 mwyfolaeth yn ddaf. Cymru'r bwysig hwnnw, a chyfnodd i'r bwysig. Rwy'n gweld, Oeddech chi, ac rhaid i'n gymryd hynny. Fy fideoch i ddwydden nhw, a chyfnodd i ddweud o'r 25 ddweud i griffwyd a gwybod gennym slowlyr. Rwy'n clywed yn ein bod yn dechrau i ddweud o gwaith o ddweud o phoenol a i'n gwybod i amhwyloasoddol. Mae hi'n gwybod i gyddo i wneud ddweud i ddim llaf фawr o'i swfa ar ystod, ond nhw maes gennym thatch, a trafnwyr ei chwliadau i, maes nhw'n droi ei risi ac yn schod trefnwyr ar gyfer companyi llai. DEECTVIDEIS一个 ystau meddwl am y Rhydd y Prifor Weithrau, oherwydd, maes NYG yn cymdeithas i'r Maesileu those facilitating i'r Robert N해�. Nicotine and Care Scotland Bill, the Transplantation Authorisation of Removal of Organs, etc. Scotland Bill and its inquiry into pallent of care in private future meetings. We are happy with that. We now move to agenda item number 2, which is subordinate legislation. We have four negative instruments before us today. The first instrument before you is community care provision residential accommodation outwith Scotland regulations 2015, SSI 2015-02. There has been no motion to and all and the Delegated Powers and Law Reform Committee have not made any comments on the instrument. Do you members have any comment? No. We have no comment. The committee therefore agreed to make no recommendation. Thank you. The second instrument before us is Honey Scotland regulations 2015, SSI 2015-08. There has been no motion to and all and the Delegated Powers and Law Reform Committee have made no comments to the instrument. I invite comments from the committee. No comments. The committee therefore agreed to make no recommendations. Thank you. The third instrument before us this morning is the National Health Service Optical Charges and Payments General of Phthalmic Services Scotland, amendment regulation 2015, SSI 2015-219. Again, there has been no motion to and all and the Delegated Powers and Law Reform Committee have not made any comments on the instrument. Do you members have any comments? No. No comments. I put the question that the committee has agreed to make no recommendations. Thank you. That is agreed. I'll suspend at this point till we see it. Oh no, there is a fourth. I thought we had… No, there were five then, wasn't there? I'm sorry, there was five originally in the four. Anyway, the fourth instrument is and the very, very last instrument before us this morning is the Public Body's Joint Working Integration Joint Board, Establishment Scotland, amendment order 2015, SSI 2015-222. There has been no motion to and all and the Delegated Powers and Law Reform Committee have not made any comments on the instrument. I invite comments from members. No comments. Is the committee there for a recommendation? No. Thank you. We now move to agenda item number three and will suspend for a moment to allow the panel to take their places. We move to our third item on the agenda, which is a second evidence session on national health service board budget scrutiny. Last week, you will remember that we took evidence from the director of finance, NHS Greater Glasgow and Clyde, NHS Ayrshire and Arran, NHS Tayside, NHS Dumfries and Galloway and NHS Western Wales. Today, we would like to welcome Paul Gray, chief executive, NHS Scotland and director general health and social care. Welcome. He is accompanied by Dr Kathleen Calderwood, chief medical officer, John Conaghan, NHS Scotland chief operations officer and John Matheson, director of health finance, e-health analytics, Scottish Government. Welcome to you all this morning. I understand, Paul, that you want to make a short opening statement. Yes, please. You do that and then we'll move directly to questions. Thank you very much. I want to thank the committee again for this opportunity to discuss the budgets. We've just concluded the financial year 2014-15. Subject to audit, we can report that boards have delivered services within financial plans for the seventh consecutive year. In doing so, delivery of efficiency savings has been a key part of maintaining financial balance and boards achieved savings of £284.9 million, which is 3.1 per cent in 2014-15. We start from a strong base in NHS Scotland budgets. We plan for the long term and the short term. We have clear financial planning assumptions. I wanted to assure the committee that budgets are not developed in isolation. They form part of boards planning for service delivery and workforce. Our methods of funding are designed to provide equity, as well as stability and to incentivise the right behaviours on efficiency and planning. Boards plans for 2015-16 will deliver a balanced position. We recognise, however, that it is becoming increasingly challenging to do so, and that challenge will continue. That is why we have a strong focus on improvement and efficiency, and it is why we are continuing the very important work on the integration of health and social care. As always, convener, if there is information that the committee wishes to know and we don't have it immediately to hand, I will undertake to provide it as quickly as possible. I will also make good use of my colleagues who are with me who have expertise in particular areas in which the committee might have an interest. I am grateful for the opportunity to make that brief statement. We now go directly to Bob Doris. Thank you very much, convener. Good morning. I am going to ask about the data that the Government collects and garners from health boards and whether that is done in a consistent, meaningful and comparable way. I am going to mention some information on hospital drugs anticipated price uplifts in relation to that and other MSPs who wish to talk about that in terms of cost pressures in the NHS, but that is not my reason for giving an illustration of the figure. For example, if you look at hospital drugs anticipated price and volume changes from 2015 to 2016, I will give two boards for example. For example, Ayrshire and Arran have an assumed price uplift of 2 per cent and an assumed volume uplift of 22 per cent, as reported to this committee. If you look at comparison Dumfries and Galloway, they have an assumed price uplift of 8.7 per cent but an assumed volume uplift of 2.5 per cent. They are just numbers in one respect, they are meaningless except for this. When this committee does our budget scrutiny and indeed when the Scottish Government takes a view on the local delivery plans of each health board, how can we be sure that those figures have been collected, collated and analysed in the same way and just finally in relation to that? I have no idea looking at those figures if they reflect, for example, the cost pressure mitigation of drugs going from patent to generic. I have no idea to take account of the £80 million new medicines fund that the Scottish Government has supplied. I have no idea if it is a horizon scanning of new drugs that are likely to be approved by SMC and then through to the ADTCs, I think it is. I do not know, but the Government has to look at each health board across a variety of areas as part of the local delivery plan. I apologise for starting off committee on relation to process, but this is very much a budget scrutiny process that the committee is involved in, so how do you ensure consistency and comparability to interrogate the figures of the local delivery plans from each health board? Thank you, Mr Doris. I am going to signal to my colleague John Matheson that I will bring him in on this shortly. Dr Calder would also want to comment on any clinical aspects. I will focus on the question that you have asked, although I realise that it has broader applicability in other areas where there may be comparable or not comparable figures. First of all, boards will make an assessment based on their own local demography. In other words, the patients that they expect to treat and the age of the population would be two factors. For example, we know that certain drugs—if I use greater Glasgow and Clyde, which is not one of the examples that you have advanced—are used more frequently and at higher costs in greater Glasgow and Clyde because of the type of patients that they have within the board area. Therefore, it is not a concern to us if different boards make a different assessment. However, you are pointing to quite sharp variation in the assessment here, both in terms of the likely cost pressures and the likely numbers. We look at the budgets across the piece to assure ourselves that boards have made rational assumptions. That said, we do not seek to second-guess the boards and the clinical advice that they will have had from their own medical director and the clinical governance and assurance processes that they have in place. John Matheson might want to say more about that and then, as I said, Dr Calder might come in to you. Thank you, Mr Gray. Mr Doris, you are right to highlight drugs and to specifically pick on drugs. After staffing, drugs are our next highest spend area—it is £1.4 billion. What we do with boards genetically is that we have a collegiate approach across boards. We discuss planning assumptions as we move forward into not just the next financial year but future financial years, and we do that through the corporate finance group. We look at pay assumptions, inflationary assumptions and the impact of pension increases and national insurance increases. Specifically on that, Mr Gray is right to the extent that there will be a differential approach. It depends on how efficient boards have been at the moment. You picked up specifically on branded to generic and where they are positioned on that. We would expect variation across boards. With regard to your specific detail, we would expect boards to be including within this the new medicines fund pressure. Hepatitis C is another positive example, where there is a differential approach across boards. There is a high prevalence of Hepatitis C users within greater Glasgow and Clyde. They are 25 per cent of the population, but they have about 40 per cent of the Hepatitis C patients. The new drug that has been brought out recently, which actually cures Hepatitis C patients, has a significant impact on greater Glasgow and Clyde. We would expect a differential position. The split between price and volume, I am more concerned about the total trend in expenditure. I am also concerned about how proactive boards are in looking at further efficiencies within £1.4 billion. For example, we are being proactive around the introduction of the Scottish Therapeutic Utility tool, which is made available to GPs to review repeat prescriptions. It is focused on reducing harm and variation, but it will also have financial savings. There is a complex matrix here. The differential is not a surprise to me. The key for me is the robustness of the estimates. Throughout the year, we will then go back and review how accurate those estimates have been with boards. Another example might be that 60 per cent of cancer patients are treated by the Beatson hospital in Greater Glasgow and Clyde. As a subset of drugs that are chemotherapy, drugs are some of the most individual expensive drugs. Again, it is the population that is needing those expensive treatments. There are also very expensive immunomodulator drugs, which one or two individuals may be on. Within a certain health board, we would not know the clinical details of that, but that might be enough to push up an individual budget quite a lot. I thank the witnesses for the clarity in terms of understandable variations in relation to drug costs. I do get that. For example, at Glasgow and Clyde, we know that the committee visited the new robotic centre in the south of Glasgow and the health board's ability to deal with polypharmacy and efficiencies in the system. We get that there can be variations based on performance and best practice, but that was only half my question. The other half of my question, which I do not think was addressed by the witnesses, was about a matrix or a framework by which each of the NHS boards report to the Scottish Government in a consistent and comparable methodology. For lack of a better expression, is there scaffolding around the returns that they have to give and a framework around the returns that they have to give to the Scottish Government? What we have is numbers here. I take on board absolutely all the reasons for those variations, but what we do not have is an explanation as to whether how the boards collect those figures is done in a consistent or comparable way. That is what we need to know. If it has never been done, it is not a matter of blame, but what I want to do is to get to a position where it is done. That is a broader question about making comparisons. Every time we make a comparison, we will get a long explanation about why there is a variation in Glasgow or rural. It is the consistency of the information that has been put before us and how it is collected. And whether those boards use the same methodology to collect that information, or whether, in some cases, they do not collect it at all. That is entirely understood. John Matheson will help us to understand how we collect the information and the consistency of the framework that are applied. I will make this very succinct. We have the corporate finance network, which is the senior directors of finance, deputy directors of finance, who come together and review the planning assumptions going forward. They look at the consistency of the approach across payment prices. We then get the individual returns coming in from boards and we will then respond. If we take Ayrshire and Arden as an example, we will say to them that the average across Scotland for drug inflation and the volume increases is x. If they are an outlier, they will review their position and either change it or confirm that there are specific reasons why they are an outlier. There is a basic framework in place through the corporate finance network, which brings the planning assumptions together proactively for the next two or three years after that. There is a review mechanism built into that whereby the returns are then played back to the boards to allow them to either confirm that their assumptions are still extant or may moderate their assumptions. I will come off the process and allow my colleagues to come in and ask different questions, but it is important. I am partially reassured that there is a corporate finance director framework, whatever that is, in that dialogue between the finance experts in each of the health boards and the Scottish Government and outliers. I get all that and understand all that, but it is the reported figures that we get. Are you saying that they are collected in the same way? They do have the same framework and therefore we can directly compare. For example, when Ayrshire and Arden say that there is a 2 per cent assumed price uplift and the boarders say that there is a 13.6 per cent assumed cost uplift, we can go, aha, that is because of demography. It is not because Ayrshire and Arden have taken into account generics and boarders have not, or Ayrshire and Arden have done a better horizon scanning exercise with future cross-pacers than boarders have. In other words, are the numbers collected in a consistent way, other than just waiting to see how they are collected and then asking outliers to explain themselves? I will not come back for a follow-up on this, because I want to come off the process, but it is quite important. I have picked drugs, because that is the information that I have in front of me. It could be any part of the NHS. Is Dileo's effective budget scrutiny? I am getting maybe that there is good budget scrutiny between the Government and the health boards, but there is a three-legged stool that has this committee as well, and we want to be part of that process. I absolutely recognise the critical role of this committee. The aim here is that the core planning assumptions, which would include those factors that you are identifying, Mr Doris, if you focus specifically on drugs, are included within the planning assumptions of the boards, so that any differentiation is a differentiation in terms of the impact of those core planning assumptions and not the absence of them. I will reflect on that rather than ask a follow-up question. Would it be helpful, convener, if we set out for the committee in writing the basis on which the financial plans are constructed, the basis on which they are scrutinised and the basis on which they are then reviewed at the end of the year? Would the committee find that helpful? I am sure that we would, because the following questions will say that you have got that. How important is the information that you are gathering and how important is to push forward your strategic plan? How do you build on risks to that, like politicians complaining about access to those very expensive end-of-life drugs and cancer drugs, which the boards of our health boards were squealing about? How do you build on that risk of politicians announcing an £80 million fund for rare diseases in the newspaper? How do you build on that risk to all that strategic planning and financial planning? Just to make an additional offer to Mr Gray's offer, I would be happy to take a couple of boards where there seems to be a differential outcome and explain to the committee why that differential outcome has occurred, if that would be helpful. In terms of the £80 million new medicines fund, the boards will be looking at their individual cost profile against that, so we will have from the SMC horizon scan in terms of what drugs are coming down the pipeline over the next financial year, we will have the impact of individual patient treatment requests, the impact of ultra-orphan drugs, and as Dr Caldy would point it out, because they are a low volume high cost, there is a different profile across Scotland, so I could lose a map for a specific fibrosis. It has a very small number of patients across Scotland, but the cost of the drug is several hundred thousand pounds. It may be useful if you compare reality and the pressures that run the system against budget plans. Since I was on the health committee and it goes back a number of years now, we have been talking about controlling the price of prescribed drugs, and we are still at it and we have estimated that when drugs going off-patient would generate an X amount of money and would reduce the drugs bill or whatever, it has not happened to the significant extent that we expected to happen. We are focusing on a bit too much on drugs here. We will get a wee bit more coherent as we move in. We are trying to see where the budget planning actually is pushing along the priorities and the long-term strategies of government about delivering care more away from clinical and community settings. We are hearing about all the pressures that affect a budget, and some of the priorities are trying to get at the heart of that. We are focusing quite rightly on the cost of drugs, but our focus on how we look at how drugs are utilised is not more focused on the variation in patient harm to try to ensure that we have that clinical focus on how we review the drug expenditure. It could be drunk, but it could be workforce planning. We assess the health of the health service and the basis of how many doctors and many nurses have an old-fashioned idea now, but we still do that. We spend an ordinal amount of money recruiting people outwith the budget planning. That is what we are struggling with here as a committee. Who have we got? Richard Simpson. Richard Simpson, I congratulate John Matheson on his honour after Richard Simpson. I want to focus on the question of the incremental cost of achieving targets. There is no doubt that the whole committee would agree that targets have served us extremely well since the Parliament was formed. It has driven forward performance in a way that previously had simply not been possible. It was quite clear from both an FOI that I did and the evidence last week that we have some problems. First of all, the FOI in which I did, the overwhelming majority of finance directors could not tell me the incremental cost of achieving targets, the final group of pushing them through. Last week, we heard from Derek Lapsley at Ayrshire and Anne, an example of a waiting list initiative where they were having to pay the consultant three times the normal rate in order to get them to undertake a waiting list initiative. All the finance directors agreed last week that the cost of achieving that final element in the target, particularly when it is 100 per cent and it is a legal target, is just a huge cost to the health service that is actually not spending money wisely. Can I ask you whether you think that this committee, as a collective, has nothing to do with party but whether we should be joining the RCN's call this week to say that we need to look at whether we modify these targets in a position of austerity that we are in to actually spend our money more wisely? What are the costs? Do you ask for the costs and is it money spent wisely? Dr Simpson, you are right to say that it is hard to determine the incremental cost of meeting the last 1% or 2% of any particular target that we could apply to the treatment time guarantee and doubtless to other targets. The position of someone being paid three times is the standard rate in terms of asking someone to work at a weekend and that is the rate that applies. If there is a waiting times or other high-profile target that is being addressed through an initiative, some of those costs will certainly be incurred and it is possible to calculate what those costs are, but the overall cost of meeting the last percentage points of a target is not something that we routinely collect. You are asking me whether I think that this committee should join with the RCN and others in seeking a review, particularly of the treatment time guarantee. It would be for the committee to decide its own position on that, I would say. What I will say is that, as the chief executive of the national health service, I must and will remain committed to meeting the treatment time guarantee for as long as it is a legislative requirement. I cannot do otherwise, but if the committee, on the basis of the evidence before it, felt that it ought to press for a change in the legislation, that would be a matter for the committee. It is fair to say that the last percentage points of the target cost money to meet, and it is also fair to say that some clinicians have questioned with me whether at the far end of the target it is absolutely clinically necessary to meet it in every single case. However, having made those points, I must none the less proceed on the basis of the legislation. I cannot do otherwise. It goes back to the original, the first five minutes of going round the issues bit. This committee cannot make a recommendation unless we understand what is involved. Until we get some idea, some modelling, which I am really surprised is not being done, of the incremental cost at the far end of meeting, or not meeting in the case of 10,000 Scots who did not get the legal guarantee last year. We are not even reaching it. I know that the fractions are small. We are 99 per cent there, which is fantastic. It is a great achievement. However, to force the system to achieve that final 1 per cent and indeed not achieve it is costing us a fortune, which could much better be spent in other areas, I think. But unless you in the centre can supply the data, get the boards to model, there is no way that we can make recommendations on this. Thank you, Dr Simpson. I am happy to take from the committee a request that we seek to do, first of all, to establish what we do have available. Finance directors have said that the information is limited, but let us establish what we do have. I will also consider ministers, because ultimately it will be a decision for them what more we might do to collect information about the incremental costs of meeting the last percentage points of the target. I am happy to take that away from me. When we decided to improve the waiting time targets, did the people doing the budgets now say, well, that is a great idea, minister, but this is what it will cost? Or did that not affect this budget process at all? We just said, oh, that is fine. However, there was no information about costs and outcomes at the heart of that decision to go further in waiting times. Is that what we are hearing today? What I am saying is that I cannot speak for the advice that was given to ministers at the time, and of course advice to ministers, as the committee knows in private. However, the decision was made through a parliamentary process. The legislation was scrutinised in the normal way. There would no doubt be the normal costing information associated with that. However, what we were not asked to do once the legislation was implemented was to collect information on the incremental cost of meeting the last few percentage points. Therefore, we do not have a system in place that routinely does that. The committee, as I take it, is saying to me today that it would be interested to have information on that. I will raise that point with ministers and we will come back to the committee quickly on that point. Bob Doris, you want to comment? Very brief supplementary, because we already had an opportunity to convener, but very specifically on Dr Simpson's point about 100 per cent treatment time guarantee, whether it was 100 or 95 or 90. As soon as you set a target and there's a number, you're always just going to be half a percent or 1 per cent or 2 per cent away from meeting that target. So, if targets are reduced, be it from 100 per cent or 95 or 90 per cent, is the principle not just the same? To meet that target in absolute terms requires additional cost, so it's not that the target sits at 100 per cent. It's as soon as you put in a target, when you're just short of that target, it's one final heave to get over the finishing line to meet it. Would that be a reasonable thing to say? So, we shouldn't just focus on the treatment time guarantee. We should look at that additional money and cost to get over any target, and then, of course, for the politician to decide which targets we believe are most important. Can we broaden that, Bob, because it wasn't just the money we were hearing. We were hearing that these targets were driving the priorities more than the planning frameworks or whatever they were doing. So, it's not just about money, it's about how they're diverting us from some of our other strategic objectives and policy. That's, I think, what we heard last week. I'll bring Mr Connachan in a second convener, if I may. The chief medical officer may have a comment on the clinical aspects of this, but let me try to cut this up into three parts, if I may. First of all, there is a difference between 100 per cent target and, say, a 95 per cent target such as we have an accident and emergency. What we're saying in accident and emergency is that it will not always be clinically appropriate to have someone seen, treated and discharged from A&E within four hours. Most of the time it will, in 95 per cent of cases, the clinical advice is that it is appropriate to do that. For example, within the past few days, a person in one of the A&E emergency departments in Glasgow was there for well over four hours. Throughout that four hours they were receiving appropriate treatment and care and they were too unwell and unstable to be moved. It would have been wholly inappropriate to take them out of A&E within that four hour period. That's the first point. A 95 per cent target with some flexibility for clinical judgment is different from 100 per cent target. Second point, therefore, the cost of meeting a 95 per cent target will be driven somewhat differently from the cost of meeting a 100 per cent target. There is a degree of flexibility for clinical decision making in the A&E target, which is not present in the treatment time guarantee. Thirdly, I'm slightly hesitant to say that targets are one thing and priorities are another. I mean, it is a priority to see and treat and discharge people from A&E within four hours. That's a priority, as well as a target, although we now call it a standard. So, to say that those are deflecting us from priorities, I wouldn't like to go that far. However, I take the point that the committee is making, that if the expenditure to reach the last fraction of a target is proportionately excessive and doesn't deliver clinical benefit, then that may be something that we should look at. I think that it's probably worthwhile just remembering where we were back in 2005-06. At that point, the NHS had what we call the performance assessment framework. There were over 200-plus individual targets boards. At that point, we're complaining, look, what is the priority here? We need some degree of focus in terms of what we're doing, and out of that came the then heat system, which was established in 2006-07. As of today and listening to the advice that we've taken from this committee and, indeed, through consultation, we're going to have 20 standards in the NHS, which I do agree with the committee. Those do drive investment in certain respects. It's worthwhile, I think, maybe just saying that these come into seven broad categories, so you can subdivide the 20 into seven broad categories. These are cancer standards, mental health standards, waiting times, infection, finance and governance, emergency services and, broadly, some standards around health improvement. Those are things that are really all important for both the health of the population and, indeed, the efficiency of how we pursue the deployment of our budget. When we engage with bodies, for instance, like the College of Medicine on what is appropriate, they invariably come back and say, look, our particular standard, which is the four-hour A&D standard, is one that we really don't want to shift or move away from. It's important, so we do take advice on those, but I do think as a moot point about the incremental cost. I have some sympathy with Mr Doris's point that, if you were to make, let's say, 12 weeks, 15 weeks, then there's an incremental cost in reaching the 15th week, if I can put it like that, but I do think that the tighter you draw a particular standard, there is an argument about some incremental cost. I think that we've heard from the director general that we would supply some information on that. Dr Conlow, do you wish to add anything to that point? I suppose just to say that if we stick with the four-hour A&E waiting time target, that's a process measure. It doesn't tell you how good you are at the end of that time, but what we do know is that it's based on evidence that the longer you spend in A&E, the poorer your outcome and the more potential harm that occurs. Those are proxy measures that are driving clinical improvements. We have outcome measures and the cancer standards would be more along those lines where we know a percentage of patients who serve a five-year survival, for example, but what we really struggle with and those targets are proxies for our quality of care measures. It's very, very difficult to measure quality of care. Of course, not everyone will have a good outcome, but what we want them to have through our NHS is a good quality of care, even if the outcome is something that we cannot prevent a poorer outcome. We need to make sure that we understand that the treatment time guarantees, or the four-hour waiting time, are based on good sound clinical advice. It sounds like just a number, but in fact, they have always been developed with patient care and patient outcomes behind them. I think that, with the recent raising of the RCN of looking at these targets, we know that this is an evolving process. We've changed over time, as Mr Conahan has said, and I think that we would always be willing to revise targets, to revise standards, partly because the way in which we work in medicine changes. That engagement has been quite important to make the point that progress has been made. I recognise that, presently, there are a number of targets, and there are also heat targets, such as performance targets. There seems to be an awful lot, but, in comparison to what we had, there has been a reduction there. We also picked up last week about gathering information that doesn't really tell us very much about how many people died in hospital as against the community, and then boasting about how more people are dying at home, but with no reference at all to the quality of that care or engagement. Hopefully, you see where the committee is going with some of that. Can there be more clarity? Do we need more clarity? Do we need more focus? Certainly, the good point was made by Dr Calderwood. How do we measure quality and the impact in patients in all of this? I will let you back in, Richard, because there are some of the other headings there that you might want to speak to. Richard Lyle wants to… Richard Lyle Do you come in on this factor? A number of years ago, I wore glasses. I had cataracts. I went and got cataract operations, both eyes, on two weekends. At that time, you had the number of people waiting for cataract operations. With the greatest respect, I have to ask this question, because it's a question that's always annoyed me. Does it annoy you and politicians from whatever party interfere in the NHS by turning on and saying, change that target, put that target up, put that target down? How much does that annoy you? Richard Lyle I think I'll answer for all of us, the interests of diplomacy. Mr Lyle, if it was my stock in trade to be annoyed by politicians, I would not be a civil servant. I respect that. I respect the democratic right of the people of Scotland to elect the politicians of their choice, and I respect the right of the politicians to decide. We are here to advise, politicians are here to decide, and I'm perfectly happy with that. If I allowed my personal views or what might annoy me to enter into my judgments about what I did, then I don't think I would be doing my job professionally. I welcome the challenge and scrutiny of committees like this, and I welcome the challenge that politicians of all parties provide. Generally speaking, every politician I have met has a motivation to make things better. They may have different views about how it should be done, but I respect the right of the politicians to take the positions that they take, and I'll work with that. If you have a further question, Richard, have you had a further question? Basically, along that line, at the end of the day, yes, we have targets, but should we not ask politicians every party to sit down and agree where we are going with our health service? It annoys me intensely, I have to say it again, that the NHS becomes a political football that every party takes a swipe at, and we are all in that game. Basically, what I'm saying to you is that, based on the point that Sir Simpson has made quite correctly, should we sit down and give you clear directions that every party signs up to, and once we have signed up to it, we stop throwing bombs at the NHS? The more consensual decisions about the NHS, the better, as far as I'm concerned. I wouldn't deny the fact that it makes my life easier if there is agreement about what the propositions and the solutions and the outcomes should be. That said, I would not at any time want to stifle healthy debate about the future direction of the national health service. It is a complex, multifaceted system. It does not operate in a vacuum. It operates in the context of all the other public services that are provided. It operates in the context of the demographic trends that we face. It operates in the context of health and social care integration. To suggest that there will ever be one simple solution to the problems that we face would be naïve of me, so I wouldn't want to stifle debate about the options that are ahead of us. At the end of that, a consensus will certainly make it easier to implement. I want to widen the scope a little. I want to look at how you evaluate and how you account for the preventative care aspect. When you are looking at, as Mr Gray and your colleagues have mentioned, improvement several times, does improvement equal efficiency and does efficiency still look after patient care? If we are looking at the broad aspect of prevention—at the end of the day, we would like to prevent people going into hospital and looking at other integrated services, perhaps—how do you manage to account for that? Is it not that the variables across all the boards must be complex and multifaceted? Let me start by saying that evaluating the efficiencies or savings that are delivered from preventative interventions is quite hard, because you are making a judgment about what did not happen as a result of the intervention that you made. Nevertheless, there is evidence across a range of preventative spend that early intervention is more cost-effective. For example, the early years collaborative, the raising attainment collaborative—you could argue that those are preventative measures—helping people to intervene early in the life cycle of a child, to intervene with a child and with their families, to intervene in ways that are co-produced and not superimposed. There is clear evidence that, by doing that, the life chances of children are improved. Can I say explicitly that that means that there will be so many fewer visits to hospitals, so many fewer interactions with the criminal justice system, a better education, a better outcome for every child? I cannot say on an absolute basis, but what I can say is that the evidence suggests that early intervention in these circumstances means that the life chances of children as a whole are improved, and therefore that is something that we want to have. One example, perhaps in a narrower health setting, is the hospital-at-home service, which I have seen in many places. I will pick on Lanarkshire as my example for today. That prevents elderly people from going into hospital, and I have spoken to both patients and families who have benefited from that. Now, the outcome for the individuals is definitely better. You asked about whether those were all about improvements for efficiency, and what did we think about the outcome. There is no doubt at all in my mind that the outcome for the individuals was better. Even to the simple extent of a lady being able to give an account to me of spending Christmas at home with her family instead of spending it in a hospital bed. I understand all those points, Mr Greer. I absolutely understand all those points. The thing that I am trying to ascertain is that how do you account for that from the budget perspective? How do your directors of finance model that into the framework, and how do they do that across all the boards? I will bring in Mr Korrach and then Mr Matheson on that. I will stick with my example of hospital at home. It can be applied more widely. I have asked that further data be collected on not just the outcomes, although they are really what we are striving to achieve, but also the relative costs. We are reducing the pressure on accident and emergency. We are reducing the pressure on unplanned admissions to hospitals, but we also know that we are paying a cost of having in this case a senior consultant geriatrician and a number of other clinicians working alongside that individual in Lanarkshire, so that cost has moved out of the hospital into the community. What we are not yet absolutely clear about is whether the net cost is the same or lower. We do not believe that it is higher, but we are not quite clear yet if it is lower. I am just being honest with you about that, but I will ask Mr Korrach and then Mr Matheson to add something. Thank you. For the past few years, we have taken the opportunity to publish a number of case studies where efficiency and productivity gains have been realised while also benefiting patient care. I think that you asked a direct question about how you account for those things. The annual report, which is a calendar year annual report, was just about to be published shortly. It has about 50 case studies. Most of those have quantification in them. A small example is a board case study in here from NHS Lothian about how to promote quality and cost effectiveness in use of wind dressings. It is not just Lothian blowing its own trumpet. It is a series of examples that are applicable to most boards, and we encourage most boards to adopt these good principles. There are other examples, but we have been doing this now for about four or five years in publishing that annual report. Mr Robertson, just one generic point and then two of the specific examples. The overall strategy that we have in NHS Scotland is the quality strategy, and the thrust of the quality strategy is safe versus entered effective care, and people have been treated at home or in a homely setting. Our sub-strategies all point in that direction in terms of supporting that. I mentioned earlier prescription for excellence, so prescription for excellence from a preventative perspective is looking at how we get a strength and engagement with community pharmacists, how we reduce the number of unnecessary admissions that are due to medication errors, where the figure at the moment that Dr Caldwell can correct me is around about one in seven of all the admissions that is caused by that. A more proactive engagement with community pharmacists is a reduction in harm there. Within our overall financial strategy, we identify specific sums of money to take forward that preventative agenda. We have a very specific investment in telehealth, telecare, looking at home monitoring, looking at the use of technology to delay admissions. Another example is within the Scottish Ambulance Service, where we have just invested as some of money as part of an on-going programme to upskill paramedical technicians, to allow them to assess people in their homes and rather than take them into A and E to stabilise in their homes. That needs a strength of community engagement in terms of community nursing, social care etc, to enable those people to be kept in their homes. Those are two specific examples in the context of our strategic direction. Community automotry, for instance, if people have regular eye tests, it prevents maybe trips and falls, that sort of thing. It is pretty subjective, isn't it? And what I'm saying is what numbers do you assign to it in terms of money? Because the finance directors have got to come up with some costings in their budget for this strategy. The definition between specific investment, appropriate investment, sufficient investment to drive more people being treated. There are no targets to ensure that the X amount of people will be cared for in the community, at home or close to home, but we have if you've got polyps or something or that you can get through the system. I suppose what we see is the absence of a number of features that we would take for granted within the NHS setting, which would be prioritisation, quality of outcome for the basic guidelines and standards, all applying targets to drive that activity, budgets to support it, whether it's the equivalent within the community and the integrated boards. Are we investing enough there to drive that change over a period of time? Sorry to come in on the integrated joint boards. The outcomes for the integrated joint boards are set in legislation, so they're clear. The budgets for the integrated joint boards are subject to scrutiny, and this is the shadow year. To go back to the point that Mr Dorris made early on, there is variation in the budgets of the IGBs, which is not all explicable by the demography and geography of the IGBs, but it is also explicable by the fact that there are certain things that they must include in their integration scheme and certain things that they may include in their integration scheme. Different integrated joint boards will have decided to include different things. I realise that what I'm doing at the moment, convener, is describing to you the things that always make comparison harder, and you're asking me how can we make comparison easier. There isn't a straightforward answer to that, because different factors apply in each board and in each integrated joint board. However, each board is operating to the same financial standards, each territorial board is operating to the same performance standards, each integrated joint board is operating to the same set of outcomes set in legislation, so to that extent there is commonality. The question that you're asking, and it's a legitimate one, is how do I assure myself as the accountable officer for all of this that the different portions of money, the different budgets that are set in different places, are all going to add up to the outcomes for the people of Scotland that we want to see. The answer is I do it through a series of assurance processes that already exist. I have to accept some of the assurances I get on clinical and financial matters from the people who are expert in these matters, but nevertheless I am able to look down a series of assurance and governance mechanisms that help me to draw this together into a single picture and I am confident that what we have in place is at the moment providing me with sufficient assurance, I'm equally confident that it could be better. So there are areas in which we could improve and in the year of the shadow integrated joint boards we will look to review and analyse the propositions that the integrated joint boards have put forward and to learn from these so that when we come to the first full year of operation in 2016-17 we will not simply walk into it as though this year had not happened. Dr Caller would have a specific example on maternity services which I think may be of assistance to the committee. I'm delighted Mr Robertson that you've asked a question about preventative spend because as you may know I'm an obstetrician and so I'm always telling my colleagues that if you only invested in the pregnant woman you would have a healthier baby who would grow into a healthier child and adult and in fact I could solve the costs of the NHS in the future. I'm sure that the committee is familiar with quality adjusted life years, so how much do you need to spend in order to have a one more year of quality life and if you take prevention of pre-term delivery that is the ultimate because for these babies if they live long healthy lives of course they have very long lives and in fact the prevention of pre-term delivery only costs £300 per quali as opposed to something that we would up to £10,000 would be deemed value for money. The investment though is difficult because it's multifactorial so Scottish Government has invested in a maternity collaborative, a maternity safety collaborative which involves reducing all sorts of harmful problems in pregnancy such as smoking which would in turn prevent pre-term delivery but the difficulty of measuring that is that if we also reduce all sorts of other issues we may also have other knock-on effects on to pre-term delivery so the boards have invested £1 million across Scotland in some maternity champions who are looking at tackling all of these outcomes for pregnant women but I suppose to then go back to them and say well how much did you save is very difficult to actually quantify that so what we can see already is very impressive reduction in stillbirth rate we know that the smoking ban across Scotland generally has reduced our pre-term delivery rate but actually being able to say we spent x and gained y is extremely difficult I would however commend you on continuing to ask that question thank you I'm just trying to get the efficiency every board is asked to have an efficiency spend our reduction I suppose across all the boards and what I suppose concerns me is how you prioritise and what falls off the end what what's not happening maybe to attain those efficiencies are we not delivering a particular aspect of care to a patient for that outcomes that we look for because when you're asked to prioritise does something have to give and if it does where is it is it around the preventative spend is it with the joint integrated boards you know I'm just trying to work out in terms of the spending because we have finite resources everybody has their own budget but you're asked to have that efficiency so if you have the efficiency in every board has one how do we prioritise it I'll ask mr Matheson and mr Corithon to come in but I will share with you mr Robertson an area where I am currently taking some steps to see if we can improve I am concerned that in the pursuit of efficiency and delivery we are under playing our hand on developing leadership capacity within our workforce what do I mean by that well it would you see because leadership capacity is one of the in my view one of the keystones of prevention it prevents things from going wrong so we've had a very helpful and robust conversation for example with the academy of royal colleges in Scotland and that has in part been about the extent to which consultant contracts allow sufficient time for consultants to develop themselves and their leadership capacity and while I have not sought to impose a particular solution on boards what I have said to boards and I've said it in writing is that I expect them to be flexible in setting up and then reviewing consultant contracts because I attach great importance to senior colleagues whether they're clinicians or administrators or whatever they are within the NHS having the time and space to develop an exercise proper leadership because if they do not the impact of that can be quite high so that's an area which perhaps is overlooked in terms of prevention but I see a very strong link between leadership capacity and prevention just repeating on the consultant contracts now the consultant standard contract is 7.5 2.5 that's the nationally agreed contract 60% of all the consultants appointed since 2011 have been on 91 so how does that fit with your concept of leadership if we're requiring our consultants to only have one session for audit research leadership development continued professional development training of staff if they're not in a teaching hospital you know that's really not fitting with what you're saying and I entirely agree with what you're saying about leadership it isn't working and the second question asked was how many of them are converting because maybe you're saying oh well you know consultants now are starting younger they don't have the same breadth of experience they need to do the clinical work for a year that was what I was told by the board in Tayside which I raised it with originally and I said right okay well how many are now converting after a year or two to eight two or seven point five there's very little sign of conversion very little sign so you know I'm just say whilst agreeing with you let's start with having these clinicians who are complaining quite strongly about being overworked and stressed and we've got the highest vacancies we've had for a long long time in terms of health service and consultants and so I just ask how you monitor that because on the centre you can't control it that's the boards that do it but I mean you know we have that national contract how do you monitor it what advice do you give them and how does it actually fit with your leadership plans well um Dr Simpson maybe the simplest thing I could do would be to share with this committee what I have written to the boards and what I have agreed with the academy of royal colleges I'd be very happy to share that and Dr Calder would may have something to say in the meantime about the approach we're taking to consultant contracts and ensuring that consultants do have sufficient time to develop themselves and develop the others around that I think this has been raised and and my colleagues are raising it with me particularly some health boards where it's been applied more stringently I suppose we we need to remember that although it's 60 percent of consultants that that's a very small number of the total consultant body and we we also need to remember that the many many more jobs with more consult the same department has many more consultants within it so that there is perhaps an argument that not everybody needs all of the time to do these extra things than was needed previously because for example in emergency medicine we have 170 percent uplift in consultant figures over a very short period of time what we're talking to the clinicians about is is the standard being one PA one session but that in fact if they have coming to their interview or coming to their job plan to say but I'm doing this teaching session I'm also involved in college work x y z that is actually able to be defined as time that is being spent properly and that the NHS is getting good value for that that time that in fact that is a negotiating stance that they can have with their health board what I think we worry about was that people were being automatically having a lot of time and that's a lot of time in a week additional if it's not being used efficiently and effectively and there was definitely evidence that it wasn't being so people were going home early or doing other things with that time so I think it's a matter of of enabling with proper job planning that those sessions to be allocated but only if they're going to be used properly for for additional improvement to patient care teaching etc. I don't know whether anyone wants to come in about the wider workforce planning in terms of the overall strategy to take more people at home, closer to home, near at home or you know you know well obviously there's been something going into that in terms of consultants and availability if they're at a conference or they're at a training session or they're not in the hospital that impacts on the rota and impacts on weekend cover you know make sometimes the job less attractive and smaller health boards as I recall from my own experience in Berclyde you know so what it might not be today but I mean a response today in terms of workforce planning what sort of and and and how we view the total workforce not just the consultant then because it'll not be the consultant that's you know providing that that that day-to-day hour care at home you know what's what's happening there we let me pick that back if I could I remember giving evidence about a year or so ago on just the very same topic and at that point I think I used the term we need to consider workforce planning as part of a triangulation of looking at what service we want for the future looking at the available resources yeah we do have I think a very comprehensive framework which if we haven't given it to the committee maybe we need to do so but at the broadest level that framework talks about three big principles three big principles are about designing the future workforce around an understanding of what new services will have when the current and future workforce developing the workforce and Mr Gray made some reference to one element of that which was leadership and in delivering the future workforce yeah and against all of that the framework which I won't go into just now and clearly lays out a step-by-step methodology that we expect each NHS board to follow it's a sickness call we call it the six steps methodology and that's contained in the guidance that we have and does that focus on the NHS workforce or does it recognise that the new strategy will include you know the private sector the voluntary sector and indeed integrated joint boards I think what we have here is a framework but does it does it the framework you're talking about talking about the NHS workforce or does it look at a broader view of the workforce and the strategies going forward and in this here in the guidance we've got it by and large concentrates on the NHS workforce but there is there is reference here to the fact that planning for other groups including voluntary services should be taken into account. Mr Gray you'll tell us what else is going on to join this up. So when I came into this role of chief executive NHS Scotland that was as part of that role chair of the leadership advisory board and when I took over the leadership advisory board that was a health service leadership advisory board I have changed that and in fact as it simply as it happens the second meeting of the new leadership advisory board meets tomorrow and that includes representation from social work social care from the third sector and that is deliberate because I didn't see how we could construct a leadership development offering that was was narrowly restricted to the national health service within the directorate responsible for the integration of health and social care under the leadership of jeff huggins we have a specific work strand on workforce development recognising that what we are doing here is asking colleagues from health from local government from the third the voluntary sector to work together in new ways and that simply saying that that would be a good idea and we hope they'll get on with it is wholly inadequate we need to provide workforce development across all of the elements of the workforce and there's budget allocations that will thrive that is that it yes yes additional money it will be to use the phrase convener it will be within existing allocated budgets we didn't get to that bit at all convener it's how do we actually assign the budgets for that efficiency but i'm not clear on that sorry mr robert isn't it Dennis is great Dennis is asking for an answer to his question about how we assign because there is a there is an issue about how the how the budgets to integrated boards are being assigned and there's some some differences there i think you responded in that it was a shadow year acknowledging there were some differences but i think that's satisfied Dennis is it so you want some further clarification on that Dennis it is because we looked at all the other aspects and you know i was trying to say you know efficiency equals improvement and i remember just trying to find out how you assign them because we look to all the other aspects of prevent and spend and how i was saying priorities and there's something fall off the you know the the end because you got to prioritise because you have set a efficiency targets so so i was giving an example of something that i was concerned might be given less priority because of the pressure on delivery so again just to quote discussion i've had with the academy of royal colleges concerned expressed that newly appointed doctors and consultants would be given less time in terms of personal development because the focus was on you know getting people through a and e or getting people through the hospital and that would not be to their benefit mr matheson will come in in a second but clearly efficiency is not all about simply stopping doing things it is sometimes about doing things in a completely different way and doing it in an innovative way changing completely how we deliver a service so for example and again just to give one very simple example gentlemen in cumnock who has c o p d would have had regular visits from a clinician or had to go regularly to some place where he could be diagnosed and cared for is now able to have most of his care and diagnosis of any difficulties with his condition conducted over telehealth over a video link and i've seen that in operation that is far more efficient is far better for the individual concern so that wasn't about stopping doing something that was about doing something completely differently and therefore the efficiency gain accrues to the individual and to the service but mr matheson do you want to say more about that thank you mr gray so efficiency to me is around doing what we do at the moment but doing it in a more cost effective way it's not a cheap way but a more cost effective way whereas innovation is doing things differently and in a more radical way so in terms of efficiency we look at procurement the not just drugs but the general supplies we have a national procurement service by the NHS in scotland we're looking to in terms of health and social integration where that expertise can be used in a broader area across the public sector we look at to local expenditure both in terms of a nursing expenditure medical expenditure how can that be reduced when i talk about financial performance in the efficiency context i talk about quality driven financial performance because if you get the quality right then the money tends to be going in the right direction in terms of innovation though within the scotland we have eight innovation centres and we have two within the health service one of them is the digital health institute and it's just moved from me the centre of edinburgh out to a lannux or to a euro central and it's going to set up there a simulation laboratory where a ward environment a home environment will be set up to allow SMEs to come in and show their products their innovative practices in a real-life environment and allow clinicians then to take a view on that in terms of the applicability so efficiency we have delivered £1.4 billion of efficiency within the NHS in scotland over the last five years and that has been reinvested back within the health boards Mr Gray mentioned the performance at the end of 1415 which is just under £300 million and boards have identified that they have identified a further £300 million of efficiencies innovative practices going into to 1516. We look at that very closely to ensure that it is about delivering best practice to ensure that the sharing of best practice to ensure that the efficiencies identified are consistent with our strategic direction and they are not stepping back from our strategic direction but for me efficiencies have been very positive but I think going forward we need to be more innovative in terms of where we look for solutions. Just on the evidence that we have here the 3% of efficiency savings are applied across the board we've heard this morning that many of the boards have different challenges. Glasgow health board, hep C, cost of that drug so how do they achieve that? It's not a there's a flat 3% saving but there are different challenges in the board some other boards they can make savings on the prescribed drugs productivity staffing whatever whatever it leaves boards who have got a disproportionate pressure like Glasgow on hep C cost of that how does the Scottish Government discuss these these very impressures within that that efficiency saving with the different boards. Convener if I can come back on that please if I gave the impression there was a set target then I apologize for that. I was talking about the overall position within NHS Scotland there will be a differential position within individual boards in terms of their individual targets but across the whole of Scotland it averages out at around about 3%. We assist boards in terms of efficiencies by identifying best practice. Mr Gray has mentioned the coming experience. We have a number of European projects looking at the comorbidity and sharing of best practice across that so we look at making sure that boards are aware. Prescribing is a good example. A number of boards are very high. Mr Doris's point about the genetic prescribing are very excellent performers in terms of genetic prescribing and we share that best practice with the rest of Scotland so we allow people to learn from best practice but the efficiency savings are identified at a local level but if we see something innovative then we do make sure that other boards are aware of that and the corporate finance network and the other fora are a part of that mechanism. Is there not a target of 3% of each board that's got you? There is an overall target across NHS Scotland but individual boards will determine what their local needs are in terms of being... Coincidentally comes out an average across the boards of 3%. It's not coincidental. It is say that that's what it's been over a number of years but we do not say that each individual board needs to achieve a 3% target. So what happens if they don't? So what happens if they say well this year on they'll be saving 3% target and they'll be saving anything because they've got all these costs and prescribing. What happens in the process when that? That situation has never occurred. That situation would mean that they would not be achieving their financial targets which are statutory financial targets. What we do, convener, is we do ensure that they have all the information available to them of the best practice not just within Scotland but internationally in terms of how they can improve the efficiency of the services they provide and the cost-effectivity... I was just telling the assemblies whether a place like Glasgow is mentioned twice in terms of the beach and the cancer centre, disproportionate costs there and high costs of cancer drugs, the hep C with the levels of the problem in the population. We know that some of that will be preventive and have some long-term savings but how does that play into this financial plan and target? Where's the variance in that? Is there a flexibility in that or is there a recognition? The flexibility is for some of those high cost drugs for example hepatitis C then we do give a differential supplementary allocation to recognise the fact that that is atypically weighted across the country. I think that Mr Massen might have answered the question in relation to hep C drugs much more eloquently than I'm going to put it my understanding as a lot of the new curative, quick revolutionary hep C drugs that are now coming to health boards is through the new medicines fund and there's a huge chunk in relation to that. Would that deal with cost pressures but actually as I was sitting there listening to talk about efficiency savings it's my understanding that it's been the case for the last few years that if a board makes a 3% efficiency saving by redesigning services the money that frees up stays within the health board is that correct? Absolutely correct and that has always been the case and that's the point I was making about the £1.4 billion historically that those efficiency savings have then been retained by health boards or re-invested by health boards. Thank you convener. I was interested in what Dr Calderwood was talking about in terms of preventive spending and the health economics of that and the interplay between finance and economics is quite an interesting one and I wonder how that's reconciled in terms of you know typically we look at budgets usually on a yearly basis targets maybe yearly maybe you know in smaller intervals than that and yet the the results from preventive spend often manifest themselves over longer timeframes so and I'm mindful of what Paul Gray was saying in as much as very difficult to do a financial analysis of what those benefits of preventive spend are. So my question is twofold how do you how do you decide how much of a budget in any given year that you're going to allocate towards preventive spend measures? Do you just think of a number and double it perhaps? Is there some rationale that goes on a calculation and then secondly is there a higher strategic level overview and planning of spending beyond just the year to year financing and reacting to targets so two parts to the question. Okay so I'll bring Dr Calderwood and Mr Matheson and Mr Conachin if he wishes in on this but we expect all expenditure in the NHS to be based on evidence so in terms of your question do we just put a finger in there and say 3% or 26% on preventive? Absolutely not. If a health board advanced a proposition for preventive spending we had no evidence based for it we would say no. I think I can be perfectly clear about that. That would be part one. Part two, Mr Matheson will speak in a minute about our long-term financial planning. We come round this every year, we do long-term financial planning and we take it very seriously not just one, two, three but five and ten years. We look ahead to the demography, the trends that we expect to see in our case the pressures of an aging population and multimorbidity and we plan for services not just now but for the future. One of the things that I hope the integration of health and social care will do is help with the somewhat artificial barriers that if a saving was made in one place the benefit accrued in another and therefore you might question why would I make a saving to benefit somebody in another organisation. I do try very hard to see public sector money as a whole rather than as a series of pockets so if I do something that helps the police service I don't regard that as a bad investment. I think that the conversation then has to be about what they might do to help me in the future rather than saying that I won't do it because it's saving me nothing. Dr Calder would want to come in on the evidence base for preventive spend and then John Connachon or John Matheson on the longer term as well. I suppose if we take the public health aspects of preventive spend all of those are long term strategies so we albeit that the money individually is allocated year on year or three yearly we we have as you will know Scottish health obesity strategy smoking etc etc so those are those all have long term goals interestingly some of them have targets attached to in order enable us to keep working towards them financially on a person by person basis it's very difficult to measure it and I think that that's where we we always go back to say well if we do such and such will that make a make a difference so it's it's it's definitely based on clinical evidence and I think more and more we've now got health economic evidence in everything we do if we if we take the example of our investment recently in IVF treatment for fertility problems what I was tasked as part of that looking at the clinical evidence that if we were to change the the criteria what would that do for the success of the treatment of course in fact women who don't smoke women who are of a healthy weight have much more successful IVF treatment so you could argue on the one hand well you would what why would you give something that's not going to be as successful this is a relatively invasive treatment to somebody where you knew that something would make it work more effectively but in fact so some of this is done on the basis of better clinical outcomes but in fact those sort of preventative particularly around the obesity and smoking as part of society as a whole are actually going to make much investment in those make much better use of our money in all sorts of other parts of the health service if I can if I can give you perhaps a practical example with some with some figures attached to it that might be useful because I think you're asking about a rational allocation model here so enhanced recovery for patients undergoing surgery one of the objectives of that is that patients spend less time in hospital they're able to spend more time at home and you've got that I think led very impressively by our clinicians so this is something that started in the golden jubilee in the national waiting time centre a few years back and it was about mobilising patients almost immediately after joint surgeries such that they were up and about and then could go home earlier but there are also some clinical benefits about reductions in catheterisation for patients the results of a three-year pilot show that catheterisation is halft in that select group of patients blood transfusion requirements have halft now since that pilot started back in 2010 most boards have started to adopt enhanced recovery pathways that will drive some investment decisions about where they put some support in to achieve that but it will also drive future investment decisions about how much they want to spend in surgery orthopedics etc and how they recycle some of that money so that's a practical clinician led change that started with a pilot the investment in that pilot has proved to have paid for itself many times over as we have rolled that out the country and the last thing I probably want to say about that is that as we roll that out through the country different boards are at different starting points in that it involves some changing clinical practice and that's why you can see that boards sometimes have a differential savings target as they go through the year using that as an example because they might have started later but they're still pursuing that we would expect all boards to eventually get to a clinical model that's much more acceptable and that using that as an example thank you that's very useful I think that I may just have a couple of comments on that the the first one is I think that the because we have annual financial targets in terms of breaking even within a 12 month period there's say a potential tendency to have a short term approach in terms of financial planning that is say not sensible you need a medium and long term approach so we have the corporate finance group which looks at planning assumptions over the last four or five in the next four or five years but some of the the major pressures that we're facing just now in terms of the pension increase in 1516 the national insurance increase next year we've known about those for the last four or five years and finance directors have known about those and included those within their planning assumptions we have a 10-year capital plan which was signed off by the previous cabinet secretary and that takes us forward over that to horizon in terms of the strategic direction we have our 2020 vision and we have a financial plan that underpins that but the other factor there Mr Mackenzie which is an important factor is not micromanaging the boards in terms of the financial planning and the financial allocations and what I introduced about three or four years ago now was the bundling of a discretionary spend so boards have flexibility over how they spend that area and what I've done in 1516 for the first time for the three island boards is I've given them total discretion so rather than even having just a reduced number of bundles they will get one bundle of funding they will still have to meet the targets the standards associated with these allocations but they will have flexibility within that and that has been generally welcomed by the island boards and that's a model I would like to see going forward so it does give boards that to financial flexibility at a local level if they don't need to spend money on the alcohol services because they're meeting their target to those briefing dimensions then they can divert that into other areas of local prioritisation thank you I mean I'm struck by the idea of this rational allocation model and obviously that's quite a sophisticated model but I just wonder if it would be possible to you know rather than this being an anecdotal discussion a subjective discussion with all of our own hobby horses I'd be very interested if you were able to share with the committee in written form some of the thinking or calculation that goes into the construction or operation of a rational allocation model it strikes me that that should be you know used in the context of guidance I take the point you make about the the island boards and discretionary spending to suit local circumstances and challenges and so on but it'd be comforting to know that rational decisions have been taken both in the short term and in the long term bearing in mind the possibilities for preventative spend and the tension that inevitably will always creep in in any budgetary discussion about you know spending for the here and now and spending for the longer term benefit so it's certainly very happy Mr Mackenzie to to write further to the committee if they would find that helpful I don't know if Mr Matheson convener if there's time can add more now or whether you'd rather just have something from us in writing about that it may be because I noticed that you mentioned the 2020 vision and I noticed from recent statements from the cabinet safety indeed in the chamber last week we're talking about 2020 beyond in 2030 now which is you know drifted into the limie so it might be helpful you know I don't know whether that's due to financial considerations or whether that's been tweaked for some other reasons but you know just a note about that in the context of 2020 and beyond would maybe inform the committee and satisfy my colleague Mike Mackenzie and his inquiries I've got a supplementary I think from Colin Kear or supplementary the question yes thanks very much convener very quick one really something about what Mr Gray said earlier in relation to the public pop being is in his view just being one as against several if you like and just can do maybe you've answered this before is just I haven't picked up on it but the strains between the different sides setting up the joint integration boards has there been any difficulties with people being a bit overprotective of budgets and in this well all of the all of the integrated joint boards have delivered their integration schemes on time by the 1st of April this year I'm absolutely certain Mr Kear that the health and the local government components of this will have thought very carefully about what elements of the budget they would they would put into this but I would I would be hesitant to be honest to at this stage to suggest that that any aspect of this whether it was health or local government have been protectionist about it I think what what we'll be doing in the course of this year is to look at the budgets with with the partnerships and ultimately we have to give ministers assurance that the budgets are sufficient to meet the to deliver the outcomes that the partnerships have been set up to deliver but I mean it would be fair to say that you know both local government and health do face pressures as a result of the demographic trends and the the changes in the state health status of the population over time that we expect to see but so far I have seen very good evidence of joint working the rate of delayed discharge in Fife has come down very considerably and and just to be simple about it that is because I'm certain there have been some fairly tough discussions between the health board and the council indeed I know there have been but they have been committed to achieving a solution so I don't actually mind if people have robust discussions in fact frankly it's sometimes worse if people say oh we've all got very good relationships with one another but nothing much actually happens I'd really rather people got to the nub of the difficult issues I don't see that as protectionism I don't see that as in any way deviating from the overall standards that we set I think it's important that people have these robust discussions and I can see that where they do happen results are produced that's a rather long answer to a short question thank you convener I had been going to ask about deficiency savings but I think that's been dealt with quite a lot so I'll change tack but before that could I just maybe maybe more a comment or flag up for future discussion the emerging serious issue on recruitment and retention of doctors in general practice I know there are other ways of delivering general practice but I think there is becoming quite a lot of parts of Scotland now I think a serious issue and I think it will have to revisit that as we move forward I wanted to raise the issue of palliative care because some boards said it wasn't possible to separate out general care from palliative care others gave information on either specialist care or general care so I just wondered how is it possible to get data on providing palliative care costs and how availability of this information can be improved and if there's not financial data how can Government assess whether appropriate resources are being devoted to palliative care and the next point that is to do with CHAS funding whether there's a new agreement between health boards to provide Tayside with I think it's 12.5% of funding and then that's co-ordinated to fund CHAS and I don't think that's being met by a number of health boards so maybe some comment on that as well. Thank you for that. On the CHAS funding I'd got some information about that this morning which is therefore not in my pack so what I will do is I'll write to the committee about that point because I did think it would come up but we'd involved me switching my mobile phone on to get it so I'll not do that right now but I will write to you on that specific question. On the palliative care element and I'll bring Dr Calderwood in in a second where someone is receiving palliative care as an element of other care that they may be receiving then it is genuinely difficult to separate out the palliative elements and I mean we had a discussion and evidence about this recently. I am clear that we could we could do more to separate it out and I think I undertook in the in the evidence session then to consider that further but the way the way information is recorded at the moment does not make it particularly easy to separate it out. Therefore you're right to ask the question how do we know if it is sufficient. Now one of the ways in which it's a slightly different point but one of the ways in which I'm seeking to advance this is to ensure that more individuals have anticipatory care plans so that we're much clearer about what individuals are looking for particularly as they come towards the end of their lives but Dr Calderwood do you want to add anything on palliative care? You may be already aware that there's a commitment to a strategic framework for action on palliative care. I concur with Mr Gray that the difficulty that you're pointing out with the data and the way that we're collecting it or rather not collecting it at the moment doesn't enable us to really understand what is going on in different boards and perhaps that's partly why they can't articulate it to your committee. There will be stakeholder events, engagement events which are planned in different parts of the country as part of the development of that strategic framework and I'll be doing particularly keeping very close eye on that to ensure that some of the points that you're concerned about are brought up in discussion and we find a way, a better way forward. That's helpful because I think that the anticipatory care planning is very important too because we know from people like Mary Curie there are many people who really ought to be receiving palliative care who are currently not and they need to be identified very early on so that that can be planned for and I look forward to more information on that. Did that amount to a commitment to try and establish some sort of database for what is available? Is that right or is it not correct? Yes, convener. We need to improve the information that we have and as Dr Calderwood has said, we're going through the strategic framework for action, we're seeking to improve both the delivery of palliative care and understanding of what people actually want through their anticipatory care plans and the information that we have to assure us that palliative care is being delivered appropriately in appropriate settings. So, yes, I mean we absolutely want to improve this. I've seen some briefing papers that was like 2008 or something, whether it was almost like a nod at a year on terms of how many beds, who was providing palliative care or not or whatever. Is that a baseline that's worth anything at all? Are we building on that or are we starting something completely new? I think we need to refresh what we have. The 2008 information is good as far as it goes but I don't think that it's information that is going to take us much further forward. I think that I wrote to the committee about this fairly recently and in the last evidence session Mr MacKenzie asked how many people had palliative care plans, how many people needed them and my answer was I want to get towards as far as possible everyone having a palliative care plan. That said, the evidence suggests that about 70% of the population would benefit from having it. You know, someone who dies suddenly or any other certain other situations that palliative and anticipatory care plan is not actually either necessary or helpful but the evidence such as it is suggests that roughly 70% of the population would benefit and we're quite away from that at the moment. You'll keep the committee up to date on that. No other questions? Good. That concludes our session. Can I thank you all for your attendance this morning, the evidence you provided. Thank you very much indeed. We now suspend at this point until we set up our next panel. We now move to agenda item number four on today's agenda. We're going to have two evidence sessions on smoking prohibition children motor vehicle Scotland bill, our second evidence session on that bill. I welcome Simon Clark, director of freedom organisation for the right to enjoy smoking tobacco. Thank you for your attendance this morning, Mr Clark, and we're going to go directly to our first question, which is Richard Lyle. Mr Clark, can I say to you that I'm a car driver and I am also a smoker, and I don't feel threatened by this bill. In regard to your position, forest does not support the introduction of a ban on smoking in cars carrying children. We would encourage adults to not smoke in cars carrying children because now you children should not be exposed to cigarette smoke in a small confined space, but you then go on to say, in our opinion, however, there's no justification for the Government to ban smoking in any private vehicle or without children. So how do you square your position? You say you shouldn't smoke in your cars because children are in them, but then you say, well, but the Government shouldn't ban it. How do you explain that? Well, I don't think you should ban everything just because it might not be wise or parents should err on the side of caution with certain things. I mean, we've said for many years that smokers need to be considered to people around them, not just adults, but particularly children, clearly, particularly if you're smoking in a confined space. So we don't condone and we certainly don't encourage people to smoke in a car with children. And I think over the last 10, 15, 20 years, I think huge numbers of smokers have actually changed their behaviour because they realise it's wrong. And the reality is very, very few people still smoke in a car if children are present. And I would like to think that we could give credit to smokers for having changed their behaviour, for having become increasingly considerate to people around them, let's say children in particular. We don't think legislation is necessary for a number of reasons. First of all, I think very few people still do it. People often say, well, what about the seatbelt law when that came in 1982? The point then was that my understanding is only about 25% of people actually wore seatbelt at the time. So it was decided that in order to get, you know, increase that number significantly, they had to bring in a law. We don't need to do that with smoking in cars with children because, say, the vast majority of smokers wouldn't dream of lighting a cigarette in those situations. I mean, they feel like you. They don't feel particularly threatened by legislation coming in. But I don't see why we should bring in legislation when it's not particularly necessary. So few people do it. I think also, as we may hear in the next session, I think it is going to be legislation that's going to be very, very difficult to enforce. Perhaps, you know, we might want to come on to that a bit later. But I do think if you're asking the police to enforce it, if you've got somebody driving along at 20, 30, 40 miles an hour, they may be smoking a cigarette. But how anybody is going to tell whether there's a small child in the bag, I honestly don't know. The only way that you could do it is to have spot checks, pull drivers over. And I personally think that is a waste of police time in order to do that. Well, I actually have two grandchildren. I actually have two child seats in the back of my car. And I don't smoke in my car for my grandchildren are in the car. So, you know, at the end of the day, police can spot you as you're going along on the phone, most of the time without your seatbelt. And I'm sure they could spot two kids in the back with, if I was sitting in the front, not that I would be doing this, by the way, but they were smoking a cigarette. But can I come on to the point that also, the British Lung Foundation said that 19 per cent of children alone to 15 reported being exposed to cigarettes, 51 per cent of children aged 8 to 15 reported being exposed to cigarettes, and also research has shown that 86 per cent of children across the UK want people to stop smoking when they are in a car. What do you think of those figures? To be frank, I am slightly sceptical about them. I think introducing legislation on the basis of surveys of children of that age is frankly a bit dodgy. I simply don't think you can assume that children are being totally accurate when they respond to questions of that sort. I mean, I would like to think before legislation is introduced that proper hard evidence, not just the opinions of children is brought into account. Now, for example, in Dublin, University College Dublin did some research two years ago when they monitored 2,300 vehicles, I think, during rush hour in Dublin as people were taking children to school, and of those 2,300 vehicles, only eight drivers were smoking, and of those eight drivers, only one driver had a child in the back. Similar research was carried out in New Zealand, a much, much bigger survey. I think it was something like 189,000 vehicles, a huge number, and they found literally there was just a handful of vehicles where the driver was smoking with children in the back. Now, I accept those other countries, albeit English-speaking countries, but I would like to see similar research carried out in Scotland to find out exactly how much of a problem this is, because I don't think in terms of numbers it's as much of a problem as is being made out, and I just come from a position where, and I believe in education, not legislation, if at all possible, I think legislation should be a last resort, and we would happily join with the Scottish Government in a media campaign to encourage the handful of people who still smoke in a car with children not to do it, say, look, think of the children, this is inconsiderate, don't do it, and I personally think we should be looking at doing that before we go the whole hog and introduce legislation. I think also it's important that we don't stigmatise the vast majority of adult smokers, because when you introduce a law like this, I think it does stigmatise smokers. You're basically saying to smokers you don't know how to behave around children, nothing that's wrong. Also, the reason it's important to us is because, symbolically, this is quite an important step because it's the first time you're actually banning smoking in a private space, as opposed to a so-called public space. That's where I think you get to the number of your argument is that you feel it's an encroachment on people's civil liberties. I don't feel threatened, and I smoke in a smoke in my car, but you're basically saying, well, if you allow this, you then will ban everyone from smoking in their car. Where are you going to go next? You're going to ban us from smoking in your house, and where are you going next? You're going to put us all in a desert island somewhere, but convener, if you just allow me, the also one of the arguments you've got is that the police shouldn't do this, that we should have environmental health officers doing it. What are we going to do? We're going to station environmental health officers in streets to check our street, because we certainly can't have them driving round looking to find out if they can spot the spoker. Is it not, if this comes in, the police have done well in seat belt legislation, done well in car phone legislation, so at the end of the day, I'm sure the police in their cars could spot someone with child seats in the back if they're sitting smoking? I can't speak for the police, obviously, they're going to speak on that subject a bit later. Again, just as a member of the public, I personally am not knowing enough about the police's work. I've thought they have enough to do without criminalising another section of society and pulling cars over to check that the driver who might be smoking will not have a car in the back. You said earlier that they can tell quite easily if there's a child in the back. Well, I disagree. A lot of cars these days have tinted windows in the back. You'll never see if there's a small child there. I think we have very serious concerns that, as soon as this legislation is introduced and enacted, the anti-smoking lobby will come back and they will say, right, let's ban smoking in all private vehicles regardless of whether children are present. We know that's going to happen because, in fact, the British Medical Association since 2011 has been calling for ban on smoking in all private vehicles in a regardless of children being present. Ash in London published a report called Smoking Still Kills. It's their five-year strategy. In it, they want a consultation about banning smoking in all private vehicles. Now, we know where that's leading. They want a ban on smoking in all private vehicles. You'll have a situation where a lone driver sitting in his own car on his own lights a cigarette. Suddenly, he's a criminal and he's going to be prosecuted for it. I think that's very, very worrying. You say we won't have a ban on smoking in the home if children are present. I certainly hope not, but likewise, I hope that parents will be considerate and will have patch one room where they can smoke or they'll smoke in the garden. These are all important things, but let's face it. It's 15 years ago. Nobody thought we were going to have a smoking ban, a public smoking ban that would not allow smoking in any single pub or club, including working men's clubs in the country. Nobody foresaw that back in the year 2000 and yet within five years, six years in Scotland, we had a comprehensive ban. Another year, we had a comprehensive ban in England, Wales and so on. So, I think it's very unwise to predict and say, no, these things aren't going to happen because I'm afraid the tobacco control lobby has a policy called the next logical step. They are never satisfied and they'll go from a ban on smoking cars with children to ban all private vehicles and they will up the ante and they will try, if not to actually ban smoking in the home, they will quite likely try and almost name and shame people, make people feel incredibly guilty about having the temerity to light a cigarette. I mean, I was doing a phone in on the radio Scotland this morning and somebody was saying, we need to ban mothers who are pushing their buggies and they might be smoking at the same time. So, again, where is this going to go? Are we seriously going to ban, you know, a mother from pushing her buggy in the park and smoking at the same time? I'm a great believer in education. The big drop in smoking rates in this country happened between the mid-70s and the early 90s and it was all about education, educating people about the health risks of smoking. What we've seen over the last 15 years in Scotland and the UK generally, yes, the smoking rates have continued to fall but, you know, not by huge amounts and yet we've had a whole series of pretty draconian legislation, ban on smoking, tobacco advertising and sponsorship. We had the smoking ban, ban on vending machines, ban on display of tobacco in shops and of course now there's plain packaging. All these things have had relatively little impact compared to the basic education, health education that people were given back in the 70s and 80s and 90s and I'm just concerned that we are legislating for legislation's sake and I'm not convinced it will have any significant impact because the sad fact is those people who are anti-social enough and inconsiderate enough to smoke in a car with children will probably just ignore legislation. You mentioned that the mobile phone legislation has been a success. I'm not convinced it has been to be honest and of course before the mobile phone legislation was brought in there were some very very clear cases of accidents involving lorries, drivers on their phone, where cyclists for example were being killed. I mean I'm not going to refute, I mean I'm not suggesting there is no risk to a child's health from somebody smoking their presence but I'd say the very, I mean you would have to be, point about the passive smoking evidence is that you have to be exposed to environmental tobacco smoke consistently day after day, month after month, year after year, perhaps for 10, 15 years for it to have any significant impact. Now I'm not suggesting for a second that we turn ourselves, go back to the 60s and 70s but the fact is in those days a majority of the population smoked and children grew up in smoky households, which no we don't want to go back to, they grew up, been brought up in you know having been transported and smoky cars and vehicles and yet that baby boom generation is living longer and healthier lives than ever before. Now if anybody jumps in clearly I'm not you know associating the two things what I'm saying is I do think sometimes the impact of second hand smoke is exaggerated and it's done so to make smokers feel guilty about their habit and I'm a non-smoker, I'm a lifelong non-smoker and I just feel the attacks on smokers over the last 10, 15 years has been disproportionate. They're an easy target and it's very easy to make a smoker feel guilty and I don't think smokers should feel guilty as long as they smoke responsibly and considerably because they're smoking a legal product making a huge contribution through tobacco taxation to the sort of finances of the country and so on and I think we've got to draw a line and say look you know enough's enough we've got a public smoking ban, we've got a display ban, we're getting plane packaging, where is this all going to end? Mr Clark thank you very much, thank you. Can I just correct one thing and that is that Kenny Gibson with my support moved a bill in 1999 we were proposing that there should be a ban on smoking in restaurants anywhere where food was being served so bans in public places were not something that was actually post 2000 it was before 2000 one of the first things was done in this parliament and I should declare that I'm on the co-convener of the tobacco cross party tobacco and health cross party group but if I can summarise your arguments they are we shouldn't do it because it's a slippery slope we shouldn't do it because it's small numbers and we shouldn't do it because it would be difficult in enforcing well can I suggest to you that actually there was real concern about the public smoking ban and that this would there would be riots on the street people would would act against this this was an infringement of liberty that was going far too far and that second down smoke actually could be dealt with by pumping the stuff around or air conditions or whatever just clearly was rubbish but the fact is that people obey the law and by your own admission it is the irresponsible individual who smokes in the car not the responsible smoker and surely the in protecting children which is what this law is about it's not about the smoker it's about protecting children are you really saying that we should not seek to protect children as a parliament by passing legislation which ensures that they are not exposed to second down smoke which we know from the research and I wonder if you accept this research Mr Clark we know from the research that the smoking and in the enclosed circumstances of a car the the levels of pollution are actually hugely higher than they are in most other circumstances it's one of the most polluting set of circumstances that there are personally I mean I'm not an expert so I'm I suppose I shouldn't really answer that question I do think that parents should err on the side of caution it's common sense when you've got small children babies in particular any parent I think should and most would err on the side of a caution I do think a lot of the research into passive smoking has either been flawed or the if you take the largest study ever done into passive smoking carried out in California where they studied a group of 119,000 people between I think it was 1959 and 1999 that found no significant impact of passive smoking I think the problem with the research that's been carried out in cars is that it's inconsistent because there are so many variables you know whether a window is open even a window being open one inch two inch three inches it all makes a huge difference and often the research that we've seen focuses on that moment which may be literally a few seconds when the car is smoky somebody's just lit a cigarette and there's you know a significant amount of smoke in the car within seconds that smoke has normally been massively diluted because there's a window open or whatever I mean so I don't want to come across that I'm justifying it or defending people who smoke in cars with children I'm not I simply think that legislation is excessive and if it makes just step back a bit and talk about the smoking ban that came in Scotland 2006 well I'm sorry I still think that was grossly excessive I totally accept that's fine to ban smoking in restaurants banning smoking comprehensive ban every single pub and club in the country not even allowed designated smoking rooms I think is absolutely outrageous and and I still believe that here we are nine years later and actually I'm not alone because we did a poll only last week before the ash report came out a populist poll 2000 random sample 2000 people and we asked them the question would you allow well ventilated designated smoking rooms in pubs and private members clubs 57 percent said they would allow them so the idea I totally accept people obey the law people don't want to get their landlord or publican into trouble so they abide by the law but the idea that the smoking ban has been is hugely popular I would dispute that it's very high compliance rates I totally grant you but when people are often are asked would you allow well ventilated designated smoking rooms people generally speaking in the majority favor that and the idea he said that this is complete nonsense the idea that you can have a so essential well ventilated smoking well it's not modern technology actually can solve the problem of environmental tobacco smoke extremely well sadly we've not gone down that route because I think what underlies this legislation is a desire to stop people smoking I think that's what it's it's come down to despite the fact that tobacco is a perfectly legal product there is a program I mean we know because there's people talk about making Scotland smoke free by what is it 2035 or 2030 whatever the reality is if you leave smokers alone smoking rates will continue to fall slowly because a number of reasons health is a serious issue a lot of people start smoking as we know when they're quite young but a lot of people give up in their 20s their 30s when they start having families themselves and I don't want to smoke around children and all the rest of it so we'll continue to continue to see a decline in smoking rates but it'll be a gentle decline unfortunately that's not good enough for the tobacco control lobby they've already set a target getting Scotland to be smoke free by 2035 by which they say smoke free is five percent of the population the only way they will get smoking rates down to five percent is to introduce more and more bands more and more legislation restricting where people can smoke the way we're going eventually they won't be allowed to smoke in a public park they're starting off by banning smoking in children's play areas even though they're in the open air we know some councils in England are now having exclusion zones around play areas eventually they'll say you can't smoke anywhere where a child might be present these rules and regulations are not being brought in because for health reasons because nobody's arguing that smoking you know in the open air is a risk to any bystander whether an adult or a child the argument now is we don't want you to smoke in a public park or anywhere near children because we don't want you to be a bad role model for children if a child sees us you know smoking in a park it might encourage that child to take up smoking well again there's no evidence for that no evidence that children take up smoking because they see a complete stranger smoking all the evidence suggests that children take up smoking because of peer pressure or because of the influence of family members which is again is another reason why some people are trying to crack down on to family members smoking whether it's in the car or at home or whatever because there's this sort of desire to stop you know parents from smoking in case they then become bad role models for their own children but at the end of this we must remember tobacco is a legal product and I would have far more respect for people who came out and said let's ban tobacco completely you know instead of which Governments are more than happy to put 86% taxation on tobacco that's the average taxation on a pack of cigarettes in this country 86% goes to the government so again it comes back to this this this principle let's try and discourage the few people who smoke in a car with children present and say forest would be more than happy to join with that campaign as long as it as long as it was an educational campaign not threaten people with fines and penalties and all the rest of it we feel the same way about litter we would like to encourage smokers to not drop litter but it's a two-way thing it needs it needs some help not to rather draconian bullying tactics where smokers have been threatened with fines and other penalties if they if they drop litter or say if they if they smoke in a car so we can add passive smoking research is not valid and uh no your research in the car so i think i think that's what you're saying i'm not saying it's not valid unless it supports your case i think i'm not i'm i'm saying i think the threat of second hand smoke has been exaggerated because most children if they are and again i can't repeat often enough i'm not encouraging people to smoke in a car with children i would urge anybody to earn the side of caution um but i do think that the research exaggerates the risk because in real life conditions most children only expose for a very short time um to other people's tobacco smoke i have to say mr clark the reason the government didn't accept kenny gibson's proposals in 1999 because at that point the passive smoking research wasn't good enough but within two to three years a lot of the studies that were being undertaken were completed and did demonstrate very clearly that passive smoking is has an effect not as much as direct smoking but nevertheless a significant effect and that's one of the reasons why the government actually adopted the public health smoking ban which is was also about protecting workers within the restaurant and pub trade from exposure to smoke because they're working there all day so you know as far as i'm concerned we will go on trying to protect people from the effects of irresponsible smokers in cars and in other places the problem is that workers could have been protected by having designated smoking rooms no we tried that that susan deacon said when she was refusing to take that bill up we will actually introduce a ventilation system and and it was very clear from the research that was subsequently done that that was ineffective so the technology may have moved on but at that time it certainly was ineffective it was a sop that's the part dealing with another bill today any other questions on on the bill before us Dennis Roberts very quickly and almost a clerk i'm a bit confused because you say you would have more respect if they just banned back altogether well fair enough there'd be no taxation you know i'm not saying that i would disagree with that either but you keep referring to like small numbers and then huge numbers and but you don't actually associate the numbers i think from the submission was it something like 24 percent of children are exposed to smoking in a vehicle that's quite a high number i don't see 24 percent as a low number because i actually think one child is too many if it's exposed to smoke and dr simpson mentioned the ventilation and yeah it gets rid of the smoke it doesn't get rid of the chemicals the toxins and that's what causes most of the damage so you know i i can hear what you're saying but surely and i did ask last week is legislation necessary surely we should be doing more education and the answer i got was we've tried education we continue with education and we will continue with education with legislation because we deem that necessary don't you accept that argument no sorry no you would i mean i i well i'm not quite sure where you got the 24 percent figure our understanding is that um from research that's been carried out it's less than 13 percent of children are exposed to tobacco smoke in a car uh that's still probably too high but in terms of being regularly exposed so your figures too high the figure is about one percent of people who are regularly exposed if you're just exposed very occasionally and that 13 percent i don't believe that anybody's going to come to serious harm but let's try and get that figure down and let's do it through education not legislation let's state that different from false okay why state the number 13 percent okay you've no idea if any of these children have respiratory problems because it's just a number now if an adult is smoking and it's irresponsible smoking and a child does have a respiratory problem say asthma for instance um you know that's going to be exacerbated by so what we're saying is we have tried the education route we have done as much as we can i think through the education route it's not working because people still think well so what now if the legislation is there it becomes law and i think we've already seen that it does work within the public places people have obeyed that legislation they go outside they don't smoke in a restaurant they don't smoke in a pub they don't smoke in a club surely you know for the distance that maybe people travel with children in a car um smoking we should just say absolutely not well again it comes down to the fact i think it's uh patronising to the vast majority of smokers who know how to behave i'm a bit disturbed about some of the language you use you talk you know use a word like obey uh tobacco control is called tobacco control for a reason because a lot of people are beginning to feel it is all about control and that parental responsibility is actually being taken away from a lot of decent uh decent people now if we basically introduce legislation on smoking cars then what about uh you know the the parent who has an overweight child are they going to be prosecuted um you know where does this where does this go to i'm glad you mentioned asthma because uh smoking you know often gets the blame for uh for for i didn't say it was a blame for i say the child may have and it could be exacerbated by sure um but i mean i don't think we've gone down the educational route when it comes to smoking cars with children and i think that let's say a legislation should be a last resort i think there should be a three year moratorium in which you do have an education campaign and you specifically target the issue of smoking cars with children let's say we would be more than happy uh to support that campaign but legislation i believe when you're talking about private vehicles i mean this is the difference pubs and clubs were public places in the sense that you know the public could go into them i mean they were still private businesses so but that's a different argument but we are now talking about private spaces and as i said to you earlier i can guarantee that as soon as this law is passed and introduced the tobacco control lobby will be back here i'll probably be back here in five years time maybe less three years time having the same discussion about banning smoking all private vehicles they they're relentless they never stop of course you know i you know i'm mr claire the thing i i can't you know come come to terms with with with your argument you seem to be accepting there's a three year moratorium you're you're accepting that children will still be exposed to smoke in a in a confined space and you're happy for that to happen well as i was trying to explain i think the um health impacts are exaggerated but i hold my hands up i i'm not an expert on the subject i did say earlier that a generation of children grew up in smoky households smoky cars and that generation of children is living is the longest living generation in human history now i'm not suggesting there's a correlation between the two things clearly but what i'm saying is that that baby boom generation of the 50s and 60s does not appear to have come to any long-term harm and the reason i brought up asthma a few minutes ago is that it's interesting that in during a period 40 a period where smoking is halved in number cases of asthma have tripled and we know that allergies are a huge problem these days and the way they weren't 40 50 years ago and yet there is this obsession constantly with smoking and with giving smokers a good kicking and i do believe uh i believe very strongly about this because say i'm a i'm a non-smoker but in my lifetime and i grew up in scotland um in my lifetime i've seen scot smokers treated abominably um they are an easy target what's happened since the smoking ban came in is that people are now complaining about the smell of tobacco now that's got nothing to do with public health it's simply because people are now so sensitive to any whiff of tobacco smoke because then most people are not normally exposed to tobacco smoke in our lives we're not exposed to it in the workplace very rarely exposed to it in the street when some people sort of get a little whiff of tobacco smoke they react to them and shot i mean it's getting utterly ridiculous and i think we've just got to have a bit of proportion here and i think legislation to ban smoking in private vehicles is disproportionate to the actual problem can i just agree with dr Simpson it's about child protection i'll leave it there convene i don't have any other question from committee no mr clark thank you for your attendance here this morning you're written evidence and we'll move to the next panel thank you very much indeed thank you suspend at this point or pause at this point can i now continue with our evidence session and welcome brine old director of professional development royal royal environmental health institute in scotland welcome william hamilton environmental health manager glasgo city council professor allison britain a convener of the health and medical law committee of the law society of scotland murder wallace community services manager sterling council bernard higgins assistant chief constable operation operational support police scotland and chief superintendent hene murray police scotland welcome to you all and i'm going to go directly to our first question which is from the net milling i just want to open up the discussion about enforcement of the bill because i think it's one aspect that has actually given me some concerns and most of our evidence indicates that police scotland should be enforcing the bill but some organisations including police scotland themselves don't agree that that should be the case so i'd really welcome views from everyone as to just how how this this proposals can be enforced and who should be taking responsibility for enforcing them yes good morning convener perhaps i'll just start firstly can i say that the police scotland absolutely supports the introduction of this bill anything that makes scotland a healthier place and protects communities from harm then we absolutely buy into it and there's no no question of that we're also happy to be an enforcement agency in terms of enforcing the legislation but there are some practicalities around it and we don't believe that if you wish the bill to be as impactive as i believe you do that we should be the sole enforcing agency the reason for that is quite simple one of our key priorities is around reducing road deaths and reducing persons that are seriously injured on scotland roads last year fiscal year ending 31 of march we had sadly 191 people killed in scotland roads as i understand it smoking was not a contributing factor in any of the fatal road accidents so whilst there is absolutely clear health benefits for it in terms of reducing the number of people killed in scotland roads it wouldn't necessarily be something that we would see as having a great impact speeding mobile phones seatbelts drink driving are the clear causal factors for fatal roads road accidents and serious road accidents and that's what we would wish to continue to target that said i do really want to emphasise it we do believe we would have a role to play in this we would be an enforcement agency but i just want to make the subcommittee in parliament aware that in terms of of how much we could contribute to it perhaps there would be benefit in extending the legislation to include for example environmental health officers local authority officers traffic wardens the numerous people just now that are in power to issue anti social behaviour tickets they could comfortably deal with those people that are smoking in vehicles that are stationary and i do accept that in terms of stopping moving vehicles on the road only police scotland has the authority to do so but i would also contend that there are a number of people that will smoke with children in their vehicle who are stationary car parts parked up and again the legislation could be extended to authorise other authorities to deal with that particular set of circumstances but wholly supportive and happy to be one of the enforcement agencies still in council fully support the bill as well i think her view is that this should be a partnership approach that police scotland should be the enforcing body but it's actually about different partners playing their part as well and it's a wider prevention intervention education and enforcement and enforcement essentially for the people that aren't responsible and i think that it's a more about a partnership approach for us and as you say it's more about cars that are actually stationary from the council perspective obviously because that's a more practical element for us yes please professor good morning the law society are very happy to see the provisions within this bill and we welcome anything that will protect our children in scotland and we see this as a range one measure and a range of measures for smoking cessation strategy our concern then is also to try and make enforcement workable practicable with limited resources across all the organisations pertaining to this and one of them would be perhaps that the committee would consider the responsibility of the driver rather than attributing responsibility for smoking and the penalties incurred on the person actually smoking in the vehicle that the driver maintains control of the vehicle he or she are responsible for the vehicle we see this in relation to young children under the age of 14 the responsibility is incumbent on the driver that that child wears the seat belt and evidence has already been given how challenging it's actually going to be not necessarily when it's young children in car seats but children from the age of 12 onwards it's so hard to know how old they are we'd been wanting them to be carrying some form of photographic evidence for identity their date of birth something that might try and simplify that procedure and utilise resources effectively so the responsibility and the driver might be one way of taking that forward anyone else mr old and then mr hobbles continue down the line first of all the institute fully supports premises of the the bill my understanding is approximately about 79 percent of those who responded to the government consultation is fully support of police scotland undertaken as the lead enforcement authority for that and we fully appreciate the difficulties and restrictions that police scotland are under as many public services across scotland the environmental health profession has had a leading role in the banning of smoking and enclose public spaces between 2006 and 2012 there's been approximately 5000 fixed penalty notices served across scotland but the one thing that's really important to recognise is that enforcement is part of a multi-model approach to smoking so it does include a lot of education a lot of guidance that we would fully support in line with this new legislative approach the other point that we would like to make is environmental health departments across scotland routinely work with gleece scotland as it is we buy in for one of a better word the resources of police scotland for example with emissions testing now there is some issues with that it's very reactive the chances are we are going to miss a lot of the individuals we would want to target with such legislation but we would fully appreciate a partnership approach and a collaborative approach to undertaking enforcement activities within the bill mr hamilton thank you convener i'll just add my perspective from the point of view i'm here to speak about the enforcement aspect from glaser city council alone i do however endorse my colleague from reis's views we also support the bill it's just a cautionary note from our perspective that we have real difficulty seeing how environmental health can really engage with us to the kind of extent that would be meaningful i take the point about the stationary vehicles but in reality we don't have the people on the ground in the street to the same extent that the police do so intervening with our stationary vehicle yep it's conceivable it's feasible but in terms of the numbers involved i really can't imagine it happening to any meaningful extent something because the number of people involved is so so low and you know people are you might pick something like that up while they're traveling from A to B and i don't see there being any huge and sensible local authorities to enforce it in that way if we do so proactively in terms of stopping vehicles again that would involve police scotland we'd be more than happy to work in partnership in that way it's just the concept of intervening in an unexpected and unplanned way would be problematic and i say i'm really to be truthful unlikely to happen to any great extent thanks for all that i'm certainly worried about the actual practicalities of what would trigger looking for well identifying young people i can fully accept what a lot of the talks mean about children and young children car seats and i can fully accept that that's i suppose relatively easy to find it you select these people i mean i have a grandson who's 15 and five foot two and if he was sitting in a car you could quite easily think he was over 18 and this legislation does go up to 18 year olds and what would trigger the investigation there i mean do we depend on these people saying that they're adult in the car with them and smoking i just can't work out the practicalities of how we get to the stage of saying accusing someone of smoking in a car with children any advice there i think that's one of the reasons that i'm just going back to the point we made about the responsibility being incumbent on the driver there's been some discussion earlier on about the success in relation to sanctions for not wearing a seat belt if you're a driver if you're using a handheld phone the cameras can pick that up it's clear and reasonably easy to evidence given the person sitting in the front of the car the reasons that you've mentioned as well you could have somebody sitting in the backseat smoking somebody could smoke a cigarette inhale a cigarette put it underneath the dashboard i also have teenagers and i know how crafty they can be in relation to passing cigarettes back and forward it could stub it out by the time they're perhaps apprehended the smell of cigarette smoke lingers a long time evidence is going to be so difficult and since this is such an important component part of smoking cessation strategy we have to make sure that we were as resourceful as we possibly can be there to support professor's point of view that the concept of that making the driver the keeper of the vehicle responsible would mirror the original smoking ban legislation where it was effective largely because the licensee for instance and a pub would be held responsible for people on the premise of smoking so there was this kind of degree of managing the complies themselves and i think that principle would apply also for the smoking in the car also i think it would to be truthful and make it more straightforward in terms of identifying the person responsible something because they are the keeper of the car if it was a passenger in the vehicle it would cause some significant difficulty especially if we were environmental health officers identifying our intervening in a situation there was no police constable available we might have some difficulty trying to get any meaningful information out of the person involved imagine almost random checks on drivers if you see a driver smoking or people in the car smoking you're not sure would you just target that particular person randomly is that how your visit should work? There are two main ways in which it could happen i would envisage colleagues and a police mate or other colleagues to make on it one would be to respond to to complain their accusation which is not really going to be a major part of the work two would be to simply pick something up in passing to identify or to notice it and then to add a third and a third one would be the kind of pulling vehicles over relatively random that does happen at the moment for emission testing for instance it's pretty successful it works well we need to work in partnership with the police with that but i can imagine that happening it's probably quite effective in terms of sending out the message and getting the awareness levels up which itself is probably what's going to succeed in this case rather than any any rule enforcement activity. Thank you convener again there has to be a degree of pragmatism about how this would be how to operate and again our officers make judgment calls constantly every day every minute of every day they will be deciding what action to take or not to take for example kids are in possession of alcohol and making the assessment of whether they're under 18 or not so again from a pragmatic point of view our officers are well versed in assessing the situation as they see it so if they pass a car and they see somebody smoking within and they also see child seats in the back then that's a fair indication that the child will be under 18 but again it would be about overlaying a common sense pragmatic approach and considering every circumstance as it presents itself at that time and again just to clarify there is no will for police Scotland not to do this what i'm simply saying is that there's perhaps opportunities to widen the number of authorities that can enforce it and there have a greater impact and i do wish to make that absolutely clear we're in no way abdicating responsibility for doing this but i do want to be very frank with Parliament and say about our capacity to do this over a long period of time and there are other opportunities as well. Necessity to ensure that community wardens traffic wardens what action would be necessary to create that wider partnership is there any additional powers that we need to have? Yeah i mean again i don't know is the answer i would assume there would need to be some extension either to this legislation or local bylaws but if you look through the walk through the sheets of Glasgow as i did at the weekend i saw a number of community warden issuing fixed penalty notices for litter so again whilst it might be a rarity for them to have the ability to deal with somebody on a car that's smoking with a young child is better than not to have the ability even if they don't use it on many many occasions and again i'd like to echo colleagues comments about partnership and education it's something that we do in every aspect of road safety right across the whole road safety spectrum and so we are very much signed up to that and we would absolutely work in partnership with colleagues around the education aspect of the smoking and so again there are opportunities here and again we are very happy to offer our advice on that. Any other response to? Yeah i've just had a couple of points and the first one being that many local authorities throughout scotland have warden based services to meet the needs of their local community so they will go out and they'll do things with dogfiling littering and they are skilled with some legal procedures and the ability to serve fixed penalty notices another comment i would like to make is something that was quite missing from the bill is although we are working at enforcement there was nothing really mentioned about working with industry so for example car dealerships and where people are actually buying cars when cars are going for the MLTs for example and putting some advisory notices through that particular system and that's another avenue that we would potentially ask government to consider but there's no barrier to giving additional powers to people who are already existing powers through littering there's no barrier per se it's easily done no it comes only down to training incompetence with the officers we're giving those powers to make mckenzie once and if nobody else covers it we need to come back to some of the others maybe unintended consequences like getting a ride for every child in the children's act and and the potential that was mentioned earlier about third parties reporting smoking cars and how that would be dealt with but make mckenzie thank you convener it was my question is really directed at professor button because i'm i'm a bit surprised at the law society in suggesting this kind of vicarious liability on the part of drivers for somebody that might happen to light up a cigarette and just at that moment you know a passenger and the driver could ask them to desist or whatever but they may be on a motorway they may be on a bit of road but it's just not possible to stop and assistant chief constable higgins or one of his sharp-eyed colleagues happens by at that moment the blue light goes on and the poor old driver is a wonderful sort of if you were representing a client in court who happened to be a driver of that vehicle what kind of defense would you mount on his you know in order to try and prevent his conviction and then i've got a further point about the the nature of this being a form of summary justice and perhaps the the police feeling under some kind of pressure to produce a set of statistics that show that they're enforcing this and again just the the opportunities for and i take it that you know i'm not implying any good faith on or bad faith rather than the part of the police but you know the the opportunities for mistakes about age of children you know i know some 18 year olds that look younger you know and just take you back to your days as a law student when justice was perhaps maybe more uppermost in your mind than i'm getting the sense that it possibly is now oh mr mckenzie that's a terrible thing to say indeed thankfully i'm an academic and won't be defending or representing anybody in court you talked about vicarious liability a driver of a vehicle i think has a very very special responsibility in relation to road safety now i know that here we're talking about the health and wellbeing of the occupants of that vehicle so point that the example we already made was that if a child under the age of 14 is not wearing a seatbelt then the responsibility for that child to wear the seatbelt is incumbent with the driver there hasn't been anybody that's given evidence this morning in this session who is not very very supportive of this bill and the issue then tends to be effectiveness a good use of resources and ensuring that if this legislation is going to be passed that it is as effective in protecting young people as it possibly can be so i'm certainly not trying to be draconian i'm trying to take a practical approach in relation to a set of circumstances that everyone has said can be challenging in terms of enforceability um i believe on behalf of the society and i personally believe as well there could be a statutory defence built into the legislation to say that the driver of the vehicle reasonably believed that the people in the vehicle were all over the age of 18 um and we'd be able to be on the uh beyond a reasonable doubt we'd be able to use that as a statutory defence but if we're looking at ways of being able to set a good example in relation to smoking cessation strategies there's been some evidence um more in other countries New Zealand Canada Ireland where such legislation has been a little bit more established to say this is a very effective way of setting normalising behaviours that people don't smoke in vehicles so we have to use the resources as effectively as we can and that to me seems the most logical way of doing it the second point you made i don't feel i'm even beginning near qualified enough to answer that so perhaps my any other responses to Mackenzie's question mr again yeah in terms of the enforcement and my sharp-eyed colleagues again that would just be down to professional judgment i mean i think i think that's what we ask our officers to do in every point one of the things that we train our officers from day one in police scotland as well as our ethos around treating every day with fairness integrity and respect is that you have to use your professional judgment and on occasions discretion so whilst we might stop somebody that's smoking and they have young children in the car it isn't necessarily the case that they would always get a ticket and it might well be that part of the enforcement strategy is exactly that that the police officers issue as many warnings as they do tickets and so there's a whole round way that we can work jointly and make this legislation as an impact of as you wish it to be that's very reassuring if with your indulgence convener i'll just come back to professor button because with the greatest of respect i don't feel that you're really properly you know answered the question but perhaps i could rephrase it in a slightly different way um you haven't made the case i think for the merits of prosecuting a driver rather than the passenger that's committing the offence and i'm not clear where the advantage is in prosecuting the poor old driver for vicarious you know liability rather than just prosecuting the passenger that may may be convicting committing the offence i don't think it's the role of the law society to look at issues of prosecuting anyone in our submission we were considering the robustness of any possible legislation prosecution is not the remit of the law society being able to contribute to effective legislation is hopefully within the remit of the law society and that's what we try to do in our submission the decision on whether to prosecute would lie if the vehicle was moving with police scotland and my colleague here has already said they would take a practical approach they have experience already in relation to other road traffic offences and they would apply that experience convener i can only comment that yet again i'm disappointed that you know the law society as i understand it have suggested that if this legislation goes forward if this bill's passed then it should be the driver that has a you know a liability under this law rather than the passenger or a passenger if it's the passenger that's committing the offence i would be really pleased if you'd be able to describe why it is you feel that the driver should have this legal liability you know and not a passenger if it was the passenger that's committing the offence i don't i don't understand what you feel the merits of this argument are i can only reiterate what i said already that it's first of all a responsibility we're trying to take a responsibility in relation to protecting young people in a vehicle setting good patterns of behaviour to protect their health and wellbeing and on the basis of the law society's understanding in relation to issues of enforceability other jurisdictions have introduced legislation that is before this committee today and the thing they keep going back to is the challenges in enforceability and one possible consideration for the committee would be that it may be easier that the responsibility is incumbent on the driver Is there any other views on whether it should be incumbent on the driver or the person who spoke with us Brian? The institute's response is that it's the driver's responsibility and the most simplistic terms is without the driver the car can't go anywhere or the vehicle can't move so they are responsible for those who they are transporting in that vehicle we understand there may be some situations where the driver may not be able to control the behaviour of individual passengers but that comes under to what should be considered as a defence to allow someone to smoke in the vehicle. Any other comments? Police Scotland got a view on it or come on now? You know you could you could describe the the causing permit you know so if you're in charge of the vehicle and you cause a permit somebody to commit an offence then you're as liable as the person committing the offence so again not wanting to give you another option but potentially you could charge both the driver and the passenger. Look at that for a neutral stance put that in your pipe and smoke it. Richard Lyle Thank you. I think you sat through the session with Mr Clark. Have you not just all of you made the case for Mr Clark? We've now got police, council officers, traffic wardens, community officers, the general public, CCTV and by the way we're going to set up roadblocks to pull you over you know have we not just went from the police who do a good job in checking people for seatbelts, drunk driving on the phone and and as they're driving by generally most of your cars have two officers still in them checking somebody you know with the their maybe as I said earlier on I've got two kids seats so you can see my three-year-old grandson my one-year-old granddaughter sitting in the back and basically you know have we not just made the case for Mr Clark saying in for me in for me you've all got it in for me. I don't agree with that Mr Lyle I think my opening comments I talked about the number of people that are dying in Scottish roads and that's a priority for Police Scotland now smoking cigarettes as we understand it is not a causal factor for people dying in Scottish roads but it's a significant health issue so what we are saying is that in terms of the the benefit to the health of the nation we absolutely get it and we absolutely support it but the reality is I'm not going to be setting up roadblocks to check for people smoking in the cars because I need my officers on the fast roads the big roads the roads where people are dying and tackling the issues the issues that that cause people to die in our roads and if I can draw a very um forgive me crass comparison um dogfouling dogfouling is a huge concern huge concern right across every community they tell us you know it's anti-social it's unhealthy um we still have powers um to deal with dogfouling but more often than not it will be the community wardens in that particular area that deal with it so what I'm saying is absolutely we've got a role to play in enforcing the legislation but in terms of the impact of our priority to make the roads safer and reduce the number of people killed then it won't have a huge impact on that and as such we would have to prioritise what action we take to actually reduce the number of people that die in Scottish roads and I daresay that smoking would not fall into that category so whilst we would absolutely enforce it all I'm suggesting to committee is that you look beyond the role of the police and see who else could assist in that aspect of the legislation bearing in mind that all colleagues at the table have also said that it can't be done in isolation it's got to be a collaborative partnership approach and actually it's got to be in the back of a fairly robust education programme as well. Professor and then Mr Old. I would just like to support exactly what's being said there one would hope that any form of criminal sanction would be a last resort it would raise awareness it would perhaps make people think about whether or they not they smoke in a vehicle it might help them perhaps consider whether or not they would look for other smoking cessation strategies change their pattern of behaviour how they wish to enjoy a cigarette I would be hoping that as one aspect of a whole range of measures this is something that just raises the profile the statistics are incontestable in relation to the dangers of secondhand smoke one billion people will die worldwide by 2050 I think these are beyond argument there are less statistics available in relation to the benefits of having legislation such as what's before us today but those jurisdictions that do have it are acknowledging that it does start to show an improvement in young people and smoking related disease and setting importantly particularly for teenage years setting a pattern of behaviour that these people will not smoke in the future so this should not be something that we rely on as a first point this should be part of a measure but something that perhaps just raises that awareness in people's mind to perhaps make other choices themselves and empower them to make choices Mr Old's coming back but I mean your professor is legislation he made an argument I think everybody's made an argument of educating and campaigns and whatever whatever it's a point being made for legislation I think is it's the next question legislation that is going to be difficult to enforce low on the priority to enforce because there's a lot of bigger you know and you know so it's that question isn't it about whether this legislation is is necessary to do that or whether we just do a better job in communicating and educating I think that's a lot of society's points of view we believe the legislation is necessary okay Mr Old I would just like to reiterate convener I agree with everything that's been said up until now with regards to that and with respect to Mr Lyle with the examples that you had given about the different enforcement options available it'd be very unlikely all that we've undertaken simply on our resource premises sorry I don't mean to show any disrespect with that enforcement authorities work under many different tools and what they want to to ensure is compliance through advice education publicity guidance and a fair and reasonable approach to enforcement and I do agree enforcement is regularly regarded as the last sort of method that you would use to ensure compliance and that was certainly seen through the smoking ban as well I mentioned earlier on about the number of fixed penalty enforcement notices served in Scotland and it is relatively a short or a small number with regards to how long the legislation has been enforced and that is partly due to the enforcement activities undertaken by regulatory bodies enforcement should be seen as the last resort to any form of compliance and that also supports the principles of best regulatory practice most of the panel sitting there witnesses all said that they could take part in the police can issue tickets council officers can issue tickets for dogfowling for the successful campaign you have in Sorka Hill Street and other places in Glasgow for people throwing down cigarette butts you can get a ticket traffic wardens can give you a ticket community officers you have in Glasgow can give you a ticket you know I've just mentioned everybody but everybody could pick on and the point that Mr Clark made earlier and that wasn't supporting him if you listened quite closely to the point I was putting I'm a smoker I believe this legislation is required but you've just made the case for Mr Clark that everybody is going to pick on the smokers who sit in their cars thank you Candina the point I was trying to make is you're absolutely right in terms of who can deliver the enforcement activity but I don't think it would be reasonable to expect that all these activities will will be undertaken at exactly the same time because there is just not the resources to do it so I think it will be up to the local enforcement authority to determine what would be the best course of action to ensure enforcement with the legislation I mean I think we all understand that most people are law abiding would comply anyway so it's not context and the context you know the focus on enforcement here today is because of the nature of the panel that we have here today you know so you know that's where your focus takes it so I've got Bob Doris and then Dennis Robertson. Thank you convener in the written evidence we we've got some information in relation to whether there's enough clarity in the bill in relation to exemptions for certain vehicles where it was used for human habitation and the the term where it was used not less than than one night whether that's mobile homes or caravans I just this been opportunity for some of the witness maybe to put their their own perspective on the record during the evidence sessions this afternoon. Scotland perspective I'm quite content with the exemptions as laid out there's there's nothing that we'd want to come back on in that point. Everyone agree with that on the record Mr all? Yeah we fully agree with the exemptions as described within the bill I think the the main area of contention from us was around convertible vehicles I think there's an argument for and against. In terms of the science behind convertible vehicles I think it's still a moving feast when we talk about third hand tobacco smoke and people think when you're in a convertible car the cigarette smoke will dissipate quite freely but a lot more people drive convertible cars with windows up so that prevents a barrier and there's now more evidence coming through about how volatile organic compounds for example a safe gun or an upholstery and how long they remain therefore and how they are getting into into the human biological system so at the present time we would fully support removing convertible vehicles from the exemptions and being enforceable for those driving convertible vehicles. Anybody any any no responses on going to third hand smoke that's a lesson for those who smoke in their car when their grandchildren are not in it anyway we'll leave them pondering on that one. Thanks for that I've got Dennis, Dennis Robertson. He's made me smile today it's unusual. Most people are law abiding I think we all accept that. Early along this year there was another piece of legislation came into being which gave powers not duties to local authorities in terms of the disabled parking the blue badge legislation and that was brought about because there was a non-compliance by some people in the general public. Are we saying that we need the legislation because the education hasn't worked so we need to actually have something there to make to try and enforce the sensible approach to smoking in cars when there's children because that's what we had to do in terms of the other legislation because there was a situation that it you know for years we thought the message had got across it obviously didn't so we had to bring forward legislation. Do you see this as a similar situation maybe Police Scotland first? I think that's a very difficult one for me to answer Mr Robertson and I'll tell you why again at the risk of repeating myself we concentrate on road deaths and fatalities so frankly there are child protection potentially child protection issues with smoking in vehicles but in terms of actually us reducing fatal and seriously injured people on Scottish roads this hasn't really featured in our radar. I probably don't know more about park vehicles and obviously police officers sometimes are obviously on the beat as well and that was a situation because before it was only police officers that could enforce that aspect and now it's been widened to council officers etc in this partnership collaborative partnership it sounds very sensible to me and I'm just saying that the education in itself doesn't seem to have got the message through so is this why we require the legislation and this partnership approach? I think that there's a to my mind a clear correlation between making something illegal and diminishing it and we're never going to eliminate this thing but what will happen is if it becomes known to the public that this is a criminal offence people will correspondingly stop doing it. Not everybody but the majority people do the seat belt ban the seat belt requirement was probably the first obvious case of that and personally I believe that it's not really a fear of being caught that stops people, deters people it's actually the fact that it's now become socially unacceptable so if you're happy with it that the impact that it will have upon people to that degree that may just be enough to satisfy us all but it certainly won't eliminate smoking in cars with children but it'll probably reduce it quite significantly and do we give another one to you there? I just think that when we're trying to make that big cultural change and make people good responsible citizens and allowing children to have a voice enforcement just becomes the next step to making that cultural change unfortunately it would be great if people were responsible and actually we the education and prevention stuff the intervention stuff actually had a wider impact but I think when enforcement's there people then start to question that actually this is enforceable and it also starts to change that whole cultural element of actually what is acceptable and what's not acceptable. Do we give the local authority the powers rather than a duty through this bill so it means that they can or they cannot I mean if they give them the powers it's up to them as to whether or not they obviously go down that road of enforcement or not. The duty obviously is a completely different approach and obviously is more about ensuring that the law is is complied with. Should it be powers or duties? Yeah again Police Scotland's position would support that Mr Robertson again I don't think the legislation would have the impact if we were the sole enforcing agency and as I said earlier it's better to have the ability to do something and use it rarely than not have the ability to do it at all. Anyone else? Okay just on like some views on Police Scotland's submission in regards to potential consequences of legislation in regard to something we found smoking in the car which would lead to a concern that would lead to including a raising of a child concern forum which would be shared with the name person under getting arrived for every child principles and Children and Young Person Scotland Act does it does everybody agree that that would have that for it you know if somebody's speeding me a child in the car does it there's a consequence run that that person is putting that child in danger in a report and you know. Circumstance in certain circumstances where the road traffic agencies might end up doing that but the purpose within the submission was to highlight this as being because there's obviously the public health concern and the wider was just to make that issue you know just to air that issue to say that actually is the expectation that you know as we're finding children who are believed to be in a position of harm that we will be looking at these child wellbeing and concern forms and that would obviously go to the name person and that then allows you to then take that to a different sphere in terms of education or intervention with parents through the named person through schools or whatever but obviously there's an implication for local authorities and for the named persons to take that work on and in terms of repeat offending how that might continue. Has anyone else thought about that issue or no? It might be useful if some of our other witnesses would give that consideration Professor or indeed the local authorities in any impacts on their responsibilities. I suppose the other one that was raised about the third party reporting you know and you know given what we've heard in terms of lists of priorities if somebody was reporting on a regular basis when the neighbour or the guy across the street was taken to kidsdie school they would smoke in or whatever whatever would that result in an investigation would that would people act on that third party reporting? Mr Hamilton. He would come down to this bit about the duty and responsibility. I think that it happens all the time with pubs so we would respond. There's a workplace with somebody smoking if we just look at the scenario if we were advised that a neighbour was driving a car regularly with a child and I would think it wouldn't be unreasonable for us to approach the individual and warn them and warn them the fact that this had been observed or reported to us and that they should be mindful of the fact that they're committing an offence. I can't see us taking formal enforcement action in the back of a third party report. Mr Higgins. Very similar position convener if you've got a third party report then we would be duty bound to do something with it. I would have envisaged it would be a simple contact with the person who allegedly is committing the offence highlight the fact that it's been brought to your attention and simply asking them not to do it. I do not envisage fully investigating it in a traditional sense as in going and taking statements from people and doing scenes of crimes examinations on the car. We would have to have an absolutely proportionate and pragmatic response to it and it just echoes what my colleague has just said there. Mr Old. I completely agree with what's been said by my colleagues across the table for reactive third party reporting. What I mentioned earlier on and I wasn't sure if you're going to come back to it was third party proactive reporting where we perhaps work with the motor industry. So when you are putting your car in for an MOT, if there is evidence that there is children being transported in the car and there's evidence of cigarette smoking for example, there's perhaps an advisory notice given. I'm not suggesting it's then reported to Police Scotland or another authority, it just comes under this educational approach of advising. Professor. A brief point. We have to remember that the ultimate aim of this bill is to reduce harm and to protect the health young people. So one would hope that all of the stakeholders involved in taking this legislation forward, if it does go forward, we'd remember that that was the priority there. I think a view should be taken that's very different from running a red light to trying to protect the health and wellbeing of occupants of a vehicle. Yes, I think maybe that's what the police have been saying to us all morning in terms of whether there's a clear role just for the people. We'll take all of that away and consider that. There's one final question just following on from Bob Doris' question about the question of human habitation and not less than one night, and again here we're talking about enforcement. How would something like that, everybody would be supportive of it, but how would something like not less than one night be enforced? It's a very difficult one, convener. If it was on a campsite, for example, you'd be able to see when the camper van arrived on the campsite and how long they were tethered there. If it's in a cab of a lorry that's parked up overnight in a lorry park, so again it just goes down to assessing what you see in front of you at that particular time and applying a pragmatic common sense approach, although speaking out louder if I've got a child in the back of a lorry camping overnight then there might be wider issues than just simply smoking, but I was trying desperately to think of an example there, but it would be simply assessing the circumstances as you see in front of it and taking a pragmatic common sense approach. Anyone else, Mr Rhold? I think it's just to add to the point that it's for people's home, so motor homes for example, and it's not for those that are maybe being rented, for example camper vans and travelling round, because they're already covered under the smoking band for such vehicles. Right, okay, thanks for that. Is there any other, excuse me, nearly stretched these there, sorry about that. Is there any other questions from the committee members? Can I thank you all very much for being with us this morning, the written evidence you provided and the good evidence you provided to us orally today. Thank you all very much for your time and evidence. Thank you. Is there anything? Yeah, we'll just close there's nothing else there is there. Well we'll close the meeting at that point. Thank you all for your patience and participation.