 Welcome to the eighth meeting of the Health and Sport Committee of 2018. We have received apologies this morning from Sandra White. Can I ask everyone in the room to please ensure that your mobile devices are switched off and ask you also not to record or film the session? This will be done by the Parliament. We will start with agenda item number one, which is subordinate legislation. We have three negative instruments to consider today. The first instrument is the National Assistance Summs for Personal Requirements Scotland regulations 2018. There has been no motion to a null and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Do any members of the committee have any comments on this instrument? In that case, can I take it that the committee is agreed to make no recommendations on this measure? Thank you very much. The second instrument is the National Assistance Assessment of Resources Amendment Scotland regulations 2019. There has been no motion to a null and the Delegated Powers and Law Reform Committee has not made any comments on the instrument. Can I invite comments from members if there are no comments? Can I therefore take it that the committee is agreed that we make no recommendation on the instrument? Thank you very much. The third instrument is the Personal Injuries NHS Charges Amount Scotland amendment regulations 2018. There has been no motion to a null and the Delegated Powers and Law Reform Committee has not made any comments on this instrument. Either. Can I invite any comments from members of the committee? There are being none. Can I take it that the committee is agreed that we make no recommendations on this instrument? Thank you very much. That takes us neatly to our second and main item of the day, which is to hear evidence on the impact of leaving the European Union on the health and social care sector in Scotland. This first session will consider a number of areas where it impacts on the general public and on access to health. Can I welcome to the committee Mark Dyan, a policy analyst of the Noffial Trust, Dr Syed Ahmed, the clinical director of health protection Scotland, and John Watson, deputy chief executive of our Scotland. We have a number of questions, of course, for the witnesses and I would therefore like to start by inviting Ivan to open the questioning on the impact on public finance. Thank you, convener, and good morning panel. Thanks for coming along to talk to us about this obviously critically important issue and value, your insights. The area that I wanted to focus on was round about the potential for public funding challenges for the NHS going forward. Clearly, if you look at the assessments that have been done by the UK Government and by the Scottish Government on the impact of Brexit, they range from a complete disaster to an utter meltdown in terms of impact on the economy, depending on the scenario that we end up with in over the next number of years, that is going to have a significant impact potentially on funding available for public sector finances. Have you had any thoughts on that? Are there any data that you could share or any evidence or any comments on how that might play out and any fears that you might have as to what we could see unraveling there over the coming years after Brexit? What you say there is quite right. There has been a large number of different estimates on different timescales. In terms of the impact on the public finances, perhaps the clearest estimate on that is from the Office for Budget Responsibility in London, which obviously sets the UK Government's expected income for future years. They think there will be about £15 billion less by 2020 in the Treasury as a result of leaving the European Union. When you go a bit further out into what you might think of as a medium term to 2030, as you have probably seen, the estimates start to diverge much more sharply, so from anything from 2 per cent to 6 per cent, less than we might otherwise have had in the economy at large as a result. Obviously, you would expect that to feed through more or less one for one into public finances as well. I would say that those impacts range from substantial to really serious. Unfortunately, it is not entirely clear. There is not as clear a correspondence in those studies as you might expect between softer forms of Brexit that are necessarily providing less of an economic impact, but on balance I would still expect that to be the case. Either of the other witnesses want to add anything to that? Just following that through, I do not know if you can maybe put some colour around about what public sector funding cuts of that kind of level could have on the health service, given that we have become used to health services funding increasing by more than inflation over the years. What could that potentially look like on the ground for people? I would not expect it to result in outright cuts. You are still talking about an economy that will be growing and therefore a tax base that will be growing, but you will be talking about less of an increase than otherwise expected. As you quite rightly say there, we have just come through across the UK several years in which health funding has been held, not quite flat but near to flat, while demand and the pressures of medical technology have seen the call on funding, if you like, rise more quickly than that. That has resulted in a wide range of pressures not limited to difficulty in waiting times, pressure on wages, which has contributed to difficulty recruiting staff, difficulty in adopting the latest medical technologies. Unfortunately, insofar as Brexit prolongs a period in which we are not able to return to the historic trend of about 4 per cent funding increase per year, you would expect it to prolong the period for which those things are a reality we face. Perhaps one of the most immediate impacts on the public or the most visible impacts on the public of leaving the European Union will be access to healthcare outwith the United Kingdom. I think that David Stewart wanted to start the questioning on that. Thank you, convener, and good morning. Can I ask, as Cymru has mentioned, about receptacle healthcare? We know that the real jewel in the crown has been the European health insurance card, and over 27 million UK citizens have this card. How important is this card for European and EU citizens, particularly UK citizens? What would the effect be if we lost this receptacruosity? I think it is quite important. There are two levels to the value that I would say it delivers as an initiative. One of those is just, as we all know, you can use it as a form of travel insurance when you go on holiday to supplement private travel insurance. That can also be helpful to business travellers. From that point of view, it probably helps to smooth travel and tourism across the UK and the EU. In doing that, I am sure it contributes both to the ease and enjoyment of people as consumers, holiday makers and travellers, and probably also to the tourism industry in some extent to other service industries that involve going back and forth. Then, for a minority of people who require quite intensive regular healthcare sport, so dialysis is a good example, it also makes it possible for them to travel and be sure that they will be able to access, say, weekly dialysis abroad when otherwise the cost of doing that via private insurance would be pretty huge. I think it does provide substantial benefits. I would say that financially speaking and in terms of the scale of the impact on many people's lives, arguably more significant is the S1 scheme, which, as you may know, is the scheme whereby you can work in one EU country and retire to another one with many of the benefits that you might get as a pensioner intact, including healthcare. A lot of UK citizens have availed themselves of that to move usually to southern Europe, which, obviously, provides the basis of their health coverage there. These are often older people, so for them that is very important. That is an issue that has been hopefully dealt with in the withdrawal agreement, assuming that that is successfully passed into a treaty between the UK and the EU. Future access to e-hit cards, on the other hand, for people who are not already in another country, would need to be sorted out through the future relationship. Unfortunately, there is not a precedent for that happening outside the single market. Thanks for that answer, Mark. You have predicted my second question, which was about the S1 card. I am concerned about the possible loss of S1. If you have moved to Spain, Portugal or Italy and you are well established and you are getting on in years, you will be using that for on-going healthcare. If that ceases, is there any estimate being made on the effect on the British health service, on returning UK citizens who are currently living abroad? Has there been any assessment on the hit that that is going to have on our primary care services? We did a calculation that looked at the relative cost of each pensioner receiving care under S1 in another EU country compared to if they were in the UK. Our estimate, which was kind of surprisingly high to us, was that it would actually cost around £500 million more to care for those people in the UK. That is assuming rates of the English NHS, which is actually slightly lower than the Scottish NHS, and potentially an extra 1,000 hospital beds. Again, given that, as I am sure many of you know, that the NHS across the UK is in a period of real squeeze on bedspace is not something that would be easy to bring on stream. That would be an extra level of uncertainty and risk for services in the UK who obviously would have a duty to provide for these people because they have a perfect right to receive healthcare here. What I would say is that in the withdrawal agreement reached last December and in the legal text that the European Union has produced as a basis for turning that into a treaty, these issues, at least people who already have them, should be dealt with. People who are in a cross-border situation on exit day should be able to retain the rights that they currently enjoy. The effect might well be on people who are currently thinking of leaving the UK and staying in an EU country. That might affect their ability to move because they might not get healthcare or social care in the future. That is absolutely right. That forms part of a wider set of issues around the free movement of people after Brexit. It might not be merely that you cannot access healthcare if you go to Spain, but that you might not be allowed to go. Obviously, that would have implications for the demographics that the NHS is addressing gradually. Can I go back to the European health insurance card? You have touched on my potential question. I think that Macmillan Cancer gave evidence to the Commons health committee. They were very concerned about the withdrawal of the card for those who have cancer or, indeed, any serious illness. In some senses, if we lose the card and then, of course, it means that private travel insurance is very expensive, is there a real possibility that those with cancer or with mobility problems or serious illnesses will effectively be restricted from travel within the EU in the future? In at least some cases, if there was no replacement for the EU card in terms of providing some sort of subsidy, then it is hard to see how that would not be the case. I would like to follow up on some of David Stewart's line of questioning with regard to the EU card, as I would have referred to it. You have not provided Mark Dana a written submission today, but in your submission to the health select committee inquiry in 2016, the Nuffield Trust said that there is a risk that without the S1 e-hick card, more unwell British citizens facing high private insurance premium would return to the UK to exercise their right to free healthcare, effectively cancelling out significant proportion of any savings. In the submission that we have received from Community Pharmacy Scotland, they argue that the biggest risk to the Scottish health and social care system faces in this respect is that there is no transitional period or that current e-hick arrangements are not adopted into domestic law in time for March 2019. That would leave Scottish citizens both with and without any existing healthcare conditions vulnerable when travelling in EEA member states. They talk then about this being mitigated by some sort of transitional period within either the relevant legislation as transpose or new similar arrangements are made preferably the former they argue for, this transitional period to be in place. That is currently not the case as far as I understand it. What is the panel's view with regard to there being a transitional period in the meantime then with regard to e-hick provisions? So the current, I mean it might be a bit generous to call it a plan but the expectation is that there will be a two-year transition period between March 2019 and roughly the end of 2020 as the UK leaves the EU and during that period the entire body of EU law if you like will be rolled forward and will continue to apply so to simplify a bit in many ways it will be like remaining a member of the EU but without voting rights and that effective continuation of membership would apply to e-hick and S1 as well as anything else so I mean I think what possibly those submissions including ours are getting at is that it's certainly not a done deal that this will happen this relies on us actually signing that treaty at the end of this year the beginning of next year having actually come to agreement on some of the difficult issues that remain but as long as we do reach that the current plan is there will be a transition that would apply to e-hick cards. In terms of healthcare obviously it's a largely devolved matter and that's what community pharmacy Scotland go on to argue they say that it's appropriate that reciprocal healthcare is dealt with using a common framework following Brexit it's difficult to comment without speculating but whilst an arrangement any arrangement would likely mirror Westminster's initially the devolved nations must have the freedom to pursue relationships with individual countries independent of one another is that a matter that the panel might have a view on? I think that's an interesting thought I mean there is a sense in which it has proven very difficult to negotiate reciprocal healthcare agreements outside the EU so we don't have agreements with that many countries other than the EU Australia and New Zealand are about it we used to have them with some countries in the Balkans but those have lapsed it might be quite challenging to reach any agreements and from that point of view I suppose the UK as a whole might be the easiest unit to do it but whether as part of those agreements we could leave there to be room for for variants based on what the devolved countries wanted I think is an interesting question yeah I mean I looked at your submission obviously from 2016 and you go on to say that developing a full set of separate arrangements with EU members would be a formidable task but as you say it is already the case with Australia and New Zealand so it's not impossible and I suppose what we're interested in is the powers of this Parliament and with health being a power of the Scottish Parliament it's important that we look at how those powers that are coming back to the UK are then also devolved back to the respective nations within the United Kingdom yeah and then that's a very interesting area which certainly applies to many aspects of healthcare whether they can be brought back in a devolved sense I suppose the tricky element in terms of reciprocal healthcare is that the current system at least with the EU is funded through Westminster and obviously derives from a treaty signed at Westminster but that's not to say that there wouldn't be that you can't write into any treaty you make a role for devolved governments to to vary it as it were thank you thank you very much do any of the witnesses have a view on whether there are any potential benefits from brexit in terms of the promotion of public health policies within scotland are there aspects of leaving the european union that create opportunities to do things that have not yet been done certainly there are there are opportunities that come from brexit and from our perspective we are we work in an area where largely the work that we do is about regulating commercial entities who are producing harmful products and the importance of us for trade deals is that you're setting down some kind of balance between the the rights of companies to produce and distribute and sell the products they produce and the rights and the powers of governments to regulate that activity and to interfere in the market so at the moment being part of the european union we are signed into a body that is very largely focused on having the free movement of goods between countries who are members of the european union and that does place some restrictions on the ability of governments to look at particular products and say we're going to put restrictions on that because you are restricting the ability of companies to to move those products in between the countries so for example the scotland is interested in banning plastic drinking straws in order to do that that needs to be notified to the european union there is a period whereby other countries can say well actually we think that's going to particularly influence our companies we think that's an unreasonable restriction on trade and so there are hoops that need to be gone through before that can be continued domestically the same is true with with some of the the projects that we would like to see taken forward in terms of regulating tobacco in scotland that there are many more avenues that we have to pursue in terms of actually having a properly regulated trade in what is the most harmful consumer product around so the same analogy for plastic straws could actually be taken for cigarette butts and the most common form of plastic waste that's in our streets and on our beaches and in the sea it's not drinking cups it's not plastic straws it's plastic cigarette ends but these don't actually bring health benefits so we'd like to see that brought into the discussion but in order to do that there are various hoops to go through in terms of the european union now this is something that can be taken forward while you remember the european union but brexit makes it easier to do that because there are fewer hoops that you have to jump through in order to bring about that restriction on the sale of a product thank you very much dr Lamont no nothing else to add obviously maintaining health protection and health security requires close collaboration with our partner agency so i think anything that we're going to interfere with that collaboration and cooperation is not good for health protection sure Alison Johnstone I think convener to be honest you you know i was you know wishing to to frame a similar question but i'd just like to understand the panel's view on the need to tailor regulations to that Scottish context some of the evidence we received from community pharmacy scotland for example said where health related powers returned to Westminster from the EU scotland needs to ensure that those are devolved as opposed to following a common framework as our public health services are already at a more advanced stage than other home nations and development would suffer if it was necessary to pursue UK legislative change to allow further innovation so i'd just like to understand your views on the need for scotland to exercise those powers over health post brexit don't you'd like to kick off our interest is in i could summarise our interest in brexit with a simple phrase that you know we believe that governments need to retain the right to regulate harmful products that are being sold by companies so this is a very good example of somewhere where we need to see government interference in the free market if it were simply a matter of the UK leaving the European Union we would probably be quite confident in the way that this would be taken forward because we've actually seen some fairly proactive policies from all of the constituent parts of the UK but actually particularly scotland in terms of robustly interfering in the market in pursuit of public health goals so if it was simply a matter of leaving the European Union and deciding domestically how we were going to do things we would be quite confident that this parliament would be continuing a fine tradition of engaging with the market and actually trying to bring about better goals than the market itself left to itself would would achieve so yes i'm very pleased to see powers coming to this parliament where i think they've been very well used in the past the other side of that coin of course is that the UK will then be entering into different trade deals and that will bring about probably an emphasis on free trade and so that balance may shift again once the UK enters into an entirely different set of international trade deals and our concern is that that pendulum may swing back too far and that the opportunities we have for regulating for interfering in the market will be traded away in order to get some wider trade deal is that a concern that other witnesses share yeah i certainly think it's possible that that some of the freedom of maneuver potentially granted by brexit could be removed again either through trade deals with third countries or indeed the trade deal with the EU itself which according current plans will be a very deep and trade deal which is likely to make the EU want to ensure that it's on a level playing field and that the UK does not have rights as they tend to fear to to deregulate and and just just to build on on what was said there i think there are certainly areas where it it's worth looking at scotland having a separate devolved set of policies you know aspects of public health would certainly be that potentially areas like procurement um i can't see any reason why it shouldn't be looked at though that scotland could go its own way on that once those powers come back from the EU i would caution there are some where i think there is a genuine argument for a common framework across the UK so thinking about for example human tissue regulation i think we've already seen that the european unions harmonisation of um how things like blood and organs are dealt with has facilitated those moving across borders within the EU to some extent to address what are often obviously you know very pressing medical needs um i think it would be a great shame to lose that um but if we are going to lose that harmonisation with the rest of the EU i certainly wouldn't want to lose at least the ability to move organs um between scotland england and wales um so in that case i can see the scope for some level of cooperation just to make sure that that in what will often be very time pressed and difficult situations there can still be that ease of movement around the UK whereas in other areas i think you know and there is a principle to consider as well um it is worth considering how scotland could evolve and go its own way on some of these powers brought back can i just be clear that the panel do see that there are potential risks here i mean particularly if we're pursuing a hard Brexit with an emphasis on deregulation there are potential risks to public health in scotland yes absolutely a hard Brexit that gave additional rights and freedoms to commercial companies would put real restrictions on the ability of the government to take forward public health policies so for example we we recently had the negotiations between the european union and the united states around the transatlantic trading investment partnership which was of great concern to us it opened up whole new areas of rights for companies to demand access to markets now for us if we're talking about tobacco companies demanding access to markets that's of great concern to us and even just looking at the recent example that we've seen in domestic courts in the UK where it was quite galling for me to see tobacco companies opposing public health measures using the european convention on human rights so claiming those rights to property that i feel it should be available to individuals but claiming those for themselves and using that as the basis of attacking and challenging government policies to try and and limit advertising of tobacco so i wouldn't want to see that kind of prospect coming up in future trade deals thank you very much and i'm moving on to future trade deals after thank you you meaner i think some of my line of questioning has been covered in answer to allison johnson but just to dig into it slightly more obviously the UK government as we've just mentioned wants to pursue you know common frameworks in order to facilitate potential trade deals going forward but obviously at the moment we're in a situation where there's been very little input for the devolved nations into any any process around that so obviously there's a potential risk there and the other risks as has been touched on is this investor state dispute settlement clauses which obviously would allow corporations to potentially sue governments that they thought were pursuing legislation potentially in a public health arena that they thought would interfere with their profits so clearly if that was included in a future trade deal that is quite a risk potentially to Scottish public health and the other one is that the Scottish health services obviously much has much less private provision within it at the moment than for instance the English NHS does and so if you know the Scottish health services actually included itself in a trade deal that would obviously be a risk as we would see it to the you know the principles of the NHS so does the panel think that the NHS should actually or the Scottish NHS particularly should be excluded or exempted from any future trade deal so i think that that's an important point you've ended on there's often a lot of concern about things like investor state dispute settlement systems to my mind all those are doing is enforcing the terms of trade deals domestic courts would be likely to enforce them in a similar way the issue really is what you've signed up to in that trade deal in the first place and from the point of view of the English NHS which is as you say much more marketized has a greater role for private providers this is very much a live issue because the the relationship between the UK and the EU has meant that the English NHS had to be fully open to market-based tenders for anything for which it provides a contract for internally which is nearly everything so there's I think a very live question about whether that would remain the case under future trade deals with the EU or indeed with other countries now whether or not the Scottish health services would be part of that I think has to start from recognising that the Scottish health service works very differently and it doesn't have contracts internally so that is to say there is nothing there which a private company could claim that it would be able to tender for in many cases however with that said it's also certainly possible within international trade deals to either limit the sectors covered or to limit the the institutions covered so for example you could say for instance that Scottish health boards are not one of the bodies subject to this trade deal and there's an element of that for example in the recent Canada-Europe trade agreement so yeah I would say the important thing is what's written in the trade deal there is a place there for exemptions and that includes exemptions at the level of bodies potentially in a Scottish within a UK context for example there are some Canadian states and territories which are or are not included in the in their trade deal so I think that is possible and there is important implications at a Scottish as opposed to a whole UK level in which you would make a lot of sense to the Scottish Parliament and Scottish Government to have some sort of input into. Does the rest of panel agree with that? Yes and I think on that point about the importance of what it is that you're signing up to a trade deal we have seen deals being negotiated which have included rights for companies to sue Governments when they enact or when they're proposing legislation that would impact on their profits and that really comes home very strongly for us now we are in a business whereby the Scottish Government has set a target for reducing the overall rate of smoking and the amount of tobacco consumed in Scotland it has cross-party support and there you have it coming up absolutely directly opposed to the profits of the companies involved you have a Government target that's not about changing the way it operates it's not about having it sell different things it's just saying we want you to be selling less of this product so an absolutely legitimate public health policy would come up against that kind of trade agreement and if the companies were given the rights to sue the Government for enacting those kind of legitimate health policies that would be a disaster for public health. At the health protection point of view most of the preventive services like screening, immunisation, dealing with major outbreaks and so on these are mainly funded by the Government and they're a very limited scope for private sector in those areas. Thank you very much. Alex Crowe-Hamston. Thank you Beno, good morning to the panel just picking up on Ash Denham's point. I think it's been clear since the days of the general agreement on trade and services and the negotiations around that WTO treaty that America in particular has often looked with hungry eyes at NHS and the services contained therein as a potential emerging market. And it's clear I think from the Trump administration the very sort of isolationist, protectionist policies they're beginning to adopt that a trade deal with America in particular is going to be incredibly hard without some sweetness to that deal. If Theresa May's Government capitulate on the idea that the NHS is for sale and parts of the NHS are for sale to American company provision or American to open up to American companies, in addition to the points made by John Watson about the potential for litigation by companies who think their profits will be affected by policy, what are the other negative consequences of opening up to that wholesale potentially race to the bottom provision from aggressive American companies? Yes, so I think it's worth looking at this from the point of view at which the English NHS starts, which is in England with a marketised system, under EU law it is already the case that it must be fully open to private companies. So that's not something that could potentially happen in a future trade deal, that's very much the starting position. So it wouldn't be a change if that were to occur, that is where we've begun. Without wanting to cast judgement on the entire English marketised system, a significant number of people in the leadership of that system would say that, quite apart from anything else, it does result in a lot of paperwork and a significant amount of additional work just for every or most contracts for different services to be put out to an open tender. In some people's opinion, in many cases it's fairly obvious that the local NHS hospital is the only body which can really provide them, and that level of extra process and bureaucracy is not always welcome. And drawing on the same thing, I would say that while it may welcome into a trade deal with the USA, the first point at which it will come up is the trade deal with the European Union. The European Union's made it quite clear that it wants what it calls a level playing field, where the UK is not allowed to deregulate, to start subsidising its companies more and so on. And to their mind, I think that there's at least a chance that that will include not wanting the UK to close access to its public procurement. So I think we start from a position of the market being quite open to international companies coming in and providing services. In England at least, and Scotland is protected from that simply by the make-up of its health system and the fact that it doesn't have an internal market. We start from that position and the first, if you like, fork in the road in terms of whether we keep that will be the trade deal with the European Union itself. Any of the other panel members want to comment? Do any of the witnesses have evidence of active engagement by, for example, tobacco companies or health providers in the commercial sector in relation to trade deals negotiated, for example, by the European Union while we've been a member? We certainly know that tobacco companies are very active in lobbying. For example, the recent European Union tobacco products directive was the subject of absolutely vociferous lobbying. There were hundreds of people employed by the tobacco industry around Brussels at the time of those negotiations. Obviously, we don't know what they were saying or what they were doing in terms of engaging with the decision makers, but we know that the international trade is something that they see as absolutely paramount to their business interests. We've seen tobacco companies taking forward legal challenges under a host of other trade agreements internationally, so when the Australian Government introduced standardised packaging for tobacco products, that was taken to a challenge to the world trade organisation. When Uruguay brought in pictorial health warnings on their packets, that was challenged under an international trade agreement as being a barrier to trade, so we know that it's something that they're very focused on and that they see has real potential to restrict public health interventions. Are there examples where interventions of lobbying of that kind has been successful, the challenge has been upheld and a country's ability to set terms of trade for public health reasons has been limited by that lobbying? Generally, we know that they tend to lose the court cases, but we do have to accept that there are two reasons why they would bring court cases. One is that you're never quite sure what a judge or a panel is going to come up with, so if you've got deep pockets and lots of lawyers, it's always worth a go, but the other is that it's very expensive and time consuming for Governments to defend those challenges. We've seen here that several years spent by the Scottish Government in the courts defending the alcohol minimum unit pricing. That has the knock-on effect of discouraging Governments from trying to do anything new and innovative that leaves them open to challenges, even if they think they're going to win the challenge in the end. There aren't many civil servants who feel that they have the time and the energy to spend years in courts trying to defend something that's already been passed democratically, so it does have a real disincentivising effect. Can we now move on to talk about the surveillance of communicable diseases and other health protection matters, and Emma Harper? I'm interested in communicable diseases. The issues around cross-border threats to public health are monitored currently by the European Centre for Disease Prevention and Control, the European CDC, in Sweden. It says that the ECDC runs systems for surveillance and early detection of communicable diseases that facilitate prompt sharing of information and expertise when required, for example, in relation to pan-European responses to H1N1 or swine flu, as well as efforts to tackle antimicrobial resistance. When we manage influenza outbreaks, it is crucial that countries work together. According to the community pharmacy Scotland's submission, it states that it is essential that the UK remains part of the process or the health of the public will be placed at risk. I'm not suggesting that there will be a mass zombie flu apocalyptic outbreak when the UK leaves the European Union, but what mechanisms might be put in place for sharing information and expertise on communicable diseases and cross-border threats so that we can protect the public? I'm interested in what is happening right now as far as conversations to protect the people in the future. Okay, there are a number of issues raised. I think that the important thing is that ECDC gets the data from individual member countries, so we already got a very effective surveillance system in Scotland and we feed the information through public health England to ECDC and they collate it for the whole of the EU countries and there is, as you correctly say, there a large system where they alert us, but there are two things. First of all, think like flu pandemic, like swine flu. Over and above the ECDC it is really caught in by the World Health Organization and there are international health regulation, so they will remain in place. So international health regulation will automatically alert all the member countries, WHO member countries of any emerging new virus which might cause pandemic. Clearly we also work at the ECDC level and they do risk assessment and we work very closely with them and at the moment at the UK level public health England is the national focal point for the whole of the UK, therefore we work through them with ECDC and public health England just set up a group looking at the implication of Brexit regarding surveillance and also our ability to respond to any major outbreaks and clearly when you look at each of the individual element as long as there are collaboration and cooperation continues with European countries through ECDC and there are acknowledgment that you know that this disease doesn't recognize boundaries and borders there shouldn't be any major issues so we are looking at the mitigating factor that we need to put in place to be able to respond to those but on the whole UK and Scotland particularly with a very good and robust system of identifying and managing and responding to outbreaks and quite often I'm pleased to say that a lot of the EU countries look to the UK public health system for support and learning lessons from us. So just as a quick supplementary, Norway, Liechtenstein and Iceland participate in the European Centre for Disease Control but they're not full members but they still have to pay without a vote so would that be what the UK would be doing would be buying into this European Centre for Disease Control without actually having a say in how we manage things? I mean I don't know exactly what arrangement the UK Government may have with the ECDC but our main interest would be sharing intelligence in both ways and also continuing collaboration between the scientists and others who have been doing a lot of research and so on. So whether they're going to purchase anything from ECDC, I'm not sure. We are not looking to purchase anything because a lot of the surveillance system as we say is we give them the data and that they produce a EU-wide database so it is there's nothing that we do within health protection that requires us to buy anything from ECDC other than continuing collaboration, sharing intelligence and sharing data and so on. So no zombie apocalypse? Hope not. Emma Harper's reference to some of the countries out with the European Union which are full participants in the European Centre for Disease Prevention and Control parallels I guess the discussions around whether or not to be within the single market in trade terms. Is there a direct connection between the two and how does that potentially work? In other words, from your knowledge of working with colleagues in Norway for example, are they in professional and practical terms full participants alongside the UK and other countries? That's my understanding and as in Switzerland who is not party to this agreement with the EU again colleagues from, as it happens, colleagues from Switzerland actually sit on UK expert committee on immunisation, JCVI, joint committee on vaccination immunisation because they got the special expertise and vice versa we go and sit in their committee. So I don't think being full member of the EU either help or negate of this kind of scientific and in a cooperation between the professionals who work closely with other professional bodies. Sorry, just quickly what I would say is that I mean I shared to some extent seeds optimism that you know there is good joint working there and it's in people's interests to continue but I would add the slight warning note that all of those countries being discussed Norway, Iceland, Lichentine, Switzerland are mostly in the case of Switzerland, they are members of the single market, they do abide by the EU's body of collective law and they do pay into a wide range of EU funds so in some ways they do have a closer relationship with the European Union than what we are currently on track for generally speaking. Emma. It sounds very altruistic and unselfish, shearing of intelligence and information but somebody has to pay for people to transfer from Switzerland to London for meetings and so that's a UK Government input I'm assuming. Yes, I think that's an area that we need to be obviously be mindful that ECDC do organise various scientific conferences and meetings of all the EU countries and quite often scientists from Scotland and other UK countries do attend those meetings quite often paid for by the ECDC fund so I think that's what you're looking at Public Health England and us working together looking at the implication when you come out to make sure that there are funding available for our scientists and the doctors and so on to be able to go to those without any hindrance without putting any funding obstacle so the other area that where they do access funding quite often is the research funding from horizon 2020 obviously the EU have a big research fund and quite often our staff do apply for research funding on various area on health protection, topical aid on health protection again currently we are looking at the implication of if we are not able to access those funding and again we to make sure that there are appropriate mechanism available for our scientists to be access that kind of funding from the UK countries. Okay, thanks. Thanks very much. You mentioned that Public Health England act as the focal point in relation to communicable disease control now we will have a few more questions in a moment about common frameworks but can you describe how that relationship works currently in other words do you have members on the working group from Health Protection Scotland within Public Health England? Is there a formal agreement or is it an informal working arrangement? It's a formal arrangement I mean we have very regular meeting with Public Health England for example the medical director of Public Health England have a four UK countries teleconference every two months so we discuss any issues that affect all the UK countries and almost because infection disease doesn't recognize boundaries and borders almost on a daily basis we talk to Public Health England and dealing with cases for example this weekend there was a case of Hepatitis A a case from Scotland actually went to Spain came back so we had to actually communicate with Public Health England to the Spanish authority to give them a list of contacts who require urgent treatment for example vaccination so that kind of collaboration happened on a daily basis but it is governed by a formal that's right a formal arrangement and some some of the services for example the chemical and radiation response we don't have the capacity within Scotland so we buy it in from England called the CRCE Center for Radiological and Chemical Research for example what happened last night about the you know the poisoning of the the Russian resident and again that response was led by CRCE if something like that happened in Scotland would be looked to CRC to support us to respond to that sort of incident thank you very much I'm interested around the discussions of the common UK frameworks after Brexit and the likelihood that there's a number of policies that will fall within a legislative competence of the devolved institutions I wonder what your thoughts would be around the what we consider as a key priority in relation to the common frameworks given that UK government are you know that they're currently subjected to the EU law and many of them are related sorry many of the devolved competencies will fall within you know the health and social care market and in the reality that that's that sort of effective dialogue between the the government UK government and devolved ministrations will have to continue to preface this by saying that although I look at Brexit and the NHS I'm not an expert on devolution and so I don't necessarily have an expert's view on what would and wouldn't be covered by common frameworks or what otherwise might be expected to return to the Scottish Government with that said I would say there are certainly some areas of health regulation where this is a live issue perhaps less than you might first think because health is not an EU competency fundamentally a lot of powers have always resided with the Scottish Government as part of the fact that they have general power over health where it tends to be and some of the major areas of EU action on healthcare for example medicines regulation and professional qualifications are also things that have reserved powers already within a UK context but there are particularly around the edges of health and social care some key areas where it does seem likely to me a lot suggest that you also ask someone who looks very closely at devolution law that there will be a question of powers coming back from the EU which otherwise might be expected to sit with the Scottish Government but which might be retained by Westminster through common frameworks and so those might include working time which is obviously a very live issue in medicine the regulation of things like clinical trials and some other aspects of science and also the levying of public contracts and also I think potentially some areas of tobacco and other public health regulations which I assure John will know better than me. I think we've seen regulation of tobacco coming from the European Union and most recently that's been around standards for electronic cigarettes it's been mandatory picture health warnings there's a ban on mental cigarettes that are coming up so all of those I believe will be taken forward after Brexit there may be some discussions that we'll see around electronic cigarette regulation but on the whole I think that in terms of looking forward to new regulations our view on it has been that we see it important that we are able to maintain the flexibility and the innovation that we've seen coming from different areas so for example an idea like the tobacco retailers register that was set up in Scotland has been picked up by other parts of the UK sometimes one of the one of the administration has put forward a policy that hasn't gone so well and hasn't been picked up by others so there's for us the important thing is being able to maintain that innovation and we haven't had a great deal of need I think for common frameworks because if an idea is working well it will be picked up by others afterwards. If I could just follow on from that I wonder what you believe your thoughts are around how stakeholders should be involved in the scrutinising of the common frameworks and who they should take place? I'm not sure I have any particular views on the process but I think you're absolutely right in what you're driving at which is that you know many of these cases and I mentioned human tissues earlier these will be quite technical areas which it's very important to get right in the interests of co-operation and vital services across at least the UK and hopefully still the EU to some extent so there will need to be I would hope a very careful process of drawing those up. Thank you very much and in relation to those discussions around potential common frameworks it almost sounds as if you're describing a position where the common framework within the UK is pretty light touch other than on areas like professional qualifications and the common framework within the European Union is pretty light touch as well so does that mean in this area we would anticipate relatively little issue in terms of addressing that and taking forward the position post Brexit? It does vary greatly so in the core business of health services actually there has never been that much EU regulation and control but in some of those areas around the sides and I mentioned earlier the hours that people can work which is obviously very relevant in governing how the progression of medicine works and also the conducting of clinical trials which is obviously both how we get new medicines and also something that goes on in a lot of NHS hospitals in Scotland and across the UK in both of those areas actually EU law has been has been very powerful and so the return of those either to Westminster within a UK context or to the Scottish Parliament really would open up significant freedom of movement to decide on those although I would also say that in many of those areas and clinical trials I think is a good example we would still very much say that the ideal situation is probably to continue to work with EU standards so even once we've left in the interests of things running smoothly across the continent as a whole it does make a lot of sense to continue to cooperate with the rest of the continent I mean presumably and said Ahmed may have a view on this as well presumably clinical trials have value the more standardised they are in terms of you know what you know what standards apply wherever you do the trial therefore you're you're attracting trials on the basis of your ability to innovate rather than by having a different set of standards absolutely there is an element of that there's also the factor that for some rare diseases in particular it really won't be possible to get enough people in the whole of the UK for a work in clinical trials so they need to be run multinational and then the European Union at the moment is introducing a sort of single streamlined system both legally and in terms of literally there is a a single form that you fill out to do a clinical trial which should make it much easier for cooperation within Europe and does raise I think the possibility that in some cases UK scientists or doctors might might not be included simply because it's a lot more complexity to include them very very similar certainly in health protection Scotland a number of our colleagues do take part in clinical trials which is Europe wide because they need the numbers to pull together to be able to make them certainly sort of for a statistical point of view point of view that the confidence interval and so on the other issues obviously the for example the the medicine license of medicine there the European Medicine Agency because currently the the vaccines and other you know medicines are licensed by the EMA and once they're licensed by the EMA it is applicable to all the EU countries and for us to replicate it and all the UK countries might delay introduction of vital medicine to the UK countries so my understanding is that again my understanding from Friday I speak by Theresa May is that they're looking at some kind of associate membership of the EMA so that whenever the EMA actually licensed something you'll automatically accept those because they will follow the same standards so that depends on what kind of measures you put in place to mitigate some of those issues that might affect us. Just for clarity here we were talking we were talking about clinical trials of rare diseases it's my understanding that there's already a mechanism in place that we can you can do that globally we can recruit trials globally so out even out with the EU as well is that the case are the other major barriers to recruit outside the EU? I'm not expert on that my I believe the answer is basically yes to both of what you've mentioned so there are mechanisms globally I'm familiar with for at least some disease areas but there are also more barriers to doing it outside the EU than there are to doing it within it so it's still easiest to do it on a within EU basis and and as I say there's the potential for that to be enhanced as we get the new clinical trial regulation which actually streamlines things more within the EU. Yeah there are lots of international clinical trials goes on in clinical medicine you know and a lot of the collaborative countries are in United States Australia and New Zealand but what they will do they will have each of the home country will have a base and they will collaborate with each other following the common protocol so but each of the countries need to abide by their own country regulation of clinical trial but on the whole there are international standards for clinical trial as well so they will collaborate with academic centres in various countries all over the world but as I said there will be collaborators based on those countries as well as in the UK. Thank you very much this is a nearly we'll pick up further in next week's meeting finally can I simply ask for any comments that the witnesses may have on the impact of leaving European Union on health inequalities one of the areas of particular interest to this committee. It's a very broad question I know but simply if there are impacts whether it's for example through the impact on public funding that was mentioned at the beginning or the impact on the relationship between public policy and commercial interests which has been part of our discussion this morning. Any thoughts? John Watson? I think the the connection I would make it's really it's it's to reiterate and expand upon our previous point in that for us the the flexibility of government intervention in the market is is really important and we've come quite a long way in terms of tobacco regulation but there's still actually an awful lot that we have to do we are facing an issue that is far and away the largest preventable cause of illness and death in Scotland but is increasingly concentrated amongst disadvantaged communities so looking to the future we need to be looking at interventions that narrow that inequalities gap so for example we are conscious that of the nearly 10 000 places that sell tobacco they are concentrated in disadvantaged communities and this is actually associated with with higher smoking rates so we would like to have some kind of intervention from a public health perspective that sees fewer retailers selling tobacco particularly in disadvantaged areas but obviously that comes up against the legitimate concern of retailers in those areas of harm to their business an innovative approach might include some kind of licensing that raised funds from across the tobacco supply chain and channeled that money towards small retailers in disadvantaged communities to help them diversify away to other products that are less harmful to their communities but which actually have better long-term business prospects as well you can't do that at the moment because you can't have a licensing scheme that raises funds in that way because of European Union rules so if you're trying to be clever and have something innovative that people haven't done before but which actually tries but which is addressing the complex situation that we're now facing you have more opportunity to do that if you have fewer restrictions on the Government's ability to intervene in the market thank you very much so I think I don't have a very direct answer to that question because in many senses actually the duties and the powers to address health inequality do rest here at the Scottish Government level already and they always have done but what I would say is that in some respects the impact on NHS finances is something of a health inequalities issue in that a universal health care system is how the majority of people and certainly the most deprived people have their vital health care needs met and there are certainly a laundry list of ways unfortunately which brexit does risk extra pressure on the health service both in terms of reducing the amount of tax revenue there is to put into it but also in terms of disruption to trade potentially raising prices which takes money away from investment in actual services and interpaying for supplies also in terms of the possibility for disrupting the medicines market so that we can no longer buy from cheaper countries where that makes sense so I would say that that that it's an indirect relation but the additional pressure that brexit has the potential depending on how it's handled to put on the health service generally and across the UK does relate in some ways to health inequalities thank you very much I'll echo that because most of the health protection services we provide are intended to reduce inequalities in health because unfortunately it is those who come from the most deprived part of the community are more likely to suffer from some of the health protection disease like tuberculosis the various drug various the viruses like hepatitis bc and and so on so as long as there is no overall impact on the financing of this health protection services in the UK and Scotland I don't say any implication can I say thank you very much to all of our witnesses for a very informative session we will now take a break for five minutes and we will resume with our new panel of witnesses at five past 11 thank you very much and we will now resume our meeting can I remind colleagues to ensure mobile phones are switched off or to silent and can I welcome to our committee this morning our next panel of witnesses who are to comment on the impact of leaving the European Union on professions in health and care can I welcome Paul Buckley the director of strategy and policy with the general medical council Dr Peter Benny the chair of BMA Scotland Dr Donald McCaskill chief executive officer of scottish care and Joanna McDonald director of adult social care with NHS home good morning and welcome to you all we have a range of questions again on the impact of brexit on the professions in which and sick questions that you are involved and if I can start again with Ivan McKee and good morning panel yeah there I'd like to get your thoughts on is round about the potential impact of brexit on workforce and clearly we're aware that there are a significant number of EU nationals working here across a range of of occupation some of them very skilled so I'd really just like to get your thoughts on how you see that scenario unfolding and how much potential damage it could do to the NHS which is struggling as it is to find enough training skilled people to staff the service who would like to start scottish care submitted to the committee our data from three pieces of research last year highlighting that in general terms we're talking about between six and eight percent of the total social care workforce predominantly working in my context with older people in the communities and in care homes who are ea nationals significantly that goes up to about eight percent of nurses who compose and comprise 10 percent of all nurses in Scotland so we are profoundly concerned and have been for some time about the potential impacts of brexit and I use the word potential because somebody said to me recently it's a little bit like having fog around you familiar landscapes and points of contact have disappeared but unlike a journey that I took from Glasgow through to here today where there was dense fog once the fog disappears you have a degree of certainty we do not have a degree of certainty in terms of what will appear at the end of the current negotiations and it is that profound uncertainty that is now having a direct impact on the women and men who are caring for individuals up and down the country last week we had an astonishing positive dedicated reaction from our staff up and down Scotland who literally walked the extra mile to care for some of our most vulnerable citizens it is those individuals whose livelihoods whose futures are at risk and that fog of uncertainty is profoundly concerning to our members and to the women and men who are working in social care in highland we obviously remote and rural we're often the first to experience recruitment challenges to key posts and that's something we're already experiencing we're dependent on locum consultants for some of our most critical services at the moment but the anticipated prospect of brexit which again the uncertainty is the key element to encourage and promote people to come and be part and valued of our health and social care workforce in highland is something we've been doing we've been doing pretty successfully in relation to the migrant community and and really welcoming them as a fundamental and reliable part of our particular or social care workforce in our care homes and in care at home and the uncertainty about the future is something that we're starting to experience a reduction in the migrant workforce coming also in highland it's more profound because our demographics are that currently we have one in five people over the age of 65 by 2035 that's going to be up to one in three and even worse in our remote and rural areas if we're going to see an increase in the number of older people living by themselves with complex care and support needs and uncertainty as to how we're going to support them so we've really welcomed them in the migrant community they're part of who we are in highland and how we deliver our services and we've got concern about what may happen or may not happen. I'd like to start by just backing up exactly what's just been said by the two other speakers and particularly the care sector the rest of the the health service is entirely dependent on the care sector running well and I have really major concerns about the effect of Brexit upon the care sector and one thing that hasn't been spoken about yet is the generally lower wages in the care sector and the potential for that having a knock-on effect certainly in terms of current immigration rules so we are totally uncertain as to what we're facing going forward. From a medical perspective we've given you a written evidence we've given you the facts and figures from our survey you've got them already I came here thinking about this coming in just wanting to put across to you the human and emotional level of this. The European doctors who are working with us are our friends and colleagues and the whole Brexit process has been immensely disruptive and disturbing to them. We don't think that a substantial number of them have left the country as yet but we know from our survey that at least a third of them are considering that and quite frankly why wouldn't you? They give their all to keep our health service running we all know how stretched the health service is already and the thanks that they get from government and I'd suppose in effect from the people of the country who voted in the referendum is a feeling that those efforts are not appreciated at all. In terms of the potential problems going forward and specifically looking at the situation with doctors, at present within the EU there is mutual recognition of professional qualifications and so it is entirely straightforward for a doctor from any of the EU nations or the EU nations to apply for and take a post in the UK and medically we totally rely on them as well. We don't yet know what that will look like after Brexit. The current noises from the UK Government remain reasonably positive about maintaining that freedom of movement for doctors but we don't yet know for certain and if that goes it will have a major effect on our ability to fill the recruitment gaps in the NHS and again as I'm sure you all know we simply cannot fill those recruitment gaps with homegrown doctors we don't have enough at present and it takes upwards of 15 years to train a doctor to be fully able to take on those responsibilities so we can't just snap our fingers and sort it locally. So a number of points on that I echo the issue around uncertainty which all the colleagues have raised so UK exit day is we're told to be the 29th of March 2019 which is one year and three weeks from now. We don't know on what basis EA doctors wishing to come to the UK after the 29th of March will be able to access the medical register. As Peter said the Government's policy which is reaffirmed by the Prime Minister in a mansion house speech on Friday is that there should continue to be a mutual recognition of qualifications but obviously until that is reflected in a legally binding withdrawal agreement there remains uncertainty about what the future will hold and we are doing some serious thinking about what that means in terms of contingency planning in terms of our processes. Second point is that in terms of the Scottish medical workforce the contribution of EA doctors is immense undoubtedly it is it's around six percent of the medical workforce in Scotland but the contribution can't be understood purely in terms of the raw numbers it's also as the Scottish Government's submission to the migration advisory committee said it's also about which specialties the doctors are working in some of them are on the Scottish shortage specialties list occupations list like pediatrics like oncology like radiology and it's also about geography so the territorial health boards in remote and rural areas depend very very heavily on the contribution of EA doctors so there's an issue in relation to the stock of doctors currently working in Scotland and their future plans which Peter referred to but there's also then an issue around future flow into the to the UK and all of that is uncertain and we feel we can deal with most things but uncertainty is the most difficult thing to deal with. Thank you very much. Yeah I mean just to follow up on that and it's very worrying concerning but not unexpected your comments on this area and taking particular the human aspect that you mentioned very well Dr Benny. The Scottish Government obviously is would be keen to have control over some or all of its own immigration policy in this regard as is the case in several other subnational jurisdictions in other countries. Do you think that in that scenario that would be would be helpful is that something you would support in the Scottish context? Certainly at present we don't have policy either way on that was in the BMA so I'm not going to give you a black and white answer on that but we are looking for immigration policy post Brexit which is able to deal with the problems at hand that is practical that has straightforward ways for doctors from outside the UK to come and work in the UK obviously including in Scotland. Paul had briefly mentioned the shortage occupation list and the committee will presumably know there's a UK shortage occupation list but there's a supplementary Scottish shortage occupation list above and beyond that so already we have a degree of separation a degree of ability to pick and choose which areas we in Scotland see as being shortages we're very comfortable with that mechanism and we would certainly want to continue a process that allows Scotland to be making sensible decisions for the medical workforce here in Scotland. The social care perspective Scottish Care has already submitted evidence to the Migration Advisory Council and also to the Westminster review of potential migration policy and practice. We have familiarity and experience with the current shortage occupational list what we've been calling for is wherever model is adopted and by whom so ever that that should be as flexible and responsive as possible one of our experiences thus far in migration outwith the EU is that the practical difficulties for particularly small providers particularly in rural and remote areas makes it completely impractical as a resource and our concern would be that any migration process post Brexit whoever has responsibility needs to be enabling of fairly quick inward migration to key areas both in terms of geography but also specifically in terms of role and we have concerns that that's not what is currently being discussed. I also need to have a default option to ensure that those who are here do not fall foul of relatively detailed legislation to give you an example. A colleague of mine came to the NHS from India and took a decision with the health board to start work at the specialty doctor level even though technically he was entitled to work at consultant level and he did that on a kind of trial basis and then after both he and the health board were very clear that he had the capability to work at consultant level he went through an appointment panel and was appointed as a consultant however nobody spotted that they had to tell the home office that and at absolutely no notice he was told some years later that he was working outside of his legislative abilities and was facing deportation there and then he wasn't deported but he spent three weeks basically uncertain as to whether he and his family would be allowed to stay in the country and we've got to have flexibility and common sense within any migration rules viewing as a a start point what does the country need does the country need these doctors and health service staff to be here and looking after our population or does it need to be finding ways to get rid of these people I believe the former thank you very much David Stewart thank you can you ask a specific point from evidence we've had from the Royal College of Physicians and Joanna McDonald's partly answered in my question already which was there was a disproportionate reliance on EU nationals and doctors particularly in hard to recruit specialities like pediatrics one of Joanna McDonald's got any additional point you'd like to add about how NHS Highland are planning the workforce management post Brexit? An area that we have been working on collaboratively with the University of the Highlands and Islands is around promoting NHS Highland as an organisation that really will focus on research development innovation to attract people from across EU and even internationally to come and work in NHS Highland and that's an area we've had significant success in it's also an area that we have some concerns around because the University of the Highlands and Islands is the university in Scotland that will be most affected by the withdrawal of European Union support we've benefited greatly from the transition region status of the Highlands and Islands and actually we've got a number of projects and areas of work across the UK as well as across Europe where we are unclear and uncertain as to the future of that funding but I would say that research the development has been an area that has been a real attraction to obviously a minority of doctors and consultants but certain an area that we're progressing and if I could also add I think it's been vitally important the rule of horizon 2020 in hands and hands and the structural funds and you'll know there's been a lot of good collaboration between UHI and private institutions over diabetes research for example which I would highlight can I take you on to the point that Dr Benny made which was about the recruitment of non-EA citizens and I think Dr Benny had a point extremely well it's of course much more difficult to recruit out with the EU because of Home Office visa restrictions which you've just heard about one of any of the panellists of any general views about recruitment of scarce specialities such as trainee psychiatrists which I think 41% come from the EEA is it very difficult to recruit out with the EU in terms of Home Office restrictions? Does anyone else want to comment on that? I know Dr Benny gives a very good example previously but Joanna MacDonald? Obviously we're currently looking regionally because the issues that affect NHS Highland and I would argue more significantly than other aspects of north of Scotland although colleagues possibly wouldn't agree is around the recruitment retention to remote and rural. We've got the most sparse hospitals where recruitment is just a huge issue and I think in relation to recruiting from the EEA that we're currently looking at how we really promote ourselves internationally. The flip side of that is the ethical dilemma of which I was discussing with colleagues earlier on where we're potentially recruiting expert consultants from countries where actually they would have enhanced benefit from remaining within their own country but we're obviously having to look at everything that we can. It links in also with our current models of health and social care service provision that we recognise prior to Brexit that we need to change them and adapt them reflecting the challenges around recruitment across health and social care staffing. There's significant work going on there but, as I say, the ethical issue is as much as we need to fill our vacancies issues. Dr Benn? Add briefly to that. For the written evidence, she asked us to come up with potential benefits for Brexit and you may have spotted we struggled a bit with that but one potential benefit is if, as a consequence of this, we can get the type of more flexible recognising service needs migration system across the board for people coming from any country outside the UK. My fear about that is that it does seem to me that the whole question of freedom of movement and of immigration was very closely entwined in the Brexit referendum and it does look to me to be quite a challenge to tease those two things apart but perhaps the way to achieve that is to focus on the actual crucial importance of immigration to running the national services, health services and others. A big difference between equalising up and equalising down, I suppose, is the point that you made. Paul Butler? So it wasn't on the point about immigration which isn't directly within the GMC's sphere of responsibility. It was more on the point that the alternative to the current mutual recognition system is for specialists, something that's very burdensome and time consuming. If you're wanting a consultant post and you come from out with the EEA, you have to go through a very, very laborious process that can take many months and involve huge amounts of documentation. The same applies incidentally to getting on to the GP register. Work's being done in parts of the UK, including in Scotland, led by Dr Emma Watson, on looking to simplify that process. However, without changing the legislation, there are limits to what you can do. We feel that as part of trying to future-proof the system against the risks of Brexit, we should be looking also at getting doctors on to, particularly the specialist and GP registers from other parts of the world, much less burdensome than it currently is. That's something that we think needs to happen, regardless of what scenario ensues with Brexit. Thank you very much. Miles Briggs. Thank you, convener. Good morning to the panel. I was interested on your comments there, Mr Buckley, with regard to future-proofing. This is something that, as a committee, we've been incredibly involved and concerned about because it's quite clear that, over the past 10 years, we've seen a real issue with NHS recruitment and specifically around social care workforce, hence why we did a short inquiry ourselves. I wanted to look at unintended consequences of policies that are both here in Scotland and also within the European Union. Where do you see a need to change to stabilise the sector, especially with the challenges that you've already outlined? Specifically, I would point towards two areas where this Parliament can have a role, firstly, with the cap on the number of Scottish medical students that we have in place and also specifically with regard to future recruitment around social care. At the last meeting, Dr MacAskill mentioned the fact that child care of places had become the real focus within the college sector. I wanted to see what the panel feels can be done to stabilise all the challenges that you've outlined. Clearly, there are potential unintended consequences. The workforce plan, the second part of which relates to social care, highlights what I'd stated in evidence before, and that is that the recruitment of 20,000 individuals into early years potentially has a negative impact. I was not saying then, nor now, that we shouldn't be doing that. The role of early years is hugely significant. Alongside that, and in response to Mr McKee in a previous meeting, I suggested that we needed significant investment in social care to address the fact that 9 out of 10 providers are struggling to recruit and a survey that we are due to publish next week highlights that we are losing. Those who we manage to recruit lose a third of them within the first six months. We are, and we need to collectively look at some of the reasoning behind that, but it's not necessarily a single policy that needs to be altered, but that wider landscape. Dr Benny has already referred to the elephant in the room, which is the fact that social care workers are relatively speaking, underpaid for their huge, skilled role that they deliver in Scottish society. That goes beyond the committee, but we can't look at the impact of Brexit without looking at specifically the fact that we value so little our social care staff in care homes and at care home services. I raised the question of medical student numbers, and the committee will be aware of the new graduate entry medical student programme coming on stream later this year. It is designed to try to maintain more Scottish graduates staying in Scotland and, in particular, to encourage greater recruitment into general practice and into rural practice. It remains to be seen how successful that is and, of course, that has all the delays that are inherent in starting from scratch and trying to develop new doctors. There are moves afoot to try to increase the number of medical students in Scotland and, therefore, by definition, the numbers that are staying in Scotland to work later on. Another thing that is almost certainly not directly the issue for this committee, but joined up policy making has to recognise that we have really serious problems with both recruitment and retention. Retention seems to not feature anything like as much as recruitment in our considerations, and yet recruitment, particularly to medical school, does not solve a problem until 10, 15 years down the road. Retention or the lack of it when people get to the age of 55 or 60 and stop working is far more of an immediate issue and tends to have less of a focus on it. In terms of what Dr MacAskill said specifically into low-paid work, what impact has the pound, for example, being devalued, had in terms of EU nationals not wanting to come and work in Scotland? Specifically, the EU labour market recovery that we have seen in recent years. For all of us, we value what EU citizens do to help to run our health service, but are we becoming less attractive because of pure economics? Is that something that you have undertaken any work to look at? We have to a degree, undoubtedly anecdotally, the number of individuals who have chosen to go back home to Europe as a result of the devaluation of the pound is not insignificant and that is often cited. It is not a lack of desire to remain in Scotland to bring up their children and have this place as a home, but the sense of unwelcome that has already been referred to by others and the sense of uncertainty combined with an economic reality that, as Brexit uncertainty has made and has resulted in a devaluation of the pound, which makes home a previous home more attractive. It is a circular argument, and it is undoubtedly having an impact. We have undertaken significant work in Highland. Obviously, we have been integrated for six years now, so we have a better flow between health and social care, but working with our care homes and our care at home sector more collaboratively, we have seen improvements. 100 per cent of our NHS care homes have got grade 4 and above from the care inspectorate, 87 per cent of the independent sector, so we have looked at the value of the care homes. However, what we have not been able to address—again, it is an uncertainty and a concern about Brexit—is the high number of staff vacancies. We have now got even some of our own care homes where we are dependent on agency staff and agency nurses in the independent sector. An unanticipated consequence of the living wage that was welcomed by the sector was that we have got staff in some of our independent care homes who are at more senior levels and are getting paid similar grades. Again, that has been a bit of a concern. When we are projecting that, even prior to Brexit, looking at how we address that, there were issues around how we would sustain the current care home model. We also again recognise in NHS Highland and across Scotland that where we have got a care home and if it is in a rural area, that will be an attractive resource for adult social care staff to work in. We are pulling more so with integration with our auxiliary nursing posts and social care posts on the same population of staff. One of the opportunities that we have is to look at how we encourage the younger workforce to come into the health and social care sector. NHS Highland is not unusual in that we are seeing our workforce ageing over 50. I am nearly there. There is something about why that is happening and why we are not recruiting our own younger workforce into health and social care. That is an area that we are starting to look at as well. I am very grateful for the written submissions that you have provided. In particular, there are a number of breakdowns of actual workforce in respect of EAA citizenship. I was really struck by the exposure that we seem to experience in terms of the number of surgeons who are from other European countries. All of my colleagues around this table are familiar with casework that comes in through our surgeries about extended, prolonged, protracted waiting times for surgeries. There are two reasons for that. One is, obviously, capacity within the workforce and there is an immediate risk to that. The second, I think, touches on Donovan Caskill's point about social care workforce. The fact that without adequate social care provision in our communities, you see people staying in inpatient beds for longer and elective surgical appointments cancelled as a result of that bed blocking. Are we facing a perfect storm in that regard? What should we be doing in workforce planning times to ensure that there are sufficient home-going surgeons should there be a sudden dramatic reduction in those from European countries? One thing that is happening is substantial changes and improvements to the surgical training schemes. This is a pilot that will start running in the summer of this year. It is a UK-wide pilot, but the majority of the training posts are actually in Scotland because Scotland has taken the decision to basically change all of the training posts in Scotland across to this pilot. A very simple summary of the pilot is—this kind of sounds odd when you say it, but it concentrates on the training that is being trained. Those of you who have spoken to any junior doctors will know that there is a model for years and years and years that tend to be providing a service and you happen to pick up some training as you go along. This new pilot is all about prioritising the training, time away from the workplace altogether, to work on simulation, changes to rotas so that you have enough space and time to be thinking and training properly. That is all the theory of it. It remains to be seen how that works in practice, but if it does work in practice, the Scottish surgical colleges and the Scottish surgeons have effectively taken a decision to try to get ahead of the game and to change to this new form of training before it, hopefully, comes across the whole of the UK. Anyone else would like to add anything on that front? If not, can I ask Brian Whittle? I just wanted to pick up on a point that Miles Briggs made from a personal perspective in the last couple of weeks. I have had a couple of people in my surgeries suggesting that they had the qualifications to do medicine at university in Scotland, but there was not a place for them. I wondered whether, as a consequence of what is happening with Briggs, I certainly accept your point about retention, but specifically in recruitment into the profession, whether or not, as a consequence of Briggs, there may be more places available for those people who are qualified and have the qualifications to do medicine yet there is not a place for them. We cannot know for sure, but it is a reasonable assumption to make that there will be fewer people wishing to come across to Scotland and the UK to study medicine from the rest of Europe in future years after we have gone through the Brexit day. Having said that, it has always been the case that medical school is hugely oversubscribe. There are many more people wanting to study medicine than there are places, and we have tended to view that as not entirely a bad thing because it means that there is strong competition to get into the training in the first place. Perhaps a key issue about that, though, is making sure that we are selecting as best we can. It used to be the case that selection for medical school was pretty much the main priority was do you have the qualifications in Scottish terms, do you have the hires? We moved away from that to try instead to identify those who are most likely to have the attributes to be good doctors. Yes, you have to have the qualifications, but to try to identify the attributes for good doctors as well. Just as I said, does that not mean that if we are hugely oversubscribed, as you say, to medical school and we are short of doctors, is there not attention on that? Absolutely. Bear in mind also, though, that the training of medical students is not primarily done by the universities or by full-time university employees, it is primarily done by NHS, GPs and consultants, usually doing that with limited recognition of the time necessary to do it. Any substantial increase in the number of medical students would genuinely be unsustainable at the present time because we do not have enough doctors to train them when we do not have enough patients for them to see and we do not have enough space for them to train, so you have to have that tension within the system as well. Thank you very much. Can we move on now to consider recognition of qualifications and regulation of professions and if I can start with Alison Johnstone? Thank you, convener. I think probably my first question has already been answered. I get the opinion certainly from Dr Benny that you believe that reciprocal arrangements such as the MRPQ should be maintained. I just wondered if you thought that there was any opportunity here to review and agree minimum training requirements shared. I was going to say that that is probably one for Paul to start with because that is your area of expertise at the GMC. I am so happy to start with that one. As we have said in our submission, we do see significant benefits from the current regime of mutual recognition, but we do see some downsides as well. It is possible that, in looking to a future beyond 29 March 2019, there may be opportunities to achieve what we would see as a slightly better balance between flexibility and speed of getting on to the front line and providing assurance to patients about the capabilities of doctors and other healthcare professionals. Just to give a couple of examples, if I were training to be a surgeon in Latvia, I could complete that training in three years as an anesthetist. In the UK, it is seven or eight years. If I am trained to be a family doctor in parts of southern Europe—Italy and is one example—I would not be doing much, if anything, by way of paediatrics or antinatal or postnatal care, where those are staple elements in primary care in the UK. Those are two examples of where we have some concern about what is really quite a blunt instrument in the directive. We do feel that there is an opportunity to revisit some of that as we go forward. Those are examples of where the current regime is too permissive in our view, but there are also examples of where we feel that it is too restrictive. For example, if I am training postgraduate paediatrics and I want to change to be a general practitioner, I do not get any discount or allowance under the directive for the training that I have done to date in paediatrics that I can carry across. I can only get a discount of up to 50 per cent if I complete my training in paediatrics. Most people who want to change horses do so mid-stream rather than when they have got to the other side. We think that that is another example of something that needs to be revisited. It is not a perfect system by any means. In reverse order, it has certainly been the view of the BMA for a long, long time that it should be more straightforward to be able to move between specialties. When you are training, we are all aware of people who have done seven or eight years of training and a specialty decided that they would prefer to do something else. I have looked at having to start from scratch and do another six or seven years in a different specialty when, clearly, there is some common ground in learning how to be a doctor. In many ways, that is not purely bound up in Brexit. We are trying to make changes to that anyway via the process of shape of training. On the first point, it is important to remember that having the legal right to be on the GMC register as a specialist in surgery is not the same as simply walking into an appointment's panel and being appointed as a consultant surgeon. There is that quality process right at the start where, if you are applying to be a consultant, you are in front of a panel whose job is to ensure that you are able to do the job in front of you, not just that you are able to be registered as a specialist. More widely, and probably like colleagues, we have received an email this morning saying that 10 health boards in Scotland have not met their CAMHS waiting times targets. David Stewart was making the point that 41 per cent of psychiatry trainees are from outwith the UK. Even if we perfect and improve the ability to have a more sensible qualifications framework, if it is still practically or very difficult indeed to have people from outwith the UK come to work within the UK, we are not going to really get any further, are we? I just have a feeling from what I have heard this morning that we are not giving due attention to the need to have a more welcoming immigration system that will allow us to keep the people in Scotland that we need to have in Scotland. Even if Donald MacAskill, we were to promote social care as an attractive career, as it should be for UK nationals, I am just very concerned by what I have heard this morning that we simply will not have enough people in post, regardless of how we refine training requirements and so on. Is that a view shared by the panel? Donald MacAskill. Dr Bennie has already highlighted that retention is critically important. We as an organisation have been producing report after report highlighting the recruitment challenge. We have astonishingly skilled women and men, predominantly women at 86 per cent, working in social care provision in Scotland. We need to do everything that we can to retain them. In social care, we have seen in October the introduction of qualification requirements through registration with the triple SE. We have some concern that we have got to get the balance between valuing a role and the skill that is required to undertake that role by professionalising it over and against the recognition that the majority of our workers are individuals who are, as Joanna has hinted, post-50 and mature in life and for whom concepts such as doing an apprenticeship or not having their skill valued because they have to go back to train again presents a real challenge. That is something that we are going to have to keep an eye on, particularly in the care home sector, because we have 6,000 people who are currently registered who need to finish their qualification by January 2019. We will be supporting with triple SE those individuals to finish. We have got to get the balance between retaining a skilled workforce, valuing that workforce, rewarding that workforce and making social care attractive because, while Joanna is right, we need to continue to try to attract more and more young people, the majority of individuals who will enter the social care workforce in the next 18 months will be women over the age of 45 who have multiple skills and life skills but who have, for various reasons, a very low self-esteem and for whom formal training in education is actually quite frightening. So there is a lot of work to do to retain as well as build this into what it is, a profession and a career that offers real potential and attractiveness. As far as the GMC is concerned, we are trying to make a contribution where we can, for example, with our welcome to UK practice programme, which helps healthcare professionals and doctors coming from other parts of the world to understand the context of practising in the UK. It is a small but valuable contribution to setting them up to succeed. I think that Peter's point about needing to do more to retain good doctors in the system is absolutely right. That is why, for example, within our education training responsibilities, we take issues around culture and bullying so seriously because it is those kinds of problems that drive people out of the profession or drive them elsewhere. It is really important that those issues that go to retention are addressed as well as getting people on to the register in the first place. If I can just add, the debate is about Brexit, but one of the areas that I have already mentioned that the Highlands and Islands have benefited from has been recognised as a transition region. The status that has enabled us to access and benefit from European funding and recruitment and retention in the Highlands is a huge challenge for us. I am concerned about University of the Highlands and Islands, as I have already said. There is a risk, not just about us looking at migration but within Scotland. The draw of the central belt for our young people in the Highlands and in the north is huge. When we have our young people coming down to universities, colleges and Glasgow and Edinburgh, often they do not return. I suppose that it is just a plea to look at how we support the whole of Scotland and the diversity and the richness with all the challenges that we have been describing today. We have to be so careful here because everything is coming together at once. There is a potential real vicious circle here, as we were already facing our recruitment crisis within the health service before the Brexit vote. It is very hard to imagine the outcome of Brexit being anything other than considerably worse problems with recruitment. Another aspect of all of this is that there is going to be a temptation in medicine when we are running short of doctors in any individual unit to, for some pressure, to start building to weaken the current legislative protections, which ironically started from Europe with the European working time directive over a quarter century ago and are now enshrined in UK law as the working time regulations. One of the first things that comes under pressure when you are missing doctors from a rota is to try to get the others to work above and beyond and without those protections, there is even more risk of that. Now, at present, we are receiving reassurances from Prime Minister down that there is no intention to make any changes to those working time regulations within the UK, but we are always conscious that every few years this tends to come up as a potential issue, and as soon as Brexit was starting to be talked about, those who oppose the working time regulations were saying that this is our opportunity. We need to be vigilant from that. Thank you very much. We will come on to that in more detail in a moment. I wonder if I could ask Paul Buckley specifically in relation to the advantages and disadvantages of the current mutual recognition arrangements that apply. What changes does the GMC believe will need to be made to its powers under the medical act of 1983? I believe that that is the key thing to your future regulatory activity. It would be possible to simply roll forward the current regime. There would probably need to be some minor changes to the medical act so that, for example, if there are references to directives or European institutions that the UK is no longer subject to, I think that that is in drafting terms relatively straightforward, but the principle of mutual recognition can be rolled over. I think that without any difficulty. I think that what we are saying is that in doing that, though, we do need to just return to whether there might be a slightly better way, a more proportionate way of doing this. We would want that opportunity to be at least considered before it is dismissed, but we do recognise the workforce pressures that might lead you to say that we do not want to make any changes. Presumably, the timing is such that negotiating line-by-line changes in recognition arrangements with the European Union because of differences in training regimes would be difficult, given the time constraints that are faced in terms of delivering a final outcome to the Brexit process. I guess that there are a couple of issues there. One is about transition. We are all assuming that there will be a transition arrangement because that was in the withdrawal agreement that was reached, but that is not yet enshrined in law. At the moment, it is perhaps more than an aspiration, but it is not a certainty and that is a problem. It was one of the reasons why the chair of the health select committee in Westminster wrote to the secretary of state on 15 February asking for certainty beyond UK exit day and asking for a declaration between the UK Government and the European Union as to what the position was going to be. In the event that it was not possible to get to a joint declaration that the UK Government would make a unilateral statement as to what the position was going to be beyond March next year. Thank you very much. Emma Harper. Dr Benny, you mentioned the working time directive and I am interested in pursuing that a wee bit in more detail. It was introduced in the EU in 1993, 25 years ago, and it has been successfully implemented in the NHS since the beginning. It limits the staff time to 40 hours a week and sets the minimum daily weekly rest breaks. The rules include time that is spent on call, so it is intimated that Brexit people have jumped on the fact that let's change those rules. I am curious about the long hours. Do they present an optimal learning opportunity or do long hours present a safety issue? I have a couple of examples such as assessing and diagnosing patients when you are tired or given intravenous medications, complex calculations are required, or even working in surgery where swabs, needles and instrument counts are really required to be accurate. I am a former liver transplant nurse who has witnessed doctors fall asleep while holding abdominal retractors in the middle of a long on-call shift, so I am curious what the possible advantages and disadvantages would be if the working time directive was altered. I guess that the first thing to say about it is that, at least at present, we are getting clear reassurances that there is no intention to alter the working time regulations, but we will continue to stand up strongly for them. Yes, I am of the generation that remembers before there were restrictions on junior doctors hours, and I have done those 100-hour weeks, and indeed I was holding retractors during some of that time. I will be honest with you, I sometimes nearly fell asleep holding a retractor after I had only been on for two hours, it is immensely boring and I am now a psychiatrist. Nevertheless, joking aside, we have always viewed junior doctors hours as a health and safety issue, primarily for patients, but also for the doctors, because the one well-known side effect that you did not mention is the potential damage to the individuals themselves up to and including fatal car crashes when driving home after a shift where you have had no sleep. We are very wedded to the principle of maintaining regulation on doctors hours. The arguments such as they are that have come up over all of the quarter century and even before the working time regulations came in have tended to be about it is necessary to do a particular number of hours. You have got to do those shifts in order to get the experience and the training, and that is clearly debunked now, including very well by what is known as the second temple report by Professor John Temple, a surgeon, that the importance of training is the quality of training that you receive, not the number of hours that you do it in. That is very much ingrained within the pilot for changes to surgical training that I mentioned earlier. Paul Buck, please. We commissioned some research on the impacts of working time regulations a few years ago from the University of Durham, and a couple of things came out of that, which I briefly mentioned. One was that it is not simply about the quantum of hours worked, it is also about the intensity of what is happening during those hours, and you need to be looking at both of those. Second thing was that part of the difficulty, as far as there has been some difficulty, has been the interpretation by the European Court of Justice in two particular cases affecting medical training. One is called CMAP and the other is called YAGA, which basically said that you have got to count rest periods as work. That has caused some difficulty in designing rotas. At times, you get to a paradoxical position where something intended to help the health and safety of the employee, the doctor, can have some unintended and adverse consequences. I do not think that anybody would argue going back to the long hours of the past, but it may be that there are one or two issues around interpretation that it would be helpful to look at as we move forward. Thank you very much. Can we now move on to the areas of the impact on health and care of trade agreements and the issue of common frameworks? I asked a very similar question this morning, so it is basically just about what potential risks there are to Scottish NHS, health and social care of these potential future trade deals that the UK Government may negotiate perhaps on Scotland's behalf, even without very much input from potentially the devolved nations. In the BMA written submission, it says that one key issue would focus around competition and whether any potential deals could lead to enforced competition in public services. My question to the panel is what risks do you think are here and should the NHS potentially be exempted from future trade deals? Professor Time, I do not think that I will get anything different to say to what we have given you in the written evidence, so I will let the other speak. Who would like to add any comment on this area? John MacDonald? I think that it is interesting, and it was interesting listening to the previous witnesses around the difference in Scotland and the pride that we have in our NHS and it being our NHS. My own view about that is that what we have got and what we have built on and where we are going with integration of health and social care, some we should be proud of, and look at what potential negative impact and positive impact might be through looking at trade deals differently. I do not have a view at the moment, so I do not have the knowledge around it. We have a tremendous piece of legislation around procurement in Scotland, specific guidance for social care procurement, which is based on principles of personalisation, engagement of those who are impacted by the service and human rights. All three of those, it is not without imagination, could be challenged in an overtly competitive model of procurement. We in social care have for too long experienced in the home care and housing support sector the misuse of competitive tendering models, ostensibly because that was the best available approach to designing packages of care for people. As I think that we are collectively agreeing that we need to move away from such commissioning and procurement models to build more reciprocal models, it would be deeply unfortunate if, because of behaviours elsewhere, we were not able to continue that journey to making the art of procurement and commissioning more person-centred. Good afternoon to the panel. With regard to the final question as part of our inquiry, we are looking at common frameworks. On a note from the BMA submission and the GMC submission, there was not an explicit answer to that question, so perhaps it is an opportunity to get on the record your views. Donald McCaskill accepted that you did provide an answer to that question in your written submission. In our written submissions, we also heard from NHS Orkney who told the committee that the common frameworks could limit the extent to which the Scottish Parliament can tailor legislation to meet Scotland-specific requirements, particularly if the frameworks are developed via legislation at Westminster rather than as intergovernmental agreements. Does the panel have a view, therefore, on how stakeholders could be involved in scrutinising those common frameworks? Yes, please. Curses, you spotted that we didn't answer that question. The reason we didn't answer that question is that we've talked about the fog of Brexit. This aspect seems even foggier, if you like. It's the foggy hills beyond the foggy plain that we're on just now. We don't have an answer for you because we don't know what we're going to be facing. To some extent, almost all of the evidence that we're all giving you just now is partially hypothetical, but on this issue we really struggled to know what we could say at this point that we'd be meaningful. I'm sorry. I think that the fog surrounds us as well a bit on this. The only thing that I would add is that we're very clear that we are a UK regulator, but so far as we possibly can, we want to tailor our regulatory model to meet the circumstances and challenges in each of the four UK countries that recognise that healthcare is a devolved matter. That's what we're trying to do and we will continue to do. Maybe just to express one solid concern that we have in the midst of the fog, and that is that we have developed and are developing in Scotland a health and social care system legislatively based on sound human rights principles, our core legislation around adult support and protection, adults with incapacity, mental healthcare and treatment, all coherently based on the European Convention on the Human Rights Act. We have health and care standards being rolled out, particularly within my own sector, the care home sector, which are deeply rooted in the Human Rights Act and human rights principles. Part of the on-going background noise to some of the common framework discussions is against a context where part of the administration south of the border wishes to remove us from the protections and the safeguards of the Human Rights Act. That, for one area, is causing us profound concern because it impacts on day-to-day delivery of care and support, all the way up to procurement and commissioning, all the way through our training and development. If there was greater clarity in the fog that that became something which was an increasing threat, we would be extremely concerned about the negative impacts, not just on social care but on the NHS. Governance that we have around particularly social care service delivery in Scotland is unique in the UK. We have our care inspectorate who have their inspections and regulation over our care services. We have a workforce that is increasingly becoming qualified, competent, confident and registered with the Scottish Social Services Council. We want to build on to enhance and have confidence in the care and support that vulnerable people in Scotland are receiving. I would be asking, in echoing what my colleagues have said, that any framework builds on what we already have and the uniqueness that we have in Scotland and does not detract from anything that we have spent a number of years building up. In relation to Europe, the governance and the stature of adult social care is something that, again, we should be proud of. Thank you very much. Finally, we have clearly heard some very strong points from each of the witnesses in this session about things that would make a difference. Is there anything in addition that any of the witnesses would want to put to this committee as something that we can do to assist with the challenges that, clearly, you are all going to face? I take it then that we have covered all the germane points, which is excellent and a very good use of our time. Thank you very much to all the witnesses in this session. It has been much appreciated. We will now move into private session.