 I welcome everyone to the health, social care and sport committee's ninth meeting of 2021. I've received apologies from Evelyn Tweed and Paul Cain and Malay McNair and Jackie Baillie are here as substitute members and welcome to you both. Our first item today is to invite Jackie Baillie to declare any interests relevant to the committee's remit. No relevant interests, convener, thank you. Our second item is to decide whether to take item six, seven, in eight and private. Are members agreed? Thank you, we are agreed. Our third item today is an evidence session with NHS Greater Glasgow and Clyde and the NHS National Services Scotland on the Trans-Vaginal Mesh Removal Cost Reimbursed Scotland Bill. All our witnesses are remote today. I'd like to welcome Dr Ross Jameson, the clinical lead for the complex mesh national surgical service and clinical director for obstetrics and gynaecology of Greater Glasgow and Clyde NHS, Mark White, director of finance for NHS Greater Glasgow and Clyde, Dr Anna Lamont, the interim medical director for procurement, commissioning and facilities for NHS national services Scotland, Roseanne MacDonald, associate director of procurement of procurement, commissioning and facilities for NHS national services Scotland and Paul Hornby, head of strategic sourcing and commercial national procurement, NHS national services Scotland. Welcome to you all. I would like to ask about the current status of the service. I imagine that Ross Jameson is probably the person that I should direct my questioning to on this. Is the service operating with a full multidisciplinary team at the moment? I'd just give me an overview of the specialists that are part of the team and available for any kind of onward referral as well, Dr Jameson. The funding that we have received from Scottish Government via NSS has allowed GGC to consolidate and expand the mesh treatment for Scotland. That has ensured that we can provide a smooth and consistent journey for women who are experiencing mesh complications from assessment through treatment and into follow-up. Just to detail, as you have asked, some of the work that we have done, we have expanded, increased our cohort of urogynecology specialists to four. I think that this is important, as women have expressed in the past, the desire to have a choice of surgeon, and this is something that we are now able to provide. We have dedicated colorectal surgeons who are vital in providing this complex surgery. We also have in place experienced radiologists with an interest in experience in gynaecology imaging, which is vital to the planning of this complex surgery. We have also put in place other specialists to support women through their journey, so we have specialists who can provide pain services, and they are available at the clinics where women attend to discuss their issues and plan and the treatment that they wish to progress with. As well as supporting women, we have recruited a clinical psychologist who is dedicated to the mesh service to provide this critical level of care. We have also recently appointed two whole-time equivalent CNSs for the mesh service, and they will provide a vital role in the pathway. One of the feedbacks that we got from asking women who are currently going through the service expressed that they would like to be able to contact the service in between planned appointments and those CNS posts will provide that ability for women to contact and discuss or express any issues that they have in between those planned appointments. Another area of feedback that we received was that women would like an increase in the physiotherapy aspect to their care. We have increased our physiotherapy capacities so that physiotherapists are also able to attend the planning clinics and see the women through their journey in the wards and also through follow-up. To support the service in other ways, we have also recruited a data manager for the mesh service. We feel that it will be important that we are able to provide and make available the outcomes of our treatment. I think that that will be helpful to us. I think that that is an overview. I am happy to answer any questions about that. CNS clinical nurse specialist. We had a bit of a conflab as to what we first mentioned, but we could not quite catch that. I want to come back to the issue about the choice of surgeon. That has been a focus of some of the mesh survivors. That has been an issue. I asked last week in our open session about whether women may not want the surgeon who put their mesh in or possibly who partially removed some of their mesh and they are having to come back to be their surgeon again because they have not had a good experience. Are you able to tell me in terms of the historical procedures that have gone on of mesh removal that these women have an issue and the surgeons involved, whether they are part of the team or whether you have got new people with new experience and new training in as a result of some of the things that have become up hold for the past few years? Has this been a topic that these women have brought to public attention? Yes, absolutely. As I said, we have increased the cohort of specialists to four. That will include two specialists who have been with us for a longer term and then two additional posts. That will bring in a choice for women to see someone who has not been involved in their care historically. How is Covid-19 impacting the service, in terms of staff absence or redeployment, or people being able to access a referral because of capacity issues in primary care? I think that is probably for Dr James Cymigayne. Happy to answer that. Unfortunately, Covid, as you will be aware, has affected the whole of the NHS services and the mesh service. In terms of a reduction in the capacity of our accessibility to theatres, we have not been able to do as much surgery as we would have liked, but we are still able to perform mesh surgeries. In the financial year 2021-22 to date, we have performed 20 mesh removal surgeries, and that varies between five to two per month. We have a waiting list of 20 women who have been through the pathway and are waiting for mesh surgery. We are hoping that, as the Covid situation is reduced, we will get more access to theatre and be able to treat those women in an appropriately time-less manner. I am interested in how the specialist mesh removal service has been communicated to health boards. How do the health boards know that you exist? I think that it is really important. When I am speaking, I can only see Mr Hornby. I cannot see who asked the question, but that is okay. I will carry on. I think that it is really important that this is seen as a national mesh service. We have communicated to the boards information about the service. We have given information as to referral criteria and what should be done locally and what can be done locally. We have also developed our referral form so that as much information can be sent with the referral so that the process is streamlined and we do not have to go back and ask for more information. We have also distributed a pathway so that the different boards can see what happens to women's journey. When they have finished their treatment, we have aimed to communicate with the different health boards as to what the follow-up is and to communicate what the treatment is and then what can be done locally. It is one of the things that we are trying to improve. The physiotherapists are communicating with local physiotherapists to ensure that those women, no matter where they live, get appropriate treatment and management in the period after their surgical treatment. Thank you, Dr Jim. That is just another couple of follow-up questions. We heard last week that maybe some GPs need help to diagnose mesh complications. It is similar to the other question. What help has been provided to primary care to know that this service exists, but also what help and support will be given to general practitioners so that they can, I suppose, better refer as well? I agree. That is really important. As a group, I think that these women are appropriately aware. I think that they will help their GPs to make appropriate referral into secondary care. I think that that is on-going work to ensure that our service is known throughout Scotland and that GPs are aware of it. I think that that is on-going work. Good morning. Just a follow-up question. Can someone self-refer to the service directly? No. Their initial referral would need to be through secondary care, but once they are known to the service and in the process, we have this contact ability through the specialist nurses. I was just waiting for you coming on there. I just wanted to ask you about what health professionals will be part of that multidisciplinary team. How wide does that go, depending on the women's needs? I am just going to bring up my list. We are following the nice guidance on membership of the multidisciplinary team, and it is really helpful in that it is really clear as to what type of professionals and specialists should be at it. That includes urogynacology specialists, dedicated colorectal surgeons and anaesthetic input. That is a really interesting part of the development. Quite often, women progress quite far down the pathway and then hit a hurdle just before the surgery, where we realise that we have not done appropriate pre-operative work-up to bringing any statistics into the pathway much earlier on. We hope that that will prevent some of the disappointment that can happen with physiotherapists, as I mentioned, and the pain specialists. It is a very multidisciplinary group, and it is functioning well. It is important that those specialists are also in the mesh clinic so that women have access to them and can speak to them. Putting that in place and being able to speak to a colorectal surgeon and discuss what is involved in this complex surgery will really help to inform women and make them able to make the choice that is appropriate for them. That is really helpful. Can I ask as well about the team making decisions about whether the best care and treatment available can be delivered within the specialist service? Is that completely down to the team, or what level of choice will women have around onward referrals? To mention the decision making that we are using and have adopted the use of the nice patient decision aids, that is work through with the women at their initial consultation. We have expanded that consultation appointment to one hour, and I think that that is really important that women have time with specialists to discuss what can be a very complex treatment. The decision is then not made at that appointment. They go away and have time to consider, discuss with other family members or other people who may have gone through treatment, and a second consultation, or any questions that can be answered, is arranged. Just to be really clear on that point there, when the women are going away and they are given time to consider, are they given options as such to think about and consider and then play quite a big part in the decision and the second consultation? Have they got real input in that? Absolutly. We have also developed our patient information, and that was something that was fed back to us through listening to women. We have improved our patient information so that in hours not enough time to make a decision that they can go home and make that decision with that information and then come back with any queries. Sue, I will bring you in. Yes, thank you very much, convener. A very quick question, Dr Jameson. What is the time between that first consultation and that second consultation then, because that will have a big impact on your plan and your service? Absolutly. That is usually about four weeks between those two appointments. It is important that, after that, the decision then is rubber-stamped, if that is the right word, as it goes back to the MDT. Initially, with the referral being presented at the MDT and discussed what the range of options would be, that is then discussed with the woman and then agreed and then goes back to the MDT final approval. I am interested in the clinical nurse specialist role. I have read that, in other services where they have that role, it can be quite successful in confidence for patients and developing right through the care pathway. I was just interested to know how that role will work and how early on the women might meet a clinical nurse specialist to go through some information with them. Yes, thank you. I would agree. I think that that will be absolutely crucial to the service, because what they can do for women is give them time and clinical expertise. We have recruited two whole-time posts consisting of three people. They will attend the MDT—I do not think that I included them—in the list, but they will then be at the initial consultation clinics. It was expressed to us that with the follow-up, we did a patient experience of feedback on women currently going through our service. One of the things that was commented on was that they felt that the follow-up needed to be more consistent. I think that this is a vital role for the specialist nurses. They will see them in the ward and then arrange a one-week follow-up telephone call and, as I said, be available in between the next planned follow-up, which would be with the surgeon. That is really helpful. Thank you. Thank you. I have some questions from Jackie Baillie. Thank you very much, convener. Those are also for Dr Jameson. I want to go back to issues of timing. You talked about 20 people waiting for surgery. How long is their anticipated weight going to be? As I said, our goal is to be within the Scottish Government recommended treatment times, which is 12 weeks. We are not at that at the moment, and I think that it is understandable that that is the situation. We estimate that we will be able to do two mesh surgeries per week, and that is eight per month when we are running at full capacity. It will depend when we are able. We are given access to our dedicated theatres again. Currently, as you are aware, GTC is prioritising the theatres for cancer treatments. I know that the pressure is easing on the service. I hope that our ability to get back to full service will not be long. You are suggesting that it will not be long, but we are all aware of winter pressures coming. Is it not more realistic to plan on the basis that it will be after winter before you are back doing full surgery on those 20 mesh women? I am not really able to predict that. Even though the majority of elective surgery is not going ahead at the moment, we are still able to have been delivering some mesh surgery in the past months. We are grateful to GTC for allowing us to do that. Although it is reduced, we are still able to get some treatment through, as it has been recognised as being a priority as well. Can I ask you how many are referred into the service? How many have been referred so far, and how long are they waiting? Finding that, we have had evidence written into the committee by some women, one who went to the obstetric service in the gynaecology service in Paisley, the same health board, and it is taking two years for a referral to the mesh service. Somebody, similarly, reported having an MRI in September, told that they would have an appointment with mesh service, and the initial appointment is July 2022, 10 months away. I am trying to drill down into how long people are waiting before they even get to you. I do not have those exact figures here with me today. I am aware that our waiting times for consultation are longer than we would like. I have some figures here that 64 women were reviewed through the MDT service in September, which is 26 more than was in August. There is turnover, there are longer waiters, and part of our job is to ensure that other boards and other areas are aware of the service, so that delay in referral is reduced as much as possible. As we progress, more and more boards will become aware and, hopefully, that delay in women getting referred into the service will be reduced. Can I ask a final question, convener? Is the delay the responsibility of the referring health board, because it sounds to me as if the referral is made, and then there is real pressure on your service in terms of being able to see people as quickly as you would like? I think that our expansion of our specialists and expansion of the whole service will be adequate going forward. I think that the delay has been due to a significant part of it, and I do not mean to keep starting and blaming Covid, but it is a fact. We had to redeploy our clinicians, and all of us were redeployed to deal with the pandemic. I am confident that, the way that we have expanded and set up our service, we have also moved into new facilities. That was one of the feedback that women gave to us that, when they came to their clinic appointment, the outpatient facility was a joint area with other outpatient services. We have moved the mesh service into the new Victoria hospital, which is a very nice new building with a dedicated area for the service and expanded number of rooms. We are developing and will deliver a service that is fit for purpose and will meet the demand. Unfortunately, at the moment, there is no longer a way that we would like. Mark White wants to come in on one of Jackie Baillie's questions. Mark White is just in response to Jackie Baillie's first question about the length of weights. As a board, we are currently operating around 40 to 45 per cent of our pre-Covid elective activity. We did have that as high as 60 to 65 per cent. As we came out of the summer months with the much publicised current pressure that we are under, we are back down to about 40 to 45 per cent. As you say, I doubt that the next few weeks will give us much respite around that. Clearly, much of that capacity is taken up with emergencies and urgent cases, but we are doing everything we can to get that level of activity back up. However, we are hopeful that, through the winter, and certainly as we come out of the winter, we will get back up to the rates that we are operating with at the end of summer, and then wrap that back up again to pre-Covid levels as we move into the spring and summer. We are now going to move on to the reimbursement aspect of the bill, which is that the main focus of the bill is on the reimbursement for women who have gone to get surgery privately or have arranged their surgery privately and drilled down on some of the eligibility criteria. On that, I have a question for Stephanie Callaghan. I just wanted to ask you what further detail is required as far as the eligibility of the scheme goes. Is there anything further that we should be looking at there? I can answer that if you want. I think that it is quite comprehensive, the details that are outlined in the bill. I guess that every case is probably going to be different in its merits. I think that the majority of information that is proposed in the bill is probably at the correct level. I think that one of the questions that I alluded to is probably around about any funding that any patient has received to go abroad, in other words, if they have used crowdfunding or whatever, then establishing that before the claim is processed would probably be quite critical, but I think that that can probably be covered in the application. From my point of view, I think that it is pretty comprehensive, and the information that is required is pretty much as documented in the bill. Does it seem reasonable that the idea that women may have lived in Scotland may be back in Scotland now but may have actually been in England at the time of removal that they will be excluded from this? I would doubt that. It does not sound fair to me. I am not sure if there is any clinical background to that, but from my financial point of view, I would not imagine that there would be grounds for exclusion. However, I am not aware of any background to any previous decisions around that or any clinical decisions on that. I do not know if any of my clinical queries can help with that answer. Dr Lamont, that was asked in speaking this. We will just get broadcasting to unmute you. There we go. Good morning, Carina. Good morning, committee. Thank you. The specific eligibility of who will be provided for the reimbursement of previous surgery is a question that I would defer to my colleagues in the Scottish Government. We are primarily here to be able to speak about the commissioning of the services and the commissioning of the external provider and the current provision within GGNC. The provision of the bill is specifically around the reimbursement of previous surgery that was organised and substantively organised while the person was resident within Scotland. That is our understanding of the bill. Certainly, from our perspective, we will be administering the reimbursement, but who is to be reimbursed under the exact criteria will be established through co-ordination with our Scottish Government colleagues. I wonder whether I could raise with Dr Lamont the group of women who would describe themselves as the in-betweeners in the process of arranging private treatment and their doing so whilst the bill is going through. Do you think that they should be covered by the bill? Do you think that the setting up of the specialist service has any impact on them? Could they be asked to start at the beginning and be referred through the specialist service or should they be covered by the bill? As I said, our requirement for the Scottish Government to specify and we will be working with our colleagues there. However, the bill is specifically about whether substantive arrangements have been made prior to 12 July. My understanding would be that if the substantive arrangements have been made prior to that period, whether surgery has or has not occurred by this time, it is to do with where those arrangements were substantively arranged. Specifically, it was raised at the evidence session previously. The expectation would be that following the announcement that was made by Cabinet Secretary on 12 July, women would then be aware that the free provision through NHS Scotland or surgical removal of mesh will be available, as you are already aware, through the specialist centre in GDNC, but will also be available through providers in NHS England and also the option of those external providers that we are developing commissions for. Would you consider 12 July quite an arbitrary date and another date could be equally picked? 12 July reflects the decision-making process and commissioning process within national services. The initial commissioning panel was established within June. However, the invitations to tender were sent out much earlier than that in the year. The commissioning panel agreed that there were two providers that would be allocated to the framework in July, and that was what led to the announcement on 12 July. Typically, we would expect there to be about six months' process from the announcement of an award to a commissioning framework to be able to have eventual contracts for women to be provided with surgery. That period is variable and there is a continuing process that we are working with the private providers to establish that surgical service. One of the things about the service is that, if women do not want to go to the mesh removal service, they may have the option to choose a private provider. Where do you stand in helping women to do that? How does that pathway work, as far as you see it? Thank you. It is an important aspect of the private providers that the option is provided, though we have to ensure that the options provided do align not just with the informed choices, but also with the needs of those women. I will defer to my colleague Rizam Adon to speak about the actual referral pathway, since she has been very involved with that. As Anna Cymru says, we have been working with two independent providers to progress the contract for Scotland. It is important that the pathway for every fail-out of Scotland is overseen by the specialist MDT in Glasgow. The reason for that is that we feel that any women going forward for mesh removal needs to be assessed and taken through some of that decision process before the referral to the independent provider is made. We are hoping that we will anticipate that we will work up a relationship with the MDT in Glasgow and the independent providers. As Anna Cymru said, that is about ensuring that the informed choice and the needs of the women are closely aligned. We would anticipate that, when women are referred to Glasgow, they would meet the team and have a choice of surgeon in Glasgow. They would then go through the consultation. There is an option for an NHS provider in England to be considered. If that is not an option for women, there will be, or there will hopefully, once we progress to contract, an option for independent providers. To get your views on some of the costs that have been outlined in the bill and the new experience, how appropriate they are, I will move on to questions from David Torrance. We heard from witnesses last week that costs could vary, especially women who had sought treatment during the pandemic, but also one witness because of medical conditions incurred higher costs. Should more costs be specified? I will look for one of you to the most appropriate person to answer that. I am not quite sure who would be best to answer that. We are asking for your opinion, but those of you who are in procurement might be the best to answer that. If I may go to Mark White. I am not in procurement. From a finance angle, the costable area does acknowledge that. From my point of view, reading the bill sets out a range of assumptions and estimated costs. I would assume that, if costs vary from the benchmark or the guides costs in the bill, they will be treated in individual merits. I would assume that providing them are not too far away from that, then that should be a problem to processing them. In terms of procurement, in terms of the contracts that are set, if procurement colleagues in the NSS would be to tell us what parameters they have set, then those contracts would be set. In terms of our request to the independent providers, there are a number of different types of interventions that we have asked for costs for. I can advise that the range of costs vary between £12,000 and just over £17,000, so that is for the actual provision of that surgical intervention. Obviously, there are lots of other costs involved in that as well, but it is for the actual provision. That is the range that we have engaged from the market. David, do you have any more questions on that? Women who have had previous treatment, what were the same criteria and standard rates applied to any women in the future who will be referred for private treatment? I think that, as Dr Lamont has outlined, we are in the process of just finalising that. We have a favour agreement with the providers, but those costs that are shared are the ones that will be in place. We have gone for one year plus another year for an extension, so they will be the costs. Again, it is just for that operation side. Obviously, there are other costs that are indicated by part of the whole service, but those costs would be in place for at least a two-year period of time. I am going to make a point of difference between the funds allocated for the bill and for the on-going commission services. The cost of commissioning surgery from an external provider, as Mr Holby has described, refers to on-going costs. In reference to the previous question about refunding of additional costs, as was outlined in the evidence session previously, there are additional costs that will be accounted for, including the costs to do with travel and substance and insurance. The exact details of how those costs are refunded and what is eligible and what will be covered in that is a question for my colleagues in Government. For the commission going forward, it is important to recognise that the care that we must commission is a wraparound. Although we are focusing on a very surgical service, people are more than just needing a surgical service. It is about ensuring that we have that holistic wraparound care that ensures that they can both attend surgeries safely, that they can be cared for before, during and after the surgery and to be able to travel home and receive that after care that is so important. It has been recognised by the women that have been harmed by mesh that they are looking for a personal, flexible and personalised service that recognises that everyone is different. We have to ensure that the surgical service that is provided and commissioned does not just provide for those people who are not very well and have low surgical risks but also allow for those women who have additional surgical risks. As my colleague Dr Jameson has described, that involvement of that multidispray team and anaesthetic colleagues is so important in that particular factor. It is the sort of factors that we are continuing to explore with the private providers. Dr Lamont covered my point very nicely. The only other point that I wanted to add is that, as part of the independent provider procurement commission, we are working on a travel and subsistence policy. It would be our intention that women's travel for themselves and a partner would be covered in daily subsistence, so that is very much in line with our intentions. In evidence last week, the bill team says that there has been no cap on costs. Why do you think there should be a cap? I just looked to see who would like to come in on that. I draw a distinction between the services and the costs that we are speaking about, as I said, between the services that we are commissioning and the costs that are in the bill. It is important to draw a distinction here that the bill that is being discussed today is about previous surgery and refunding the costs that have been involved with that. Exactly what will be provided and what will be refunded is a matter, as I said from my colleagues. There has been an indicative cost provided, but they have also indicated that that is an indicative cost and that each person will be considered as an individual personal case and their own personal circumstances taken into account. From the perspective of costs going forward, we are commissioning the surgical service, so the costs that we are particularly looking at at the moment are the costs of providing surgery in the future. However, there will be additional costs, as Ms McDonald spoke about, that will be for that wraparound and holistic care that does carry them from Scotland through to surgery and back again safely and effectively. In terms of the administration of the scheme for the women who have had surgery or have applied for surgery, do you think that the number of women that are, as I suppose, estimated in the bill is realistic? We are obviously having to look at your resources and finances in response to the new administering scheme. There is an estimate that it is around about 20 women, so it could be up to 40, but we really do not know yet. In the financial memorandum, do you think that that is a realistic estimate? The issue here is in terms of the historical surgery that has been provided. We are reliant on understanding how many women have privately thought surgery having had that arranged within Scotland. Our will then seek for reimbursement. There are circumstances in which women may choose not to seek reimbursement, and that has been recognised as being a particular issue, perhaps, where crowd funding has been involved and where reimbursement may be more difficult. That is why there is significant uncertainty at the moment regarding the numbers that will seek reimbursement through this bill. In its response to the consultation, NSS said that reimbursement should only be made when the outcome of the mesh surgery was fully successful and requires no further treatment on the NHS. Can you expand on that? Is it fair to exclude women who may have suffered complications or had an unsuccessful surgery through no fault of their own? I will go to Dr Lamont. Thank you. It is very important that each person is considered independently. That is not about excluding women. It is very important that a surgery has been undertaken and there is further surgery required. Those people do not feel excluded and we recognise that further surgery and further costs may be incurred. The exact eligibility for what is within and without the refunding, as I said, is for a matter for my colleagues. The bill does not seek to exclude women just because, as you said, some surgery has perhaps not been successful, as intended. On the other hand, it recognises that additional costs may be incurred and that those costs need to be taken account of. If I may refer to my colleague Mr Hornby, who may be able to provide more detail on that. I am sorry, but I am not quite sure what else I can add to the comments there in terms of that proposition that you have pointed out. As Dr Lamont has pointed out, every case has to be taken by case basis. Therefore, as those cases are presented and reviewed with the information from the colleagues in the Scottish Government, they would have to be reviewed on that basis. Most importantly, it is to find out how the patient can be resolved, how they can be helped to get to the place where they want to be. Sandesh Gauhani has a question. Thank you, convener. I have just been said that Dr Jameson was my clinical supervisor to make sure that that is on the record when I was doing my work. I have a question about the cost, though. Obviously, we are reimbursing. We are talking about the reimbursement here, but what do you think the indicative cost will be for women in the future for NHS Spire Bristol and going to the US, probably to Dr Lamont? Thank you. You said that this is about reimbursement. However, the future costs are not part of the reimbursement bill, but part of the service that is being established going forward. It is important to recognise that the first choice that we would always put forward is that the special service in Greater Glasgow and Clyde is under its importance. We try to explain to women who have been harmed by this to recognise the options that are now available within Scotland and that we do recognise that the expertise and skills that are available within Scotland and the credentialing that will be available to be able to demonstrate those skills and expertise. However, we will also be able to provide those services within NHS England, and that is again through an NHS commission service. Also, there is the third option, which is through a private provider. That is not part of the reimbursement bill, but, going forward, my colleague Mr Stormby has provided some indicative costs for that, and that is a range. The exact costs that, at the moment, we only have related to the individual's surgical procedures, are continuing to be developed because we have to make sure that we cover four complications. We need to cover the insurance, the provision for women to be able to travel to, the place of surgery and back and safely. I must emphasise that our focus here is on ensuring that there is not just safety, but that there is key informed decision making, informed shared care decision making. However, at the moment, it is available in GNDC that we are able to guarantee that that service or an equivalent service is available through commissioning with the private providers. I just want to ask a question. It has been referred to a couple of times about this third option, but I am unclear about the timeframes for this and whether you are clear about the timeframes for this and when we will actually get an answer on that. Would anybody be able to answer that? I will just check to see who would like to come in on that. Paul Horanby? If I could be start off, in terms of where we are in the process, we have identified two providers that are able to provide that specific service. We are now working closely with each of them to understand how each of those specific surgical interventions work in with that whole patient pathway that my clinical colleagues have described so far in the call. We have been working with those providers since the July period and continue to work with them. Dr Lamont indicated that there is normally a time from when you can award clinical service providers and work through them in detail with all the different potential clinical patient journeys that could take place and all the different types of care that needs to be continually provided for that. The point that Dr Lamont made about the key is that all those contingencies that things may not go exactly to plan. How are those managed through that whole different pathway journey? The work that is on-going with clinical colleagues and the suppliers now and just working into that detail, Dr Lamont indicated a period of about six months. I think that it was from when we have gone from the award and that is where they are down that journey just now. I think that they are quite well developed. I think that it is just finalising that so that the services are ready and the referring clinical staff can be confident that that option gives as good an option to the patients as they would do if they were remained within the NHS. We are awaiting formal confirmation that the lead surgeon is a member of an NHS England mesh centre. That was part of the specification. We are anticipating that that formal notification will come through shortly and we anticipate that we will be able to move forward with this by a healthcare contract in the near future. With regard to working with the vaginal and urogynecology surgery, the company that Dr Veronica's overseas, we are working very closely with him to understand, as Dr Lamont says, the contract that he has with the hospital where he operates to make sure that we have covered all the bases of not only for mesh removal but for any incidental complications that happen also. It is very important that we consider those facts because the mesh removal is one aspect but we have to make sure that we have cover for people if they were to have a claw or a heart attack or something like that. We are working very closely with Dr Veronica's around that so that we can proceed with the contract. We do not have any time scales at the moment but we are happy to update as we go forward and we are hoping that we will be able to get an update in the near future. That is very helpful and I guess that that goes to show why the individual patient experience is very important. There is no way that you can just say that there is only one type of procedure involved because everyone will be different. I bring in my colleague Sue Webber who has some questions on the administration of the scheme. Thank you convener. Just a quick follow-up there with Roseanne, please. You mentioned that the clinician that is going to be carrying out the procedures in the SPIRE and in Bristol, you were seeking to assess if they had an affiliation with an NHS trust in England. Is that because they are only working privately at the moment? I could not comment on the position for this particular surgeon at this moment in time but it was recognised within the clinical advisory panel who overseen the specification for the independent provider that it is very important that the lead surgeon had a volume of mesh reportable outcomes and that they actually operated within an NHS mesh centre. That is what we are waiting on. I am not particularly sure of that individual person's actual working arrangements. Dr Lamont wants to come in on that. Thank you. One of the key elements that we are looking for to establish with any external provider is that the care that women can expect when attending these providers is that they can experience a very similar level, at least as good as NHS Scotland can provide around that wrap around holistic care. In particular, we are looking for standards of shared decision making, competent MDT, multidisciplinary team input that is able to have that shared discussion that my colleague Dr Shemerson has described that women have the opportunity to have that conversation to go away and to come back with GGNC. We are looking for a very similar level of engagement. Similarly, there are the issues about volumes and standing that the skills that are involved in the previous session have been conversations about credentialing. That is something that we are working with to establish that level of credentialing to provide that confidence for those women who have been affected by mesh, that the services that can be provided in Scotland are of the very highest quality. While we are looking at that, we will provide an assured external provider that the first option for women—we hope that they will understand the best service—is that local service that does have that wrap around care. I have two questions. One is looking at the reimbursement process and one is looking at the service commissioning for the future. We will deal with the reimbursement element first. Mr Hornby has spoken about it being a case-by-case basis. We have heard from many of the witnesses about how complicated and the unexpected costs that come from—as we have already known—surgery is very complicated and no case is the same. If the administration of that sounds like it might be quite complex, but at the same time, because the payment is not coming until everything is concluded, those women are going to be wanting to reimbursed as quickly as possible. So, what extra resource is being put in by the National Service of Scotland to administer the scheme successfully to really tie it all in for the women at the end of what will be quite a traumatic period of their lives? I will just look to our colleagues to see who would like to come in. Dr Lamont, do you want to come in on that, or is it better to do so? If I could come in briefly and then speak to Mr Hornby, the reason I wanted to come in at this stage was just to clarify that, from the point of view of reimbursement, those are costs that the women will have already experienced in terms of the reimbursement bill. Again, I draw a distinction between the reimbursement bill and the commission service going forward. The reimbursement is for costs that women have already experienced. That is, for those people, substantially arranged surgery prior to 12 July this year. Going forward, the costs that the women will have will be essentially free. We will be looking to provide a contract that pays for those services up front. Now, there are likely to be incidental costs, or maybe some costs that require refunding, but the substantial cost going forward for the commission service such as around surgery and travel, we will be paying up front so that the women will not be reimbursed. That will be very similar to the idea of providing surgery through the NHS or any other provider, and you would not be expected to pay for that and then claim it back. Thank you. The question is about what extra resource you are trying to say that is required within the NHS. On the commission side, we have resources that administer a number of services or part of that. That would be included as part of the service that it delivers. I am not sure whether any additional resources are required. The stage where we are just now is just getting the bill through and understanding how many and what level of detail. If the NHS is being appointed to administer that, we will have resources accordingly. Certainly within the commissioning side of the McDonald's side and the procurement side, we would allocate the resources to ensure that the patients who need to be reimbursed can administer as quickly as possible. I do not think that we have identified that we need to get so many people to do that. I think that that is still to be understood yet. Thank you for that, Paul. That answers my question specifically. We have heard in terms of the new commissioning of the service wherever it might be, whether it be in the Glasgow mesh service, the site in NHS England, the site that we have potentially expired and then overseas. However, those women are still all having to refer in via NHS GGC. I just want that to be clarified. I will use the word hierarchy, but that might not be correct, but you will understand that. Is there a preferred route? If the women do not want Glasgow, are we encouraging them to take the service up in NHS England just because it is in NHS England and that wraparounds might be a bit more definable? Is it a sort of question that I am looking for or is it a very much patient-driven choice? That is a bit complicated, that, hopefully. I am just looking to who is best to answer that. I will go to Dr Lamont first. I think that it is important that we hear some input here from my colleague Roseanne MacDonald and Dr Jameson. In terms of referral and present, the pathways in through the patient's GP refer into the local services within subsequent referrals, we have heard on to the specialist mesh service within GGC. I do want to emphasise here that the vital involvement here—and it was recognised by Baroness Cumbled as well—of shared decision making and the multidisperate team. The multidisperate team is a vital part of the service in terms of understanding the specialist needs of all those women in terms of their particular circumstances. It is not a case of selecting a surgical process from a menu or selecting them from a menu. That is what is required. It is really important that we take into account and understand what the women's choices are, but we also need to look at what their needs are and what can provide a positive contribution to their life. I will defer to my colleague Dr Jameson, please. I would again like to draw the distinction between the cases of the women who need reimbursement for the surgery that they have already had and the women who are now coming through the service. I hope that I have been able to explain and demonstrate that the service that we are currently providing will constantly be improving going forward will be valued and seen by the women who are coming through it as a quality service and that they will trust in it and want to stay in our Scottish service. That is my job and our job as a team to deliver that, whilst accepting that it is appropriate to offer choice. Whether that is in England or with a private provider, I think that women need to be explained by the pros and cons of that, including the travel and away from home. That will all be done to the best of our ability. I bring in Rosalyn MacDonald, who wanted to come in in the substance of your initial question as well. I will just get broadcasting to unmute. I miss Ms Donald. Thank you. I do not know if I did not catch. I wanted to come in to say that the principle here is about women having trust and confidence in the surgeon. Our absolute primary aim is that women feel confident in their choice of surgeon. It is our absolute ambition and intention that the Glasgow service is seen as a first choice. We are setting up an exemplary service. The Glasgow service in terms of the UK is recognised as one of the leading centres across the UK. It has been established longer than the NHS England centres. We very much want to set that up so that people see the value and want to do that. In relation to people's pathway, it remains in the NHS because their care is absolutely in the NHS. We understand the credentialing and what we are offering women. I think that that would be an intention, but it is down to the women. If they want to, after going through the shared decision making process, decide that they want to go to the independent provider, that will be respected. Going back to what Jackie Baillie said earlier on with the correspondence that we received last night, the trust and confidence are still not there. That one route into referral via Glasgow will be an issue. I am trying to get some sense that it is not just about the choice of the surgeon. That is significant, but it is also the fact that the Glasgow service, for whatever reason, has a bad reputation at the moment with the mesh survivors. What are we doing to specifically give them the confidence to come into that service and know that they will get a good outcome wherever it might be for treatment and an approach that might be needed at the other end? I think that it is important that we also hear from Dr Jemison, but it is to emphasise that the surgical service that is being provided within the agency is not just a single surgical service, and it is also about that multi-discreet team, which I appreciate that we are emphasising. It is a team that is unique to what we can provide in Scotland, and it is recognised by colleagues as being a specialist service. It is sad, but we do recognise that there is a significant confidence issue for women who have been harmed by mesh. It is part of our job now to be very clear in establishing that the service that we can provide in Scotland is exemplary and is the best service that those women can be provided. However, if women are still of the mind that the service that is provided in Scotland is not what they want to do, even if it is a different surgeon, even with a choice of surgeon and involvement of a wraparound team, even if that is not something that they wish to engage with, we will be providing NHS services through NHS England. If they choose the services that they do not want to be involved with, there will be the options that our provision of surgical service is still local to the UK. If that is not something that they wish to engage with, there will be further options for an external provider, which we are trying to develop within the US. While the single point of contact at present remains the MDT within Scotland, that is important to establish that all those risks and wraparound care that we have spoken about the mental health concerns and any other concerns that women have, we are able to address. It is important that we recognise that the surgical process that one particular day that a woman has surgery on is only one part of their journey to recovery. We must have cognisance that we must provide more than just that one day of surgery. That is why we have that single entry point through Glasgow that we are being able to provide that personalised service. However, as I said, I will defer to my colleague Dr Jemison for more details about the pathways for the GG&C service. I was just going to go back to the point of trust. I think that this is a real priority for the Scottish National Service in GG&C. We really hope to maintain the trust of current users and, if possible, regain the trust of users that have been had treatment in the past. We understand the difficulty and challenge of that. The ways that we are doing that are several different ways. We recognise the importance of publishing and making available our data, and that will be a priority. We are currently engaged with the other mesh centres and accredited centres in the UK. One of the purposes of that is to agree the outcomes that all the mesh centres will make available, so that those outcomes are the same, so that women have the opportunity to see them and be assured that the outcomes of the Glasgow centre are as good, if not better, than the other mesh centres in the UK. The other way that we are hoping to maintain trust in our service is by listening to women, and we have had very valuable feedback via the Alliance group that we have responded to. It has really helped us to form and shape the service in the past months. We value that interaction and hope that that will continue. We are also asking ourselves, the women who are going through the service, and we did a feedback questionnaire at the beginning of the year. Again, we have got some really helpful feedback on how, where we are doing well and what we need to improve. We are doing that again for women who had treatment in July and September, and I am sure that different things will come out of that. I think that this is another way of ensuring that women feel that their voice is being listened to and in that way that they have trust in what we are providing. I think that you have pretty much clarified it. To be sure, the bill is about reimbursement for women who have paid for surgery already, and you are all representing the specialist mesh centre in Greater Glasgow. I am just reading here that 20,000 women in Scotland had mesh implants in the last 20 years, and some 600 have suffered agonising, debilitating complications. What I want to hear is, can you provide the women who will be hearing from this or watching the session a clear, person-centred pathway or a clear, person-centred approach will be taken by the specialist mesh centre so that we can address some of the issues and maybe have direct access to what Jackie Baillie was saying, that one woman said that her appointment was not going to be until July 2022? Is there a way that we can expedite this so that a truly person-centred approach can be taken? If anyone else wants to come in, please put an hour in the chat box and that will bring you in before we wind up. I think that the Scottish Government has recognised the volume of women, potentially, that have been treated by mesh and will have problems from that, and that is the purpose of funding the service and allowing us to expand, to cater, going forward for the need. Those specialists are training, spending years, learning these skills, and that is appropriate because we anticipate that we will need to provide the service for years going forward. That is not for the next 18 months or two years, because we do anticipate that more women will come forward and need the treatment that we are able to provide. I want to thank you all for your time this morning. It has been very helpful. We are going to take a short break before we go to our next item on the agenda. Our fourth item today is an evidence session with the Cabinet Secretary for Health and Social Care on the Transvaginal Mesh Removal Cost Reimbursed Scotland Bill. The Cabinet Secretary is with us in person, so I welcome Humza Yousaf, the Cabinet Secretary for Health and Social Care, who is supporting the Cabinet Secretary in the remote aspect of our meeting. We have Greg Chalmers, the head of Chief Medical Officers Policy Division, Terry O'Kelly, the Senior Medical Advisor, David Bishop, the mesh team leader and Alyssa Garland, the Solicitor from the Scottish Government, all from what we heard from last week, so thank you for coming back. Cabinet Secretary, good morning. This is obviously the last part of our scrutiny on this very narrow bill, but obviously, as you imagine, the bill might be very narrow, but some of the issues around it make them into questioning from members as we go forward. I think that eligibility is one of the main issues that we want some clarity on. We know that the reimbursement is for women who have opted to go to other places out with Scotland on mesh services to get private treatment, historically, or women who have arranged for that treatment within a certain timescale. One of the things that we would like to know is why you have excluded women who had their surgery in Scotland initially for the mesh to be put in, whatever surgery that was. However, when they went to have the private treatment, they were not resident in Scotland, even though they might be resident in Scotland now. Why has that exclusion been made? Thank you, convener, first and foremost, for the invitation to come and give evidence. You are right, the bill is very narrow in scope, but the interest in this is huge from members of the Parliament and women who have been affected in their families. I have been able to meet a number, more than one constituent per cent of the active constituent case that I am dealing with in this regard. We know that the interest is huge. From the outset, we want to acknowledge the real pain and suffering of the women involved here in their fight for not just justice but, importantly, for relief from the pain that their feeling is really at the top of our mind. That is why I am really pleased that, convener, you were able to help in relation to the Government's bill's passage to try to do this as quickly as you possibly can, given the pain and suffering of those women. I want to acknowledge that before I go into the detail of the question that you have asked. The next thing that I have tried to say and give an impression of, I hope, throughout this session is that we want to try to be as flexible and open as we can. Therefore, the evidence that you are taking and the report that you will produce as a result of that evidence, we will look at it really, really closely before we go into the stage 2 debate. This issue has enjoyed good cross-party working. I would argue that this issue may be more than many others that I can think of has shown the Parliament working at its best. I think that it is absolutely worthwhile to put it again on record, although I know a number of MSPs have been involved in the efforts of Neil Findlay MSP, Alex Neil, who is retired as an MSP, and Jackson Carlaw, who continues to be an MSP in the working that they have done in order to highlight the plight of the women. To get into the detail of your question on eligibility, you are right that the current eligibility criteria that we are looking at is for those women who had to get or paid for mesh removal surgery carried out by an independent provider, but those individuals were ordinarily resident in Scotland at the time that treatment was arranged. I suppose that it goes back to our view that the state has a responsibility for that individual, regardless of whether, for example, they have mesh implanted in NHS England or any other part of the UK or overseas. However, when they are ordinarily resident here in Scotland, the state has a responsibility towards them. We recognise that those women, regardless of whether they are a Polish, Scottish, English, Pakistani or Scottish for 10 generations in this country. If they were ordinarily resident in Scotland, then it is the state's responsibility to reimburse them for the cost of that mesh procedure previously. I suppose that what we are not getting into and the difficult territory that we might get into if we opened up for anybody who got that mesh removal, sorry, that mesh implantation, transvaginal mesh implantation on NHS Scotland would be, if that was the criteria, excluding women who might have got the implant from elsewhere, but were ordinarily resident in Scotland and felt that they had to pay for a private mesh removal. Other officials wish to come in to add anything to what I have said. What I would say again is that our approach to the entire scheme is to try to be as open as we possibly can be but it is fair as we possibly can be. However, I do not know whether or not any of my officials who are joining first would like to add to what I have said. If anyone does, please speak up. We will go to Greg Chalmers. Yes, morning, convener. Good morning, minister. I have to add a very few points to what the cabinet secretary has said there. I think that our present definition in the bill and the scope of eligibility reflects one of the primary motivations of bringing the bill forward, which is that the Government has now decided, as he heard in his earlier session today, to procure surgery from independent providers, and that process continues. One of the primary purposes of the bill is to reimburse people resident in Scotland who decided to pay for that surgery themselves and who, if the policy that the ministers have now chosen to adopt was in place and being implemented, that would be provided to them free of charge. That is the essential reason for the eligibility criteria, as it is. As the cabinet secretary has said, we will consider the report of the committee, but somebody who was not today ordinarily resident in Scotland would not be able to take advantage of the possibilities for the range of options of surgery treatments that are now going to be available. That is the primary reason behind it. I will add just for completeness, as I mentioned in my letter on 29 October to the committee. I suppose that one thing says that over the years that team has been involved in this situation, we have not received correspondence, and you will imagine that we have received quite a lot from somebody in this particular situation that has been described in the convener's letter to me on 27 October. Obviously, it goes out saying that it would be interesting to know what you have, but that is the background. I just missed that. You have not received any correspondence from women who might fall into that category so far. That is very interesting, because I was going to ask what would be the potential impact if you have, but that is very difficult to quantify. Can I move on to some questions around the eligibility theme from my colleagues in Murri McNair? Good morning, cabinet secretary, and thanks for your time here this morning at the committee. It is envidaged that there will be a deadline for applying to the scheme. How flexible is that deadline? Will there be a meaningful approach to accepting reasonable grounds for late applications? Again, I go back to my opening remarks to the convener that, recognising the suffering of the women involved, we should obviously try to apply as much flexibility as we possibly can. Obviously, at the same time, we have to balance our obligations under public finance and public funding, but at the same time, we should be as flexible. The plan is, if the bill passes the appropriate parliamentary passage that it has to go through, we would hope to be able to in a place post-passage, post-royal assent to be able to open the scheme as soon as possible. So, summer 2022, initially keeping it open for a year, but that does not mean that people would have to wait a year. Let me give that assurance that it would be a rolling process of reviewing those applications. However, the reason why we would open it for a year is that it might take people quite a bit of time to get the appropriate advice that they need to get from the independent providers, contact an airline that they were using a year ago, two years ago, to try to see if they can get that proof that is required. If we had to extend that deadline, of course, we would look at that favourably if it was needed to be done. At the same time, we would want to try to take a flexible approach, realising that people do not keep airline stubs from five years ago. We will try to be as flexible as we absolutely can be, but we are also mindful of our obligations under public finance. The cabinet secretary will be seeing the correspondence from women that raises the issue of it in tweeners, those that started the process of pursuing surgery themselves. How are they going to be accommodated and supported? That is a good question. Again, I will keep emphasising and re-emphasising that point about trying to be as flexible as we can. The reason why we have chosen the 12th of July as the date, as a kind of cut-off date for eligibility in relation to the scheme is because that is the date that we made the announcement of the independent providers. Therefore, in all the communications that followed from the 12th onwards, we have been keen to say to women that we are working as hard as we possibly can with those independent providers to finalise the contracts and to have the appropriate pathways in place. However, if they can hold off from our arranging any surgery with independent providers, that would be favourable until we have that scheme up in place. There may well have been some women—in fact, there definitely was—who arranged prior to the 12th, but their surgery would not have taken place until after the 12th. In that case, they will be reimbursed when the scheme is open. If I were to get into the granular detail of that, there is something for us to consider about what we mean by making an arrangement. If it was understood that surgery would take place on a certain date by both the patient and the surgeon and the clinical team performing at the surgery, then that would be an arrangement. If it was an initial preliminary inquiry, but nothing had been booked, then I do not think that that would count as making an arrangement. However, we would look at each individual's circumstance on a case-by-case basis. That was an area that I hope to question the cabinet secretary on. Given that, in all honesty, it may just be a small number of women that would be affected. Why are you sticking rigidly to the 12th of July when you could make it the start of the introduction of the bill, for example, or at stage 3, the passage of the bill? We are not talking about a huge number of women, and I am just thinking of the consequences of them not being reimbursed and then having to go through the mesh service right from the beginning when they are making progress already. It is important to just separate out what we are doing in relation to not just the complex pelvic mesh removal service, but also what we are doing in relation to the pathways for independent providers and what the bill is seeking to do. They are clearly interlinked, but just to try to answer your question, I want to separate them out for a second. In relation to the bill, there has to be some kind of date. If ever he is being really pushed hard on it, we could absolutely consider where the flexibility lies. Though once we have a contract, I should say finalised, which I would hope to be relatively imminent and there are no contracts of this nature, particularly when we are dealing with providers overseas. We are going to take a bit of time to work through where those services are different to the NHS here, but once we get those contracts finalised, there is a pathway that exists for women. That pathway would include, for example, a multidisciplinary team, which again would include the likes of Dr Veronica's and Dr Hasham from Aspire Healthcare in Bristol. They would be part of the MDT process and decide what the best pathway for treatment for those women is. I would not see the reason when that pathway is up and running to have to reimburse, because that procedure, if it is Dr Veronica's that is decided by the MDT as the best route, that is being provided free of charge anyway. I do not think that it would make sense to have the eligibility criteria at the end of when the bill will receive royal assent, but I can see you wish to come back on that point. I am not suggesting that you need something once those contracts are in place. The key question is that there is a gap between 12 July and when those contracts are established. Given that they are unlikely to be a huge number of women—we are talking about a small number of women here—why can't you close that gap and make them covered by this reimbursement bill? The reason why I referenced when the bill was passed and royal assent was because that is the question that you asked why it did not wait until the bill was passed and royal assent, so I do not think that it would. It seems that we are on the same page in that respect. In terms of the gap between when I made the announcement and the contracts being finalised, I do not think that it is an unreasonable point and it is one that I am happy to take away and look towards whether there is flexibility. As you said, there is probably a small number of women. If we said that, we could get a rush of women who all decide that they want to be seen, for example, by Dr Veronica's. Of course, I understand that because he is such an expert in his field. That could complicate matters, given that we are in the midst of a contract negotiation. What would happen with those women? Where would they be on the list? There is an MDD process that we want women to go through before, because that would help with preoperative care, postoperative care and so on and so forth. That is where the nervousness comes in. Jackie Baillie has asked me to look at that in good faith. Some of the women who are involved and I have spoken to have asked me to look at that in good faith. I absolutely will consider that issue between 12 July and contracts being finalised. However, as I said, there is some nervousness about the unintended consequences that that might have, but also just what that might do in terms of the current contract negotiations. I think that it is really important that we are clear with the women, the people that describe themselves as in-betweeners, what we mean by entering into arrangements, because having spoken to women, any movement towards going for this surgery was quite a trauma to go through. I think that we need to be clear. I think that coming back on Jackie Baillie's point in the last evidence session, we heard that we are not clear about when people may have the option of going to Dr Veronica. It did not seem clear in the last session when we might settle that date. Is a small number of women and could we be clear with them, please? It is very important for those women to be able to move on. Yes, that is a short answer. We have arranged, as Ms Mawkin might be aware, some consultations with the women through the Alliance, who are an excellent organisation and a well-respected right across this committee table. We try to be as clear as we possibly can about arrangement. It is difficult, but I am happy to look at whether or not we can be clearer on our communication. Generally, if it is understood by both the patient and the consultant stroke clinical team that a surgery would be taking place at a specific date, I think that that is an arrangement. Again, a preliminary call inquiring about the services that a particular provider does provide to me is not an arrangement. If there are specific cases, I would say this very openly, because I know that many of the women involved will be watching this session today. If you are in doubt about that, please do contact the Scottish Government. We would be happy to be as explicit and clear to you on what we mean by an arrangement or not. We will also be entirely flexible, as best we possibly can. However, the message at this stage remains, please do not make your own arrangements. We are close, I would hope, to finalising those contracts with the two providers, both Dr Hashum and Dr Veronica. We hope to have that pathway up and running very, very soon. I know that that can be a bit of cold comfort given what all the women have gone through in the past and some of the fact that there have been some false starts for them as well. However, we are progressing on that, but I take Ms Mockins' point about if there is anything more that we can do to be clearer on the language around arrangement. Thanks, convener. Good morning, cabinet secretary. Thanks for your time this morning. I am interested in women that have been affected. This is a mesh reimbursement bill, so women who have already paid for surgery already. Would women still qualify if they have raised the money through a crowdfunding type platform? That was an issue that was raised by the committee in its previous sessions. My view would be no if a portion of the funding was crowdfunded, because that would not have come at a cost to the women involved, so what we are looking to do is reimburse the women for the costs that they would have had to pay out of pocket. If you open it up to donors and crowdfunders, you get into some really difficult territory when it comes to public finance and the surety of that money going to the places that it is meant to go to. I do not mean that there would be any malicious intent from the women in that regard at all, but some people donate to crowdfunders anonymously, so how would you know who that money would go to, for example? At this stage, I would not open it up for money that is crowdfunded or given by the nation, because it is not incurred by the women involved, but we are hoping that the scheme would cover all reasonable costs for the women that have been involved. Indeed, if somebody went with them to support them on that surgery, their costs would also be covered. Women would not be excluded if they had a partially funded from a crowd funder, but they were able to supply evidence that they had paid for a flight, for instance, or transport, or whatever, through their own means. Let us just say that the cost of surgery overseas in the United States was £20,000 and £10,000 was covered by a crowd funder and £10,000 was covered by the women themselves. That £10,000 was covered by the women themselves would absolutely be eligible to seek reimbursement, in fact, it would be the right to seek that reimbursement for that cost. As long as it was reasonable cost attached to the surgery, it could be flights, it could be accommodation, it could be travel to surgery, it could be—I am sure that we will get into this in greater detail—it could be any reasonable cost food and drink, and so on and so forth. That portion that was non-crowded funded, it would be eligible for reimbursement. A couple of other questions that have been raised about the eligibility and reimbursement. I get your point about crowdfunding, but a lot of women will have had family members giving them substantial donations and they will want to see that their family members might be reimbursed as well. Is that taken into account as well? If you have had thousands of pounds given or loaned by family members or anyone, and the women want to be able to give that back? I understand the point and I understand it well. It would be a really challenging one for us to be able to reimburse for a loaned family member and square that off with our obligations and public finance, which we have to follow pretty rigorously. That is public money, of course, ultimately at the end of the day. I will take the issue away and see if there is any flexibility. I will speak to economy and finance colleagues around whether there is flexibility. We begin to get into, again, some dangerous territory—not dangerous, but difficult territory—because you might get a loan from a family member. I think that all of us around this table would have some sympathy around why you would want to reimburse that family member. What about if it is a friend? What about if it is a work colleague? What about if it is a—you are in desperation, so you took money from somebody who had a classic loan shark back in the day? You just really begin to get into really difficult territory around borrowing money. At the moment, the eligibility criteria is only to reimburse the women who have had to pay out of pocket and all reasonable costs incurred with that. Let me take this one away, though. I recognise that, when it comes to particularly people who have been generously gifted money by family and friends, I can see why that issue is of interest to you. That has been raised with us, but it is also the issue of people who have taken out loans that might have interest associated with it. That is another issue that has been brought up by some of the women that we used to work with. I think that that issue, more so, would be able to evidence how that is a reasonable cost to me. It is slightly different to a loan from a family member—it is unlikely to be charged interest by a family member, but that is my family. I want to take that as granted, but you are absolutely right to take a bank loan out, so of course there would be interest applied to that. To me, if we can evidence that loan that was taken out and the interest involved in that, to me that is not an unreasonable cost to ask for reimbursement. On the eligibility theme as well, questions from Sandesh. Thank you for your first answer to Gillian Martin. It is not either or that we are asking. Women who have had surgery in Scotland and have moved away, so they have had their mesh implanted in Scotland and have moved away and then paid to have their private surgery. It would be nice to have them added on to that list, because it was NHS Scotland that put those meshes in and so for them to be reimbursed for any out-of-pocket expenses. I understand from Greg Chalmers that you have not been contacted by anyone as of yet, but even if that helps just one woman, surely that would be something that would be good for us to do. After the community has asked the question, you have reiterated and re-emphasised that I will certainly commit to going away and looking at the issue. There will be other schemes that will be in place in other countries to help mesh women who have had transvaginal mesh implants, so they may be able to access support and may not have to access support here. However, I take the point that there may be other women who had the implant here in Scotland and live in other parts of the UK or overseas. Therefore, in some respects, the pain that they are suffering is a direct result of the implant that they received in NHS Scotland, so is there a fairness argument there around whether or not we should reimburse them for any corrective procedure that they had to have? I am not going to shut the door on it, but I will go away and look at it. We do not think that it is a significant issue given that we have not had correspondence, and we do get correspondence on this issue, as you can imagine, quite regularly. Dr Gohani's point is a fair one. If it helps one woman, that is one woman's life that is utterly transformed by that corrective surgery, so I will not close the door on it. I will take a look at the eligibility in that regard again. Thank you. When you are contacting women, if you will look at this, will you then look at writing to everyone who has had mesh implants in Scotland to highlight the scheme and say that the scheme exists if you have had your mesh here and you are eligible, if you have done your private surgery, we will reimburse you? I did not see that as one of the things that you are doing to promote the scheme. At the moment, women who have had mesh surgery in NHS Scotland but live elsewhere, not ordinarily resident in Scotland, are not eligible, so we would not do that just now. If we looked to change the eligibility criteria, we would look at the appropriate communication that would surround that and accompany that at the time. At the moment, that is not the eligibility. If we do change that, we will look at what the appropriate communication might be to reach out to those women. We are now going to move on to talking about the costs and the financial memorandum of the bill. David Torrance, do you have questions on that? Thank you, convener. Good morning, cabinet secretary. We heard in evidence last week from witnesses that costs varied. One of the witnesses was due to their own personal medical conditions, it was others, it was due to seeking treatment during the pandemic. If it is needed, will additional resources be made and funding be made for reimbursement? The short answer is yes. We have taken what we think to be reasonable costs into account if somebody has surgery overseas but also what we think the reasonable costs are if they had corrective surgery in the UK. All of the reasonable costs are taxed from Bristol healthcare to hotels. We have factored in as much as we possibly can and around food and subsistence. Through our pretty detailed engagement over the years, we have a number of women that we think would be affected by that and would be eligible for reimbursement. Based on that, that is how we got to the figure in the financial memorandum. Of course, if there are more women that have not previously come forward, although I will go back to the point that I have made to Dr Gohani and also to the convener, we are being contacted very regularly by women who have been affected by that. If there are a number of women that have not contacted us previously and will only contacted us once the bill has passed, then of course we would look to make more resource available. Cabinet Secretary, NHS and NSS, will it have access to the required staff to make sure that they consider each application properly in resources? Yes, again, the short answer would be yes. We think generally speaking that the number of women affected by a reimbursement scheme, not the number of women affected overall by mesh, but that it would be eligible for a reimbursement scheme, we think, will be a relatively small number. Therefore, we do not think that there is a huge resource implication around an application scheme, but I suppose that I will go back to the point that Mary McNair rightly raised, which is getting the balance right between a quick application process, because some of those women, of course, have been waiting years and years for reimbursement when they had the surgery, but also giving enough time to make sure that those women can gather the appropriate evidence that is required to evidence their costs. Is to do with staff once again and the scheme, will it have the required detail around expenditure and proof required so that staff do not feel that they might face litigation if they make the wrong decision? Yes, again, we will be clear to staff once we have the final details of the scheme, which is dependent on the passage of the bill by Parliament. I am keen to get the balance absolutely right, which is to ensure that the scheme is as flexible as possible. We have to be a rigid scheme for women who may have had surgery a number of years ago, expecting them to keep a taxier receipt or something that is not going to happen. I am being unreasonable and demanding that bank statements from x number of years ago are somehow found. We have to be really flexible in that respect, and that is why we are looking at, for example, what a public finance manual suggests in terms of the appropriate level of subsistence per person, etc. We have to be as flexible as we can at the same time be really mindful of our obligation under public finance, which we cannot veer away from. There should be no pressure on staff who are deciding on whether an application is eligible or not. What the level of that eligibility is in terms of cost recovery, there should be no pressure on them to feel that they have to work within a particular financial envelope. Of the back of that as well, it is about the application process. Obviously, the detail, of course, is not in the bill around that, but it is worth mentioning that a lot of the women who are applying undergun surgery very recently are still very much in recovery and still might be quite unwell. I would hope that the process for application is not going to be onerous or overly bureaucratic, notwithstanding what you have just said about the obligations that we have for audit purposes and public finance. Exactly that. Nobody here, certainly not me or my officials, is not getting any of that pressure at all from finance colleagues or anybody else in the Government that is sitting there with a pot of money and saying, look, we cannot go a single penny over this. Of course, we would want to keep it within the scope of that financial memorandum, as we have said. For example, if we have underestimated certain costs and there are reasonable costs, then nobody is going to be constrained if they can demonstrate those reasonable costs. We have to get the balance right between an application system that is relatively easy and user-friendly for the women involved, not too onerous but has to align with our obligations under public finance. Thank you, convener, and good morning, Cabinet Secretary. We have heard from some of the women in the past couple of weeks that they have lost trust, some of them in the mesh services themselves, some of them in the Scottish NHS as a whole, and for many of them, this will have been a traumatising event. Earlier, you broke one of Jackie Baillie's questions down in terms of the bill, and going forward, what consideration has been given for women who may have already paid out of pocket for other wraparound pieces of care, such as mental health support, and what consideration is being given on-going to women who may not feel able to undertake any form of mental health support physiotherapy or any of those things within NHS services, because of that mistrust that is there? That's an excellent question, or a couple of questions from Gillian Mackay. Nobody in the Government, certainly not me as Cabinet Secretary for Health, is going to have any issue with those women who wish to be seen by a provider that's not the NHS. That's why we obviously went out to contract, because there was a recognition within Government that, because of the process that the women have been through already, some of them don't have trust in NHS. I'm deeply sorry about that, and I'm regretful about the fact that they don't have that trust, but I do accept that that is not the fault of the women involved, because of the failures that they have been presented with. That is why, again, we've gone out to those providers outside of the NHS. It should be said at the moment, if a woman wishes to be referred to one of the specialist centres in England, the NHS England, they can be. That exists at the moment, even before we get into the contracts around Bristol healthcare and hopefully the contract with Dr Varonichas, as well. I don't know if I understood Ms Mackay correctly, so she can tell me if I haven't. Once we have that clinical pathway up and running, the MDT, the multidisciplinary team that considers each women's case in a case-by-case basis, will absolutely consider pre- and post-operative care as well, including mental health support, physical health support, physio or anything that is needed. I'm not the clinical space, so I couldn't speak to that, but any pre- and post-operative care would be considered. When we had dialogue with a number of the women in a recent consultation that was arranged by the Alliance, a number of the women there said that, even if they had surgery elsewhere, they would expect their post-operative care to be here in Scotland. We would have to make those arrangements for those who didn't want that and wanted that post-operative care to be somewhere else. That multidisciplinary team would absolutely consider that, but that would be a clinical decision for them to make. If Ms Mackay's question is about reimbursement for costs, again, to me, that would fall into the bracket of reasonable costs. If they did not have the procedure and there were costs that resulted in the effect of their transvaginal mesh implant, that wouldn't be considered at this stage, because it is cost-related to the surgery for removal. However, I'm happy to take the issue away. It's not one that has been raised with me directly. I don't know if it's one that has been raised with my officials and if they wish to come in on that. However, if that is the question, I'm happy to take that one away. I'm reassured to hear quite a lot of the answers to those questions there, Sandesh Gillian and David. It was good to have that reassurance around David's first question about additional funding being available if required. Just to confirm and be really clear there, some of the on-going treatment costs for women require multiple corrective procedures. I take it that that would also be covered as well, so that we would make sure that those costs were reimbursed. Yes. In short, if there was a need for those women to go through multiple surgeries for removal of mesh, that would be covered. That's great. Gillian mentioned the trust issue as well, which is obviously a huge thing for those women here. It's so important that their views are taken really seriously and that their expertise and their condition are taken really seriously, too. I know that there has been engagement with the women. Is there still on-going engagement in discussions with the women as well as we continue to go through this process? Yes. Whether it is myself or through my officials, and again, I have referenced this organisation a couple of times, but the Alliance has been really, really helpful. They have expertise in this area, and they have been exceptionally helpful in helping us to engage. Excuse me, with the women who have been involved. I think that I have from the women involved a bit of frustration about what the next steps are, a bit of frustration around the fact that we made the announcement on 12 July, and here we are in November on what is being said and what is being done. That is difficult because we are in a really challenging space about contract negotiation, which is always complex. Generally speaking, particularly when we are dealing with the independent providers, they are not NHS Scotland providers, so we have to make sure that we have everything tied up. Again, it is no fault at all of neither Dr Hasherwood nor Dr Varwick, because they are engaging very well in the process in which we are thankful for. We hope to be able to tie that up soon, but the feedback that we are getting from the women involved is just an understandably real desperation to hear what the pathways are for them to get the corrective surgery that they require. There does seem to be a huge amount of compassion coming through today, and I really thank you for that. I think that that is really incredibly important to the women. I hope that that will be reflected as well in the decision making process when we come to that point there. I want to ask as well where women are unhappy with decisions, be it around eligibility or cost reimbursement. What methods or processes will be available for women to challenge them and ask for reviews? That is a really good question. I do not think that at the moment we have considered what the appeal process would look like, but there should be an appeal process. In any application scheme, it is absolutely necessary to have a process whereby those individuals can question why certain costs may not have been reimbursed. I would hope not to get to that position, but I would hope that the approach that we would take would be that, if there was a cost that was questionable, that we would then go back to the women directly to understand more about it before it was absolutely decided upon. My view and my direction, certainly to those that are operating the scheme, will be to, again within the rules of public finance, of course, to be as flexible as they possibly can be, understanding that none of us keeps certain receipts for years and years and years. Therefore, I think that it is important for us to take a fairly liberal view of what a reasonable cost is, but again, being mindful—I can almost feel Ms Forbes' eyes in the back of my neck here—of our obligations under public finance, which, of course, is important when we spend even a single penny of the public's money. That is good to hear. You do not think that that appeal process will be necessary, but it will be there to provide the issues for the women that there is. There should be some sort of process whereby they can challenge the decisions made. I am going to bring in Greg Chalmers, because Greg wanted to come in on an earlier point. My apologies, convener. I pressed the wrong button in the wrong place, so I missed my moment earlier. However, it is relevant to the question that the member has just asked. I suppose that one thing that we would highlight is that, of course, in terms of the administration of the scheme, NSS is at the moment and has been, for some time, administering the Scottish Government mesh fund available to a wider group of people. They do have a lot of experience of working with the women affected and know a lot about the background. I hope that we are starting from a position of quite a high level of informed decision making in terms of the patient group. I was just going to briefly add to what the minister said, just to reiterate the point around consultation with the women. We had our most recent consultation event with them on 19 October. In that event, we have been getting into quite a lot of technical detail about various issues of receipts and processes and all the things that we have been touching on. I hope that that will inform the drafting of the scheme. I am very, very finally very pardon, but the bill does provide in section 21h what exactly is a system of review that the member was just asking about. Sorry for coming in late. That is fine, thank you for clarifying some of that. Emma Harper, do you have some questions about reaching out to particular groups? I will come to Mreni McNeary, who wants to come in on the cost. In your opening comments, cabinet secretary, you talked about Polish Scots and Pakistani Scots. What work is going to be done to help to engage people where English is not their first language and that they may have experienced adverse complications for the mesh implants? Again, without too much detail, I am dealing with a case where that question is very relevant. The NHS is well versed in dealing with people where English is not their first language. Once we have the eligibility criteria decided upon, and it will be this Parliament that decides, it will help us to engage in that process around eligibility with the passage of this bill. Once we have that fairly well defined, I think that it will be important for us to make sure that we are communicating through all the channels possible and reaching out to communities that, again, English may not be their first language. We have had good experience of how to do that with the pandemic, and we have made really good progress. Many organisations have helped us with that, such as the Black Ethnic Minority Infrastructure, Scotland and Bemis, for short. We would like to utilise those networks. A good question would be what we can do now, because it is not just about the eligibility criteria for the scheme, although that is the purpose of why we are on the table today, to discuss the bill. There are pathways, and that can sometimes be complex to explain and to understand. There might be a bit more work that we can do with our networks. Once those contracts are finalised, that should be, I would hope, relatively soon. Once those contracts are finalised, we can explain the pathways for women to the complex. We can measure removal services in Glasgow and the pathways thereafter in terms of the multidisciplinary teams, if they want to refer along to other independent providers. I think that that is a good point raised by Emma Harper, who, after this committee, I will double-check what networks we are reaching into. The cabinet secretary has acknowledged how difficult the unsat factory experience has been for women affected and what they have endured as appalling. Obviously, there is no doubt that there is a lack of trust in the service. How confident is the cabinet secretary that confidence can be re-established and what lessons can be learned from this whole process? We are working really hard to re-establish trust, but, again, we are not making any judgment on those that wish to use the services of a provider outside of NHS Scotland. That is their right to do so, particularly given all that they have been through. We are trying our best. One of the ways that we are doing that is that we are adapting our own service, the complex pelvic mesh removal service, that is under the auspices of NHS critical Glasgow and Clyde. We have made some changes to that, even from when that service first came into inception. We have made changes. For example, we have changed the site of where that service was taking place, because that was direct feedback from women who wanted a more private location. We have made other changes around the arrangements around that service. How do I know whether trust is, hopefully, being regained by some of those women affected at least? I suppose that the fact that the mesh removal service that I am speaking about has been used by a number of women. Between April and September of this year, 19 mesh removal surgeries were carried out in Glasgow. In September, more than 64 patients were reviewed at the MDT as an increase of 26 from the previous month. I hope that that would suggest that there is trust there. There are a number of patients on the waiting list. Since the service was designated, there have been 32 mesh removal surgeries that have taken place. I suppose that those numbers would suggest that there are women who trust the service that we have here in Glasgow. However, I absolutely accept that there are a number of women for where that trust is broken down, maybe even damaged beyond repair. However, we will keep reaching out and doing our best to try to rebuild and regain that trust. I want to talk about the fundamental need for the bill and see whether it is going to lead on that. Thank you, cabinet secretary, for coming along. You have mentioned the cross-party support that there is for the bill, but given that there was always the ability to refer within the NHS between us and England anyway for services, for example, so can you see any reason why you might not need to establish the reimbursement scheme? It is just that essential need for it. Can you see any reason? No, no. I think that the reimbursement scheme is essential from the feedback that we get from women in terms of the reimbursement scheme, so no, no, I think that we absolutely need that and there is reasonable cost there on the issue that is related to that, the second issue around the pathways. Although Ms Webber is absolutely right, there is the ability right now to refer to providers outside of NHS Scotland, so those that are in NHS England. What we heard back from women really clearly was that they wanted bidders that were available, independent providers, and there is a lot of faith and trust in both Dr Hasham and Dr Veronica's rightly so, because there are leaders in their field. Thanks. You have spoken at length and we have heard about the complexity of the wraparound care that is needed with those women. Do you satisfy that the bill, in terms of looking forward, in terms of the procurement of the services from the private sector, and we have spoken with how all sorts today will not undermine the NHS in any way? Yes, yes. Again, this is an exceptional situation. I think that everybody around this table would recognise just how exceptional this issue is and I think that all of us have probably met with some of the women involved and we understand that it is best to be possibly can in our own limited experiences just how much they have suffered as a result of what has happened. The reason for the bill and the reasons for the pathways is because the unique nature of this particular issue, I do not think that it would irreversibly damage trust in the NHS. Again, the figures that I read out in relation to Ms McNair's question would hopefully give a sense of the fact that although some women have been affected by the implantation of transvaginal mesh, many of them are seeking surgery and treatment through the NHS here in Scotland. NHS National Services Scotland has actually expressed concern that the bill might set a precedent for other groups to need something similar. What have your team learned from this experience to ensure that we are not going to have to look at something similar for other procedures in the future? I think that that is a very fair question. That is why I was keen to stress my previous answer just how exceptional the plight of women who have had transvaginal mesh is. We are not setting that precedent, but we are recognising the unique nature of what has happened to those women. Therefore, there has to be a unique solution to them. I suppose that the obvious point to make is that the way that we avoid that is by making sure that we do right by people at the very beginning, so that there is no need to be hoped for this type of situation to unfold in any other type of procedure again. As the member will be aware, there is an avenue for people if they believe that there has been NHS negligence or even a misdiagnosis. There is a process for them to seek a claim in that respect. I think that those figures are published annually, at least, about the number of claims that are made and the value of those claims. There is an ability for people to seek redress, but my hope would be that the good faith that I hope that we are showing in the introduction of the bill would restore some of the faith that those women understandably have lost in their healthcare system here in Scotland. Greg Chambers wants to come in. Thank you very much, convener. We did an opportunity to talk about this important matter last week. I suppose that Mr Attivot, the cabinet secretary, said there in terms of ensuring that these circumstances do not arise in the future with a good discussion last week about the importance of realistic medicine and the fully informed consent between patients admissions. Asking about the benefits, the risks, the alternative treatments available and the option of no treatment is really taking those further steps forward in the chief medical officer's addition to the realistic medicine to have those fully informed conversations. Conversations where the patient feels empowered to ask questions, to challenge, to think about alternatives, we would sincerely hope that the situation that is arisen here, which Baroness Cumbulidge is driving in some detail in her report, is not one that we see repeated. From the point of view of the officials supporting the cabinet secretary on this and developing those initiatives, we do not underestimate any way that, although we hope that some important progress has been made in realistic medicine, there are substantial steps still to be taken to, as much with the public and patients and encouraging them, to feel empowered to have those conversations, as with clinical staff. We know that we are at a point in that progress and that there is some considerable progress to come. That is why we are so keen to continue working with the alliance and other representatives to make sure that patients, as they go through the pathway that the minister has described, at all times feel able to present their points of view and to describe their preferences. I know that Dr Kelly, who is on the line, is very focused on this example, which has been so tragic and regrettable in so many different ways. It sets a challenge for us in making sure that everything that is possible is done to make sure that nothing like this happens again. I will move on to talk about the specialist service, with a very useful session earlier with Greater Glasgow, Clyde and NSS, on some of the issues, but there are still some things that members would like to ask you, cabinet secretary. I will go to Jackie Baillie first. Gillian Mackay raised the fundamental issue of trust. We would all welcome the mesh service set up in Scotland. There is almost a perception that there could be gatekeepers to the service and that there is somehow a hierarchy of choice, with the Scottish mesh service being the first port of call, then the Spire mesh service with Professor Hashim and then Dr Veronica in the States. Can you clarify absolutely, cabinet secretary, that if a woman wishes to receive treatment privately, will that be supported from the outset or will she have to go through this hierarchy? That hierarchy does not exist first and foremost, so if I can be absolutely clear, there is not a hierarchy there that exists. The one thing that I would say to Ms Baillie, I know that she understands it, but it is always worth raising the record. It is neither going to be a decision that she or I are going to make, but it is going to be a decision that a clinical team, an MDT, a multidiscipline new team will ultimately make. My not just expectation, but I will clearly communicate that in whatever form is necessary and appropriate, is that a woman's choice is a primary consideration. There could be why I cannot give her the absolute 100 per cent cast-iron guarantee that if a woman wants to go to a particular independent provider, then absolutely 100 per cent she would, because the clinical team might decide that there is a good clinical reason for a particular provider over another. The assurance that I can absolutely give Ms Baillie is that Dr Hashim and Dr Veronica will be part of that MDT discussion, so they are not sitting in a different room. The complex service and those involved are making decisions on where a woman goes for surgery. Dr Veronica is absolutely as well as Dr Hashim. We will be involved in that MDT discussion, but the woman's choice has to be one of the primary considerations. That is very helpful and clear. I wonder whether I could ask a question that is not directly linked to the bill, but is a matter of concern that we heard and discussed this morning, and it has been raised by the women affected. That is the question of waiting time. We heard that 20 women were waiting for surgery. Dr Jameson rightly pointed out that it was unlikely that the 12-week treatment time guarantee would be met. We understand that, for reasons of elective surgery being cancelled because of Covid, that is perfectly understandable. There are 64 women reviewed, but the suspicion is that many, many more have been referred. We do not know how many more, and I would welcome the figures being provided for that, and some are waiting up to two years. Let me read you a couple of quotes. I just had a letter today from my gynaecologist in Paisley that it is taking two years for referral to the mesh service, which is part of the same health board. Another comment made that I had an MRI in September that showed inflammation around mesh. I was told that they would send me an appointment to discuss it with the mesh service. My initial appointment is July 2022, 10 months after the MRI. What can you do to improve those waiting times? I am sure that you would agree with me that those women have waited long enough. Yes, I would agree with that last sentence from Ms Bailey. I received the same letter that she received. I was also CC'd into that letter as well from some of the women involved and read those quotes last night and was taken aback. I will ask my officials to make contact with those women. Obviously, we would respond anyway, because we have received a letter, but I would be keen to make contact with those women. There is a challenge. I will not rehearse and reiterate too much of what Ms Bailey has said, but clearly, because of the challenges of both the direct impacts of the pandemic and the indirect impacts of the pandemic, there is a challenge there. Waiting two years for a referral for me is not an acceptable situation. I will respond to the women who wrote the letter as quickly as I possibly can, but if they are able to also provide those particular circumstances, then we would look to see how some of those issues raised can be resolved. Cabinet Secretary, it says here that when we call for views from the various boards for this bill, that we only receive responses from Highland and Greater Glasgow and Clyde. That indicates to me that perhaps the health boards are not quite as aware of what is going on, despite the publicity that this has had. What work is under way to publicise the service with the various NHS boards across Scotland and what is the timeline for them receiving guidance on the referral routes to make things clear as possible for the women who are going to access via the local health boards? Again, I cannot speak for each of the individual health boards that did not respond. I suspect that a lot of that may well be due to some of the pressures that they are under at the moment. I would not take it as any of the health boards suggesting that they do not take the issues seriously. I know that that is not what Ms Webber is suggesting either. In terms of the guidance that exists in relation to the ferro pathways, if you do not mind, I will ask one of my colleagues online to come in and give detail to Dr O' Kelly. He might be the best place to do that, if that is okay with the member. Terry, just to come in on that. Thank you very much, cabinet secretary, and good morning, convener and committee. As I alluded to last week, we have been working with accountable officers, one from each of the health boards, throughout the process, not only through the reimbursement, but previously with the establishment of the complex mess centre and other initiatives. We have another meeting coming up at the beginning of December, and what we would like to do is take that to that forum to discuss with the accountable officers what they think is required and how best we can ensure dissemination of information in their boards. I am very sorry to learn some of the difficulties with waiting times. I think that Ross Jameson this morning gave evidence and said that she wanted the complex mesh centre to be as open as possible in sharing information. It is important that we look at the cases and try to understand why issues have occurred. I can only reiterate what has already been said about the waiting times for two years. I am disturbed by that, and I think that we need to look at exactly what has gone on. Yes, thank you very much for that answer, Mr O'Kelly. We also know that that first point of call is often with the women and her GP, but we also know that there are very many GPs across the country. What sort of wider publicity and training about the national mesh service and the GPs linking in and understanding the complications that arise from the surgery so that they can refer quickly and effectively into the service for those women as well? All through NHS NSS, we have written to GP practices not just about the importance of any referral pathways, but we should also be aware of the fund that was open previously for support for women who had gone through transvaginal mesh complications. We would expect that anybody who has had those complications would present to the GP for help in the first instance with those referral pathways being made clear. I am happy to take that one away with NHS NSS and colleagues at our health board level, just in case there are any gaps. I have not received the correspondence that we have received that has not presented itself as a significant issue, but it is one that I am happy to take away. I am not quite directly related to the bill, but one of the important things for the women here is that we really learn from this, because it is not the first time that women have felt like they have not been listened to, they have not been believed that they were not respected. Just looking at it from that point of view, professionals in their own families as well at times too, so the impact on mental health from that can be quite devastating. Will there be an opportunity later to sit down and really take a holistic view of all the learning points that we have had here and look to possibly embed them into learning, including your overall health professionals for their initial training and for their development as well? That is an excellent question. To give you an assurance that some of that is happening right now, as you would expect it to be the case, but all of us should say that it should not have taken those women to bravely come forward, to campaign, to fight hard, to have the time, effort while they were still suffering due to the complications in their transvaginal mesh implant. It should not have taken all of that for those women to have the solution in place to help with that suffering. Although I appreciate for many of them until those contracts are signed and they go through the pathway and they get the corrective surgery, they will continue to suffer. Yes, some of that learning absolutely takes place now. It is an evolving process, and I referenced before a complex mesh removal service in Glasgow that has had to evolve and develop as we have continued feedback from the women involved. To me, that is a crux of the issue, and the promise that I will make is, certainly, Cabinet Secretary. I know that my officials also understand that we will continue to listen to the women. It is not a case that we have introduced a bill, and hopefully that bill will pass. However, we have also got a pathway in place once the contracts are signed, and that is the end of the engagement with the women far from it. We are going to continue to engage, to continue to listen, to hear what they have to say and to evolve our processes and practices where possible. That does not always mean that we are 100 per cent going to be able to do everything that is being asked of us. I will always try to do as much as we possibly can, understanding, again, the suffering that women have gone through. However, some of those matters are clinical decisions that have to be made as a reference in a previous answer. Generally speaking, we should be as open to listening to the feedback that we get from the women involved. I wonder whether Terry O'Kelly might have wanted to come in before me on the point around training. I do not know if you have passed by that yet. I am happy for Terry O'Kelly to come in. I think that the impact of realistic medicine should not be underestimated. Certainly, doctors in training, coming through their training now, this is an important component of their learning. That is also coupled to the new GMC guidance on consent. Part of that is the empowerment of patients, expecting them to be joint participants in meaningful conversations. The line to that is a greater understanding of our knowledge and our lack of knowledge about it in certain areas and a need at all times to be kind and to be empathetic. Those are big issues that have come out of for clinicians out of this exercise. I would like to think and certainly have been involved in trying to ensure that, going forward, some of the criticisms that have been levelled at clinicians will not be here again. It is worth referencing that the Alliance sends a letter of the back of their discussion with us highlighting some of the experiences that women had had, both at primary care level and when they were actually seeing a consultant about some of the issues that they were not happy about. I know that the Cabinet Secretary got a copy of that letter as well. I go back to Greg Chalmers. I am not seeing any other members wanting to come in with anything else. Cabinet Secretary, thank you very much for your time this morning. We will move on to our next item. The fifth item on our agenda is consideration of subordinate legislation. We have two negative instruments. The first instrument is the NHS education for Scotland amendment order 2021. The instrument creates additional capacity and capability within NHS Scotland to provide healthcare-related digital services. In doing so, the NHS will become one of the delivery arms of the Scottish Government's digital health and care strategy, with a particular focus on enabling the development of national patient-facing digital products and services. That is the national health service free prescriptions and charges for drugs and applies to Scotland amendment regulations 21. The instrument amends the 2011 regulations for prescription charges applied to English prescription forms, if presented for dispensing in Scotland. It increases the amounts charged in line with increased charges in England. The delegated powers and law reform committee considered both of those instruments and made no recommendations. No motions to annul have been received in relation to those instruments. Do members have any comments on either of those? Thank you. I propose that the committee does not make any recommendations in relation to those negative instruments. Does any member disagree with that? Thank you, colleagues. You were all in agreement. At our next meeting on 9 November, the committee will take evidence from the Minister for Public Health, Women's Health and Sport on session 6 priorities, followed by an evidence session on seasonal preparedness and winter planning. That concludes the public part of our meeting today.