 Good morning and welcome to the 27th meeting in 2015 of the Health and Sport Committee. I would ask everyone in the room at this point, as I usually do, to turn off mobile phones as they can sometimes interfere with the sound system. I will also point out that many of us are around the table using tablet devices and, Of course, that is instead of our hard copies of our papers. Our first item on the agenda today is a decision on taking business in private. I invite the committee to agree to take item 6 and 8 in private. Item 6 is our approach to the scrutiny of the Scottish Government's staff budget 2016-17. Item 8 is our approach to developing our work programme and, as members will know, we normally take this approach to papers in private. Can I have the committee's agreement? Thank you. We now move to agenda item 2, which is a final oral evidence session on the health, tobacco and nicotine etc. Care Scotland bill. Can I welcome to the committee Maureen Watt, Minister for Public Health. Welcome minister. Claire McDermott, bill team manager Scottish Government. Lyn Nicol, quality team leader Scottish Government. Siobhan Mackay, head of tobacco control team Scottish Government. Professor Craig White, divisional clinical lead Scottish Government. David Wilson, solicitors food, health and community care Scottish Government Ann Ailsa Garland, principal legal officer of the Scottish Government. I understand the minister wishes to make a short opening statement and thereafter we'll go straight to questions. Thank you very much convener and good morning members. Thank you for the opportunity to say a few words about the health, tobacco, nicotine etc. and care Scotland bill and why I believe it's important. The bill has three distinct health topics, each with their own important part to play from helping people in Scotland to live longer healthcare lives and safeguarding our health and social care provision. The programme for government announced a commitment to provide a right to voice equipment and I intend to write to the committee to detail the Scottish Government's plans for bringing forward a stage 2 amendment in this respect. Part 1 of the bill seeks to reduce access to nicotine vapour products to under 18-year-olds and to reduce their appeal to both children and non-smokers in Scotland. It also seeks to place further controls on the sale of tobacco and to continue to denormalise smoking. In a climate of on-going debate, it is my belief that the bill has struck the right balance of regulation of NVPs. You have heard that the revised EU tobacco products directive will place restrictions on cross-border advertising of e-cigarettes, for example TV and radio advertising. This will be implemented across the UK by May 2016. The bill builds on this by taking powers to prohibit domestic advertising, such as from billboards, posters and leaflets. However, it is not the intention to ban certain points of sale advertising of NVPs in Scotland. It is important that current smokers are able to ask questions and receive consultation about which products might be right for them. I am aware that introducing an offence to smoke outside hospitals has also stimulated debate from those who believe that the legislation is unnecessary to those who believe that the legislation should uncover the entirety of NHS hospital grounds. The bill proposes an offence of smoking in a perimeter around hospital buildings. The perimeter will be consulted on and determined in regulations. Preventing ill health is a major challenge for our health services now and in the future. Tobacco remains the biggest cause of preventable disease and death in Scotland. It is therefore my view that our NHS must show leadership in supporting and promoting healthy behaviours, particularly around denormalising smoking. The provisions in part 2 of the bill place a requirement on organisations who provide health and social care to follow a duty of candor procedure, where there has been an instance of physical or psychological harm. The procedure itself will set out in regulations to be made using the power in the bill. The proposals have been intentionally focused on an organisational duty. The introduction of this duty will provide a further dimension to their ignorance already in place to support continuous improvement in quality and safety culture across Scotland's health and social care services. Part 3 of the bill creates offences of ill treatment or willful neglect, which will apply to health and social care workers and provider organisations. The offences will cover intentional acts or emissions and is not intended to catch incidents of mistake. Neglect and ill treatment occur very rarely in our health and social care system, but the criminal justice system must be able to identify and deal with those cases effectively and appropriately when they arise. The offences are intended to help to secure access to justice for those who suffer neglect or ill treatment. It is important to emphasise the difference between those offences and the unintended or unexpected incidents covered by the duty of candor. The willful neglect offences are intended to relate to very deliberate acts of or emissions. That is all that I would like to say at the moment. I look forward to the committee's consideration of the bill and the discussions to follow. We go directly to Richard Lyle with our first question. Good morning, minister, and thank you very much for your clarifying and your opening statement on the actual physical question that I was going to ask, but I will ask it anyway in order to ensure that it will be the case. I turn to smoking in hospital grounds. Most people have had concern that we are totally banning or allowing the local health board to ban smoking in hospital grounds, but in your opening statement you basically said that it would be a case that would be a perimeter set. Have you any idea what perimeter will be set in regards to this? I, like many others, oppose the fact that people are going through or going into hospital. People are smoking, but I can understand the reason why. They may have had some bad news or they have been in to see a relative who has, unfortunately, just died or whatever. Again, I agree with the parts of the bill that suggest that we have to remove them from the entrance, but can you give us an indication of how far, how the perimeter will be identified to smokers? Is there a case, as one witness suggested, that you may consider putting up a shelter, that people could then be visited by other people to explain to them the reasons why smoking is bad for their health? Well, I think that the perimeter, if no hospital grounds are the same throughout Scotland, it would be very much up to health boards to decide what they want. However, in order to get away from the situation that you described to Mr Lyle about people going through a wall of smoke as they enter the hospital, something like 10 to 15 metres would be roughly what we were thinking about, but that will be set down in the regulations. With the convener's agreement, can I just ask you one more question? NHS boards cannot, repeat cannot, ban smoking on their grounds totally. They must act within the cartilage of the bill that, when a metreage is set, would suggest that 15 metres is too short. I would suggest that it would be a little bit, maybe double that, but basically within that range, and we would disagree on the range, but can you give me assurance that the NHS boards cannot ban people from smoking in their grounds totally? Banning is not a word that I really like, and obviously it will be up to each health board to decide what they want to do by policy, but the legislation in this bill will not make it compulsory for health boards to ban smoking within their grounds. We know already, and the evidence that you have taken, that different health boards are different ways along the journey to making hospitals and health places. I am very much in favour of the health promoting health service, and I think that it is an anomaly that we allow an activity that damages people's health within a hospital setting. I think that health boards, some such as Ayrshire and Arran, are much further along the line. That is not something new, but it has been an on-going process to discourage smoking in hospital grounds for a long time now, and, as I said, different health boards are on a different path along the journey. However, the bill itself, to answer your question, will not be banning or prohibiting smoking in hospital grounds. That has to be left to the policy of the health board. Thank you for that reassurance. Again, I welcome this and wish it to happen. Can I ask about the role of staff in policing the smoking ban around hospitals? It says in the bill that management and control of a no smoking area is known only to permit smoking there. I am thinking of a member of staff walking into work seeing people smoking outside. Do they have a role in trying to stop those people from smoking? Indeed, if they have a patient who they believe for their wellbeing that they should allow them to smoke, take them out and allow them to smoke, would they be breaking the law as well? I think that we need to be clear of the role that staff play in this. Staff of themselves are not the ones who would be telling people to smoke or not. I think that what we are looking to see is very much a culture change. I think that the advertising that we have done around the green curtain and taking smoking right outside has been effective. However, we would not, to answer your question, expect all staff to say, no, you cannot smoke here. That will be up to the health boards and other organisations to deal with people. However, the perimeters will have a signposting that smoking is not permitted in the hospital grounds. That is already, as you have probably seen in most hospitals. In terms of your other question in relation to, I suspect that you are thinking of perhaps people in mental health wards or people who are long-term patients who have gone in smoking. We are trying to make sure that, for example, people who are going in for an operation are given some of the initial appointments that they have with their consultants and are made aware of the smoking policies and are offered smoking sensation before they go for their operation. In terms of people, for example, who may have mental health issues, there will be areas set aside for that. However, in the overarching policy that we will be trying to encourage people to stop smoking because smoking does not actually contribute anything towards their mental health and wellbeing, particularly the opposite. What I am thinking about is that, if a patient is unable to go outside to smoke themselves and a member of staff takes them outside and facilitates them smoking, I understand in mental health wards that there will be areas for people to do that. However, in normal wards, if someone has mobility problems or whatever, what is the reason that they are in there? I think that it will be up to each individual circumstance for the hospital and the nurses or the doctors in consultation with the patient to decide that. There will be areas set aside outside the perimeter, but I do not know. Siobhan, do you want to come in on that? NHS Health Scotland published guidance earlier this year to support the implementation of smoke-free grounds across all NHS sites. That set out standards for boards and including what the roles and responsibilities of staff are. No staff would be criminalised for assisting somebody to go out and smoke, although that would be a matter for the NHS board. I think that the minister is right to consider what the individual circumstances of that occasion were. The minister is aware of a local case in my region where there has been an issue about a patient being banned from smoking within mental hospital grounds. I want to clarify, because I will raise it with the health board very soon. Is the health board still responsible for—can they still say in that instance that grounds must be smoke-free or when she spoke about some sort of shelter being available for people like that? Is that something that the health board could be asked to do or pressurised to do? Again, it will be up to the health board to decide what their policy is. I do not think that it is right for me to talk about any particular individual case. Again, it should be a consultation with the patient and the consultant and other carers to decide what the best course of action is for that particular person. There may be something that we do not know in relation to that particular case, so it would be up to the health board. Anyone else on the—how will those exemptions be clear to not just the health board? If we have a situation where we go to many different hospitals in a region where one has a 15-metre exclusion and another one has a 50-metre, there will be exemptions at one hospital but there will not be exemptions, how do we get clarity of message on this? If we are taking an ad hoc approach to— It will be the same as the 2005 act, for example, regarding residential hospitals. There will be residential properties that are in and around hospitals, and it will be roughly the same. We are on a journey. We want to make sure that people visiting hospitals and going into hospitals are absolutely aware that our aim is to make hospitals and hospital grounds smoke-free. We are relying very much, as we have done in the past, on people realising, as I said before, that we want to make hospitals health-promoting places and that smoking damages your health. Therefore, why would you allow smoking in an area where people are there to get well? As I said, it is a journey for people to realise that hospitals and hospital grounds are places that we really do not want people to smoke. I think that that message is already through. The Green Curtain campaign has had a great deal of success. Obviously, in the run-up to the implementation of the legislation, there will be more advertising and leaflets to make people aware of what we want around our hospitals. We will progress with our questions then with Dennis Roberts. Questions about the advertising and promotion of the NBPS, the nicotine vapour product probably were commonly known as e-cigarettes. The policy memorandum states that it is looking at retaining the point of sale advertising. However, what does not seem to be particularly clear is what other types of advertising that you may consider are acceptable and how you are going to restrict other forms of advertising around NBPS. Perhaps you can clarify that for us. In terms of advertising, yes, obviously shops selling NBPS will be allowed to advertise the products so that people know which kind of one will be particularly suited to them and what it is that they want the product to do. In terms of other advertising, much of it will be covered by the European Tobacco Product Directive. What we want to make sure is that there is no advertising at events on billboards, posters, moving screens and things like that. There seems to be an acceptance that e-cigarettes, in terms of getting people to come away from smoking, can be an extremely useful product. In community pharmacy, we are suggesting that this is a method of not encouraging people towards, but trying to ensure that people are aware that they are there and they are free and available. Is there no intention to extend the advertising away from just point of sale in order that we can encourage, because it is a preventative health message and we tend to accept that. I think that we all accept that the NBPS is a good thing in terms of getting people away from tobacco smoke. In terms of pharmacies, the NBPS are not medicinal products, they are not regulated as medicinal products and the manufacturers and sellers are not, as far as I can see, interested in getting that kind of regulation as a medicinal product. It is not licensed as a medicinal product. I am sorry, minister. I am not really suggesting it as a medicinal product. What I am saying is that community pharmacy sees the benefit of having perhaps e-cigarettes available to people within the pharmacy and various other outlets. I think that what I am trying to establish is whether or not there is going to be any additional advertising other than just point of sale. Clare, do you want to come in on that? Yes, I think that we recognise or the bill recognises that there is potential for NBPS to act as cessation advice. Point of sale will still be allowed under the regulations in pharmacies, or at least that is the intention, but no, the regulations do not envisage any advertising beyond that. However, if they were, I mean that medicines licensing is a matter for the medicines healthcare product regulatory authority, but if they did get a licence they could advertise under those separate regulations. So the only advertising that will be available is point of sale. There will be no further advertising to look at the benefits of NBPS. I think that the point is that we want there is a fine balance to be drawn with NBPS. We are not totally aware of what the effects of them are. There has not been that much research into them, and you would not want to advertise them to the extent that you were encouraging people who would not even think of smoking to take up NBPS. We recognise that, for many people now, they are a process for stopping smoking, but you would not want to advertise them as a thing to do. I think that that is reasonably clear to me now. I think that that is just on the point of sale, full-stop. Anyone else on this team? I think that you are treading a fine line, and we have heard conflicting evidence and certainly different emphasis on the evidence that we have received. I have noticed differences among medical opinion over the past few weeks about that. It is one of those areas that is possibly a little bit confusing for the public, but I think that probably most people are reasonably happy with the line that you have trod. Do you think that there is room to have a slightly more positive attitude about e-cigarettes coming from the Government? I think that, surely, everybody has agreed that there might be some disagreement and uncertainty about whether there is a degree of harm, but everybody is united in believing that they are massively less harmful than cigarettes. Do you not think that Cancer Research UK takes this view and Professor Linda Bolt, who gave evidence to us, takes this view if I am not misrepresenting her? There really should be a clear message about that. I am aware of what Linda Bolt and Cancer UK said. As I said in answer to Dennis, we recognise that people are using them as a method to stop, but it is also recognised that they are more effective in ceasing to cigarette smoking if they are used in conjunction with other methods that are already available, such as smoking cessation services that are already available. My worry is that we simply do not know enough about the long-term effects of NVPs. I have been reading about something called popcorn lung, so I think that in drafting the legislation, we need to be very cautious and draw a very fine line about promoting them as a healthy product for stopping smoking and a thing that people do as a recreation. I recognise and we have debated long and hard about it, but I hope that the legislation proposed strikes the right balance. In that sense, do you disagree with the guidelines that have been issued by Public Health England on this? I have seen their guidelines. I suppose that the short answer to that is, at the moment, yes, but I do not want to be behind the curve on this, but the products are not licensed as medicinal products and there is not that much research on the long-term effects. We recognise that people are using them as a method to stop smoking. That is a good thing, and the rates are coming down, but I am very cautious, if you like. You are to be commended, because you at least have not gone down the route that they have gone down in Wales in terms of conflating them with cigarettes in terms of smoking in public places, but some hospitals have banned them on hospital grounds, which I suppose is an example of the Welsh approach in one particular location. Do you have any views on that? Lothian has decided not to allow them in hospital grounds. That is where each health board has the ability to decide how they want to progress, and it will be interesting to see how Lothian fares with that compared to other health boards. It is very much a new area, if you like, of legislation, and we just have to hope that what we are proposing in the bill strikes the right balance. Just on that point, in terms of flipping back to the exemptions with the MVPs and the different health boards making different decisions on that, I think that the Scottish Government, as Malcolm suggested, is almost in the middle of making up their mind here between where they are south of the border and where they are Wales, but here there is a bit of an issue here when health boards are almost treating those who are using MVPs as smokers. We took some evidence of that. If we continue to do that, we might as well be smokers who have to leave a building or be treated like smokers. It is something that can be reflected on in terms of guidance, particularly in the area of exemptions for the smokings around the hospital. We have made very clear that MVPs are not banned by the bill, but each health board has already decided on their own policy in relation to this, as we have seen with MVPs. There are also people who have said to me that they do not like walking through the vapour from MVPs, so some asthmatics find it not very helpful. I hope that what we have proposed in the bill is the right course. If you are using a vapour, how would you enforce it within hospital grounds then? It is not covered for the bill. Would you not enforce it? As it would be up to the policy of the health board rather than the bill. We are not banning MVPs in hospital grounds, but it would be up to the policy of the health board and they are entitled to do that devolution of power. I am just looking at my script for the next one, and it is Malcolm. I have heard that one before in relation to health boards, but fair enough. If we can look at the duty of candor and welfare neglect and if we can perhaps look at them together, some people have suggested—I am not necessarily agreeing with this, but some people have suggested that the new offence of welfare neglect has the potential to undermine the duty of candor, so that is one issue that might come to. My first question is the origins of this. I take it that the origins of this is in the Francis report, but I am wondering to what extent you have looked at the legislation in England and decided to vary your approach on that, or is that not something that you have been very much involved with? In terms of duty of candor or of welfare neglect, I know that people try and conflate the two, but I have tried to keep them very separate, because I think that they are very separate. We should try and keep them very separate. Obviously, the legislation is a result of the Francis report, and we have seen the legislation in England. Sorry, I have looked at the legislation in England. Sorry, I have forgotten what your question is. No, I was just trying to get the background to where the legislation comes from. In general, I support that, so I am not necessarily putting those forward as my own views, but I suppose that some people are arguing that it deals with problems that have not arisen in Scotland, but I suppose that one way of asking you that could be, could you give an example of a pass gates that has not been adequately addressed within the existing avenues for redress? That is with reference to welfare neglect, for example. I cannot off the top of my head give an example, but if we take the two separately, I think that duty of candor is obviously in several health professionals, existing professional arrangements, but we are wanting to make sure that extended and covered all health and social care professionals are not the case at the moment. It will support disclosure and hopefully learning improvement after unintended harm incidents. In terms of welfare neglect and mild treatment, I think that it is called. Those are terms that have been around for a long time, and it is just making sure that people understand what they are. I was encouraged by when you were clear in your opening statement, but is it a problem that the bill does not define welfare neglect and mild treatment? Obviously, some of the criticisms have come from fears that they may extend more broadly than you intend, because you were quite clear in your opening statement that it should just be very deliberate acts or omissions, but I wonder if some of that needs to be spelled out more clearly in the bill in order to reassure people about that? The proposed offences are intended to reflect those existing offences. Existing offences use the term ill treatment and welfare neglect, and we did not think that further definition was necessary, because further definition might be counterproductive if that cast doubts on the meaning of the existing legislation. I expect that what you have said today can be taken into account when the legislation is being interpreted, but maybe we need to look at whether that can be defined more closely. My last question about the duty of candor is the point that came up when we visited Argyll and Hospice, and it was put to us—it could have been lots of places, because I imagine that there are quite a few individuals, perhaps particularly at the end of life but not necessarily at the end of life, who do not wish to receive information about any harm or potential harm. I wonder if the legislation will take account of that in any way. I think that the duty of candor, while some health professionals certainly have it, is more that organisations are responsible for duty of candor, and that is something that has not been covered before. Craig, you have done a lot of work in that, why do not you answer that question? Morning. I read with interest the note of your meeting of the visit to Argyll and Hospice and the research article that was mentioned. If one takes the research that was referenced there in the context of cancer, even if you look at the around 1 in 10 people who say that they prefer for the doctor to make decisions about what they are told, even those people still want specific information. One of the articles that was referenced there talks about failure to disclose information out of a belief that patients prefer not to know is not a tenable view. In the context of duty of candor, the outcomes that are defined in the bill are obviously if someone dies as a result of a systems and process failure, then their loved ones are aware of that, so the issue does not really come into play. Some of the other outcomes around severe and significant harm that people experience, most people are already aware of that. In the context of the duty of candor procedure, health professionals will of course make an assessment of the circumstances, linking it to what you said about the links to the English legislation. The bill also includes provision for support for people affected. In relation to those supportive conversations, part of that would be determining what level of information they want, what questions they have and how they want to receive the information. That would be how that would be addressed. The other main differences with the English legislation are that our proposals include the requirement to provide training for staff involved and the annual report publication outlining the changes in policy and procedure as a result of review. I am sure that we welcome the training and that is an improvement on the English legislation, but the final question is just to be clear. Is there any provision to ask the patient if they want to receive the information? The duty of candor is not about whether a patient wants to know what their diagnosis is. It is whether there has been an unintended harm incident and that people will learn from that. Being open and honest about something is perhaps—we acknowledge that it is not always in the best interests of an individual to be told what happened about them, but the organisation will be required to consider that carefully and ensure that they do not have a one-size-fits-all approach to disclosing information. The development group guidance will consider that as part of their remit when we come to formulate the guidance. I was not asking about the diagnosis. Is there any provision to ask the patient if they want to know about harm or potential harm that has been caused to them? Section 22 CND of the bill refers to the actions to be taken by the responsible person to offer an arrangement of meetings and the actions that must be taken at and following that meeting. That would be usually where that sort of conversation would take place. How often do you want an update? Do you want to be involved in the review? What information might you require? Those are the sorts of discussions that we are beginning around the guidance process, so they are very much tailored to the outcome itself but also what the person's preferences are for that information. Is that after the initial information has been disclosed or is that before the initial information has been disclosed? I guess that that would depend on what we mean by initial information. Most people, if it is a change in the structure of their body or the wrong surgical procedure was performed, are already aware of that initial information. However, the individual health professionals as part of their professional duties would also take that into account in terms of their on-going relationship and assessment of the individual. I am sure that we will explore that further when we come to that bit of the bill. Thanks, Malcolm. I think that Bob wants to come in on this theme and so does Rhoda. Any others? Thanks. I thought that Malcolm Timson's line of questioning was really, really interesting. I think that it is maybe worth putting on record that, if he speaks to the Scottish Infected Blood Forum or, you know, Hemophilia Scotland and others, I do not want to put words in their mouth, but I suspect that having spoken to them, they would think that the duty of candor should almost be absolute, because how do you define when you should or you shouldn't disclose, and they give significant examples of individual clinicians not disclosing significant aspects of their health. I will leave that sitting there because they will be following this process and I think that they would want that mentioned. I suppose that it is where we draw the line in relation to the duty of candor. Is it a corporate duty of candor or is it a duty of candor for the individual? Again, the groups that I spoke to were very interesting. For example, when the First Minister and the Health Secretary gave apologies in terms of what happened to people who were given infected blood and that kind of thing, they got something from that, but what they really got something forward when the blood transfusion service started to give apologies is because the more distant that the apology comes from, sometimes the less meaningful it can be, so it is a bit more information about who would give the apology or would inform via the duty of candor, would it be someone, if you like, corporate, or would it be someone at a more localised level? A bit more information on that would be quite helpful. The reason for introducing a duty of candor for organisations is that there is still a wide variation across Scotland in the way that health and social care organisations respond after unintended or unexpected incidents relating from harm. It is very much now making sure that the organisation takes responsibility for what has happened as well as individuals, but the detail of that will be set out in the regulations in terms of the extent. Could it be both? Could the individual who is close to patient care be at health or social care give information in relation to duty of candor, but they could have been under stress, under strain, there was no willful neglect, it was unfortunate although serious what had happened, but it could identify a systems issue in which case you might want a corporate duty of candor and an apology. Does it have to be either or? Could it be both and can that be teased out in regulations? It could absolutely be both because just what you have explained can exactly be the situation that occurs and that is why making the duty of candor other responsibility of organisations as well as individuals is absolutely necessary. Can I maybe add a little bit about that? The health service, we know the stats show that it is significantly more safe in recent years particularly through the patient safety programme, so I say this next comment in that context. Each week there could in theory be seemingly small-scale incidents which could in theory trigger a duty of candor and it is whether individuals go, yes, it does trigger that or it doesn't and quite a lot of my constituents work on a culture of candor as much as the duty of candor, so it is about openness, it is about transparency, it is about saying to the patient or the individual in social care, look, so let's take social care as a very good example. You had a leaf all there, which really should have had two people for moving and handling, the second staff member was overstretch, you said if we know the patient was in pain, we were really keen to be moved, we got that a little bit wrong, we've put processes in place, this is what's happened, I think a lot of families for example would get something very quickly and meaningful in relation to that, whether that's a culture of candor or whether that's a kind of legislative duty of candor could be two separate things, so I suppose I'm trying to tease out how we promote a culture of candor even when this isn't triggered. I think you're absolutely right, it is about promoting a culture of candor but it's also a continuous improvement process, isn't it? That we learn from the mistakes, we know what, in the case that you cited, what should have been done but we made a mistake in that particular point, so the focus is on learning from what has happened and the organisation providing the support and training and the staff development and making sure that, as you say, that the culture is that people learn from what has happened and that it's a development and learning culture across the service but Ailsa, do you want to say something legally about this? To add to what the minister said and the questions about whether the GT applies to organisations or individuals, the GT and the bill is placed on organisations but it's not intended to usurp the role of the individuals, it's just that the organisation will be under that requirement to follow the GT of candor procedure which is going to be set out in the regulations but there has been some comments I think where they're concerned that people close to the incident won't then be able to be providing information, for example. The bill does require that a different health professional makes the judgment that the incident has caused the outcome that is listed in the bill but that doesn't mean that the professionals close to it can't then be involved in the information giving and that can be something that we can look at for the regulations and setting out the detail of the procedure to be followed. I'm sure that I read somewhere in my notes that if the duty of candor is implemented and an apology given it's not net island admission of neglect or there's not an admission of their corporate admission, could it, if used at a more local level, empower health and social care workers if they give information and openness and transparency to individuals and they might be keen to do that just now but they're thinking of, if I disclose this information to them, what's going to happen in relation to myself and my practice is a protection bill for individuals who work in health and social care to allow them to be more open and transparent as they would like to be without compromising their own position so if someone says yes we got this wrong here this duty of candor's been invoked here and you give an apology at a local level are we likely to see more of that if it's entrenched that that's not net island admission that there's been neglect and can that be teased out in regulation or is it in the bill? Well in terms you know this is where we need to kind of separate the duty of candor and neglect I think the situations where there's ill treatment or willful neglect are kind of dealt with separately if you like under the duty of candor we do want to make sure that there's a culture of openness and transparency in the health service and that people are alert from their mistakes but the bill doesn't provide an exemption for example for disciplinary action where someone reports an unintended or unexpected incident if indeed disciplinary action is required that that situation won't change but yes we do want to foster a culture of openness and transparency so that the whole organisation learns from incidents and that the whole service and care for an individual is better but Craig did you want to come in on that? It was just in relation to the the bill section 232 does state that an apology or other step taken in accordance with the procedure doesn't of itself amount to an admission of negligence or a breach of statutory duty and certainly that is something which healthcare and social care professionals have discussed and commented on in terms of the importance of making it clear that apology is part of this procedure and any decisions that might be made in a legal process for example around negligence and liability are completely separate procedures. I think that I support this but teasing out more to empower those providing health and social care directly to vulnerable constituents of all of ours to be empowered to go because look they get things right nearly all the time we're all human we do get things wrong and it's almost like feeling empowered to go look we got that wrong you know it doesn't doesn't make me a bad health or social care worker but in terms of transparency and a culture of you know of candor we're giving you this information and just to give them the reassurance it doesn't yes we'll learn from those incidents as you know as organisations but they as individuals wouldn't necessarily be hauled over the coals and it's just getting that getting that balance right. As MSPs we all have incidents where people have had people in care homes for example and they think things could have been done better they don't necessarily want any reparation but they want to make sure that things are learned from incidents that they've experienced and that's certainly been my experience as an MSP and you have to follow them up and make sure that the organisations do learn from them and often that's just what that's all that the relatives want from that incident. Okay thank you thank you. I think you know in previous inquiries and and the involvement that we've had I think we all know the power of an apology and appreciate the ministers and reflect on the ministers comments there but it takes us to another stage in terms of Professor White's definition in the bill and the procedure would not admit to admission of negligence etc. The committee is also aware and as we all are the parents currently considering an apology Scotland bill in the name of Margaret Mitchell and the stage one report of the justice committee broadly supported the general principles and it's you know it's almost identical to what's in the health bill although it's extended to all public service organisations and the justice committee as I said broadly supported it. The Scottish Public Service almost has written a submission for the provision of the health bill to be removed altogether and included in the broader legislation or at least to be extended to all public sector so we've got we've got a lot of comment here from involvement should the duty of candor be part of a broader apologies legislation and therefore be taken out of the health bill or should Margaret Mitchell's apologies bill be amended to exclude NHS social care and left to the health bill to pursue? Well I'm probably going to bring Craig in on this because he gave evidence to the justice committee on the apologies bill but my understanding is the need for apologies offered as part of the duty of candor procedure should be exempt from the Apologies Scotland bill and that's been emphasised but Craig having given evidence do you want to clarify that? Thank you. The Scottish Government's position is that the need for apologies offered as part of the duty of candor procedure should be exempt from the Apologies Scotland bill. That's a position that's fine. That's on the record then and if it's not already being on the record. Rhoda Grant and then Mike Mackenzie. The area that I was hoping to explore has been fully covered now. Just a short question about the duty of candor it's obvious in the bill that it has to be quite serious incidents that triggers the whole process. Should the bill emphasise an overarching duty of candor in all situations that medical professionals should be telling patients what's going on regardless of whether it's a serious incident or not, people should surely have been entitled to information on their own care? Given that we want to have an open and transparent health service and that more and more we're talking about patient-centred treatment and that patient is the main focus of treatment then it is important that all health professionals discuss with the patient their care and treatment while they're in a care setting and the duty of candor I think will excuse me make sure that systems are in place both for the organisation and individuals together to make that happen in them perhaps more than it has happened to date. Should it be on the face of the bill though an overarching duty of candor? Well I think the way that we've set it out on the bill and description of what we mean by duty of candor is well set out in the bill. But it is termed in reasonably serious incidents? Yes the international evidence around the outcomes of the sort that we've been talking about in terms of death and significant harm is that the professional duty of candor as you've hinted applies across the spectrum in terms of all levels of any incidents where the evidence suggests you need to focus your thinking around what an organisation does is to make sure that there are the policies and procedures around the review across the organisation around learning that there's a systematic approach to providing support when there's been significant harm and the level of training that might be required to enable and empower professionals to discharge their professional duty is quite specialised given the nature of the incidents that are involved. That's certainly where the policy was developed in terms of there being additional requirements for an organisational duty relative to what one sees in a professional duty. That doesn't really answer my question. I understand that and I understand why those incidents are there. What I'm saying is that the minister in her opening remarks or certainly an answer to question said that some professionals have this in their code of conduct that they have a duty of candor. Not all professionals have this in their code of conduct. Could it be appropriate in this bill to put that on the face of the bill so that anyone who is dealing with a patient has a duty of candor full stop, regardless of the outcome of the incident? I'm sorry, I didn't answer the question. The most regulated professionals have a professional duty of candor and there are some professions such as medicine and nursing where there's additional guidance provided. Through the UK legislation that supports the regulation of health and social care professionals, those professional duties are reflected in their codes of conduct. I said that but what about the ones that aren't? That's probably covered by the duty of candor in this bill. It's putting in place the infrastructure in the organisations to make sure that they're covered by the duty of candor. All health professionals are covered by the duty of candor. I appreciate that it's not for me to determine who you want to respond to, but it may be the AILSA and from a legal perspective, I know who's been looking at the— That's very helpful. I think when we start talking about regulation of health professionals, it gets a little bit tricky because of the kind of reserved of all split because we don't have the power necessary across the board to make provision in our legislation from that perspective. So I think that's when we're talking about how some professionals have the duty and others don't, but in terms of the bill and setting out the levels of harm, I suppose that the policy has been to set a range in section 21.4 of various outcomes and you have to set a—I felt it's helpful to set a bar so that it's not covering every instance of harm, but I think it would be fair to say—and I suppose that I'm straying into policy—that the hope is that it encourages a cultural change. Even if something didn't fall within the duty of candor procedure in the legislation, it would hope that over time, even for smaller incidents, it might encourage just that cultural change of being more open with patients and those receiving social care. Just for clarity evidence in terms of the role of the independent health professional, the duty of candor would be triggered when the opinion of a health professional not involved in the person's care. How would an independent health professional be identified? Why would it only be a health care professional when the duty would cover other settings such as social care and social work? It's a person who has not been involved in the care up until that point, so that somebody independently is coming in to look at what has happened and see if there has been some lack of proper procedure or care in that person's treatment. The independent health professional, who would that be and why would a health professional if it covers all of those settings? Two points. If I give an example within a health context, as we said earlier, it wouldn't preclude individual health professionals from being involved in discharging a professional duty and the organisation's procedures. However, as I think in your evidence sessions, both the GMC and the Royal College of Nursing acknowledge that having someone independently in the organisation who makes the final decision in relation to whether that relates to the outcomes defined in the bill is what the independent health professional relates to. The reason it's a health professional is some of the outcomes that you'll know are related to health-related outcomes. There's a requirement in the bill that decisions made that the outcomes are not directly related to the course of the person's illness or condition, and therefore that judgment that's made is one that we propose is made by a health professional. It would always be a health professional, irrespective of whether there could be variants there then. In some instances it would be about health outcomes, but it may be... It's possible, for example, if we take, I again know something that your evidence sessions considered was around integration of health and social care. It's possible that a social care professional might report in an organisation that they believe that one of the outcomes has occurred, and then it would be for the organisational responsible for the duty of candor procedure in deciding to report it under that procedure to have it confirmed by this independent health professional that the outcome is not related to the course of the person's condition. Because it is an adverse event to their medical condition. Anyone else? Any other questions? I think there's just, again, just going back just to, you know, as our last session and, you know, for our consideration, and just going back to enforcement, whether the minister is confident that the smoking ban and the NHS grounds can adequately be enforced, given the witness comments that local authority officers are choosing not to enforce other areas of legislation due to resource constraints. Do you have any comment on that, minister, that would be helpful? I think that when we introduced the smoking in public places, the local authorities used their enforcement powers then, and so the local authorities, you know, were not going to expect a local authority person to travel a mile to a hospital to issue a fine, but the legislation does require local authorities in cases where maybe there is persistent breaches that the local authority might get involved. I think that we saw when the legislation came in in relation to pubs that most people obeyed the legislation, and clearly we have been working with local authorities and COSLA and the people in the local authority to the environmental health officers. They already enforce current smoke-free legislation across the whole local authority area, including hospitals, but, as I say, we are working with COSLA to make sure— To help you in that regard, have you heard of that? To make sure that they—well, we are in discussions. But we know that the public are largely law abiding, and if they know that this is coming in, and that we have good communication around the new legislation, we would expect to see similarly high levels of compliance on this piece of legislation as we have on others. Richard Lyle? Yes. I will finish off by saying that, at the end of the day, it is education. Many years ago, when there was no smoking in public places, people said that it was not work, but it did, because we steadily progressed. I am advocating that we continue to progress and remove people from the entrance to hospitals, but we are also convinced that we will educate people steadily as, over the years, people will eventually not smoke in near hospitals. I agree with that. I think that an awareness-raising campaign is absolutely vital, but we have seen most recently with the new regulations relating to drink driving that have been accepted by the public to a huge degree. I think that with this too, that will happen. No other questions from committee members. I thank the ministers and our colleagues here today for their attendance and their helpful evidence. We now move to our third item on our agenda today, which is our first evidence session on alcohol licensing, public health and criminal justice Scotland bill. I welcome to the committee Alison Christie, policy officer, Scottish families affected by alcohol and drugs. Dr Peter Rice, chair on the re-consultant psychiatrist, NHS Tayside, Scottish health action on alcohol problems. Dr Collette Mall, GP, BMA Scotland, Tim Ross, chair and chief inspector, Police Scotland, North Ayrshire Health and Social Care Partnership, and Patrina McNaughton, Research and Policy Co-ordinator, Alcohol Focus Scotland. Welcome to you all. Before we begin with questions, I will make the witnesses aware that Richard Simpson, MSP, the member in charge of this bill has joined us today. Richard, as you know, you will have an opportunity to ask questions at the end of our session, and I welcome to you also. As there are no opening statements, we now move directly to Malcolm Chisholm for our first question. We have 10 different proposals on the bill, so in a kind of way, it is quite difficult, certainly impossible, to deal with them all simultaneously. I thought that it might be a good idea—I have read all the evidence, thank you very much—that it was very useful from all of you. However, I thought that it might be useful to start with the areas in which there is unanimity in terms of agreement. There may be more, but I think that everyone has agreed on the minimum price for packages containing more than one alcoholic product. I am sure that I will be contradicted, but my impression is that everyone agrees on that. Community involvement in licensing decisions and restrictions on alcohol advertising, there are certainly areas in which there is broad agreement. I thought that it might be useful. I think that all the other areas have a measure of disagreement, even if it is just one particular organisation. However, on those three, I just wondered if there were any issues that people had, but it looks as if there is a lot of agreement around those three. However, I am sure that you will tell me that I am wrong if that is not the case. On the agreement in these areas, thank you. Right, Malcolm, now the hard stuff. Oh, right. I did expect some comments on that, but Richard O'Bee Pleasie's got three in the baggies and only got seven to go. I do not know. There may be some merit in taking them one by one there after. If we can start with the issue of caffeine, people know the background to that. I think that this was related in many people's minds to anti-social behaviour with alcohol, but no doubt there may be health issues with caffeine and alcohol as well. However, I think that there are different opinions on that, so it might be quite useful to kick off on that one. Bettina, were you attempting to come in there, and I got you over there? I am sorry. No, I agree. I think that there is broad agreement about the restrictions on alcohol advertising and tightening up the quantity discount ban and the community involvement in licensing. However, just to say that, as an organisation, alcohol focuscot and believes, the measures need to go further than is proposed in the bill. I do not know whether that constitutes broad agreement, but we definitely think that, with marketing restrictions, for instance, they need to go extend beyond what is proposed in the bill. To ask the basic question, do you believe that proposals within the bill are likely to have a noticeable impact on reducing alcohol consumption? With the marketing restrictions that are proposed, there are already voluntary agreements in place for each of the measures. I think that there is a voluntary agreement to not advertise around schools and in relation to sport sponsorship. For instance, there is a voluntary agreement not to have alcohol sponsorship of sporting events, which primarily involve young people and children or young people and children of the audience. If they are made enforceable through legislation, that adds something because we know that, in some cases, these voluntary agreements are breached in relation to advertising around schools. For instance, there has been a few instances in Wales, for instance, that have been noted. There is an additional element, but it will not make much of a difference because they are already there in place voluntarily. To make a difference, it needs to be extended beyond and to consider more restrictions around to prevent children from seeing advertising. We know that our own research has found that there is a high level of awareness of alcohol brands and advertising in children as young as 11 and 12. We would advocate an extension of a ban to consider more public places in relation to cinema advertising on television and broadcast. There is support for these measures within the population. There is quite widespread support, for instance, for a cinema ban on alcohol advertising in under-18 films, which is much more clearer, simpler measure than is currently in force. Dr Rice. I add to that that the measures would undoubtedly be a step in the right direction, but I agree with Patrina that there is still more to be done. As has been quoted in some of the evidence, we do have a situation where 10 or 11-year-olds are more familiar with lager brands than they are with ice cream brands, which is not a happy situation and is not the way that we would like things to be. In those discussions, and there are discussions going on in Europe about this, at the moment, the requirement is to prove that the marketing is targeted at young children, not that they are exposed to it. If a young person goes and sees their football team with a beer logo on it, that is substantially exposure to it. Because they are not targeted at the child, that is very difficult to regulate. That is an example of the steps that we need to take. Those are good steps in terms of the marketing that is targeted at young people. Most of the marketing that young people see is not targeted at them, but at the wider population. They see it as part of the general run of things. Those are the next steps that we need to take, but those are moves in the right direction. Anyone else? Alison Dey? It was for the DWP review, and we had responses from 70 family members. The comment that came over constantly was that alcohol was everywhere. You take your children to the deli for breakfast on a Saturday morning when the shells are lined with wine. It is about the marketing, but as Peter and Patrina said, it has to go further about the exposure. OK. Anyone else? Malcolm, I interrupted you. That was useful, because in a way, just in opening those three, it is not that people want to take away from them, but some people want to add to them. That was entirely useful. I do not know if it is up to you how we proceed, but I am suggesting that we take the issue of caffeine as if there are seven other issues that are more controversial. Can we have a response on Malcolm's original question about the caffeine issue? Anyone? Dr Mall, thank you. It is just to say that, certainly from a personal perspective, when I see patients and my surgery who are having issues with alcohol, it tends to be because it is lower price rather than because it is particularly having caffeine in it. From that perspective, I would not like to concentrate on one area of low-priced alcohol. I think that we would have to take into account all the other types that are out there. I do not think that there is a lot of discrimination at times between which alcohol people take. It is just the price that really is the problem. Is that a generally agreed position? All the data that we have is about the quantity of alcohol that we do not have any families that are concerned about particular brands or products. It is about the volume and how accessible it is to buy it cheaply. We agree that price and affordability of the key drivers increase consumption and harm. In relation to caffeinated alcohol, there is research that shows that among young offenders there is a high proportion of drink caffeinated alcoholic drinks. Considering the proportion of caffeinated alcoholic drinks sold in the country, it might be about 2 per cent of the total alcohol market. It figures quite high in alcohol-related offending. We take a precautionary approach on that. There is some evidence to indicate that it can exacerbate in alcohol-related offending. On that basis, we would advocate for it to be considered and then see what the result was and evaluate it on that basis. I think that the evidence is indicative. It is not conclusive, I agree, but the cost of implementing such restriction on caffeine content is not sure whether it would be that high by putting less caffeine into a drink. I do not know whether that would be costly measure to implement, and you could evaluate the effects of that on alcohol-related offending. Dr Rice. We felt that this was not a priority action on a number of grounds. One was, for the point that has already been made most of the harm that we see in clinics comes from low-cost alcohol, and the tonic wines caffeinated drinks tend not to be low-cost. The evidence about its relationship with offending is restricted to quite a limited part of Scotland, and even the McKinley report, I think, had no tonic wine consumers from the east coast, and that is an interesting phenomenon. If you look at that report, there was high levels—in fact, just about the same numbers of people were consuming spirits, cannabis, Benzirazbines, and Ecstasy. In fact, only 30 per cent of that sample reported that their alcohol offence was purely alcohol that was part of offence with other drugs. Out of that cocktail of drugs to pick out caffeine seems to be—I do not think that caffeine is the priority drug out of that cocktail. The further element to this is that the neuroscience on this is emerging, but it is indicating that the immature male brain and the male brain stays immature for quite a long time, probably into the mid-twenties. It has an alerting reaction to alcohol, or response to alcohol becomes more sedative as we age, some of you might even know some people who that has happened to. The alerting effect of alcohol in young men that is often attributed to caffeine may be an intrinsic effect of the interaction between alcohol and the still developing male brain. I think that putting all that together or feeling was that we understand the public concern that this was not a priority action. The very final point that I want to make is that I do think that there is an issue with suggestibility as a very important effect in intoxication. When people become intoxicated, they behave in ways in which they expect to behave. That drink will make such and such happen, is a strong predictor of what is going to happen. My own view is that the discussions around the tonic wines may, in fact, have made things worse. It may have established a reputation for a particular product that then becomes a self-fulfilling prophecy. What might have been quite a short-lived craze has become a more long-lived craze. That is one of the reasons why we have never drawn attention to caffeinated products, because we think that some of the public attention around it might be detrimental. You will keep that in response, but you just wanted some of that on the record, Malcolm. Bob has got a supplementary on the caffeine one. I think that there are more substantial parts of Dr Simpson's bill that I would like to ask a question on that, just in relation to the point that Dr Rice was making. If this was to go through and this ban was imposed, what is the likelihood that the young people involved in social disorder or putting themselves at risk with caffeinated drinks would stop drinking or would they switch to another form of drink that might even be lower cost and someone would just market the next big thing that would be the magnet for young people to drink? What I want to make sure is whether that would have a positive benefit or not. My own view is that people who are setting out to become intoxicated and expecting to become violent and disorderly is part of that. That will still happen. I think that it is a very legitimate question about caffeine. Does caffeine have a neurochemical effect that enables people to keep drinking when otherwise they would have collapsed and passed out? Does the alerting, stimulating effect of cannabis allow people to keep going, keep drinking, get more intoxicated with alcohol with more disorder coming from it? That is a very legitimate question, which is to an extent unanswered. There has been a recent meta-analysis that has shown that caffeine keeping people drinking is not a powerful effect, does not happen. As I was saying earlier, there is evidence that that alerting effect happens even without caffeine being there. I think that it is likely that people who are setting out to drink with the intention of becoming violent and seeing that as part of the experience, that that will still happen. Chief Inspector, do you want to respond? A very similar point to that. I think that the fact that that behaviour does exist in the areas outside the west coast where perhaps the prevalence of those types of drinks is not so high, tends to suggest that there would be alternatives and it is more perhaps about cost and availability. Whilst we are supportive of it as a step again, we would perhaps like to see that research that shows the effect of caffeine does it indeed augment the effect of alcohol and have you more fully before we could take decisive action on it. Richard Lyle? I, through you, convener, ask a question regarding alcohol advertising and then move on to container marketing and off-sales. Dr Peter Rice, you mentioned it a couple of seconds ago. It is my view that we have, first, I am not a football supporter. In the past, we have had sports events sponsored by tenants, sponsored by the Carlin Cup. We used to have the Martell National and the Grand National. Quite a lot, and as you mentioned earlier, quite a number of football teams have their logos on their badges, etc. Do you feel that this restriction on alcohol advertising, particularly sponsorship by alcohol brands, should be banned at sporting and cultural events, principally targeted at those under the age of 18? I go along to a sports centre with my grandson and see kids at 5, 8 or whatever playing football, but there is no advertising of beers or wines of whatever they are. However, if I take my grandson, or when my grandson gets older, if I take him to a football match, there will be the tenants' cup or the Carlin Cup or there will be flashing up different brands of alcohol. Do you think that what is proposed in this bill is workable? Yes, it is workable. One of the first things that I did in alcohol policy was to run a campaign to get the drinks logos removed from children's size football strips, and that was eventually successful. It took some years to get that through. It is undoubtedly a major part of exposure to young people when we are talking about the alcohol brands that young people know about in the Welsh research. It was the alcohol company that sponsored the rugby union competitions that are prominent in Wales. It is a big, big channel for exposure. I think that there are many countries in Europe that do not allow that. Two of Celtics 3 away games so far, they have not been able to wear their cider logo on their shirt because they played in Azerbaijan and Iceland that do not allow that. There are other countries that have worked this perfectly successfully. France is one of them for all adults. It is not a proposal that is on the table today, but my own personal view is that that type of sponsorship is inappropriate. It is difficult when you look at a local hotel sponsoring a small amateur team. There are shades within this that my own views you would not want to interfere with. However, I think that the big corporate sponsorship of big major sporting events by alcohol firms is something that I am opposed to. It is a very big business. The Brazilian Government was forced to change the law by FIFA in order to stage the World Cup. The Russian Government just agreed the same in order to have their alcohol sponsors selling their product in the football ground. The national government has come under pressure from sports associations and I have gone along with that in order to go along with it. Those are powerful forces, but I think that it is inappropriate and I would like to see them. I think that it comes back to what Peter said about the current rule saying that advertising was not particularly appeal to children and sponsorship. That distinction is quite meaningless because children are influenced by all the advertising that adults are targeted with, all the characteristics of advertising and sponsorship that appeal to adults, appeal to children as well, humour, social, sport and success. They all influence children's attitudes and it has been shown clearly that they influence their intentions to drink and when they start to drink and how much they drink. That needs to be addressed in all our rules regarding the marketing of alcohol. To recognise that, to protect children, you have to look at all advertising. There is no advertising that particularly appeals to children. It all does, so that has to be addressed. I just want to confirm that there are no other responses. Can I move on then to the container mark in off-sale, in particular to Chief Inspector Tim Ross? Sorry to interrupt you, but I thought that you were going to have another question on that. No, I did say that I was going to move on to container mark. Sorry, I missed the empty then because other members wanted to come in in the back of your first question. I'm sure that's in the interest of everybody. Colin, you wanted to come in on the advertising, didn't you? Any others and then we can move on. It was just a couple of questions that's about assessment of, we're talking about the influence of alcohol companies within sporting competitions and all that sort of thing. Has there been an assessment on the amount of money that, as I'm sure the sporting authorities might complain, if there is a massive amount of sponsorship that certainly leaves because we happen to change the law on sponsorship? The other thing is that it was put to me as I was actually coming into this meeting today in terms of there's now an awful lot of sports clubs, golf clubs, et cetera, et cetera, et cetera, who receive preferential loans, all the rest of it, through alcohol companies, you know, you think of the Bellhaven beers and all this sort of thing that are quite prevalent in golf clubs. Now, if we change the law, has there been an assessment of how much money might be taken from sporting events and sporting organisations? One at the island was considering introducing phasing out alcohol sponsorship of sport and for their public health bill, they may have done an impact assessment but I haven't seen it so I don't know for sure. There are alternative models. I mean, I know beer companies have preferred beers at events and they get the sponsored beer and such but there are alternative models for funding sport like with Hearts Football Club has demonstrated and led the way and a different ethos and it requires a different ethos and it would require alternative sources of funding so I think we would recognise that and we would advocate maybe a phased removal if we were to go down this road because to allow other funders to come on place but I mean as it is now we have a lot of funding say of football which is around addiction around like betting and alcohol and then payday lenders and it you know to move away from that to get more family oriented or more congruent sort of funders of that sport. I think you would have to phase that out because at the moment it attracts you know those kinds of funders and I think it does need a planned and phased change and a change of ethos. Do you know I think that it would be appropriate to at least work out how much in terms of a financial hit these things would you know legislationally this would make on sporting events and sporting clubs before you know before we actually go about finding a way of getting out of it because funding can be very difficult to find as we all know. Principal and we're not saying overnight to introduce a law that banned it but to have a phased removal which would allow people to source alternative funders and to allow other models of funding for the games. I mean we live in quite a rich society and there are a lot of businesses who are not alcohol related who can fund sport and sporting events so I mean it's not impossible. If there's no financial assessment on how much, how can we tell what the hit is going to be on them? Dr Rice? Yes, I'll try and keep it brief but I am a football sporter and one of my arguments was always that you might mean that Scottish football will be dragged down to the level of French football and I could live with that. You know it's a country that functions perfectly well without advertising. We did some work at UK level on sport sponsorship and in fact if you look at the English Premier League, a very financially successful league, there's only one football team sponsored by a beer company and that's by a Far Eastern beer company and it seems that English football has become too big for the beer market and in fact the biggest club that's sponsored by an alcohol company in the UK is in Scotland so I think that the argument that we'll hear is that sport is hooked into this money and can't live without it. I don't think that the evidence supports that but you're absolutely right that if it came up as a firm proposal there would need to be proper analysis of it. It may be that restrictions on alcohol advertising as it's described by the bill are much more limited. I think that you've made the argument that they should be extended rather than that. Would you understand the limits of what's being proposed then in terms of targeting for children? I think that what's being proposed is a group of good ideas but I think that the limits of them are firstly that they are working in the presumption that we need to show that advertising is targeted specifically at young people and that the round schools and so on when in fact most of the exposure is not there and the second issue would be that billboard advertising is becoming a smaller and smaller part of the advertising industry. The real prize here is social media which is a very difficult area to legislate. Finland are currently trying to do that so these are useful measures but there are bigger fish to fry here if it was possible to construct legislation on that but the social media issue particularly is not an easy one but it's one that needs to be taken on. I don't know whether anyone else wants to come in before I go back to Richard. Does anyone else want to know? On advertising Dennis, surely? Just very quickly, convener. The thing that we would probably want to do is to protect the advertising to more ethical and perhaps moral because if you remove it from, say, alcohol advertising, if you then go in to say, pay the lending as you mentioned or say betting, you know, we've actually created another problem. We've created perhaps an even, I don't know, a bigger problem in terms of people's wellbeing and addictions so how do you suggest that we control advertising to ensure that we don't actually create a bigger problem? Or is the Dr Rice's suggestion that we just don't advertise at all? Crack at that one. The first thing we need to do is to stop advertising being self-regulated. I think that's a big change. My own profession used to be self-regulated and now it isn't. The majority membership of the GMC is now non-doctors. Somehow the advertising industry seems to have retained the right to self-regulate and that would be absolutely the first step to change the nature of advertising regulation would be number one on my list. Richard, back to you. Thank you. Thank you, convener. I can again ask my question to chief inspector Tim Ross. We have a situation in container, mark and off sales. Most of the complaints that we have from people locally is that when the police catch someone, an underage drinker, they don't know or they can't find out where they actually physically bought the container. In this bill is a proposal for an identification mark, which we'll be interested to find out later how that will be done, but an identification mark on each container to show where it was bought. In your view, is that workable? In your view, where it says off sales premises, my view is that every supermarket wherever someone said earlier that they could get into some local shop or some eating place and find alcohol, that every area where alcohol was sold should have a specific code or identification mark. Is that workable and would that help the police in order to establish where alcohol has been bought by saying underage drinker? Container marking schemes are workable in that they have been undertaken before on a voluntary basis, not on a widespread basis. I understand the proposal is that it would be by order, if you like, at the licensing board in a particular area, so that we are not looking at population-wide schemes. The schemes are workable on that basis in terms of trying to track back containers to premises. Off sales is obviously because of that, particularly because we are looking at trying to address the sale of alcohol to young people. It has limits. The licensing environment has changed since bottle marking schemes were first used before the introduction of the current act. With the likes of challenge 25 and test purchasing, they gave us some stronger options for dealing with premises that do sell drink to underage people. Bottle marking schemes perhaps are a strength in developing that intelligence to allow more targeted enforcement to take place. As I said, the schemes have worked in the past and I would not say that they could not work again. They have varying success in varying areas. I fully appreciate difficulties and sometimes the fact that somebody has a drink from a certain premises does not mean that the premises I have committed an offence and sell on that, depending on who the third party has been who bought it. I think that we are in a position now where bottle marking scheme has worked. If there was community support for it, and perhaps more importantly even support amongst the premises in the area, who might wish to take part in a scheme of this nature, then it could well be a success. Perhaps, as I said, more to inform future work in terms of management and operation of premises. Anyone else responding to that one? No? Are you saying that this is a measure that could or should be available to a licensing board for a given area? It is an interesting one. I am not against it. I should point out that I am here as a representative of North Ayrshire alcohol and drug partnership today rather than the police. Of course, I am a police officer. I am certainly not against it. I think that the environment has changed slightly in recent years, and I think that in terms of what schemes of this nature deliver for you. If there is a voluntary scheme that the premises' licence holders take part involuntarily, then I think that that is a good thing, because you need that buy-in. In terms of the evidence that it provides you and the outcome that it has and the impact on drinking in the area, I think that we would have to take that in a case-by-case basis. As I said, perhaps its greatest potential is in providing that evidence-based or intelligence-based to allow further action. No one else in that one? Can I turn to the part of the bill about notification of offenders to GPs? I suppose that it is counterintuitive to me that there are concerns about that from GPs in the BMA, and I just wanted to get some of those concerns on the record, because it would appear to me that that would give a GP a full picture of their patient. We talk about treating the whole person and their circumstances and the like. It seems to me that if there is a piece of information from that jigsaw missing, I cannot understand why someone would not want it. I would probably start by saying that that piece of the jigsaw probably isn't missing, and that the GPs are probably aware of the alcohol problems that their patients are suffering. I think that we have to accept that the medical record is there fundamentally to treat patients and that to have information that is brought in just across the board probably isn't the way we would want to go. We have to look at the doctor-patient relationship here. We spend a long time with our patients over our careers building up that relationship. It's a relationship of trust that what we discuss and what we have in our records is something that we have both consented to and we've spent a long time dealing with. If a patient presents with anything suggesting an alcohol issue in the surgery on a daily basis, I will address that with the patient. If they don't raise it but I have a suspicion that they have some problem going on with alcohol, I will still raise it with them. I'll investigate it, I'll bring them back and I'll discuss the outcome of that with them. I wouldn't like to jeopardise that relationship by the patient having consented or possibly not consented for me to be given a piece of information about a criminal offence that alcohol may have paid a part in. I think that there's an issue with that data actually coming into the record and I'm the data controller of that record. I would have to know that the patient had been appropriately counseled and informed and told exactly what will happen with that piece of information that comes into the record and what will happen to that information should the patient leave my practice and move to someone else, which often is what happens with people who have chaotic lifestyles where alcohol plays a part in. I'm particularly concerned about the spent conviction part of that because that would require GPs and their practices to spend a considerable amount of time following up this information that's being placed in the record and how would I be informed about that? What would happen between the patient being convicted and the conviction coming spent? How would that information be passed to a GP who the patient had moved to? Those are some of the things. Consent, I feel, is a big issue. I really want patient information in their record for patients to be fully aware that that is part of their medical record and I don't really perceive that this is a foolproof enough system to ensure that that happens for their medical record for their entire life. There would also be quite a large administrative burden on the practices for this, both for GPs and for patients. I was slightly disappointed to note that there was an expectation that there would be no impact on a GP consultation by this additional information being in the record. If I have to deal with something that's there because I have to deal with it because GMC quite clearly states that if something's put into a patient record then I have a responsibility to act on it, that would impact on both my personal relationship with the patient but also the amount of time I could spend dealing with other parts of their health in the consultation. Practice-wise it would involve a lot of time for my staff to bring this information in for it to be sent to a doctor to be actioned and then the opposite for it to be taken out at the other end. I think that the really critical thing is the doctor-patient relationship here and the acceptance that general practitioners really have a very good idea of the health problems of their patients. Even if the patient isn't forthcoming with that, we are trained to tease that information out of them. I'm perfectly content that I will be able to deal with the possibility of an alcohol problem with any patient that presents in the practice. One of the concerns that we had about this was purely from the family member's perspective and for them the ones that we spoke to were unclear about what happened next and this caused them a huge amount of anxiety because they immediately start thinking social work will be involved, the police will be involved just from this simple statement and I think for families they already faced a huge amount of shame and stigma and the ones we spoke to just felt this was another layer that was being added on to what they already have to carry. How does that square we have just heard from Dr Mall? I agree. They have been seen from the families, they don't want the doctor to know this, they withhold that information from them and Dr Mall said well I know all the people who have got a drink problem in my practice. I think there are people who, families who will go to their GP but you have other families who, what we found on average it's about seven years that a family member will cope with living with someone's problem alcohol use before they seek help and part of that is because of the fear of the unknown, particularly if there are children involved. So well I do agree that someone who, you know, a GP is likely to know their patient's history for the family member it's quite different, they'll try and hide it for a long time and try and cope. But seven years living with that problem without seeking help? Yeah, we've recently just completed some research with Edinburgh University which is, you know, we know that anecdotally from our family members the research with Edinburgh is likely to provide evidence of that. Is there an issue there that there could be earlier intervention that could prevent the eventual crisis Dr Mall? Well imagine what the patient, as I call my patient, was attending, whatever, the ideal time for intervention would be there when they're actually being dealt with by that area who are raising the alcohol problem. I think your problem was saying that the patient, the relatives are more loath to come forward with that information but that's a different issue because I have a one-on-one relationship with my patient in the surgery at that time and there's no doubt that if the patient did present and I had any consent on it and there would be very rarely would be a consultation where the possibility of alcohol as a factor would not be addressed by the GP that I would intervene at that time when the patient's in the surgery so it wouldn't really, you know, I would, if I got this piece of information that somebody had had a drink problem I, the proposal says I don't have to do anything about it while the GMC says I have to do something about it so there's confusion there, I'm not going to ignore that information but you know am I being tasked to bring the patient in to address that issue and as I say more often than not I will absolutely be aware that the patient has issues with alcohol. So you would be aware that you would expect the justice system, I don't know why you alluded to this or not, the justice system if someone was being dealt with with that. During related offence there would be some support on that system to identify and track them to support. Is that the case? Is it? I don't think so. I mean I think it's or anything I come back to say. It is. It worked for 20 plus years as a specialist psychiatrist in alcohol problems and it was a common route of referral both from criminal justice services themselves. Sometimes from courts, sometimes from criminal justice services where people are in probation orders, sometimes from people going to the general practitioner voluntarily precipitated by an offence. It was a very common pathway for people to get into specialist treatment through criminal justice routes. It was? Yes, it was. Is it currently? Sorry? Is it currently still? Well, it's out of clinical practice for a couple of years but I don't think things have changed that much so I think you can take it that that's still a common route for people to be getting into specialist services very often with the GP involved in that process but not always sometimes from criminal justice probation teams, that kind of thing. I'm interested in that because then I'm not awfully sure where the difference lies apart from to make sure that that happens routinely when there is a problem with alcohol rather than if somebody takes that additional step to refer them to their GP, refer them to counselling services and they're like surely if it was happening you know you could get earlier intervention, you could get support for somebody you might be able to to deal with the problems long before they become worse and people end up in prison and they're like because of offending behaviour. Yes. I feel that the first intervention should be at the earliest possible time and if we were being informed down the line when the conviction had actually happened rather than the patient being in the system where alcohol had been perceived as a problem then we have a delay there. I also think that patients still are referred by probation officers, by counsellors, by you know addiction workers too is and I don't think that that needs this measure to be put in place to ensure that that system takes place and I would certainly rather see the patient two to three months before their conviction than wait till it happened because then I actually can intervene at the right time. I think that the informal system works at the moment. But people will be missed? People will be missed but you have to balance that against all the other issues that I've raised about the loss of the doctor-patient relationship, the potential impact on the families, the administrative burden, you know the data controller procedure, the GMC opinion, that has to be balanced out and I don't think that this process will help my relationship with my patient. I had kind of written down a couple of phrases in relation to the discussion, I had written down trust and patient buy-in and I'm not sure if the provision within the bill facilitates either of those things if I've been honest about it. In terms of patient buy-in I'm just thinking of a constituent of mine, any of us around this table actually who gets involved in an offence irrespective of how major or otherwise where alcohol is consumed at the time and to be convicted and then I don't know how I would feel or any of us would feel about that being flagged up to the GP in terms of trust or part of a criminal record being kept in our medical records. I think that we're all thick skinned and worldly wide enough, we'd go on and deal with it but a number of my constituents getting them to go to doctors in the first place is quite a significant achievement particularly for the hard-to-reach groups and I would be concerned that those least likely to seek medical help for a variety of conditions and the ones most likely to need support from GPs might be the ones who take greatest umbridge to that trust relationship so some comments on that would be welcome whether witnesses agree with that or not but also what I've written down was targeting and that is and I'm delighted that it looks as if it's on the way out from 2017 onwards but if politicians were to say to medical professionals pick the 100 people in your practice you think who are most at risk of alcohol abuse will give you more time to spend with them in a targeted fashion would you say give me the 100 people that have committed an offence where they have been intoxicated at the time or would there be another way of doing it so I'm just even wondering in terms of targeting the time of the GP if this is the most effective way of to get the outcome that Dr Simpson quite understandably wants to achieve so a bit more about hard-to-reach groups and whether they'll be dissuaded from going to GPs with a variety of health conditions that you struggle to get to make appointments and keep appointments currently and whether or not this would be the best way because this would obviously take up GPs time to go through this is that the best use of clinical time to target at-risk groups of alcohol abuse and who are damaging their health so I would agree with your first point I definitely agree that these are difficult to reach patients in any barrier that's put in the way has only gone to have negative consequences and as you say not just on the problems related to alcohol but all the other medical conditions that can go with that I think from the point of view of the second one I think the first thing we would have to decide is actually the GP the person who's best place to deal with this initial presentation and possibly they are for the initial recognising that there are problems there but actually who is best deal to place to deal with the long-term effects of that and to have the time and the expertise to go along with that because essentially you'll know we have 10 minute consultations and it's very difficult to achieve anything in a 10 minute consultation and to bring someone back a week later you've lost the impetus so I think we would have to look at actually yes GPs are the ones who do see most patients most of the times but we would probably be best to be a route to someone who has the time and expertise to deal with the on-going problems okay and just in terms of I'm trying to get to targeted because Dr Simpson obviously wants to target at risk groups where alcohol is a contributing factor to offending or actually it's a public health initiative rather than a criminal initiative I would suspect. If you wish to target those most at risk of public health hazard due to alcohol use and abuse is this the way you would like to use your time as a GP or can you think of other ways to use your time as a GP? I think that that's a difficult one I don't think I can answer that just now without having more information because obviously having not known who has convicted and whether it is a one-off or it's a long-term alcohol problem would cause me I would have to know the balance of that but I do think it's something that is GPs we have embraced in the past you know we've done brief interventions we have targeted patients but generally time is of the essence in the consultation and it really does rely on having a support network around that we can send people on to but yeah I think we do probably target that anyway because most people who come in with a medical problem we would tend to ask do you smoke do you drink you know you're overweight so we're doing public health promotion in every consultation anyway but it's taking that next step is where we get the best support. I've actually found sorry sorry Mr Ross did you want to come in thank you. Sorry I was just going to I've scribbled in a few things but I think absolutely you know from the health and social care partnership point of view we'd want to be really clear about exactly what the purpose of this act was because whilst on the face while you might think well that I can see why that's happening we have to be really clear on the purpose for example is there any you know in terms of patient buy-in patient engagement in the process is there anything to facilitate that you know if somebody doesn't want to engage with their GP albeit the GP may well know they now have an issue do they buy into it but it'd be also interesting to see the scale of it you know in terms of police officers assessing the role alcohol plays in the commission of our offence there's a degree of subjectivity around about that but it'd be really interesting to see the scale of what it might mean in terms of referrals to GPs and the obvious knock-on that might have in terms of resourcing. We talked about earlier schemes there have been alcohol referral schemes undertaken at various police officers throughout Scotland and at various pilots where it is more about when offenders are in custody in the police officers they get brief interventions there so that that might be something to look at as well and in terms of targeting yeah that's a really valid point again because it comes out to resource issues and you know how do you choose between the person who has committed an offence because they've been drunk because they don't normally drink you know and they've gone out and got drunk too much and committed an offence as opposed to the the long-term alcoholic in the community who perhaps doesn't come to police attention so it's I'm not saying it's a bad thing to do but I think in terms of the limited resources we have we maybe have to look and see is this the best way to use those resources. I'll make a back-in later comment a bit that that last comment from Dr Mall I found quite helpful in relation to alcohol brief interventions so this fictitious 100 alcohol brief interventions that Dr Mall is going to do and we've got all this additional timing given for you to do it which would be wonderful I know. Do you think that they're more likely to have an impact and this may be a difficult question to ask more likely to have an impact if you identify your patients in your caseload at the moment who would be most likely to benefit that based on the current relationship you have with your patients and the information you have on them or by giving 100 people as they come forward who have been up in court what's most likely to have an effective alcohol brief intervention in terms of having the positive health outcome that you're looking for that's what I'm kind of trying to get to. I'll maybe take this out having been involved in the development of the alcohol brief intervention programme and I think it's very important you mention that to put it into context. It's the first national programme of its type in the world, the Scottish programme that's been up and running for 2008 and it's been a big success numerically mostly due to general practice taking it up there was a good structure established good software and all that to make it easy to do but that programme has outperformed its target you know every year and you know people are coming to look at how this has been achieved and that has also coincided with considerable improvements in alcohol related health in Scotland so that's been a big big success and primary care have really bought into that and that's part of the context of this discussion needs to be that actually things are being you know lots of very good practice in in Scottish general practice and the ABI programme supports that. Your question with targeting related to my my previous day job in Tayside and where well again things have improved in Scotland with this but there's still a shortage of treatment there's a unmet need for alcohol and yeah the people are most likely to benefit and who I most wanted to see were the people who most wanted to be there and I think there were various ways of of rationing treatment and we need to use that word because it's a reality my feeling was always that rationing that was in the hands of the patient seemed to me to be the fairest way to do it the people that wanted to be there you know got there and and they were often getting there via their general practitioner so I think that's what I took from your targeting question is if you have a limited resource we would love to have unlimited resources but we don't who's the best to target at and my answer to that is the the people who really mean business would be my answer. Thank you. Is trying to get people who want help to seek help and take it forward and that is the difficult aspect of it but you know we do it in the surgery day and day out we discuss alcohol I probably discuss alcohol 60% of my consultations no matter why you're there so we are beginning to do that and it's getting the network around about us to support the patient and their family. Okay, that's really helpful. Thank you. I wonder if that takes us on to the next but you know another part of the bill alcohol awareness training and as an alternative to fixed penalties I don't know where the specific word training but I mean you know in terms of of direction support to people rather than the criminal sanction or where that's almost what we've been speaking about here that that training could include you know some sort of counselling support referral or even asking the question if you discussed that we are GP if you thought of it these things you know I suppose I don't know what people's view is to this and that provision in the bill that training would be offered to know where the word training but that's what's there but it'd be offered as an alternative to a fine and offensive committee done to the influence of alcohol. Any responses Mr Ross? Yeah I think we would welcome that. We recognise that generally education and raising awareness is more effective in many cases than enforcement and certainly in terms of the fixed penalty notices and I think if we had that as an option in circumstances where we felt it would be appropriate for the offender to be offered that as a means to negate having to pay a fine which is quite often punitive in the people you deal with anyway and it actually doesn't assist them at all in their situation then it'd be very welcome. It's certainly you know you look at early and effective intervention that's been running now for for younger people and it's been really good and we started to look at doing this in Ayrshire to see if we could do it and at the time we couldn't because the procedures didn't allow us to but we'd certainly welcome that as an option. Okay thanks anyone else Dr Rice? Yes just to say there's just been completed a pretty large Department of Health funded trial in England looking at brief interventions in a number of settings in primary care in criminal justice settings and accident emergency and primary care came through as by far the best setting to deliver primary care but to deliver brief interventions but the the criminal justice setting delivered by probation staff also evaluated well the problem was getting departments to do it the general practitioners are quite well behaved actually and they did it but getting the criminal justice services organised so the services actually did it and delivered it did pretty well but the job was keeping the services engaged so I think there's merit in this idea but we we'd need to look at the structure of criminal justice services and how they can reliably get themselves organised to deliver it. Okay Mr Ross and then Petrino? Absolutely there are definitely resource implications here but you know you look at models that are available in terms of things we've done in North Ayrshire trying to improve peer involvement and raising awareness of alcohol issues and it's been really successful and you think that there could be some really innovative and exciting approaches we could adopt here that might not be too resource intensive but would allow us to deliver some really effective interventions? We definitely support providing awareness training and support but the only question raised in our mind is about the cost effectiveness and if people don't have the motivation to change if it's simply you know that they're thinking that we'll get out of paying a fine and they're not ready to change their behaviour whether that approach will actually motivate them to change their behaviour and then it becomes an issue of is that cost effective in delivering this training but I guess that would have to be evaluated. No one else on that one? Yes please Bob? Thanks I'm just trying to go through each of the provisions within the bill there was one aspect of it which initially seemed fairly reasonable when you started to look at it you go well I wonder a little bit and that was the alcohol education policy statements and I think just to get some comments on that the context I've got in my head is in relation to when you get down that road I think other people would lobby me and say what about substance abuse education policy statements or what about a healthy diet education policy statements or what about physical exercise education policy statements so yes absolutely we agree there's need for better education and better information for informed choices it's whether or not we single out alcohol amongst the whole kind of flurry of other things that that I'd said so I'm open minded on it and I don't know how it would work via government and reporting back I'm not so hung up on the process of it that's something we could look at but just in whether it should be alcohol education as a standalone or just any views on that. Just to say that I wasn't quite sure with the purpose of an alcohol policy statement and what it would include and contain and what it would be aimed at and I think that's why I had reservations in supporting the introduction of alcohol education policy statements I mean if there was more information provided where we could understand what it would be set out to achieve then we'd be open minded I'd say to the introduction of them I mean I can see in licensing context as a clear need or a context for a policy statement there when it's implemented at local level it provides local communities with the broad framework in which licensing decisions will be made and because licensing is often an individual application policy process well it is and therefore you know it just in assessing individual applications how are you meeting the overall objective of the licensing system so I can see it has a place there but in an education context I'm not sure how it would work in relation to local authorities control over education policy and is it national and local I don't know there was not enough information there for me to come to a decision on that. That's helpful if anyone else wants to comment on that. Yes I could say that I'm aware that within education the preferred approach is to approach alcohol issues in a kind of general life skills personal social education kind of way so if you like the old style stuff of you know getting getting the doctor or the nurse in for a half an hour to speak to the kids isn't what happens now and teachers now incorporate that within the their curriculum so I think that's the general approach. I think in many of the responses you'll have you'll have seen some caution about being over optimistic about the effect of education as a standalone and that's partly for reasons of marketing that we're talking earlier you know young people are getting many many messages about alcohol and education is only perhaps a drop in quite a big ocean so I think that's an important context to understand when looking at this issue. There are useful things that education can do but we shouldn't overestimate its effects and as I said answer to your first question it seems to be the preferred approach amongst education seems to be in a kind of general life skills approach. I wonder if there's any additional comments on that Dr Mo. I'd just like to say that again it's evaluating how effective it is and would we be removing resources from an area that actually would be more effective than carrying out a policy like this and obviously we need much more information about the effectiveness and the cost and the balance that we might lose from other areas. Okay that's helpful. Is that no no more comments on that? No no I mean I just said no. I was going to ask just something else because I did actually see within it is there no concern because if I consider my head then it doesn't actually matter it's just in my head. There's no compartmentalising health education between alcohol or substance abuse or healthy lifestyles or whatever which was kind of the main part of my question which thank you for none of you answering that part of my question which is why I come back in. You'll have another. The question that I would like to raise just for completeness and we're dealing lots on this but is the age discrimination in off sales currently we know that that's for 18 but there is purchase for those of over the age of 18 but licensed premises may have a voluntary apply an age limit which is higher in this and we've had you know mixed responses to this. Section 3 the bill would remove that flexibility that voluntary code is it is that something that people are relaxed about content with? You'll have an opportunity to come in Richard but you must be patient you're not a member of this committee area longer so you need to wait till we're finished. I really don't see there's any public health gain in removing the flexibility I realise there's more to this bill than public health but I don't see what the public health gain is in removing the flexibility it's not a flexibility that I understand has been used and not aware of any licensing board who've done this and there's a pretty full discussion about this issue when this was aired as an idea in an earlier you know consultation process probably back about five six six years ago and it wasn't an idea that found favour and there's some pretty active lobbying against it I still think it was an interesting idea that there should be a split age limit with you know people being able to buy alcohol in a pub or restaurant the age of 18 but not an off sales age of 21 that didn't find favour in public policy but I don't see why the option should be I don't see that there's any public health benefit in removing the option for licensing boards to have this if circumstances demanded it. Any other responses? Yes please. I suppose you know the apparent absence of licensing boards trying to exercise this power suggests there's not really the evidence base that it's required so I mean that I think that was our kind of take on this is that we really weren't sure of the evidence base you know which tends to suggest that persons age 18 to 21 for example are particularly involved in disorder in area and what have you said quite difficult to measure. Okay Malcolm. I think there's only one of the 10 sections left but it actually is the one that covers the most sections in the bill which is drinking banning orders and I suppose well you know what they say so I'm really quite interested I think again that we're differing views on that so I'd be interested to hear what people think about that. We're looking to you and there's still a lot to look forward to. Yeah well again I suppose I'll start this you know I think it's an alcohol and drug partnership and health and social care partnership we welcome this as an option and there are also two routes to obtaining the orders and we can see circumstances where they would be very useful although I think they need a bit of work more around exactly how they would work and how effective they would be because undoubtedly there are problems attached with them as well but it kind of gives us a phased approach of their elements of the bill they're licensing Scotland Act 2005 which allows us to deal with violent offenders linked to licensed premises and this maybe allows us a bit more a stepped approach for those that don't reach that threshold that we can try and influence and then in terms of linking it to an approved course again we've talked already about the benefits of education and awareness for those that are ready and willing to undertake that so it'd be good if that was an option that could indeed start to impact on public's use of alcohol. I suppose you or the person might be able to answer this does it add anything to the options that are already available under the criminal law? Yes, I think it does. It would be interesting to see exactly what the impact would be in terms of policing you know it would be effectively be a civil order with the breach of which it would be a criminal offence and certainly if the offence was I suppose you'd you start to think about anything well is this easy enough to police reactively where the order is breached yes but is there an expectation that perhaps you do some proactive policing around about this I'm not entirely sure how we could do that but I think yes it certainly looks like it could feel a gap that exists just now and could be a useful option. Dr Rice? Yes, my own clinical patch was in Tayside and I had some experience of you know the same goal being achieved mostly by sheriffs in smaller towns seemed to be my observation you know sheriff in such and such a time would say you know I don't want you to be drinking anymore and the police would know that and it seemed to actually work quite well in the smaller communities so that's my observation from it. I think though that we when we're thinking about this we need to acknowledge the fact that we are no longer a pub going nation 1994 51% of alcohol was sold in pubs 20 years later it's heading for less than a quarter so there's been a big shift from pub drinking to home drinking it's been a big part of the challenges that we've faced and so I think if the thinking behind a drink banning order is based around a model of you know risky people going into pubs that battle's already lost amongst the very heaviest drinkers in the survey from Glasgow and Edinburgh showing this less than only 3% of the alcohol they consumed was drunk in pubs okay of the heaviest drinkers are coming to our clinics they're almost exclusively home drinkers so I think the drink banning order would need to be thought about in the context of that reality because that's where we are at the moment that's helpful if there's no other questions for we you know we've got approximately 12 15 for this but there's no other questions um from the committee members I'll I'll ask Richard Simpson if he wishes to ask any questions are yes I think if I can just go through them in order the the advertising uh first of all thank uh the witnesses for the their input in that we are limited as to what we can do we can't introduce the loyve here which uh Sarah Willeson tried to do in England but was blocked by the UK government so there is a problem there um but I I just wonder whether uh the witnesses are saying that we should try and extend it at the moment to include sporting events which affect adults the bill is written is designed to say if you put an under 18 game or match you shouldn't be putting screens things up on the screen you know on this thing that goes around the football pitch that would just not happen when it's an under 18 game so it is a limited limited by our legal opportunities but limited by but whether you feel we should go further at this point in time children that are constantly exposed to alcohol I know we talked about children earlier but adults are very much exposed as well and for us we work with you know over 18s and the amount of calls that we get with just this it's everywhere how can you know how can we stop this exposure when it's in everywhere you get off the subway in Glasgow and the first thing you see is a ballard with you know advertising for an alcoholic drink so yeah we need to protect adults as much as children okay well I think I think that that's that's fairly clear and it may be the government needs to look at that particularly in the context of minimum unit pricing because if the courts do decide in favour of that which they may well do as a public health issue in Scotland then the additional profit to the supermarkets particularly will be over 100 million pounds a year and some of that may well go into increased advertising so I don't know if the witnesses would agree that even if this bill which is limited goes through that the committee should consider recommending that as a part of their report okay yeah on the container marking off sales I just wonder the witnesses it seemed to be a suggestion this might be a universal scream from I think it was Richard Lyle was questioning on that the way it's done is written to be limited in terms of of the the licensees that are affected and the and the period for which it operates do they think that's appropriate to keep that as a a temporary measure and yeah I think as I said earlier I think where the schemes have been most effective in the past and certainly my own experience are where there's been community buying and local premises buying and that's where they have worked best so from that localisation point of view absolutely it's important that it's not talking of universal or measure I suppose the argument would be whether the opportunity to still exists if the if there's a statutory power whether we still do things on a voluntary basis as well you know is the statute required I'm not sure I'm not entirely clear on that yet okay if I can go on to notification I mean I rose raise this chair put this in although the consultation was BMA and GPs were against it and the courts were against it for the cost because in 30 years as a GP the only people I got referred to are the ones who actually had a really serious offence whereas the ones where alcohol was merely a small part of the offence they weren't referred and given that each GP deals now with 400 brief interventions per full-time equivalent GP a year the objective of this was to focus this and it is a voluntary thing in that the the offender does not need to actually give the GP's name so there is a process there of saying look you've got into trouble through alcohol would like to inform your GP are you okay for that that to be informed do you not think that's a reasonable approach for now we're talking about low level relatively low level offenders where the police have said that alcohol is involved in this offence I can't agree with that I think it does impact on the doctor patient relationship and I think part of the the proposal did suggest that they wouldn't need to consent and I think part of the problem would be the ability to consent at that time and I do feel that the brief interventions are best done at the time rather than at a later period when the GP may be informed of that but also we have to accept that there's an administrative burden here in a workload implication when GP's are currently failing on a daily basis because of the workload that we're undertaking we have to prioritise what's important to each patient and we have to go on the doctor patient relationship that exists so I don't feel that this would bring anything to my practice currently okay so the courts the courts estimate 150,000 cases at the moment come before the courts how many have you been informed of how many patients have come to you and say I've been I've been to court and had a conviction at a low level not talking about the high level stuff where they get referred to a specialist and as a specialist addictions doctor I had referrals from the courts as did Peter Wright but at a low level how many how many patients have come to you saying I've just been done for something which in which I got into trouble because of alcohol but I can off the top of my head give you that figure but it's not an uncommon occurrence in practice for patients to come when they either accept that they have had some form of alcohol issue or something like that has happened that's really impacted in their lifestyle okay I think the last one is caffeine I accept that it's a very small area of sales it's a particular area particular problem in the west of Scotland what do you feel about the fact that the FDA has effectively persuaded the producers in America to suspend production of premixed alcohol and that there are at least two if not three other European countries that have actually limited this do you think that they're behaving in a they've acted in a way that's not evidence based or unreasonable or do you think they're doing it for some other reason I mean what why would they do that if it wasn't my response both today and in the thing is one of priority so if there's lots of time and scope for legislation then yes this might be something that that that you would look at the american situation was interesting if you look at the american evidence there perceived trouble with caffeine is to do with sportsmen in universities that's the people who they thought were causing trouble with you know with with caffeine so quite a quite a different group from from what was described in Scotland which I think fitted with my kind of notion that this is a almost a kind of craze if you if you like that that amongst a subpopulation so it was interesting the way the FDA approached it and that they were able to you know to shut the market down it may have been that that's because those products were only part of those companies portfolio and they could live with it so it's an interesting development I haven't followed any story too closely but I'm aware that that they've done that but for my view it's an issue of of whether it's a high priority and the point that I made earlier that I think excessive focus on this issue she might be might be detrimental to the wider problems I think some of our large producers and large retailers are quite happy to see these products in the spotlight because it suits them quite well and that worries me okay thank you very much and I thank all of the witnesses that have been with us for quite a while now and for all of the evidence you've given has been very helpful and I hope you'll see it reflecting their final report thank you very very much for your attendance this morning we now get into private session as we previously agreed