing? Who would you like to address first? It is a massive problem. We were under great strain before, and we have changed the way that we do everything, at least temporarily, and some of those changes will remain. The backlog of people waiting for elective surgery is huge. For example, in my own region, I was told last week that it was probably going to be about 70 weeks before somebody who needs a hip replacement clinically needs that, because probably they are being woken up by pain every night and are on maximum doses of painkillers. Before that person gets a hip, it is probably going to be 70 weeks. That is a long, long time. That increases the morbidity that they will suffer from their painkillers, for example, and from the lack of mobility. During that 70 weeks, they will probably feel quite hopeless. They will probably have to go on more painkillers, which might have adverse effects on their health. They will get less and less active, and that, again, will impact adversely on their health. It will mean that they might go rolling down the hill before they get their hip replacement and then have to climb that hill of health again. That is a massive problem, but we do not have the facility and the staff to increase that, to meet that demand, because we only have the staff to do what we were doing anyway and everybody was working to a maximum. Without retaining the staff, without increasing your staff numbers—that is not just doctors, that is all of us that deal with patients in those positions who are waiting for what we call elective surgery, but for them it is probably something that they feel is very urgent because they are in pain. Without the extra staff and without retaining the staff and stopping people feeling like they need to retire because they cannot do their job in this place any longer, because it has adverse effects on their health and their family, we cannot then deliver that increased capacity that we need. It is not a simple, well, let's just build treatment centres and do all the elective surgery there. As I said before, this is a very complex, very difficult problem, and it may mean that we have to stop doing some of the things that we do at the moment if we are going to try and address the backlog. That requires a societal discussion and honesty, an honest public messaging about what we can do, not what we might wish to do, but what we can do and what we can deliver over the next five years. I think that honesty with the public is absolutely key at this point. Honesty with the public allows them to be part of the debate but also protects the front line healthcare staff who are being abused often by members of the public because they do not understand why we are not doing what they feel we should be doing, and it is because we are just all working to our maximum. I am going to bring in Kate Seymour. To build on what Sue was saying, the pressures will be on all parts of the system. If you think about someone who comes into the system late because of the pandemic, their cancer is being diagnosed late, they are much more likely to be diagnosed through A&E, so the increased pressures on the emergency part of the system, their needs will be more complex, they may need more input from AHPs or other professions, and the impacts on pallidive and end-of-life care because more people will be coming in diagnosed at a later stage will increase as well. We have to think of this from a whole system perspective in terms of the pressures that it puts everywhere and that need for additional resource everywhere to make the system work well. Just to come back to the importance of that integrated thinking and integrated workforce planning to make sure that we can reduce pressures where we can to make sure that people's needs are dealt with by the most appropriate part of the system right across health and social care. I know that that is a huge challenge, the most obvious example when we talk about bed blocking, but that is the kind of thing that we have to do better if we are even going to be able to begin to address the resource challenges that we face. Donald Morrison would like to come in. It is probably repeating what has been said, but one of the most important things for us as health professionals is that oral cancer is one of those answers that is picked up, but I am really asymptomatically. It is one of those things that are regularly sprained and picked up. Scotland is one of the highest oral cancer rates in Europe, and the treatment in early stages is relatively simple, but the quailie of it is horrible, disfement and really quite drastic difficult surgery. The imbalance between the two things is such a big, major part of screening the patients and seeing them on a regular basis, which we just cannot physically do just now. We are twice as likely to die of oral cancer in Scotland if you are from a deprived community, and that is only going to increase the inequalities gap and grow larger and larger. We are only at the tip of the iceberg on this. In the next 18 to 24 months, that is really going to come home to roost. I am very concerned about the fact that because of the way that screening works, we are not even feeding those people into the system yet, because we do not get to see them. Can I just clarify? You are picking up signs of oral cancer when you are doing more routine work in the check-ups and the other types of dentistry, and that is when you are spotting it early? Not only spotting it early, but people do not feel it when we find it. Often, you will get someone who is presenting with something that will say, this is a bit sore, I have noticed that, can you do something about it? But often, you look in the mouth as a routine and you see a lesion and you say to the patient, how long were you at that? They say, well, I have not even felt it, I did not even know it was there. You say, well, let us have a look at it a couple of weeks time. It is unresolved, it is then put into the system, all surgeons will see it, they will biopsy it, and find its cannot remove it in the space of about six to eight weeks. If left to go untreated, the patient does not always feel very uncomfortable, but by the time we get spread on, it is a radical neck dissection, the patient will be deformed by the surgery, it is major chemo, all those things go into treating someone with head and neck cancer, and yet when we pick up those things as a screening process, we look at a patient every six months, detect it and it is treated very early, and all of that will not be all of it, because every time we get a patient in front of us for whatever reason, we do that screening now and we try to keep that going, but there were four million tendencies lost last year through Covid, so we lost so much, so it can be just detected to general, just looking in the mouth. I will come back to Emma, but I just wanted to pick up on something that Dr Robertson said around what patients can expect. I guess that it is a difficult line, because on the one hand, during the lockdown period, people who should have engaged with their health professionals and did not, because they were worried that they were adding to the stress, but now, certainly, we are all seeing in our inboxes that we are perhaps having the public expecting more than the services can give. How do we strike that balance? How do we manage patient expectation? I think that we have to have honest conversations with the public. At the moment, we are almost in a place where, if you shout loudest, you get what you want, and as somebody who, as I said in the chat, works on an admissions unit, you see patients who have not wanted to bother anyone because they know that they are really busy, but you see them further down the line of their illness trajectory than they would have been otherwise, when they perhaps need much more powerful drugs or much more major surgery than they might have done otherwise. It is having that conversation with the public about what we can deliver, and the fact that, if you shout loudest, you will not necessarily be the one who gets the care. The care has to be delivered on clinical priorities, not on who complains loudest. If we are to be the society that we want to be, which is a caring, equitable society, we have to have that societal conversation. I just wanted to ask what the place is in that honest conversation for the media and politicians on that, because that can perhaps exacerbate some of the problems if it is not done carefully. What are your thoughts on the role that maybe we, politicians, need to play on that and, by extension, on the media, because that is where a lot of the messaging lies? At the moment, it feels like we are almost working against the politicians on the media. It feels like we are trying our best to deliver the best care that we can. For example, the NHS recovery plan, the big headline is that we are going to increase the service by 110 per cent. What we would ask is that politicians engage with us and others around the screen, and we work out how best to message the public. We take that away from winning and losing decisions, and we take it to that this is the best for our society and for the individuals in that society. It has to be taken as that. It has to be taken as something that is a very long-term societal conversation about what can be delivered, what people are demanding and where those match and where those have a mismatch, and then how do we address the mismatch perhaps in other ways. That is very helpful. I am going to come back for a quick supplementary question from Emma before moving on to talking about staffing more generally. Thank you very much. I will try to be quick. Social prescribing is something that we did a report on in the last session of Parliament. Obviously, keeping people out of hospital in the first place can be done by engaging in practices to support health and wellbeing, physical activity, preventing complications of type 2 diabetes, and 10 per cent of the NHS budget is spent on mitigating complications of type 2. I am just interested in what the panel would think, and I suppose that Gillian convener can choose somebody to answer the question. What value do we need to place on social prescribing to stop folk getting poor health in the first place, support pulmonary rehab, support type 2 mitigation of complications, things like that? I will ask Dr Robertson again, please. I think that we probably need to take that step even further back. I listened into the first session, and I listened to Harry Burns talking about poverty and health, helplessness and hopelessness. We need to look at the health of the population and try to improve that in any way that we can, and that is giving people opportunity, giving people support, making people feel like a valued member of society. We also need to increase—I know why I would say this, Emma, because I am a big physical collectivity person—the possibilities and the encouragement for people to be more active and to live healthier lives, but they need to have the opportunity to do that. Michael Marmot said that we need to look at every policy and how it impacts on health. We are looking at the built environment, building schools in places that children can walk and cycle to, so that walking and cycling becomes the norm. When the children walk and cycle, the parents walk and cycle, and they become healthier. You reduce your risk of type 2 diabetes, you improve your lung health, you improve your general health and you reduce your risk of other diseases. It is looking at health in all policies. Only by doing that can you shift the big oil tanker that is our unhealthy population and make it the next time that another Covid comes around. It is more resilient and healthier, so it is less likely to become ill or to sadly die of some other illness that will attack the least healthy of our society. I have talked to a number of years ago that the Government funded the alliance that Sam H to test out link workers in primary care services in Glasgow. Those link workers are social prescribers. They link people to things that are happening in their communities that they can do. A lot of them are physical activities, but there may be many other community things and activities that people could take in that would benefit their health. Since that pilot was written up and there were lessons learned, there was training described, there was an approach described, and then it went out to local authorities. I ask Public Health Scotland for information on that, because I am aware of tendering processes that we have a variety of different approaches to link working. In some local authorities, we have banned seven nurses who carry a caseload. In other places, we have Scottish Living Wage, third sector workers who do not carry a caseload. There is a lack of consistency across Scotland in our approach to link working, which is really confusing for patients and the workers. I think that it has been a real missed opportunity to not learn the lessons from the pilot and then implement it now. I am not arguing against local democracy here, but perhaps the Government could have been a bit more robust in its guidance to local authorities about link working based on the pilot and the study that was done some time ago. Kate Seymour wants to come in on that. A couple of things for me in response to Graham. I totally agree, Graham. That is why we set up a transforming cancer care partnership with the Government, which has that approach of link workers in local authorities supporting people with all their needs around cancer. That is just for cancer, but that is what that model attempts to do. On the back of what Sue was saying, I completely agree on the need to improve the general health of our population. Equally, it is not too late once someone is in the system and has ill health. Once you have had a cancer diagnosis, we are doing a lot of work with pre-habilitation and also looking at all those areas around supporting people with physical activity, with their financial needs. Of course, not just from that point of view, but also with their emotional and psychological wellbeing. If we can support people with that through their cancer journey, the likelihood of them coming back into the system through an emergency admission or through just their health deteriorating through their cancer treatment becomes less likely. Although getting in early is key, it is never too late. Often, when someone gets a major diagnosis such as cancer, it is a really good intervention point to look at social prescribing and other support areas to improve people's health through that and to lessen the likelihood of them needing more support later. We have a number of members who want to dig deeper into the staffing issues that you have all raised, and I will go first to David Torrance. Thank you, convener, and good morning to panel members. You have talked about recruitment and vacancies in NHS. In fact, it was Dr Robertson who mentioned that it would take years to recruit from abroad, and Brexit has not helped either. How do we encourage and make the NHS attractive for people to retrain and for school leavers to look at the NHS as a career path for them? Is that directed to Dr Robertson? It is directed to Dr Robertson, sorry. Thank you. As I said, retaining your workforce is the first thing. If you can provide a place of work that makes people feel valued, supported and included, then you will retain your workforce. It is about workforce culture and the workload. As I said, improving the work environment for doctors, that GMC paper, ABC, people autonomy and control, so some sort of influence on what happens around about you and how your service is delivered, a feeling of belonging, so improve team working, culture and leadership, and then provide see as competence. Provide an environment that allows them to manage their workload to be managed appropriately and given appropriate supervision and ability to learn, train and develop. On top of that, you have to pay people well enough for the job that they do. That goes across not just doctors but everyone. Many of our wages have gone down in real terms over the past 10 years. You have what you want in the NHS and in social care. You want the brightest and the best. You want the people who really want to be there, who want to give a piece of their life force to each patient to help them to get better. However, you need to be able to give them a place to work that does not impact badly on their health and does not leave them feeling as evidence has suggested that they do not have any energy left for their own family and loved ones, because they are so burnt out by working in the environment that we do work in at the moment. If you have people who want to stay in their job because the place of work is a place that you want to work, you immediately have them telling school leavers that this is a great place to work. Come on work here, you will feel valued, you will be able to innovate and develop and be part of improving service and developing things as they go forward. You will be financially valued but you will also be personally valued. If you can provide workplaces that do that for people, that provide them with facilities for decent rest in their breaks, that look after them when they are tired and give them a place to lie down rather than drive home after a night shift if they are too tired to save them having that crash on the way home, that leave people feeling that they still have some compassion left for their own families and their loved ones and themselves, then school leavers will want to come and work there. Society will say that this is a great place to work. You should want to come here. People within the job will not be saying, I cannot do this any longer, I am not at retirement age but I need to find a way to get out of this and do something else. The whole thing stands and falls on value. If people feel valued and supported, then people will feel well. Harry Burns said that you can create wellbeing by creating an environment in which people feel safe and supported. I would add value to that. You can do that with the NHS and social care, then you will have no problems with the staffing levels. If you can be a realistic public about what they can expect of those people who are trying their best at the moment and about being gentle to those people who are trying their best at the moment, you will make it a better place to be and people will stay and people will develop the service, they will make it better and we will have a better place in Scotland. We have other MSPs who want to come in and ask questions. It is just a reminder to all panellists if you have anything to contribute around the issues that are coming up here. Please just put an R in the chat box and I will get noticed of it and I will come to you. Following on from Dr Robertson's contributions, I am really interested particularly staff, morale and staff wellbeing. Are clinical and other staff getting enough support and what can be done in the immediate short term to prevent a morale crisis and what can be done long term to improve overall recruitment and retention in each of the groups that you represent? I would like to probably start with Dr Zanfar on that. Hello. I have just heard Sue Robertson answer the previous question. I think that if we can create a workplace just like she described, that would go miles in improving staff morale. That would be better financial rewards but that is not the whole answer. There is a resource crunch as well but making people feel valued and at least be realistic with all the staff as well what they can expect from the workplace. I will come to Graham Henderson now. Thank you, convener. The echoing Sue's point about value is not just about financial value but data as a worker in a sector that is valued by the public and politicians. I give you an example of what we have done in the past 18 months as we have brought in an additional two days annual leave and they are called wellbeing days. They are specifically addressed to wellbeing because we value people's wellbeing and they want people to take time for their own wellbeing, not just their holidays. We have also given every individual staff member a £100 wellbeing budget for them to use for whatever they want. Obviously, that costs money so because SRMH has the capacity to do that, we can do that but a lot of our third sector colleagues would not be in a position to do that so there is money to pay people but also money that needs to be in the system to allow capacity for organisations to do things like I have just suggested. Just on the question about improving morale, I want to say that allied health professionals have all health and social care professionals really care passionately about the work that they do and about using their skills to provide the best care. One of the ways that we can actually improve morale is by making sure that we have the right healthcare professionals in the right place at the right time. For example, we have been talking about backlogs previously. All allied health professionals all have the ability to assess, diagnose and treat to work as first point contact practitioners within primary and community care if they are actually placed in the right places because there is enough workforce to support that overall package across the system and they can see that actually for a patient that means that instead of being on a waiting list for 12 to 18 months it means that they are seen immediately by an allied health professional or someone else in primary community care and they can get immediate access to treatment. That is going to be such a bonus and a moral lift because they are able to do what they came into the profession to do. Just very quickly on staffing, Mr Torch raised around schools or how do we raise awareness of those professions. There is a lot of work to be done by everyone at all stakeholders around raising awareness of allied health professionals and the range of things that you can do within your careers in allied health professional. There are a couple of things that we can do from a policy perspective to improve the different routes into training. For example, the introduction of degree apprenticeships for allied health professionals is something that is very important. We do not currently have that in Scotland although it is available in other parts of the UK. We also have to look at bursaries for particular professions to incentivise people to come into professions that they may be struggling to recruit over a longer term basis. Finally, on return to practice, that is a really important part of the jigsaw and how can we incentivise people who have really good skills and they might not be currently working in health and care but they have really good skills and they could come back into that system. How can we support them with good quality CPD and training so that they can really make the most of that and contribute? I am aware that other people from the panel want to come in, so I am bringing in members to put some other things into the mix so that they can pick up on the issues that have been raised so far. I would not disagree with much of what has been said in terms of that real pressure that is on staff. I suppose that I am interested in our immediate crises, if you like, particularly the onset of winter pressures across the piece. Obviously, we have long-term planning in terms of workforce but there is clearly an immediate need particularly in acute settings around how do we actually just physically keep the show on the road. I think that we are seeing a lot of that at the moment and we are not even at peak winter yet in terms of admissions and use of service. I would be keen to understand what is needed right now and what can be done right now to increase resource and staffing and what would make the most difference. I appreciate that that is not an easy question to answer but I am keen to get a sense. Possibly again from Dr Sue or indeed RCN. RCN. I come to call and pull him on the first thing and I will go to Dr Robertson. Hang on, your microphone is still muted, so give broadcasting a couple of seconds. Thank you. I have been keen to come in. I can agree with most of what has been said in relation to everything that we need to do for the environment, culture and support of the staff. Morale clearly is under huge pressure at the moment. In your question, we need to work through what is an incredibly difficult time and nobody has all the answers. When it comes back to the difficulty that we were talking about this conversation that we have to have with the public, because we have unintended consequences of longer waits and people wishing to be treated, but we then have the pressures of the system. We get that on a daily basis and we see it in the front of the media. It is about allowing our health and social care employers to work with their staff and, to be honest, to what we can provide and to work that through in the sustainable planning. It will be very clear when we can't do things and why we can't do them, because it comes back to the pressure that staff are reading in the papers of what we have to do x and y when they know what the reality is. I think that we need to come back to that reality to say that this is what we can provide now and that this is why we have the pressures. That will mean that at times we need to reel back what we can do because we need to use the resources that we have, as well as looking in the short term at every avenue that we can to try and bring people back into service who wish to be in service around retraining and support, and also looking at other ways of staffing so that they are not just putting increased pressures on the existing workforce. The more we ask the existing workforce to do extra shifts to cover whether we increase sickness or whatever, the more pressure and more absence we will have, and that will add to more problems, especially when we are going into winter. People feel that it is winter now, that is what our members are telling us. It feels like it is winter right now in the middle of the summer, so we need to do all those things, but it does come back to that. It has really had public message from the NHS, from social care and from the media and politicians about honestly what we can provide currently and that we are doing everything that we can to move forward into the future, but it is going to be a difficult road. I come to Sue Robertson and then to Donald Morrison after that. I absolutely, in agreement with Colin on everything that he said, their public messaging is absolutely key and that is the bit that we are not in control of. We are not in control of what the public are told. All we can do is try to deliver the best service that we can, so that needs to be done centrally and it needs to be done honestly and it needs to engage the public within that as well. What else can be done right now? Social care. We need to pay people better in social care so that people are going to take those jobs, stay in those jobs, not take a job as a carer and then find that you could earn twice as much stacking the shelves in Aldi. We need to value social care for what it is. It is the bedrock of all of that. If we get social care right, then we can be a national health service that delivers what is needed. People can stay at home if they want to, with appropriate care, or they can access appropriate care facilities if they need them. If you get all of that right, you take a massive amount of pressure off the NHS. People are happier because people do not want to be in a cute hospital unless they absolutely need to be. That is also a really key message. Better IT. That is a constant bugbear for all of us. The IT that we have to support the work that we do is glitchy and is not as good as it could be. We have lots of young people working within our service who have lots of useful suggestions about how we can improve our IT in order to make the work that we do easier and quicker. That is a huge one, but it is asking people who are doing the job how we could support you to do it better and what we could put in place. For us, it is certainly increasing the number of nursing staff and AHP staff around about us and other staff members to do jobs that we do not absolutely have to do so that we can do the things that only we can do. For example, the dietician can do the dietician's job, which allows me to be able to refer to a dietician in my team and say, can you give me the nutritional requirements for this patient to keep them well while they are in hospital with this acute illness so that they will be well when they go home instead of going home having slipped a little bit down that hill? Physiotherapy, pharmacy, all those other parts of our healthcare team give us the ability to work as a team and give us the connectivity to work with primary and secondary care together as well. All those things could be addressed now. Culture within the organisations absolutely it is way past time. I would signpost you to the Fruits and Galloway Health Board, and we are part of something called the pro-social health project, which is looking to improve the team-working personal wellbeing and culture within our organisation. That is set up by our psychologists, but I, myself and part of that group, we have operational development, learning, psychology, me from medicine and our spiritual lead all working together to try and help teams improve the culture where they work and to look at the way they work as teams and try and improve that. There is lots of work that can be done. It does need people to be given the time to do it. Some of that work is almost a spend to save. If you give people some time now, then it will absolutely save time in the future. I will come to Donald Morrison and then we have some members to direct their questions to the individual that you want to answer for, because we are rapidly running out of time, as I knew we would. Donald Morrison? I will try to be brief. As far as the recruitment into NHS regarding dentistry, one of the big problems that we are having is that the hit of Covid affected extremely heavily the university intake and the qualifying dentists coming through, though we essentially lost a cohort or were sent back to do another year's study. In addition to that, I mean, two mentioned Dumfries and Galloway. In Dumfries and Galloway, over 40 per cent of the dentists are out from outside the UK. I do not know how Brexit is going to affect us, but I suspect that although we have not seen a drop-off of registrants, the general feeling from the practitioners is that anybody of retirement age will try to retire soon. It does not seem to have any immediate influx of dentists coming from outside the UK and we have a backlog of training. The dentists are coming into a position where there is not really any funding in the classic term. In the sense that high-street dentists are not salaried. I think that we have talked here about lots of things and the patients are a priority. However, it is very important to point out that most of the dentists, 95 per cent of the dentists, have a mix of NHS and private dentists that they do. The set-up is geared against them working for the NHS. The funding has been reduced to 85 per cent for them to continue to work, although they have reduced activity. However, the process that they have to put in place still means that to do a unit of work, a filling, you get the same money for it and it takes you four or five times longer to do the same thing. That just puts the stress on the workforce that means that they do not want to work in the NHS or that they cannot make it financially viable for them to do it. You lose the situation where the dentist has the luxury of being able to take a lot of time and look after the patients and see as many as possible when they have to make a business that continues to be viable. I think that sometimes the dentists tend to feel a bit like the Cinderella service, because it is a small and medium business outside of an annex on to the NHS. We work really hard for our patients and it is really hard to do all that we can, but ultimately, the perfect storm of the not being enough sustainable future funding and a model that we can all work with and understand, you will lose dentists from the NHS at the hand of the fist in the future. Thank you, convener. Earlier today, we heard that all policy should be a focus around healthcare, and we have also heard from some of the members of the panel that workforce planning should be coming first before we had that remobilisation plan. We have also heard of the many diverse careers that are available to people in health and social care, including dentistry, so I am not going to ignore that one. I suppose that this is for Sue, given that we have a short timeframe here. Maybe Sue Robertson can help us with this one. Do you think that the cap that we have on Scottish young people getting into our medical schools and universities across Scotland is negatively affecting our long term recruitment and our ability to create that sustainable workforce plan? This is a little bit more complex than just a yes or no answer, I am afraid. There is no doubt about it that we have many very able go-pupals who would make very good doctors future and who want to do medicine. However, we also have to have the ability to train them, and without the workforce to train those young developing doctors, we know that school pupils from Scotland are more likely to work in Scotland in the longer term, so that is a tick. We want more school pupils from Scotland to do medicine and stay with us. At the moment, if you increase the numbers of medical students in total, then there is going to be a significant risk that there are not enough of us doctors who train them and help them develop, and that is a significant risk. One of the main things that we need to look at is the number of doctors that go elsewhere after the first two years of their practice. They do their foundation years in Scotland, and some of the research suggests that around 40 per cent of those young doctors go to other places in the world. Scottish medical training is very high-quality and respected around the world, and that is a good thing. However, if we lose half of our young doctors to going elsewhere, because, potentially, they look and have experience of a healthcare structure that we are working within and they do not like the culture and the way that doctors are treated or the lack of ability to feel that their opinions are valued, then, again, we are going back into the same problem. It needs to be a workplace that they want to work in for them to stay. Absolutely, yes. I would like to see more young people in Scotland being able to do medicine, but only if there are enough doctors to train them appropriately, while also providing the healthcare that we need to as well. I would like to see a workplace that those young doctors would like to stay in. I applaud the Scottish graduate entry medicine courses. I think that they are increasing the number of young doctors who are born in Scotland and who often want to work within general practice and psychiatry in areas that we definitely need more doctors. I absolutely support increasing the diversity of people who become doctors and looking at how we pick people for medical school and how to increase the availability of medical school places to people who have not perhaps had the best opportunities in life in school and who may not have quite as good a CV as someone who has had the best opportunities. Absolutely, we want more young people to do medicine, but we want them to be able to do medicine working as doctors within NHS Scotland and looking at that as an attractive career and not wanting to train in Scotland and then leave because they see how burnt-out their senior colleagues are when they experience their time on the wards or in general practice. I want to ask a little bit about the role of technology, so can I comment at that from two different angles? Certainly, I have had conversations about the fact that we are not able to build all the NHS vacancies at the moment and we really need to do more things with less people. The rapid adoption of technology and how that might help the example. One of the examples that I was given was radiology, where you get AI diagnosis, but you have the radiologist doing the more complex work, and then looking at preventative care as well, which is the first one for Dr Zamvar, and then looking at the preventative care aspect as well. They are possibly ROS, looking at the idea of bed modelling and actually keeping people out of hospital, looking after them at home and getting them out of hospital more quickly when they are in there as well, using technology and using advanced practices and helping colleagues to advance their career and take on more complex roles and how we would do that. Thank you. I would definitely say that we need better technology. I have lost Wi-Fi so many times this morning. Anyway, about technology, for example, you mentioned AI artificial intelligence to look at radiology scans, etc. There is a lot of work happening, and reports are coming mainly from US hospitals where they are using this technology. It is possible to use this technology and we should look at that. The only thing is that whenever you introduce new technology, it always costs more money. Though pilots may show that it saves money, eventually it will take over and it will cost more. However, it should not stop us from looking at this technology because it saves time in the longer run and it will save some misdiagnosis as well. What was the next part? It was really about doing more with less people. Doing more with less people? Yes. We should be open to ideas. For example, in our department, I am a cardiac surgeon. We have nurse practitioners now doing ward rounds in our departments and we also have surgical care practitioners assisting us at operations. We do not really need an assistant surgeon to assist us at operations. This has been happening for a number of years, but with the staff shortages, with the Covid problem that we have had this year, moving forward, we should pay more attention to this and see what roles it can take so that we have more time to do other things. I was going to bring in Ross Barrow to pick up on that later point as well. I think that there are a number of issues with this. The first is about how to do more with less people. This is about self-care management. This is about working with patients and service users to understand their own healthcare needs and feel an agent of change in that. It is about seeing the healthcare professional as an expert guide and allowing the patient or the service user to be seen as a partner. They are in control of a lot of the interventions. You mentioned technology, and I know that there has been talk of an NHS app that people may be able to access in a tablet or mobile phone. We think that there is a massive opportunity there for two reasons. The first reason is that a lot of the self-care management advice that may be exercised videos, for example, or things to do when you come out of hospital after you have had an elective surgery, of course you need support from your healthcare professional with that, but there is a lot of information that you can give directly to someone through the mobile phone or tablet. That will not be the case for everyone. We have to really be careful about the population in Scotland that is digitally excluded, but for some people that might be a really good option for them as well. We are rapidly running out of time, but I want to bring in Evelyn Tweed who has a very specific question to ask the panel. We have talked a lot today about the health and wellbeing of our healthcare staff and professionals, but what can we do immediately to offer them support, to give them a listening ear and to make sure that they know that they are valued? What can we do immediately? A lot of the things that we have been talking about today are quite medium term or quite long term, but what can we do now? We have a number of people that we might want to address that as a final question, so if you want to… Yes, Dr Robertson, first please. Okay, what can we do now to listen to people? We can listen to them for starters. We can listen to them within their teams. Management and senior management can listen to and value the opinions of people working on the front line, working, you know, boots on the ground. I think that would be key. I think that you are listening to us and that is excellent and that makes me feel that our opinion is valued and it is amazing how far that goes. I think that we have now got gradually improving psychological services for staff, but I think that that is absolutely key. We do need access to psychological services of all different levels for all staff involved in health and social care, and I think that that is absolutely key. I think that there has been a lot done within Covid that has shifted that forward quite considerably and I think that that is really important. Simple things like having a space where patients and relatives cannot go, where staff can go to take a proper break, means that you can have a break physically and mentally so that you feel stronger to go back to your shift. Having hot food within at night times so that people who are working night shifts can access hot food in their break. Having somewhere that they can lie down and take their break, take the 20-minute power nap during the night shift that we know will improve their decision making and reduce their compassion fatigue and make them a better team player. All of those things are things that could be done right now. I think that the rest of facilities, psychological support and valuing people's opinions are all things that could be done right now. I also think that that—I am going to come back to this—the public messaging that people on the front line are doing their best. They have not designed the service, so please do not abuse them when the service does not work for you and support for staff who have to face abuse and who have a zero tolerance to that in the health service and in social care. Those things can be done right now and will make staff feel supported and feel safer within the roles that they provide in this really, really difficult time. As somebody else said, we do not need to wait for winter to feel busier and more overwhelmed than we ever have in my 35 years as a doctor. It is now, and we are really worried about winter. There will be a lot of staff who are just on the edge of their ability to cope, and it is not going to take much to tip us over. If you can put support in now and say that we value you enough to give you hot food at night time, we value you enough to give you a rest space that patients and relatives are not there, those things just go a little way to make you feel that you are a valued member of a team, a valued member of a big system and that someone has got you back. I am afraid that that is all that we have got time to take. If there was anything that other members of the panel wanted to say but did not have time to, of course, you can email us and you can let us know if there is anything that you have missed. I am going to come to Donald Morrison. Just on that note, I do appreciate, I do not want to be the one that is I like to be as positive as possible, but asking what you can do, I think that it is really important for, certainly as far as dentistry is concerned, is what not to do just now those things that do refer to this saying that can go 110 per cent. In dentistry, they decided to wheel out free dentistry for 18 to 26-year-olds. We found out about that within 24 hours before, and I think that that is a really simple thing to want, that that is not being discussed or certainly worked through with the profession and the profession feels really like it is not being communicated with. I am not doing things like saying that it is business as usual, because it clearly is not, and allowing at least our members to work under this very stressful situation without being told, without public messaging saying, go on, get on with it, it is business as normal, because it just is not. I think that that one thing would be really, really helpful. Thank you, and finally, Graham Henderson. Thank you, convener. I just want to mention a service that Sam H developed and set up in the last year, which is service all the time for you. It is a three-tier psychological intervention for front-line workers. It was mainly directed at shop workers and drivers and social care workers, but it is not exclusive and it is available to anyone. We have had just over 400 people register for the service and we developed it in partnership with Glasgow Caledonian University, and we used their trade e-psychologists to offer psychological interventions. That does not cost a lot of money. It costs about £150,000 a year, and it offers, as I say, up to 4,000 people who we can accommodate. We used an online TBT-based approach called Living Life to the Full as part of the delivery. That is a low-cost, accessible service that I think has worked really well in the past year or so. Thank you, convener. Thank you very much. I want to thank everyone in the panel for their time this morning. I am sorry that we do not have more time to hear your views, but what you have told us has been useful. The fifth item on our agenda is consideration of a negative instrument, and that is the national health service, general medical services and primary medical services section 17C agreement Scotland amendment regulations 2021. The purpose of those new regulations is to fulfil a commitment to general practitioners to remove the general requirement to provide certain vaccinations from their GMS contracts and PMS agreements with health boards, and to ensure that GPs contracts will only require GPs to provide vaccinations generally in exceptional circumstances. The Delegated Powers and Law Reform Committee has considered that the instrument has raised no issues with us, and no motions to annul have been received in relation to those instruments. I ask members of the many comments, first of all, before I ask for a decision if we have any disagreement. Does anyone get any points that they would like to raise in relation to the instrument? I propose that the committee does not make any recommendations in relation to the negative instrument. Does any member disagree? Thank you very much, colleagues. At our next meeting on 28 September, the committee will host two round-table sessions with key stakeholders to explore sessions 6 priorities in relation to social care policy and health finance respectively, and that concludes the public part of our meeting today.