 Gael amdano, ac ddwy'r newid i'r 9 ymddian â'i gydaeth y Helysiau Cymru yn 2017. Rwy'n rwy'n credu i'w ddifrif i'n dda i ddwg ymgyrch yn ddyn nhw, yn amdano, ac yn ddyn nhw fwy o ddyn nhw ymddangosol nhw, oedd yn gweithio'r gwaith yn y rhwng, ond rwy'n rwy'n gyda'u gwych ymddian nhw i'w ddyn nhw i'r gwaith iawn, ond rwy'n credu i'w ddyn nhw i'w ddyn nhw i'w ddyn nhw i'r gwaith iawn, We have two negative instruments today. The first is the Personal Injuries NHS Charges Amount Scotland Amendment Regulations 2017, SSI 2017-58. There has been no motion to annul in the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Could invite any comments from members? No. Is the committee agreed to make no recommendations? Thank you very much. The second instrument is the National Health Service Payments and Remission of Charges and Miscellaneous Amendments Scotland Regulations 2017, SSI 2017-59. There has been no motion to annul in the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Again, could invite any comments from members? No. Is it agreed? We make no recommendations. That's agreed. Thank you. First of all, a remiss of me not to mention that there's apologies from Alec Cole-Hamilton this morning. Agenda item 2 is healthcare in prisons. We have two evidence sessions this morning. First of all, welcome to the committee. Beth McMaster, national prison monitoring coordinator, Her Majesty's Inspector of Prisons Scotland. Theresa Medhurst, director of strategy innovation, Scottish Prison Service. Fiona McNeill, head of adult services, South Prison and Police custody, healthcare, Glasgow City, health and social care partnership. Gillian Galloway, head of prison healthcare, custody and forensics healthcare and out of our NHS T side and representative for Perth and Conross health and social care partnership. John Porter, national nurse advisor, national prisons healthcare network. Welcome to you all. We're just going to move straight on to questions. Why, when we are quite far down the line from the healthcare being in the hands of the NHS rather than the prison service, why do we have such a difference in the healthcare provided to prisoners than we do to people who are not in prison? If I could, convener, maybe start the response. I think the challenge around the transfer of responsibilities has been a significant challenge. I think the health and social care issues associated with the day-to-day provision of health and social care in the community are significant. Factored into that, the issues associated with the prison healthcare population itself, no two prisons are the same. From a greater Glasgow and Clyde perspective, for example, each of the three prisons within the greater Glasgow and Clyde area have different buildings, different premises, different levels of access to supports of a whole range of different requirements. It's difficult to put a size and scale on the challenge. I think that there are lots of examples of where we have gone to improve services to prisoners. Lots of different areas can cite examples in lots of different aspects of improvement, but there's still a long way to go. Five years feels like a long time in some respects and a very short time in others. How long will it take? That's not a question that I can answer. I'm not too sure that the statement is correct. I say that because the care that the population that is in the prison environment received in the community, as far as I can see from research, there is a very underserved population in the community. I think that prison unfortunately serves an opportunity to try to establish the health needs of that very challenging population. You're saying that the service provided in prison is better than what people are receiving outside of prison? I think that there's an opportunity to start tackling that population when they're in the prison environment. I do think that they are underserved in the community. Are they better served in prison? I think that their health needs in prison are attended to once they're in the prison service. I don't think that I could comment whether or not that's better or worse when they're in the community. When I was saying around, there have been some significant improvements in a lot of the establishments across Scotland. That is demonstrable in terms of the way that some of the through-care works for prisoners are on release in terms of giving equitable access, not just equal access to services, while they're in prison to meet their, as John says, quite a complex and needy group of prisoners and patients when they come into the establishments. It gives us that opportunity to work very closely with them, along with the Scottish Prison Service, to meet all of their needs, not just their healthcare needs. I think that there have been significant improvements in the past five years. Who leads on this issue in Scotland on prison healthcare? There's the national prison healthcare board, the network advisory board. It was chaired by Adrena Baddon. That's both NHS and SPS representatives, and that provides some of the direction. The accountability for prisoner healthcare, the delivery, absolutely sits with the health boards. The network was put in place to ease the transition in 2011 into support health boards, Scottish Government and other agencies. Whether or not it leads is debatable. It provides a valuable service in terms of practice. It has a workstream associated with it. It has a work plan that looks at the risky areas around prisoner healthcare, so it provides that support and advice to a host of agencies. Who's driving or who's leading this at government level? I would find that difficult to give you a name person. Following the departure of the NHS Director for Health and Justice, I would be struggling to give you a single policy lead from Scottish Government. Does anybody know? Thank you. I think that one of the panels suggested that no two prisons are the same. I appreciate that, but is there a recognised workforce model for healthcare in prisons? There isn't, actually. One of the groups that NHS board leads get together to look at sharing best practices and come up with a work plan. One of the work plans that the board leads has in place is to look at workforce. There is an intention and a new work stream looking at developing a national workforce tool and liaison with Scottish Government colleagues who lead on planning workforce models. How can budgets and services be directed to improve prison healthcare? From a Tayside perspective, we looked at the workforce tools that were available, along with professional judgment. With our nursing directorate, we worked very closely with them and the head of nursing for prison healthcare in Tayside to look at from a professional nursing perspective. We also involved pharmacy and GP so that it wasn't just nursing, it was a multidisciplinary approach to looking at the workforce modelling. The majority of that was done on professional judgment because there isn't a national tool, but we looked at the professional judgment and the tools that were available for acute wards, for emergency medicine and for community nursing. We adapted them to look at it from a Tayside perspective, and we came up with a baseline establishment for that. Does anyone else have a comment on that? I echo the approach that my colleague has just outlined. We have a professional nurse adviser in NHS Greater Glasgow and Clyde, which is one of our developments. When we assumed responsibility and that post-holder crosses over, police custody and prison healthcare are some continuity. We have taken the advice of that individual around looking at what appears to be needed on a day-to-day and on-going basis and adapted what tools are available to us generally to use. Professional judgment is much more the order of the day in the absence of a validated workforce tool for prison healthcare. Last week, we spoke with ex-prisoners and one of them suggested that when he first went into prison in 1984-85, he felt that prison was full of criminals. On subsequent occasions when he'd been in prison, he felt it now often that some halls looked like mental health wards. HM Inspector of Prisons noted that people with mental ill health are in prison when a hospital setting would be more appropriate but not available due to a lack of beds. I just wondered if you could tell us what steps are being taken to ensure that people aren't imprisoned inappropriately due to a lack of services outwith. That's a question. I'm not sure we can answer that. I mean, I think there was that deemed prisons to be the safe environment, so a sentencer will place, I think, and it's a personal statement in this, will place someone in a prison environment with a mental health condition because it's a place of safety. That doesn't strike me as a health professional that we have it right in the community. I'm not sure, and I wouldn't support that those with mental health challenges in prison should, on the opposite side, be in a hospital environment. I think resources within the community to support people and reach them at a stage where they are becoming unwell, but unwell before they reach prison, and if it's the only option is to place someone in prison because it's a place of safety, I think, is an indictment in Scotland's approach to those with mental health. In terms of the actual placement of the prisoners, that's obviously not sitting with health. I think that what's important for us is that if those health needs are identified, that there's clear pathways in place for them to access the care that they need, whether that is provided within the establishment or whether that is outwith the establishment. A prison's perspective, anecdotally, we have information that comes from courts to suggest that sheriffs sometimes, on occasions, feel it necessary to place someone in custody for their safety. It happens probably more frequently with women than it does necessarily with men, anecdotally. The other area is that sometimes they're put into custody for assessment purposes, and they will get those assessments within our establishments. As Gillian has already pointed out, when somebody comes into custody and it's clear, either on admission or very shortly after admission, that they have acute mental health problems, we will all work together to support their placement in a more appropriate setting so that we can move them there as quickly as possible, but it's variable across the country. Can I just ask one more question? What would a more appropriate setting look like? Is that more appropriate setting always available? A more appropriate setting would be a mental health facility as opposed to a prison facility, because prisons are designed for locking people up as opposed to treating them. There are certain restrictions on what type of support can be offered within a custodial environment, as opposed to a psychiatric facility. If you had concerns, you would take action to have the prisoner moved. Do we know what percentage of the prison population have mental health problems? Yes, data around... Is it any of accurate? It's accurate in terms of the time that it was published, but you're talking probably 70 per cent of the population with a mental health challenge. Good morning to the panel. I wanted to follow up on Alison Johnstone's question there with regard to the research that you're doing around that. What research have you looked into with regard to the relationship with mental health and re-offending within the prison population, especially given that in many cases we're seeing that cycle of re-offending? To what extent do you think that's not really being addressed? I'm not aware of any specific research that is looking at re-offending rates coupled with mental health, and that moved from custody back into community again. There has only in recent years been research in relation to trying to quantify the level of personality disorder within the population certainly when I was at Cortenvale, that's work that we did there, but there's nothing specifically around about re-offending rates that I'm aware of. Certainly the mental health work stream, one of the recommendations was to look at undertaking a mental health needs assessment for the population. That was the recommendation. That hasn't been implemented as yet, and there are efforts to try and source the funding that would enable that research to take place. I wanted to look into it. I've been struck by the number of people we've met who have, in terms of professionals in the prison setting, who have said that head trauma for individuals has been a major issue that hasn't ever been addressed early on. What sort of work is being undertaken within the prison service to look at that and how potentially support can be provided? There was a request from the Justice Committee to undertake an examination of brain injury in prisons. There was a work stream secured in Tom MacMillan. Professor Tom MacMillan led that work stream on brain injury. That report has now been published and with a whole host of recommendations, which I hope you won't ask me to name, but that's a concise piece of work, evidence-based, and I have to say from a very reputable chair. Final question. Another area that I've been quite shocked about is professional saying that online records are a major issue that is preventing them from being able to really improve treatment for the prison population and actually following patient records. Is that something you've tried to improve yourselves and that pushback? Is it a budgeting issue? Because it seems something very simplistic, which could make a huge difference. I didn't quite understand that question. In terms of online patient records being developed at the minute, most professionals that we've come into contact with have complained about paper trial and not being able to really focus on individuals when they're in a prison setting and they're through care, especially when people are leaving prison and registering potentially and that information being passed on to a GP or another professional. I can speak to that, I'm sure that I'll probably want to come in as well. Clinical IT is an issue for everybody that works within prison healthcare. It's called GP vision and it specifically covers all of the establishments. What that doesn't allow us to do is when prisoners are admitted to a prison, we don't have access to their GP records from the community because it's a different GP vision system that the GPs are using. In terms of that transition and through care back into the community, that is a significant challenge for us and we all have to have local solutions to that as to how we work with our primary care services to make sure that that transition is as smooth as possible for the patient on liberation. I think that there's the national work that's on going around the GP reprovisioning. Unfortunately, the prison side of that isn't part of it and it's out of scope for the national GP reprovisioning programme. I know certainly through John and Tom that they've been working quite hard with Scottish Government around clinical IT systems for prison healthcare, but it is a significant challenge. Along with the fact that we can't electronically prescribe, so in terms of all the prescribing and administration of medication, it is on a card X which is challenging as well for the number of patients that we medicate. If a prisoner comes in today and had an immediate health need, you cannot access their patient records. What we can access is called the emergency care summary and that has key information for that patient on it, but we can't access the records from their own registered GP. Does the GP guess, the health professional guess, what's wrong with the person? There's an admission process that they'll go through on admission, so initially they're seen by in ours who go through quite a detailed admission process with them. A person might have mental health problems, they may have substance issues, they may have a whole range of issues that means they are not coherent or can't remember or whatever. If there was any acute concerns by the professional nurse who was doing the admission process then they would seek the support from a GP at that time. Who would then be able to access the records? We can't access. If there was any specific questions then they would have to then be phoned in the GP practice rather than accessing it. Sorry. Which might be closed? It might be closed at that point. It might be. So all that we have is the emergency care information and whatever's on clinical portal, which some key information is on as well. So that's a huge gap in the system? Yeah, it's a significant challenge. Thank you, convener, and thank you, panel, for coming along today. I just want to take it a bit of a different direction, if I may. One of the written pieces of evidence that the committee got was from the British Psychology Society. They noted that there needs to be necessary collaboration between different agencies operating within prisons, including the NHS, Scottish Prison Service and the various third sector organisations in terms of delivering healthcare. This was an area that was also reused with us from healthcare professionals when we sat down with people who actually work in the prison service about the different cultures and the different cultures coming together, Scottish Prison Service and NHS. I wonder if the panel might comment on how they've seen that progressing over the last five years and the areas where we still need to see improvement. I mean, I think that that's certainly something that we notice frequently in terms of inspection and monitoring, really in order to make the most of the opportunity to provide healthcare in prisons. It's important that all the pieces around the table work together, and I think that where there's clear shared vision and clear shared joint leadership around about provision, that's where we see things going well for prisoners. I think that, certainly over the years, because colleagues worked jointly prior to the transition anyway, there's been that continued positive working relationship at a very operational level. Occasionally, there can be operational difficulties either on the NHS side or on the SPS side that can hamper relationships, but I think that we're all very clear that healthcare is such a significant issue. The complexities around the population that's now coming into custody in terms of their healthcare needs, not just around mental health, which has been described, but the addictions issues that the individuals are coming in with. Social care needs is increasing the age of the population. It's a much more elderly population than we've had previously, so I think that all of those complexities together mean that it's much more of a priority for all of us within prisons. We work very hard, but there are obvious differences in terms of, for a prison service, where they are to ensure that we manage the criminogenic needs of individuals, as well as the healthcare needs. Obviously, for healthcare colleagues, they're working in a secondary setting, so there are operational challenges and difficulties that we work through together, but the point that was made earlier about the relationships is absolutely critical and key and at an operational level. Generally, those relationships tend to be very positive. It's interesting that you say that, because we heard evidence that up to 50 per cent of appointments are missed due to prisoners not being taken to healthcare facilities within the prisons. We heard evidence that prisoners not being able to access outpatient appointments because there had been no escort had gone there for them, that there's an efficient use of healthcare facilities within the prisons because of the interplay between having to transfer prisoners from halls to healthcare settings. I'm interested that you're saying that it's a priority, but it doesn't sound from some of the evidence that we've received that SPS is prioritising this? We absolutely see it as a priority. If we cannot meet the healthcare needs of individuals, we know that they can't be supported into working with us around their criminogenic needs. They need to be healthy and well to be able to do that. It is a very clear priority for us within the organisation. I'm surprised to hear that you said that 50 per cent of appointments are missed. I'd really welcome you sharing that information because it's not information that I actually have. We work with our colleagues where we know that there are difficulties. For example, in Grampian, when the inspection report was published there and there were clear difficulties there, we set up a strategic workshop between ourselves and our NHS colleagues and developed an action plan to help to support improvements. Prisons are very complex environments. There are a number of competing demands that we have to work to, and we need to ensure that where there are difficulties and issues that we work together to resolve those. As I said, I'm not quite sure about 50 per cent because that's not something that I've heard previously. That for you, what we were being told was that about 50 per cent of clinical time was not being utilised, not 50 per cent of appointments—and my apologies if that's what I said—but about 50 per cent because clinicians were waiting for prisoners to be brought for appointments to see them, so it was a really inefficient use of healthcare staff time, which is obviously fine night. In addition to that, you were spending huge amounts of time investigating complaints. The complaints side of it is an NHS issue. Medical complaints are no longer dealt with by us. There are, for example—I can give you an extreme example, but it is an example. Edinburgh Prison has six different population types within it. You've got women, you've got remand prisoners, you've got long-time prisoners, short-time prisoners, you've got non-offence protections and you've got sex offenders. It's a very complex establishment. There are populations within that establishment that can't mix together, so therefore you have to take people for appointments at times when it's safe for them. You couldn't have women in the health centre at the same time as some of the other populations. We try, as far as possible, to reduce those operational difficulties, but where you have got those kinds of complexities, then there will be, unfortunately, an impact on those that can access services and how that's managed. Is that a change to Edinburgh Prison population? Edinburgh's had that population mix since 2011, I think. So six years ago? Yeah. So why hasn't a system been put in place that makes more efficient use of the healthcare staff's time? I think it's because of the way that it operates, because you have to keep the population separate. That's why I'm asking why. If that's the givens, then why hasn't a system been put in place that effectively uses the healthcare staff's time? As far as I'm aware, the establishment will be working to that on a day-to-day basis. So the approach that's been taken should maximise the amount of available time there, but there will be operational difficulties from time to time, which will mean that the position deteriorates on occasions. But where we are aware that there are issues and difficulties, no, we manage the clinics and the support that we provide, because when the last population to go in there was the women, additional staff, operational staff were put in to be able to support their attendance at appointments, so where we know there are potential difficulties, then we will look at the resource requirements in order to be able to better manage that. But, you know, let's be straight here. The staff who are working on new establishments are telling us that there are huge problems in that, and they are spending lots of time not on clinical work because they're hanging around or they're answering complaints, and the prisoners who are within new establishment or have come through your establishment are telling us that they need healthcare and they ain't getting it because the staff are spending lots of time doing nothing. That's an issue for your organisation and it has been an issue for some time and we're not seeing a lot of evidence that that issue has been resolved. I think that the issue about complaints I can't comment on the issue with regards to downtime, there are times when clinicians will not be able to get access to individuals because of things like meal times and other types of activities that are going on within the establishment. If somebody is going to visit, for example, they will have to attend their visit with their family, so there are other things that happen, which means that there are competing demands within a prison and it does mean that at times there is downtime for clinicians, but those routines have existed in prisons for some time and it's about making sure that all sides are working to achieve a better outcome. As I say, for example, there were issues and difficulties in Grampian. As I say, we held a strategic workshop between ourselves and the NHS and we looked at an action plan, so if there are other areas that we require to do that, then we absolutely will work with NHS colleagues to make improvements. Gillian, are you getting that back from your staff? I'm looking at the area that you represent and it was some of your staff who were raising this with us. I think that there is a lot of work that we are doing locally with our SPS colleagues locally to improve the efficiency of the health centre clinics. I think that in terms of downtime that they have, I think that we are limited in terms of when we can access the patient. We've got two, three hours in the morning and then the same again in the afternoon to actually have direct patient contact. That fits in with the SPS regime. Is the SPS regime wrong then? I think that there's a work that SPS are doing at the moment in terms of looking at the actual day within SPS and they're engaging with NHS colleagues around how that can improve for both SPS and NHS in terms of accessing patients. We are limited in terms of the times that we've got to see patients, which is different to in the community. Out of an eight-hour day that the average person clinician would work, the maximum is a six-hour window and there's potentially a four-hour window. In terms of direct patient contact, but there are other clinical duties that they have to do in terms of looking at card decks and prescribing and other clinical duties that they do that don't need direct patient contact. It seems to me that the relationship between NHS staff and SPS staff is the crux of this. That has to work at every level. What do you do to bring those two cultures together? What do you train? Do you work together? Could you give the committee some idea of what is done on the ground? I'm happy to take that. In terms of, from a Tayside perspective, we've got quite a clear process in terms of engaging with SPS. We have a higher level meeting with both Governors of the two establishments that we have within Tayside. Part of that is looking at direction and vision of where we're actually going. There's an operational meeting whereby the head of nursing and the head of offender outcomes and deputy governor meet to discuss any operational issues so that there's clear escalation from that if there is anything that we need to support. The team leaders and some of the nurses work very closely with the first line managers and the unit managers within each of the halls. That's quite a new thing that we've put in Tayside just to try and improve that relationship. I think that there's an element of SPS understanding what the NHS has to do and the NHS understanding SPS and the constraints that come with that. What if the issue is very personal on it and a prisoner says to the SPS staff that he knows, he or she knows best, I've got a problem with my healthcare. Are you content that the relationship exists between that person and their equivalent NHS nurse or whoever it might be that might be prescribing or at least providing medication? Are you content that that relationship is good? I think that in terms of the relationships that they have with their personal officers and the relationship that the officers have with healthcare staff, I'm certainly not aware of any issues whereby they have felt that they couldn't approach healthcare staff. Obviously, they've got the independent monitors as well that come in and act on behalf of the patients as well and certainly liaise with healthcare and we work very closely with them if there's anything that we need to address. In relation to staff, usually there are designated staff for particular halls to designated healthcare staff, so that relationship is built up between the staff member and that particular hall staff so that they've got a developing relationship over a period of time and more knowledge and understanding of the individuals within their care. There are a number of our processes within SPS, so our case management processes, our risk management processes, which involve input from our NHS colleagues, so they have direct input to how we case manage individuals throughout their time in custody. The other area is training that you touched on and there are a number of areas where our training is delivered to all colleagues who work in prisons, which it would include NHS colleagues, but there has been some training over recent years more specific in some establishments around about mentalisation, personality disorder, which has been joint NHS SPS-led and delivered to colleagues across prisons, so I think that as far as we can, we try and integrate as much as possible and develop that shared understanding. That should eventually or should be, in a way, overcoming the operational difficulties that you spoke about when being questioned by the convener. A prison has got to dine three times a day, so we have to provide individuals with meals three times a day. We've got a legislative requirement to provide an hour's exercise every day. In addition to that, we have to operate and make sure that people have got clean bedding, clean laundry, that they've got enough kit and equipment, that the prison is cleaned, so there are a number of functions that a prison has to undertake during the course of a day, which means that the time allocated for things like access to medical care is constrained because of the time that it takes to provide those things to the quite significant population. That is changing tack a bit. I think that some of the people want to come in on that point. I think that Theresa touched on a really good point. It's absolutely crucial that the efficiency of officers is paramount to the time that clinicians get to spend with their patients. I have heard on a number of occasions from healthcare colleagues, healthcare managers, boardleads, about where it works well and where there are dedicated officers to the health centre. I am not sure, and I apologise if that is… I am not sure how it should operate, but I do hear that it works better when there is a known body at the health centre and it tends to be slicker and more efficient and less wasted time on waiting about. I think that Theresa is absolutely… I know that the SPS is keen to work with healthcare colleagues in trying to deliver that degree of efficiency. I think that in terms of that point about relationships, we absolutely do see some really good examples of things that work really well. What we don't see as an inspectorate is consistency in that nationally. There is a real question for us about how some of those good examples are rolled out on a national level. While we think absolutely that those relationships do exist in some areas, we see them working less well in others. Can you tell us why? Is there any… I think that that is really hard for us to answer. It is probably more appropriate for my colleagues here to answer that question, but I think that it is about communication and it is about, again, as I said at the start, leadership. I have a slightly specific question about the healthcare assessment, which I think you said that every prisoner receives a healthcare assessment. Are you content that that is being done to a satisfactory level with every prisoner? I have a comment on every prisoner, but certainly within Tayside. I am sure that Fiona will comment from a Glasgow perspective that the admission process is quite a robust process that they go through to help to identify any healthcare needs, whether it is mental health, substance misuse, access and some of the national screening as well. It is a robust process that they go through. I echo Gillian's points. There has been work to refine the process. Over a period of time, the questions that are incorporated in that process might look slightly different now. We might need to do a bit more work around issues from a greater Glasgow and Clyde perspective around the mental health questions. We are having a look at that for ourselves at the minute, but I think that it is in the context of a robust process that could have some areas been a bit better. Thank you, convener. I have a number of questions in a number of different areas, so forgive me if I dot around a wee bit. First, I wanted to tease out a little bit more information about this anecdotal evidence that we have heard of people being sent to prison as a place of safety. I have heard that a number of times when I have spoken to folk working in prisons, and I heard it again in the evidence gathering sessions that we held here. People were very chaotic lives, possibly with personality disorders and addiction difficulties. Prisoners are sometimes considered preferable because it takes them out of the chaotic situation that they are in. I wonder whether that might underestimate the harm that is caused by prison and whether it shows a lack of understanding of the more modern. I have been struck throughout the process that what happens on the outside in terms of treatment of addiction and treatment of personality disorders is very recovery orientated. It is almost impossible to deliver in a prison institution that is essentially institutional and punitive. I wonder if you could give me your thoughts on that and perhaps some thoughts on how we might consider tackling that particular problem. I would not really want to speak on behalf of sheriffs and people further up the criminal justice chain than prisons, but very often people who are chaotic have failed to engage with the criminal justice system and I think sheriffs sometimes get to a point where they are quite frustrated over that lack of engagement. Coming into prison does stabilise individuals in terms of how they will get three meals a day, how they will have their health needs identified and dealt with, because generally they do not tend to be people who have engaged with healthcare in the external environment. I think that when they do, and I have seen from an operational perspective when I was a governor, individuals over the first two or three weeks started to improve their understanding and knowing where they are and what is happening to them, as well as looking and feeling much better and therefore better able to engage with services and better able to understand what needs to come next. In terms of recovery, that is probably something that I would leave to my healthcare colleagues, although we do in prisons try to work very hard with healthcare colleagues around recovery and there are a number of good initiatives across prisons in relation specifically to addictions and developing work around personality disorder. I think that your assessment is spot on and I agree entirely with what you said. Recovery in all these terms has been bandied about sentences, placing people in prisons, no, damage is done, severe damage to some of these individuals and recovering from that. I would be careful there because they are generally in prison for a short space of time. What can we do with that population to make them recover? They are very quickly getting back into that chaotic lifestyle. So for me it is actually way upstream. Scotland is not particularly good at challenging health inequalities. We have a dreadful record. I think that the model is wrong. I think that in terms of that population needs, we need to go way back. It is early years, it is good parenting. I think that the effort should be about preventing people from coming to prison during their early years because you can see that it is a postcode lottery. We can identify those individuals that are likely to come to prison. I know that it is a bit theoretical for me, but I think that Scotland needs to have some sincere thoughts around the model in which we occupy that kind of population. Just to build on what John says, absolutely prevention is important, but if we do get the opportunity in prison to engage with people and get them on the right track, what is really frustrating is that they then often return out to exactly the same situation that they came in. All that potential and all that work is really lost. From the inspectorate's perspective, that is something that really needs to be tightened up. Where there is good work in theory, the transfer should have enabled us to do more in terms of keeping that going. Again, we do not always see that. I think that in terms of the new community justice planning partnerships as well, I think that that gives us a really good opportunity to build on that and make sure that they are through care. We are working very much towards recovery and rehabilitation whilst they are in the establishment. The pathways for them going back out in the community should be there to support that and hopefully try to keep them off of that chaotic lifestyle. I think that that gives us a really good opportunity to make a difference. The other thing that I wanted to ask about is whether I look at the inspection of a prison. There are lots of points where you highlight good practice that is worthy of sharing. I wondered how that process happens. That is a really good question and something that potentially nationally we could build on. There are structures and routes for sharing good practice, for instance, with the health board lead network and the national prison healthcare network, but it is safe to say that we do see positive practice and we do comment on it and we do not always see that being transferred to other places. We understand that in part about the complexity of different prisons and different populations and also about different health boards' relative scope to prioritise prisoner healthcare. At the same time, I think that there is definitely a quick win there. The chief inspector of prison produces an iron report each year, certainly in the past five years. I have produced a summary of the health component parts of that and shared it with all the prison establishments, including the SPS. The final thing that I wanted to ask about is the issue of data sharing. We have identified that you guys are pretty much in the same boat as an A&E department or where I used to work in a psychiatric hospital in that you cannot access GP records. What you can access is the emergency care summary, which gives you a bit of information about current medication and past allergies and things like that, but it is not particularly detailed. It does not tell you anything about the diagnosis, just simply the drug treatment. Another issue that has been identified by lots and lots of people is the need for electronic prescribing and administration systems. The question about whether medication has been administered seems to be a source of huge conflict within the prisons. Would that also be a quick win, although I know that electronic systems are not particularly straightforward, but would that be very high in your priority list of something to do to improve? Absolutely. Unanimously, from a health perspective, it is absolutely one of the things that we want to be able to progress more than we have been able to do to date. It is one of the things that we think has the potential to give big gains to the delivery of healthcare, both in terms of the effectiveness and the safety issues around all that, but also in terms of that holistic approach, having as much information available as possible on which to base decision making and to reduce some of the areas where, undoubtedly, there is conflict. I have to say that I am looking at some of the information that the National Prisoner Healthcare Network has raised about IT. With five years, and it is presumably everybody's mind about IT for five years, and nothing seems to change, why does nothing change and something as fundamental and basic is getting a bloody IT system that works? I assure you that everyone around the table and the back of me are really frustrated with this. Who is responsible for fixing it then? If it is no you, who is it? I think that we do need some strong Scottish Government policy to take a lot of these issues forward. The clinical IT has reached eHealth and those advisors in the Scottish Government to lend support and I think it needs that and unfortunately it has taken a long time to reach the eyes, the ears of people that will enable those IT systems to take place. It may sound an excuse but it has been a frustration for all of us around the table for many a year prior to the transition also. Is that the same with a whole number of the other work streams that the National Prisoner Healthcare Network has been working on but that do not appear to have been implemented? Are these pieces of work done? They are then fed up the line and now it happens? To a degree, yes, particularly those that require finance. Is that the experience of others? I think that the board does not have any direct authority to implement the recommendations and they have to go to the health boards and it is for the health boards to then prioritize that within their funding. Is that the same experience? I think that, certainly within our experience in terms of prioritisation, we have got a clear process to go through and get support from both NHS Tayside and the IJB to support anything that we need to do. But you have not got an IT system? We do not in terms of IT but that is a national issue. That would be my point, the IT issue is a national issue. But there are other national issues as well that you are frustrated with that somebody is not making a decision to fix? Yes, no? From time to time. I just ask for clarity's sake. Is there an off-the-shelf system out there that would give you electronic prescribing administration or, like many of the hospitals in Scotland, does that not actually exist? It is not simply a financial issue, is it that there is not actually a tailor-made package there? Is that correct? Does anywhere use an electronic prescribing administration system that you guys would like to use? I think that in terms of the general GP vision, that obviously does do better. That is not an administration system, that is the problem. So you do not have an off-the-shelf package ready to use? Not that we are aware of, no. So it is not a financial issue, there is something needing to be developed? Colin. Thanks very much, convener. Can I move on to a subject that I think Theresa touched on earlier and that is the issue around older prisoners. A number of the submissions that we received highlighted that one of the key challenges over the next 15 years relates to the fact that we will be dealing with a lot more older prisoners, with a lot more complex health and care needs. I think that the Care Inspectorate at BMA, RCN and Royal Pharmaceutical Society all made that this point in their submissions. So can I ask the witnesses what are the key pressures that the service will face as a result of an age in prison population and do you consider that these challenges are currently being adequately met and will be met sufficiently in the future? I will go first. First of all, an older person in custody, we recognise that an older person in the community is generally over 60, whereas it is 10 years less in custody due to the health issues that are presented. The statistics show that we are receiving more prisoners over the age of 50. That is likely to increase due to the historical sexual abuse inquiries. What we have been doing is working with health colleagues and with local authorities on individual cases, as the more complex cases when they come into custody. We have also undertaken recently an assessment, which is not yet ready for publishing, but we have undertaken an assessment to help inform our strategy over the next three to five years, so that we are very clear about what we should be prioritising in terms of actions. We know at the moment that we have difficulty accessing, particularly, social care for individuals. There is also difficulty accessing equipment, and there has been a considerable amount of money that we have had to spend ourselves on ensuring that individuals have got appropriate care whilst in prison from social care providers, and, unfortunately, on occasions, even though it is not part of the remit, our NHS colleagues, where we have had acute cases, have had to step in and assist us with particularly acute cases where we cannot access social care within the community. There is a lack of clarity over who is responsible for social care in prisons, and we were not included as part of the legislative changes. In one or two individual cases, we have had to accelerate decisions up to chief officer level in order to get agreement on who is responsible for taking forward social care support for individuals while they are in custody. Going forward, we see it as an ever-increasing problem, and the evidence that we have so far shows that there is a proportion of the population with social care needs that are under 50 as well across the range of ages, and we would welcome some clarity over, as there are in other jurisdictions, around who should be responsible for the increasingly complex needs that individuals require support with once they come into custody. As I say, it is not an NHS issue, and that is very clear from our random understanding, which was signed in 2011. Who is that? Is it—you are saying that you are talking about legislative changes. Is that the integration change? The IGIBs were not included in that legislation, so social care in prisons was not referred to. Therefore, it is not clear who is responsibility. At the moment, we will access where we require it. We will access agency support and pay for that for individuals in order to ensure that they are getting the most appropriate care while they are in custody, but there is a lack of agency support in Scotland just now. Therefore, we have to try and work with our colleagues in the NHS, and they have stepped in with some challenging cases in order to provide us with the appropriate levels of care. I advise my colleague Macmillan that cancer support has a very close liaison with prison service. I know that the SPS is working with them. NHS Both Valley is working very closely with them, particularly in line with the population in Glenocl, which is certainly an extreme elderly population. They have adopted or adapted standards to support that prison environment, and I believe that they have appointed a professional lead, I think, just in January of this year, to assist in driving some of those standards forwards, hopefully from a national perspective, rather than just continuing it to 4th Alley in Glenocl. Good work in progress. I just want to touch on a couple of issues that have been covered to some extent before, mainly about through care and just understand that in a wee bit more detail. The point of release can you just describe what the process is for making sure a prisoner or an ex-offender is then registered with a GP as access to other medical services that they may need informations passed on? I know that it is not in the scope of wider issues such as housing etc, which have an impact on health. What does that kind of process look like and who provides it? In terms of healthcare and GP registration, there are a couple of groups of patients here, so if they are planned liberations, we will work closely with the community healthcare teams to ensure that that through care is there so that they can access and have continuity of care around mental health substance misuse and have a GP to go back to. Part of the issues that we have are around if they do not have a permanent address to go back to. It makes GP registration difficult, but certainly within Tayside we are working very closely with our primary care services to see how we can support that further. I cannot comment on the work that the through care officers do, but we will work closely with them to make sure that that through care is supported for all the healthcare needs of the individuals. Where we come into challenges are when people are liberated directly from court and we do not know that they are being liberated, so that makes the through care very difficult for us. Would that happen if they had been on demand, for example, and then got caught and got released? Right. How long would you typically be engaged with the ex-offender beyond release? We would not, in terms of post-release, what we could do and what we do sometimes do is where there are complex health needs as we will liaise with key individuals within the community to make sure that key information is passed on because we do not have the clinical IT to support that through care. I am assuming that the effectiveness of that process could have a big impact on re-offending rates. You touched on that earlier, so do you think that there are improvements there that can be made that would have an impact on that? Is there any data—I think that you said that there was no data on re-offending that we could use to guide that? Since 2015, we introduced through-care support officers across establishments in Scotland, and they focus mainly on our short-term population, not the statutory cases. What they do is support those individuals who agree to work with them to prepare for release, and, as Julianne said, one of the biggest barriers can be access to housing. If someone does not have an address and they do not have an address if they are not fixed aboard, then generally, although we work with housing providers and we are doing work right across Scotland with housing providers to support individuals leaving custody, if they do not have housing provision, it can be very difficult for them to identify any kind of accommodation for them on release, and very often it is the day of release. However, what the through-care support officers will do is ensure that all of the appointments that they have—the appointment with housing, appointment for benefits, appointment for the GP—will go along with them and make sure that they are supported during those appointments to get the best possible outcomes for them. They will then continue to work with them for up to three months after release in order to be able to ensure that they are in a stable environment, because they are individuals who can be very challenging. We know that we have occasions where they fall out with people and they can become aggressive at appointments, so the through-care support officers will continue to work with them in order to overcome as many of those difficulties as they possibly can. Does that support having an impact on re-offending rates? Are you able to comment on that? I think that because it was introduced across Scotland in 2015, it is too early for us to say that. Final point—I will go at the IT stuff as well, since everybody else has—is to be clear on that. The GPs have a system that they use to access medical records. Is that different GPs access a different medical record from other GPs, or have they only access to their own specific data sets? Is that how it works? The GP vision that is in prison healthcare covers all establishments, so where patients are transferred between establishments, that patient journey is reflected on vision. When they go back into the community, that is where it stops. You cannot access the GP records and they cannot access your records. Is that a technical issue or is that a procedural issue? It is a system issue because there are two different vision systems. It is a bit of both, but technically it cannot happen. There lies the problem in terms of engagement, and it is not fit for purpose. We can put a man on the moon, but we cannot do this, apparently, by any means. On the table that we have, it says that, if you are in shots, there is £2,455 spent per prisoner. If you are in HMP Grampian, it is £6,000. Any idea why there is that disparity? Nope. Would you prefer to be in Grampian with a health problem or shots? In your numbers of prisoners that are in the establishment and the sizes of the establishments are going to be different? There is a wide variation. It is £2,500 right up to £6,000 and everything in between seems to be quite a variety. When we were pulling that information together from the Agrieta Glasgow and Clyde perspective, we really struggled with the question because the way in which we were answering the question is a false picture. Taking the number of prisoners on the budget that you have got and dividing it takes no account of—some prisoners will be extremely complex and require lots of healthcare input. In actual fact, if you were able to quantify that and had much more detailed information, you would see quite a disparity in the cost, depending on the presentation that you have to deal with. In some respects, it is historic and it is associated with what was available at the point of transfer, with uplifts over each of the five years. In other respects, it is not a true reflection, it is simply a mathematical exercise and the actual picture for a prisoner or patient might look quite different depending on their presenting needs. If only we had an IT system that could quantify those costs. The final thing was in relation to healthcare complaints. If we look at the table that we have been providing, they seem to have increased dramatically over the five-year period. Is there any panel that will get any view on why that would be? I can perhaps say a little bit from the perspective of the independent prison monitors who deal with a large proportion of complaints in relation to healthcare. I think that it is safe to say that, often, when monitors look into matters, there has not been anything wrong in terms of clinical decisions or policy not being followed. What often is missing is that point about communication, so the extent to which people feel involved in or informed about decisions and about plans for their care. That is not what it says here. The most common reasons for complaints are treatment-received, waiting times, staff conduct and medication. If you take, for instance, medication or waiting times, often part of the issue is that people do not feel that they have clear information about how long they are going to have to wait for an appointment. It is not necessarily that the waiting time is out with what you have seen in the community. The problem is that people do not know how long they are going to have to wait. Similarly with medication, they certainly have not received that information. I echo Beth's comments. Having recognised that communication is an issue, it is about expectation. We are trying very hard across prison healthcare to be much clearer about what patients can expect from the healthcare provision, so trying to provide literature information face to face in lots of different ways around, for example, dental care, what you are likely to have to wait before you have an appointment for a routine dental inquiry, medication, what you can expect, what we ask of you as an individual in relation to the more information, recognising the more information that we provide up front, the easier it is for patients to understand what they can expect from us and the hope that that promotes a dialogue as opposed to a complaint if something is not going the way that they have expected. If the waiting time for whatever is two weeks and the complaint comes in and says, I have waited two days and I have not had that, that is not a complaint. There has been a fair bit of debate and communication between ourselves and the ombudsman about how we handle those issues. There is a hope or an aspiration that, with the new complaints procedure being introduced from 1 April and a greater emphasis and a greater length of time on the ability to resolve issues informally, the hope is that that will have an impact, A, on the number of complaints, but B, on communication generally and expectation generally. Okay, time is beating as I'm afraid. Oh, sorry, yes, I think, John. I wonder if you could help us and provide some additional information to the committee. If there's any work that your organisation has done and made recommendations that have not been implemented, or indeed that have been implemented, it would be good to hear what works has been done that has been followed through and any that has not been followed through. I think that that would be helpful information for the committee if you could provide that. We are finishing this inquiry very soon, so at the end of next week, so you need to send us that. At the end of next week? If you can. Sorry about that. That's okay, Neil. Could I thank all the panel for their attendance this morning and can I suspend briefly to change the panel? Thank you. We're going to continue our work on healthcare in prisons. Can I welcome to the committee Eileen Campbell, Minister for Public Health and Sport, Daniel Kleinberg, Head of Health Improvement and Professor Sir Lewis Ritchie, Advisor for Public Health, all Scottish Government. Minister, would you like to make a brief opening statement? I want to start by thanking the committee and offering some very brief opening and introductory remarks. The first thing to say is that the aspiration to parity and consistency of care in prison and the community is something that unites everyone who is concerned with prisoner healthcare. However, it is important not to lose sight of the fact that the prison population is already very different from the general population precisely because they come from some of the most vulnerable parts of our communities. That means that many of the people most at risk of offending and being deprived of their liberty already come from places in our society where the rates of ill health are unfortunately very high. Similarly, the impacts of poverty, addiction and mental and physical disease run at much greater rates than the average. David Strang, chief inspector of prisons, makes the point in his submission that many have poor health before they are sentenced to a term of imprisonment, and that can be exacerbated by a period of incarceration. That is not to suggest that we can be complacent. It is to reflect that, just like the general population, the prevention of some of the poor health prisoners are produced over lifetimes by the environments that they have come from. However good our healthcare is, in the community or prison, those inequalities need to be addressed beyond treatment and isolation. In the general population and prison population, the effects of those are long-lasting and complex. That is why, since April 2013, we have invested in 296 million to mitigate the effects of welfare reforms and it is also why public health measures focused on the most deprived communities smoking cessation and minimum unit price and will be disproportionately important. Turning directly to the provision of healthcare in prisons, I want to start by thanking the staff from the NHS, partners in the SPS who work hard day in, day out to support prisoners and their families. There is a frustration that, since the transfer of responsibilities to the NHS that progress has felt slow, but almost all of those involved recognise that there has been progress in parts and an aspiration to see more consistency in provision is a common theme among those who work in a hugely challenging environment. The partnership working that Mellon has entered into with the SPS, NHS and local authority to support the palliative care needs of prisoners is a good example of what is possible, as is the work on dementia that Alzheimer Scotland has done in shots. There is always more to do, but the extension of waiting time standards to drug or alcohol treatments in prison setting has been a real positive and an example of seeking to make an offer that meets the standards outside the prison walls. In prisons 1136, people started their first drug or alcohol treatment between October and December last year, with 96.8 per cent waiting three weeks or less. That sits alongside local work on recovery in individual prisons, which is hugely beneficial. It is also important to keep sight of the structures that are there, even if we need to increase the traction. Prison healthcare is the responsibility of integrated joint boards and health boards, and healthcare improvements Scotland provides the health input to the inspection of prisons by Her Majesty's inspectorate of prisons. Where recommendations are made in those inspections, local boards will work with the prison authorities to meet the required standards and levels of care. I share the analysis of some of the challenges that we and partners have gone forward. A better data collection and a move towards consistency of care are something that we all want to see, and we will seek to deliver it against a challenge in back-rope and inherited legacy systems. Ensuring that prisoners and staff are safe is a critical part of the prison care, and that means that some general things such as transport and specific things such as needle exchange cannot just be overcome easily. I believe that the collection of data and partnership working on access to services needs to be the front and centre of the forthcoming work programme of local partners and the national prisoner healthcare network. NHS standards for healthcare provision of primary care apply to the provision of care within the prison setting 24 hours a day. Sir Lewis-Ritchie's report, Pulling Together, Transforming Urgent Care for the People of Scotland, published in November 2015, acknowledges that more work needs to be done to improve the resilience of out-of-hours services for prisoners, particularly around electronic national record linkage and quality assurance of service delivered across Scottish prisons. Work is already under way that will ensure that the clinicians who are working in prisons will have access to the information in the healthcare IT system for people in police custody. Up until now, that has been a gap in data access. Building on this, access to data and data linkages are being explored further as part of the report's implementation. Similarly, we know that many people have poor mental health before they are sentenced to a term of imprisonment. We know that if we get it right or at least better for those with mental health issues who come into contact with the justice system, the benefits will be felt across communities in terms of longer, healthier lives, reduced re-offending and reduced victimisation. We expect the next mental health strategy, due for publication imminently, to give renewed impetus to working collaboratively on the issue of prisoner mental health. To strengthen the drive for change, improving our response to mental health and justice settings is a key priority for the justice strategy for Scotland, which is also presently being refreshed. I am glad to see the SPS taking on the commitment to make prisons smoke-free in the next five years for the sake of prisoners and staff, and for my part that means an on-going focus on cessation resources in areas and communities of greatest need and deprivation. Finally, I want to conclude by looking back to my opening comments about the environment and the wider context from which prisoners come. Prisoners often have young families as well as treatment within prison walls. The support that we are giving to the expansion of prisoner visitor centres to support families is also hugely important. We have worked to move away from short sentences and the unnecessary use of remand because the deprivation and liberty is rightly a last resort. It is encouraging that Scotland's average daily prison population is the lowest that it has been for a decade. All of these are important moves to try and adjust the use of prison to be as supportive of rehabilitation as possible. I thank the committee for their interest and I am happy to answer any questions. We are very, very tight for time, so short questions and answers would be appreciated. In the evidence session that we have just had, Theresa Medhurst, who is the director of strategy at the Scottish Prison Service, made the quite startling admission around social care and who is responsible for that in prisons. She said that the prison service was not included in the legislation around integration and that it was categorically not the NHS who was responsible. She was unclear as to where responsibility lay. Given that we have an ageing population in our prisons and in the world of integrated health and social care, do you recognise that there is a gap here? If so, what is the Government doing to identify who is responsible? I think that it is fair to say that across a whole host of the issues that you have been looking at and that we have heard from your panel today and the panel previously that, despite the improvements that have been made, there is still room for further and greater improvement and for the pace to be improved as well. In terms of social care, it is the prison service that is responsible for social care. That is where we would expect them to take the lead on that and will be enhanced by the fact that they have integrated joint boards as well as part of the structures that support social care provision across the country. I understand that SPS has recently completed a review of social care provision across the prison estate as well. There are also the national care standards that have to be adhered to by the prison services as well and are inspected by the HMP inspectorate for prisons. There is a regime that is structured in place. Whether there are improvements to be made, I would imagine that there are in all areas of health care and social care across the prison estate, but certainly in terms of leadership around that, it is the prison service that is responsible for social care. In relation to that, the organisation family is outside and this is in regard to the new national standards that you referred to. While they make a welcome recognition of the issue of social care for prisoners, many of the standards fail to apply to the care of people in prison. My question is what steps have been taken to ensure that they do apply because it is obviously important that they must apply. We will continue to work with partners across the piece to make the improvements that are necessary in light of the comments that you have had. There is also a collaborative partnership work that has to go across the health and social care partnerships. There is advice that has come from the care inspectorate that goes to the HMP inspectorate of prisons, which will go towards the regulation and the scrutiny of that process. We have the structures in place, the regulatory and the inspection regime in place, and those things together will help to move and motor forward improvements on social care. Just pick up on something. You said that it is the SPS that is responsible for social care. Would it surprise you that the director of strategy and innovation for the Scottish prison service told us in the previous session that she is unaware who is responsible for social care? Or is she not clear who is responsible? The SPS currently pays for social care services to prisoners who require care. There is absolute clarity that it is SPS who is responsible for this. Well, if there is a feeling that there isn't, we will again continue to work, but what we have is the SPS currently paying for social care services. Is there any dubiety about whether they are responsible? No, there is no dubiety. The memorandum of understanding that the moment is between the prison service and health boards does not seem to include integrated joint boards. Why do we have a situation where health boards are responsible for healthcare in prisons, but integrated joint boards are not responsible for social care in prisons? Why is there a difference of approach between social care and healthcare? You are right that the landscape has been changed and it has been a fundamental shift around the biggest shift for the way in which health services are delivered with integration with health and social care since the inception of the NHS. While prisons are not part of that legislation and legislative change, there are very distinct needs that I think are rightly addressed by the prisons themselves around the complexity of the need and the complexity of the challenge that exists within the prison estate. There is good reason for that not necessarily sitting within the legislation. However, partners, in a collaborative sense, are expected to work together to ensure that prisons get the services that they are entitled to, which includes healthcare and social care. Daniel, do you want to further elaborate on that? No, that is right. Prisons were not left out of the Public Bodies Act. The legislation does focus on the delivery of the service. Health services are provided to prisoners on the same legal basis as the rest of the population, but in practice that means that health boards have to work very closely with the service to make services available when a person is physically present in the health board area. Because of the special circumstances of prisons, that obviously just means that it is a different type of negotiation. You can see that in practice it means that buying the service in and the prison service does that through third-party providers. I am not clear why we made a change that health boards were responsible for healthcare in prisons. Why did the Scottish Prison Service still be responsible for social care? Why did we not make that change when integration came into play? As the minister said, it is a change that has come along since really integrated authorities came into play. There is maybe a case for that. We are looking at how those things are operating in practice in local areas, but it is— I think that, as well again, the inspection regime and the way in which it is monitored will drive forward improvements but also illustrate where there is further work possibly needing to be done. If that is something that seems to be considered a gap, we can refresh and look at that and reconsider that position. However, at the moment, the memorandum of understanding between the NHS and the prison service illustrates the differences of responsibility between the two, with social care resting with the prison service and inspected by the prisons supported by the care inspectorate. It is a population that, as far as I can see, is nearly uniquely already accommodated, fed and cared for within a prison environment. A lot of the things that you would be attending to under care standards in the general population are already a feature of what it is required to do in a prison setting. You also have security requirements over and above that and very specific considerations that bring it into the generality and make it something that needs to be an ongoing negotiation. So the Government has a commitment, for example, to make sure that everyone who requires it has palliative care by 2021. Are you saying that arrangement means that the Scottish prison service will be responsible for delivering and ensuring that palliative care is available to everyone within the prison service, which will be a growing demand? You are happy that the prison service is in a position to make sure that that type of commitment, for example, will be delivered? Well, there is already good practice around palliative care already with the partnership that we see between the prison service and Macmillan as well and, of course, bringing in other partners, whether that is the local authority or the NHS more generally, on palliative care standards. That precisely illustrates where good collaboration across a number of disciplines, a number of professions and a number of boundaries exists to drive forward the standards of care for that ageing demographic and those prisoners within the prison estate that have conditions that will require that support. Thank you, convener. I wanted to ask about IT. It was an issue that came up pretty much across the board with everyone that we spoke to. The vision system that is used in prisons is unique to prisons, and it does not connect with the vision system that is used by GPs. The GP vision system is being rescoped at the moment, and the prison system is outside of that. I can understand that in a way, because it is clear that the prison system needs electronic prescribing and administration, but I just wanted to check that that is being looked at somewhere going forward. Absolutely. I think that that has been a very clear theme throughout all of your deliberations. The different people who have come to your panel, whether it was today or your previous one, probably no doubt being an issue that is raised with your own engagement as a committee with the different stakeholders involved in this. There is a clear issue that we need to address, and that is why the Government's eHealth division has commissioned further analysis into establishing more functionality into the system, the technical requirements that are needed for the prison vision system, and there will be work on going with recommendations to follow from that, which we will also include around eprescribing as well. While it is an issue that has been identified and causing a challenge, I think that the work that we have taken to address that will allow us to make significant improvements, because it seems to be a number of times the number of issues that crop up. The key component has been around data, the collection of data, and the inability to do some of those things in a timely way, in an efficient way. That will unpick and unlock an awful lot of the challenges that are there. Clearly, IT development is something that is compelling, not only for the prison sector but also clearly for all systems in Scotland in the healthcare setting. When I conducted my divorce review 18 months ago, it was published 16 months ago, in fact, we produced a number of recommendations, and one of which clearly was to try to unleash the considerable potential of electronic records which we still have yet to do. In order to move this on, one of the things that I am currently doing with colleagues is looking at how my report is being progressed in reality, 21 recommendations, and what we are currently doing is looking at progress. I cannot tell you that, but they are encouraging yet. The actual progress report is likely to be available within the month that we are looking at. I am encouraged by some progress, but clearly there is a lot still to be done. I said so when I produced my recommendations. I said that some will come quickly and some will take much longer, particularly in relation to workforce issues. 11 out of the 28 were in relation to workforce development. One of the principles we identified was that any development of services should be intelligence-led. I think that gets back to the point about the importance of data collection, electronic systems that can communicate more effectively, and us actually having the capacity to shape services with up-to-date information and intelligence to do just that. From the previous panel, the impression that we got was in terms of AIT that everybody knows that this is a problem, has known that it has been a problem for five years. Not a lot has happened, and that appears to be a lack of, if you like, implementation and leadership from above. Why have we not seen any movement on such a fundamental thing, as, for example, being able to access patients' records, full records, when they come into the services? That is just a basic fundamental thing. When can we expect a functioning IT system that talks to a GP system? I think that, in the way that you articulate the issue, I guess that that maybe belies however the complexity of some of this as well and the sensitivities of this as well. While we have addressed and identified that this is an issue, that is why the Government has commissioned this analysis and research to look into the system to see what improvements we can make around functionality and electronic prescribing and a whole host of other things, to make the systems talk together more effectively, to make sure that data sharing and data collection can be done in a much more adequate sense. That first bit of work is expected to be with us in May, and, thereafter, we can keep the committee informed about what practical improvements we can make going forward. However, the work has been commissioned to identify the gaps, identify where improvement is, and we can increase and enhance functionality, where we can get that collection of data that is so important around how we can move the health of the prisoner population forward. I think that that is to be with us in May, and we can keep you informed as the practical improvements can be ruled out. Any prediction on a date when we might have a system? I am giving you the date, but when we are going to get the analysis of where the gaps are and what we need to do— The analysis has been there for five years. People know that it has been raised by the network. I think that it is that specificity and it is the functionality, and it is a complicated issue. I do not think that anyone is under any illusion that it is probably not ideal for people who are working on that, if the system feels clunky, if it is not delivering what they want to do, if it is causing issues at the moment, then it is something that we want to sort. That is why the Government has commissioned this work, to identify what practical improvements we can make to enhance the system. That will be with us in May. We can then work out how we are going to roll out those practical improvements. That is what I am offering the committee, is to keep you informed as that work progresses. I may add to that that, in terms of clearly urgent care services across the country, important, optimal use of current systems is important. So, consistent data sharing will be key to that. It will not just be about new systems, it will be about how best to use them. That also will be very important going forward. Thank you, convener. The Royal College of Nursing comments that, and I quote, not unlike other services within Scotland's NHS budget or a budget and workforce, we are seen as the main pressure points in delivering healthcare in prisons. The demand for services in prison outstrips the resources available to fund and deliver care. The British Dental Association notes that waiting lists have increased and the general oral health of the prison population is not improving. We heard from the earlier panel that there is not a recognised model for a workforce model for healthcare in prisons. I wonder if that is something that we need to address and also how budgets and services can be better directed to improve the health of the prison population. On that last point that you made to address, again in mountain remarks, we talked about how the health inequalities that we experience in society are much further magnified within the prison setting. There is a need to tackle some of those ingrained and deep-seated health inequalities in that prison population, which makes it complex and challenging, and it can make it tricky. The shift towards ensuring that we can treat that within the health setting, as opposed to where it was before, is the right move. Prisoners should be entitled and expect rightly to get access to healthcare that they deserve and need in the same way as if they were not within a prison setting. For that reason, we expect the NHS boards to marshal the resources in an appropriate way to help to cope with the health issues that are being experienced within the prison setting. We have, as a Government, invested in our NHS. There is record investment in the NHS. There are greater numbers of people working within our NHS. That does not take away from the fact that there is a challenging set of circumstances and that there is a challenging fiscal backdrop towards making progress on some of that, but it is around working with the resources that we have to make the improvements that we see and in which prisoners expect. Around the model, one model or template, it is also important to recognise that every single prison is very different. Perhaps it might not deliver the expected outcomes of improvement if you were to have a one-size-fits-all for all prisons. I do not know whether you can really compare Courtney Vale with Peterhead, and that might make it more difficult to have a one single model for how you would configure your workforce. For those reasons, I do not think that that would be the best way forward around configuring our workforce. Nevertheless, I think that the NHS is right to point to where improvements need to be made. Our chief nursing officer is working with her colleagues to work through the recommendations from the RCN report to make further improvements and to take forward some of the actions that came from that report. Donald, do you want to come or maybe—well, if you would like to. It is worth saying that I sit within the health improvement division that works in public health. The most immediate contacts that I have with this are tobacco alcohol and substance misuse, but also the wider health inequalities. When it comes to having a single workforce or a single template, we did an awful lot of work with the prison service and with the NHS and local health and social care partnerships to try and look at drug and alcohol waiting times and drug and alcohol treatment in prison. It is a very challenging environment. The thing that I took away from that is just how difficult a national standard or a national workforce is to apply in different areas. When I looked at the committee's submissions, watching each individual health and social care partnership work through the needs of the prison population is hugely important. For us, it is a very different offering that we need to make within Pullman than it is within Perth. The nature of the men is different and the nature of the treatment required and the nature of what recovery might look like can be very different. I am not sure that I could ever generate one workforce template for drug and alcohol treatment. I do think that what it takes is clinical and professional judgment to be put into local understanding of those populations. I am sorry that you mentioned dentists as well. There is going to be work this year done to survey the improvement in oral health following the NHS taking over responsibility for health care. That will give us more data and understanding of where further improvement needs to go. In terms of needs assessment, I think that this is why you cannot have one size putting all. What we discovered again in the round of urgent care, but also clearly applying to the prison service, was that basically we needed to scale up our workforce according to the needs of the population which are changing. Clearly, we have heard already today that the prison population is ageing. There are new needs appearing like palliative care and there is good work sponsored by Macmillan and supported by Macmillan on that. It is key that interagency collaboration of a very high order is required going forward and the prison setting is a very good example of where that should and is happening. If I may convener, I am aware that we are tight for time, so I would like to try to ask two final questions. The papers that we have show that there are clearly differences in the budget per prisoner spent on healthcare. The paper also shows that prisoner healthcare complaints have raised markedly between 2012 and 2016. Here in Edinburgh in 2012 there were 37 complaints from HMP Edinburgh and that has risen to 513. I would like to know if any work has been done on the correlation between the spent per prisoner and those complaints. My final question, if I may, in the earlier panel, John Porter said that with regards to health inequalities we have still not got the model right. Obviously, we would like to see more emphasis put on prevention and that would help to reduce the number of people who find themselves in prison. When people are in prison there is obviously an opportunity to tackle health inequalities, but we have heard from ex-prisoners who told us that managing to be clean for eight months in prison came out and found himself with a needle in his arm within 48 hours. I think that a universal experience is the lack of through care and services when people leave. If you could maybe address those questions around complaints and the need for better through care. Prisoners have the right to make sure that their voices are heard and that their concerns are known. We have also got the inspection regime there in place and we have taken action to ensure that prisoners have equitable access to the NHS complaints procedures. That has also followed from the shift to the NHS, assuming responsibility for that. In terms of through care, I think that we would all appreciate that there is more needing to be done. However, what we need to do as well is also making sure that our public services understand the vulnerabilities of the population at the point of liberation and what they need in terms of support and how they get that support. The good work that often happens in a prison is not undone through being a lack of support once they are back in their own community. That will be a frustration that will probably be felt by the prison service more generally, though all that good work has gone for not if the person spirals back into the old habits. It is also the work that the cabinet secretary leads in tackling re-offending, because we want to make sure that the support is right. That is why he chairs a group of ministers with a whole host of responsibilities around this, whether that is Kevin Stewart for housing, JB Hepburn, others in terms of employability and social security. That is why we need to get that holistic picture right and why we need to make improvements again in terms of through care to ensure that those vulnerable individuals are given the support that they require. There is statutory obligation for prisoners who have come out after four years to get that through care support as well. There is a range of people and organisations and groups that are there to support prisoners as well. I think that some of the learning from your sessions shows that maybe that consistency has not felt, and that is what we need to make sure happens in a better way. Thank you, convener. I would like to refer members to my register of interests, mental health nurse, because I want to ask a bit about mental health in prisons. We know that proportionately prisoners tend to have more mental health issues or difficulties in the general population. We heard in the last session that up to 70 per cent of prisoners have a mental health difficulty. I would like to know what planning is going in place in ensuring that prisoners have timely access to mental health services. There is considerable effort, and I think that that will be further enhanced as well through my work of my colleague Maureen Watt, with her refreshed mental health strategy, alongside the work that the justice colleagues are doing to refresh the justice strategy as well, which will give sharper focus and allow for greater collaboration around improvements that need to be felt around mental health in terms of the prisoner population. In common with people outside of the prison, people have the right to expect adequate and timely input from the right mental health practitioners. I think that the further drive and the impetus that the mental health strategy will create will further drive improvements alongside that collaborative work that needs to happen, alongside justice colleagues as well. I want to touch on issues around liberation. I think that this is something that I have found quite interesting when we have met professionals and prisoners to talk about re-offending and how important liberation is within that and potentially breaking that cycle. What would you see as the health expectations that someone leaving prison should expect? I suppose that in terms of just some of the themes that we have spoken around, it would be adequate and transition for mental health support if that is required. There would be the continuation around the work around smoking cessation or drug dependency issues. Those things will then transfer to their local GP through those records. While we acknowledge that there are improvements to be made around data sharing, some of that work is transferred to their GP and community setting. They should then, when they are out of prison, expect the same help and adherence to the same targets and guidelines as anyone else, regardless of whether they have had a period in prison or not. On some of the substance misuse work, for example, in the terrible story that we heard earlier, quite often prison is the setting where you can stabilise somebody. However good the through-care outputs are and their variable, when they are out they still want to have to attend, they still need to be able to get to their local groups or whatever harm reduction or recovery approach they want to take. That is just very challenging. You know, quite often dealing with people who have chaotic lifestyles and who do not necessarily want to engage with the authorities having just been released. That is partly why we have supported the provision of naloxone kits within prison, because these are risky times for individuals who are already living high-risk lifestyles. I think that that is where the evidence that we have had shows the opportunities that are not really being realised there. Someone is not necessarily being registered with a GP before they leave. Someone is not even having housing organised before they walk out. A set of £70 to go into their life out is not really going to resolve anything. I think that, more importantly, from people I spoke to, was the option to potentially have a placement or accommodation away from their home community, because they knew themselves that they would be back into a peer group where re-offending was going to happen, like Alison Johnson mentioned, within hours, and that was just going to put them back. I think that that is something that we really needed to see improvements made that they wanted to be helped, but that certainly was not available currently. I would regard that as a form of anticipate that it cared planning. Again, I see that going forward in terms of transforming health services, a significant endeavour needs to be looked at in terms of trying to pre-empt things, trying to plan ahead, not just waiting for the crisis to happen or the opportunity to be missed. This is, again, a very important relation to the prison population, but it is also true, clearly, of other vulnerable members in society as well, so that they can get the best service according to their need. I think that, in the same way that the prison services lead and bring together the support that is required around social care within the prison setting, so, too, would we expect that same holistic approach to be taken when somebody has left that prison setting. That is why the minister, cabinet secretary Michael Matheson, has convened the ministerial group on offending, because we have all got a stake in that as well. That includes housing, employability and the mental health support that is required. It is broader than just health. It is a bigger bit of work that requires many different players and many different disciplines and many different departments to come together and work in anticipating that vulnerability of somebody when they leave the prison setting. When the prisoner is in the prison setting and the prison service is responding to the needs in terms of social care, they are taking that lead to bring together a whole host of different disciplines together to ensure that that prison gets that holistic support that they require. A couple of things. The previous panel was at a loss to tell us who was the lead on that piece of work. Could you tell us who the lead civil servant is and who the lead minister is? I have just described how, in terms of reoffending, there are a number of different ministers with a stake to play because life does not neatly fit into one ministerial portfolio, and there is blurriness around the lines because people have—my colleague Maureen Watt will have responsibility for mental health, I have responsibility for public health. There is a range of different cross-portfolio ministers that will have an interest in it. Of course, for healthcare, in the prison setting, that will sit with the health department and outline a number of ways in which we are looking to take the improvement forward. Who are the two leads? Maureen Watt will take an interest in mental health, which is a huge part of the whole picture. More than just one minister, it is a department and it is cross-cutting many other areas in terms of the through-care. Is that the same for the civil service side? I would expect that to be the case. I think that that is a problem, because people do not know who is feeding up the information to seems to be very much across the piece. The people in the previous panel did not know who they were reporting to or who they were getting information from. There is also leadership at a local level that is required as well. It was not just around rightly that we need to drive forward improvements in a national sense, and that is why we have commissioned work to analyse what greater functionality would require around our IT systems, what more we need to do around through-care. The chief nursing officer is working through with her colleagues and through the prisoner healthcare network around what improvements we need to do in light of the RCN report that they published last year. There is also the integrated joint boards. There is the health departments as well, so there is a collaborative approach that needs to be required. There is absolutely a requirement for national leadership to drive forward improvements within a prison setting. Health care sits with me, the cabinet secretary and Maureen Watt across the piece because of the complexity and need of the prison population. Of course, that means that we have a civil service that has to work across portfolio, but that is better than sitting in one strict place without that collaborative work going across Government. However, we recognise the requirement to drive forward improvement, and that is why we will work across portfolios and different departments to make sure that we get that done in a holistic sense, as well as doing that for through-care and for the prisoners once they have been liberated. Okay, just a final thing. It may have been a slip of the tongue, but you mentioned Peterhead prison, which did close in 2013, so it may have just been a wrong selection of a bit, but we should put that on the record. I apologise. Okay. Thanks very much for the panel's attendance this morning, and I will suspend briefly. Just in a moment, I will put the session with NHS Governance on the record. Dem to what to lead with that just before. Okay. Item 3 is NHS Governance. We had an informal evidence session this morning with NHS staff, and I put on the record my thanks to them for coming in this morning and speaking to us candidly. Would anyone like to open up and reflect on what we heard this morning? Thank you, convener. I found it a really interesting session this morning, and I would like to put on record my thanks to the staff who gave their time to come along today and talk with us. Just to start from a very global point of view, one of the interesting things that I picked up was about staff being keen on having an NHS Scotland-wide governance strategy or guidance, because they felt that each health board had its own governance and given it being a small nation that it should be an easy win to have a national framework. Issues that people want to put on the record. Nails. Nails, yeah. One of the words that everyone and I spoke to this morning kept coming back to is communication. I am quite clear that communication within our health service has taken many steps backwards, and that is from whistleblowing right through to just people wanting to be able to feed into management their concerns and not feeling, firstly, the confidence that they could, but also that they would be acted upon. Some of the points raised specifically were around increasing levels of long-term sickness around this. I think that one of the key aspects of what I heard was management not ever linking in with staff, so people who have problems not knowing who their management are to take that to, but also the need for senior management to shadow staff and see what they are dealing with, and it not just being management looking after the beans, but understanding what people are facing at the coalface. That is something that was quite disappointing to learn again, seems to be completely widespread across the health service. Alison. Yes, I got an impression of an organisation under a great deal of stress. I learned that they were getting at 100 per cent capacity all the time with probably around 85 per cent of the staff that they might need, and that that lack of communication often came from a lack of time that managers simply do not have time to manage properly and develop their own skills and expertise in that management. I also heard about a culture of under-reporting incidents because of fear of doing so and potential implications. A lack of consultation too, even on something as simple as decisions around uniforms, that I moved to one uniform fit all had led some to feel faceless, very much like there were numbers, and also a view that they entered what they believed to be a profession and it has now very much turned into an incredibly hard job. Those are some of the points that I picked up. I would echo what Alison says. I did sense a lot of strain and stress in terms of what people said. There was also a word that was used that struck me, which was that there was a defensive culture in the NHS. Everyone felt very defensive in terms of what they were doing, and I think that that is probably something that we need to address. I picked up a number of things, but the one thing that they all said at the end is that please ensure that your work makes a difference. The work that we are doing makes some kind of difference. The majority of people said that they are under pressure like they have never felt before in their career in the NHS. All of them could identify the camaraderie, the solidarity that have between each other in providing that healthcare, and they got great support from their colleagues on that. They also said that they often got letters or cards or whatever from patients who had been provided with very good care, but they rarely were told thank you with any sincerity by people up the tree in the management system. That was quite a general theme that I heard from quite a few people. A number of them said that they do not know who senior managers are in the system. Even the site director of a hospital, they did not know who they were. I found that quite remarkable that they did not know who the person's name is. That did not appear to be one or two people whom I have had a grievance or a problem. That seems to be a general theme. I did have a number of issues that I have written up, but one that really concerned me on the basis of the things that was in the media yesterday and today about long hours was a junior doctor who told me that she had just came off five sessions, five shift patterns of seven days on, two days off, on eleven hour shifts, five and a row of seven on, two off. That, to me, is not healthy for patients or for her. She mentioned that a number of her junior doctor colleagues had left either the country or the profession already because of the pressures that they are under. That is quite concerning given what is in the media. There are a whole range of issues around staff appraisals, sickness absence, CPD, but we will ensure that those are captured and that everybody else's points are captured in our report. If those could be ensured, we are forwarding them as soon as possible. One of the things that was raised with us was the stress associated with having to work at 100 per cent all of the time. That was certainly made clear that there was a culture of working over time, which was difficult for many of the staff. Some of the positives that were raised with us, and once or twice one of the people in our group commented that we seemed to be talking entirely about the negatives and not mentioning the positives. One of the positives that was mentioned, which we should get on record, was the much better multidisciplinary team working than there has been in the past, which is considered to be a very good, real strength in terms of governance. Another positive was that although there is still the risk of CPD time being lost, it is the first thing to go if the system is under pressure. There was a perception that it was slightly better than it had been a couple of years ago, so there has probably been a slight improvement in that. They felt that CPD was being given a higher profile than it had been a couple of years ago. One of the things that a couple of people said was that, which I did not quite understand, but we can look into is the way in which, if sickness absence goes up, it eats into the budget for CPD. I could not quite understand how those two things were linked, but they were saying that, if it goes up and up, the budget for CPD goes down and down. It seems quite a strange way for things to operate. Did you hear that as well? Again, how that was budgeted for. One of the other aspects that I wanted to put in there was targets. Obviously, there is work going on around that, but some of the people that I spoke to specifically were quite open saying that targets are being fiddled constantly. A lot of that is just about trying to be able to say that you have met a target when, in fact, in many cases, they thought that they were completely unachievable anyway. I think that was concerning that there seemed to be this culture of trying to fiddle to chase a target instead of really looking at the patient experience. Also, what was an incredible resource of people who had worked in the health service for, in some cases, 30 years and just felt that they were not being listened to at all? Ivan, yes. On the point that you made about management, I am going to ask the people who all worked in acute hospitals what the kind of management structure above them looked like. They laughed at me because they could not even begin to describe it. They did not know how many layers there were or who was responsible for what or who was in charge. You can echo the point that you made. There did seem to be a lack of clarity and transparency around who was responsible and who was managing the thing. I think that, to be fair to many of the people who spoke to us this morning who were fair, they said that they do not particularly blame the people who are in the management level because they are under immense pressure to deliver whatever they are being told to deliver. The whole thing is that tension between the pressures that are on the system and the issue about what is being driven from the top completely having no consultation with the people at the bottom about how that is implemented. They were saying that they have many ideas about how to implement change but do not know how they can never implement that change because it is a top-down change rather than a bottom-up change. Although they did say that within their ward or section they can implement some change but when they see a bigger change that needs to happen it is very difficult to influence what is happening at the top. One of the things that was raised in our group on the issue of change was that there just is not enough room in the system at the moment to test change and that naturally clinicians are very cautious about changing procedures because they do not want to move from a system that they know is effective to something that is new and might be less so. There was a concern that it is not possible to test change because the system is currently at such a level of capacity. On the issue of targets, that came up in our group as well. We did not hear—nobody mentioned—fiddling targets. What we did here was that targets were being adhered to almost without any possibility for clinical judgment. There was the idea that the target, which might have been plucked out of the air for 12 weeks for an operation or something like that, but there was no room for clinical judgment from the individual clinician treating that patient who could possibly have judged that that individual patient could wait longer or needed it sooner and that the target was driving how, when the care was delivered rather than individual clinical judgment. A point that was made quite strongly by a couple of people a reliance or a promotion of fixed-term contracts and part-time posts even being offered to new graduates, which meant that when they came in and did a few hours, if they were asked to stay on for the rest of the day, they would not be paid overtime, they would just be paid time. They felt that the use of fixed-term contracts and part-time posts is all about avoiding offering permanent contracts with more expensive terms and conditions. Another issue that we were asked to look at was the number of consultant locum consultants who would not accept permanent posts but would work in a way that is incredibly expensive, so they did ask if the committee could possibly investigate that issue further. If there are any other issues that people picked up on, can you please fade them into the committee clerks and we will try to cover all that. As agreed at a previous meeting, we are now going to private session.