 I call on Neil Findlay to speak to you and to move the motion. It is a great honour to chair the Health and Sport Committee of this Parliament and open this debate on the committee's on-going work on the preventative agenda. Members may be wondering where our report on the subject is. The fact is that our inquiry is at a very early stage. We asked for this debate in order that all members could participate from the outset and contribute towards this piece of work. The Health and Sport Committee may be leading today, but this inquiry affects all members, most committees of the Parliament and every sector of government. This is a cross-cutting issue involving education, justice, transport, housing, the environment, social security, culture and many other areas of government. When I was appointed to the Health and Sport Committee, I made it clear that I wanted to run a very democratic and open committee and one that listened to real people. Over the last nine months, we have worked directly with patients, staff, carers, health professionals, not just lobbyists, policy officers and the politically connected. At our business planning event, we agreed a strategic plan for the committee. Our plan covers not only the current session but one that takes a much, much longer view of health and care. The plan is short, concise and highly relevant to this debate. Its overriding aim is in all her actions to improve the health of the people of Scotland. Fundamentally, that is what this debate is about—improving the health of the people of Scotland. It is not a matter solely for the Health and Sport Committee nor for the Cabinet Secretary for Health nor solely for health professionals. It concerns all of us in whatever area we are operating in, as today's motion makes clear. Modern medicine is overwhelmingly reactive rather than proactive. You get sick, you seek medical assistance and, hopefully, you are cured or made better. What is less common is the overarching community and national planning that focuses on prevention and early intervention. Prevention and early intervention is as much about housing, jobs, economic or environmental policy as it is about health and social care policy. The first paragraph of the Government's health and social care delivery plan, published in December, makes that very point, but that plan relates entirely to health services. Perhaps I can gently say to the Cabinet Secretary for Health that this is a great pity and an opportunity missed to include other areas that, between them, hold the key to reducing demand on our health services while closing the inequality gap. Health inequality is a manifestation of social and economic inequality and we will never tackle that from a health perspective alone. It has to be a whole Government cross societal approach. A focus on prevention, of course, is not new. It goes back through time in various guises. The introduction of sanitation and clean water, slum clearance, council housing and the NHS are some of the most successful examples. I suggest that that makes the point that the state has a very important role to play and witnesses we have heard from were quick to point to the effectiveness of measures that use fiscal, regulatory and legislative levers to reduce exposure to harm and address inequality. Those levers impact on the whole population rather than focus on individual behaviours. Measures such as those covering the sale and distribution of tobacco and alcohol, taxation of those products and other restrictions introduced to restrict smoking in public places are good examples. We need a dual strategy of treatment, yes, but running alongside active prevention. The Christie commission on the future delivery of public services in 2011 did not believe that there was a magic solution to the problem of resources being tied up and dealing with short-term problems, to the exclusion of efforts to improve outcomes in the longer term. The commission saw no alternative but to switch to preventative action to avoid what they called demand failure, swamping the capacity of our public services to achieve outcomes. It noted that it was imperative that public services adopt a much more preventative approach and address a persistent problem of multiple negative outcomes and inequalities faced by far too many. In 2011, the finance committee of this Parliament identified that all public spending could be classified in some way as preventative. It sought from the Scottish Government a robust and measurable definition of preventative spending to be used across the public sector. It would be helpful if the cabinet secretary and her contribution could cover that aspect and assist the committee with a working definition. If we move forward to 2016 in the Audit Scotland and Audit Scotland in their report, Changing Models of Health and Social Care, acknowledge what they call the ambitious vision that has been set by government, but note it as a key message that the shift into new models of care is not happening fast enough to meet growing need. New models in place being generally small scale and not widespread. Audit Scotland called for strong leadership, identification of measures of success, models of new investment and new ways of working. It called for a clear framework by the end of 2016 for how that vision is to be met. The health and social care delivery plan was the government response to have high-quality services that focus on prevention and early intervention. Prevention is mentioned frequently in the document as being the focus, including a lifetime-wide approach to prevention. Say again, an opportunity is missed and the plan to link beyond the boundaries of health services. A central part of meeting the vision is the national clinical strategy and realistic medicine. The problem that we are having in committee and scrutinising prevention remains the same as was highlighted by the Finance Committee in 2011. That is to understand how the shift to prevention is to be defined, how it is being planned, how it is being funded and then how it can be measured. That takes me to the committee's work to date. In January we agreed that we needed to understand what we were dealing with, what exactly is preventative spend and preventative expenditure. Spice told us that those terms are both vague and conceptual and that all public expenditure could be argued to be preventative. They warned us that public services can, because of the lack of definition, retrospectively fit their services under those headings. They warned us that it is difficult to attribute outcomes to any one policy. We also noted another audit at Scotland report changing models of care, which urged effort to address the gap in cost information and evidence the impact of new models. We put out a call for views on the definitional question and how much spending could be identified and tracked. We also asked how spending could be shifted from reactive on acute services to preventative in primary services and how that shift could be speeded up and incentivised. We received nearly 70 comprehensive and thoughtful responses. In March we explored those issues further with a group of expert practitioners in the public health field with integrated joint boards and eminent academics. They confirmed difficulties in definition and warned us about counterfactuals, what would have happened anyway without interventions. We heard about false dichotomies when considering the relative merits of addressing social determinants against more specific interventions. We were also told that shifting the balance of care does not mean the same thing as shifting resource. Community-based care will not necessarily save money even if all the work to shift the balance is successful. We were warned of the need to compress mortality to reduce the time people spend in ill health and keep people healthy for longer. Overall, however, most are saying the same thing to us. We need to have a whole system approach, joined up government and a focus on reducing the shocking levels of health and the qualities that we see in Scotland today. Fundamentally, we all need to agree what actions on the ground are going to make a difference and how the existing barriers around using resources can be tackled. I guess how we can measure the outcomes that are achieved, a subject on which I am absolutely sure my colleague Ivan McKee will cover in the debate. Although the committee was also told that the necessary evidence, information and data is available, we need to get better at measuring it from the outset and interpreting it and then using it. However, I need to avoid the danger of paralysis by examination, modelling and testing. We heard from Midlothian Integrated Joint Board about how they are undertaking to better understand their communities and how they are using that to design new-targeted holistic interventions that look at the social determinants of people's issues. They are measuring improvements or changes using gap indicators which, in effect, are the measures being taken to close that gap. However, that needs a long-term view. It is not always clear, and we heard about the difficulty in making linkages between a single intervention and an impact that may take us back to counterfactuals. Time is not sufficient for me to fully cover our inquiry. I have tried to give a flavour of what we in the Health and Sport Committee are looking to consider. The next steps will be partly to be determined by what we hear today and what members say. Should we look at discrete initiatives and evaluate how successful or otherwise they have been and try to read across their outcomes into other areas? Or should we perhaps focus on how improvement outcomes and benefits are being evaluated? Could or should we do both? We turn into our strategic plan and its focus on health and equality. Should we, as a health committee, focus on health inequalities and measures to address them, but only through the prism of health interventions? I and the committee would really value your thoughts today. My one play is that we all endeavour to take a longer-term view of this and resist to view the next election as the horizon seems like we have an election every five minutes just now. As a committee, our strategic plan commits us to at least a 15-year view. In closing, we will only see meaningful progress with a concerted cross-government approach and our approach that is properly resourced. It is absolutely appropriate that this issue has been discussed early in our work and only by joint and joined-up action will progress be possible in taking a preventative approach and tackling the root causes of health inequality. I move the motion in the name of the Health and Sport Committee. Shona Robison, the cabinet secretary, to respond on behalf of the Government. I want to welcome the debate that was initiated by the Health and Sport Committee. I look forward to hearing today's debate and the committee's final report. As Neil Findlay highlighted in his opening remarks, the inquiry by the Health and Sport Committee is building on the recommendations of the Christie commission and the work of the Parliament's finance committee, which took evidence from the cabinet on finance on prevention in the last session. Neil Findlay was right in saying that the debate needs to look beyond the confines of the NHS and needs to be cross-government in nature. It is a very broad topic and I am going to try to focus my remarks on some strategic priorities. A hallmark of Scotland, whether it is Parliament or indeed it is Government, has been a willingness to innovate and try new ideas that are relevant to the debate. Our two examples come to mind. First, our pursuit of alcohol minimum pricing and secondly, the introduction of the early years collaborative. Both are preventative measures that demonstrate our willingness to try new and challenging ideas but also highlight the complexity of understanding what we mean when we talk about prevention. Neil Findlay in his opening remarks asked for the Scottish Government's definition of preventative spending. The preventative approaches are many and diverse and any definition needs to give us flexibility to address different challenges across a range of policy and delivery contexts. We therefore believe that prevention should be defined in broad terms as activity that maintains positive outcomes and breaks cycles of negative outcomes, helping to tackle persistent inequalities for people and communities. Over the long term, those activities will reshape services and demand and contribute to the long term vitality of communities and the sustainability of public services. In this way, we look beyond preventative spending decisions alone to consider how to make best use of the totality of resource available, our people and other assets, as this will be the key to enabling a fully preventative public service culture. High quality public services play a crucial role in shaping both our economy and society and play a role in primary prevention. Our ambitious programme of reform in Scotland with its emphasis on prevention, integration and empowerment provides the means to reshape services and demand in a way that contributes to the long term vitality of communities and the sustainability of public services building. On the foundations that are established in the Christy commission report, our approach to public service reform is underpinned by the principles of democracy and reform. We see prevention as the route to tackling the most difficult and entrenched problems that people in our communities face and to achieving our goals of reducing inequalities and driving inclusive growth. We believe that collaborative partnership working across the public, private and third sectors can enable us to deal with this complexity in a more joined up way and to make the best use of the total resource available to us. By focusing on outcomes, we aim to develop and deploy resources in a way that establishes a truly preventative culture, one that forges deeper relationships with local people and is more open and responsive to what communities most value. This was the premise set out in the Christy commission's report and is the vision that we are continuing to progress towards building on the pillars of prevention, partnership people and performance. Alex Cole-Hamilton, I am very grateful for the cabinet secretary for giving way. I absolutely endorse her remarks about collaborative working across the third sector and the public sector in terms of reducing negative social outcomes in our community. How does that marry up with the cut that represents nearly a quarter of the budget to alcohol and drug partnerships in our community? As I have just said, the focus needs to be on outcomes. The Scottish Government has already invested over £630 million to tackle problem alcohol and drug use since 2008. If you look at the outcomes for the last year, 2016-17, those standards that have been set within the LDPs have been met. In fact, the three-week target for access to alcohol and drug treatment has actually exceeded the 90 per cent target and is 94 per cent. We need to focus more on the outcomes and what we will be working with shortly to set out indicative allocations and expectations in respect of ministerial priorities and outcomes that are to be achieved by boards and other partners. What we will expect is not just the Scottish Government money but the resources in our health boards and our local authorities to be working together to make sure that they deliver on those priorities and, importantly, those outcomes. We are making a significant investment and structural reform with the aim of prevention. Again, I want to cite some examples. The early years framework, the children and young people improvement collaborative, is crucially important. The reducing re-offending change fund, the Scottish attainment challenge and, of course, importantly, the integration of health and social care. I want to draw on one or two of those to illustrate that work. The defining mission of this Government is to deliver excellence and equity in education. We want to see the poverty-related attainment gap in Scotland close wherever, whenever and however it is measured. That is why we have committed £750 million during the course of this Parliament through the attainment Scotland fund, targeting resources at the children's schools and communities most in need. Through the Scottish attainment challenge, we want to break the cycle by improving literacy, numeracy and health and wellbeing, raising educational attainment and increasing positive destinations for our most disadvantaged children. That is a good example of primary prevention, alongside, of course, the fairer Scotland action plan, which sets out 50 concrete actions that will take over the course of this Parliament to tackle inequality. I want to, given my own portfolio and trust specifically, turn to one of the biggest structural changes that we have initiated and the very ambitious reform of health and social care services in Scotland, really since the creation of the NHS in 1948. That has brought about a fundamental realignment of resources that will build the capacity and strength and preventative action of our community-based services. It is clear that making a decisive shift towards prevention requires a fundamental change in the relationship between people and public services. Modern healthcare means embracing the public as partners, not as passive recipients. It is about realistic medicine. Christy got it right when he said that we have to consider our structural systems to ensure that they are better aligned to help deliver our preventative agenda. With that in mind, I cannot mention that work under way with local government to agree a set of national public health priorities that will inform local, regional and national action. Our aim is for public health thinking to be embedded in all parts of the public sector. Our shared priorities will be those activities that have the greatest potential to make a significant improvement to health gain, tackling inequalities and promoting inclusive growth over the next 10 years. Work has already started to develop those priorities. I will be engaging widely over the spring and summer to build consensus and momentum ahead of publishing priorities at the end of the year. I think that we can all agree that prevention has a potential to reduce demand for services arising from poor health. I hope that we can also all agree that there are many aspects to a preventative approach that impact at different points in people's lives, sometimes at a population level, sometimes directly with individuals. I hope that we can also agree that the prevention of poor health outcomes is not just a matter for the NHS and its professionals but encompasses the activity of the whole of Government and the whole of our public services. If we get our public services better aligned, working more closely with the people that they serve, we will make progress. To do so, we also need to develop and promote a strong, shared narrative and show continued collective leadership on this issue. Within the existing structures we have seen real successes in tackling the burdens of preventable disease. Life expectancy and healthy life expectancy have both improved significantly in Scotland over the past decade. We need to take that on and, by shifting our focus to prevention, we can make a further difference to the lives of people living in Scotland. I am sure that the Health and Sport Committee of this Parliament will help us in that endeavour. I am delighted to open for the Scottish Conservatives on this Health and Sport Committee debate into preventative spending. For the obvious reason, the debate raises issues that require urgent attention as we consider the health of Scotland's population and the consequences that it has for our NHS, not just in the next five years, but in the next 15 years, in the next 25 years, even in the next 50 years. The issue of preventative health was brought into sharp focus for me very early on as an MSP when I met two charities in the same day. Each charity dealt with two wholly distinct health conditions. One was concerned with diabetes, the other with liver disease. When asked about the solutions that were needed to make lasting inroads into those conditions, the same answer was given. We need to meet people to live a healthier and more active lifestyle. We spend a lot of time talking about the state of our nation's health and I personally participated in a variety of debates, both members' debates and general debates in this chamber, where major health issues have been discussed at great length, but scarcely have issues surrounding the root causes of so many of Scotland's ills being laid bare, as well as how we in this Parliament can focus resources on prevention rather than just treatment. There are a lot of varying opinions, of course, when it comes to Scotland's health. That's the nature of politics, but we must first be honest about the situation before we can act. It is clear that Scotland is in a desperate situation and we need to act now so that future generations will not suffer from the big health problems that we see today in such significant numbers. As the motion states, it is also clear that we need to bridge the gap between the wealthiest and the poorest in terms of health inequalities. I am delighted that, as well as being on the Health and Sport Committee, I co-convene the CPG on health inequalities along with Anna Sauer and Claire Hocky. I know that there are a number of other MSPs who play an active role in that group where we discuss those issues with professionals and interested parties. Scotland is highly unequal and has the widest mortality inequalities in Western Europe. The poorest Scots are three times more likely to commit suicide, more likely to die of cancer, more likely to suffer from a stroke and more likely to die as a result of an alcohol-related condition than those in the most affluent parts of Scotland. Almost a third of our adult population are obese, costing our health service up to £600 million per year, and Scotland continues to have the worst weight outcomes of any of the UK nations and among the worst of any OECD nation. Around one in three children live with at least one binge-drinking parent in Scotland. No one political party, professional or individual is to blame. This is a cross-party and cross-society issue and we must all be prepared to be honest about the state of Scotland's health. Only then can we move forward and tackle the challenges head-on. We must also be mindful of the fact that, with poor health outcomes, there are a range of social factors that feed into this, which we must consider and the motion acknowledges that. Education and equality is a significant factor with Scotland's poorest children, on average, 31 months behind children from wealthier backgrounds in sciences on reading and on average 26 months behind in mathematics. Similarly, affluent pupils are four times more likely to attend university than to pride pupils. We cannot expect to reduce the health and equality gap without closing the education attainment gap. I acknowledge that the cabinet secretary for health mentioned that in her speech. Turning to the committee's work in this area, I would like to pay tribute to my fellow members on the committee and the committee clerks for all the work that they have done, the initial work at least, in placing preventative health at the forefront of what the committee has done in its first year. I think that we all recognise the importance of highlighting the radical action required if we are to avoid significant issues in terms of chronic conditions that may arise in the future unless focused preventative spending is undertaken now to deliver a more active and healthier population. I understand that this is a complex area given that the success of any prevention strategy is never really known for some time and it does require time and input from all sides of this chamber and beyond so that we get it right. When the Health and Sport Committee called for written submissions from organisations and individuals on the preventative agenda, it received 67 responses from a range of charities, governmental organisations and professionals who have detailed innurable statistics and analysis about the poor state of Scotland's health. If I may, I would like to concentrate on two areas where the committee has been active. In fact, even prior to the actual inquiry, the first was in undertaking a report on increasing participation in sport. Some members of the committee visited Avimor and Kengusi in my own Highlands and Islands region to look at the work of Highlife Highland and the role of community sports hubs in a rural setting. It was hugely instructive to see on a community level the degree of engagement and co-ordination between a large variety of organisations from schools to rambling clubs who are coming together with the sole aim of achieving greater participation in sport, as well as the role of senior pupils in school providing leadership to younger pupils. Secondly, the committee sessions at the end of last year on obesity were very illuminating. One specific issue that was also covered in my members' debate in January was a link between obesity and cancer. As I noted in that debate, it is estimated that around four in every ten cancer diagnoses are preventable. Cancer Research UK have noted that obesity is a single biggest cause of preventable cancer after smoking and is linked with 13 different types of cancer. Around 10 per cent of bowel, breast and womb cancers in the UK can be prevented by being physically active for at least 30 minutes a day for five days a week. I hope that I provided a brief overview of the immense challenges that Scotland faces. I know that my colleagues and others in this chamber will go into greater detail about specific areas of preventative health that we must explore. In closing, I would observe that it is also incumbent on us to challenge established orthodoxies. Whilst we all accept the role of the preventative agenda and the principles behind it, we must be able to have a frank and candid discussion about where money is spent and how it is spent. There may be some programmes that we have supported in the past but which we need to give up because other avenues would provide better results. The committee's inquiry must be alive to radical and innovative thinking given the scale of the challenge before the country. I again note what the cabinet secretary said about identifying new and challenging areas. There are a lot of people counting on us to explore this topic, to identify solutions and to implement change, and only with open discussion will that occur. I am delighted to offer the support of my party to the motion today and the on-going work of the committee in this area. Colin Smyth is a privilege to open on behalf of Labour on an issue that I know is so important to all members of the health and sport committee. When Labour created the NHS in 1948, life expectancy in Scotland was 64 years for men and 69 for women. Today, it is now around 77 for men and 81 for women. It shows the success of Britain's greatest achievement of our NHS, but we all know that for far too many Scots today, from the very moment they are born, simply because of where they are born, that life expectancy of 81 or even 77 is something that they are unlikely to achieve. The very first paragraph of the previous health and sport committee's report on health inequalities in 2015 summed it up when it chillingly read that a boy born today in Lens-Easton-Bartonshire can expect to live until he is 82. Yet a boy born only eight miles away in Caltyn on the east end of Glasgow, life expectancy may be as low as 54 years, a difference of 28 years or almost half as long again in his whole life. It is not only life expectancy, and the most deprived areas may all spend 22.7 years not in good health compared to 11.9 years in the least deprived areas. Those figures show that tackling health inequalities has to be at the very heart of any debate on preventative health. They are inextricably linked, and if you want to prevent ill health, you need to tackle health inequalities. If you want to tackle health inequalities, you need to tackle inequalities in wealth, in education, in transport and in housing. We know, for example, that being in work and your income is fundamentally associated with your health. In Scotland today, we suffer from record levels of under-employment, job insecurity, zero-hours contracts and low pay. That means action on the real living wage, whether we show ambition in user tax, powers and how we manage our new social security system will all have a major impact on inequality and, therefore, on our health. Indeed, following the publication of the Scottish Public Health Observatory report in 2014, Dr Jerry McCartney, head of the observatory at NHS Health Scotland, said that, although tax options may not seem to be directly health related, they will save lives and ultimately save the NHS precious money and resources. Those interventions that redistribute income, such as increasing the standard rate of income tax or implementation of a living wage are among the most effective interventions for reducing inequalities and improving health. It is clear that the solutions to health inequalities cannot simply be tucked away within policies on health and social care. As Neil Findlay has already highlighted, the Scottish Government's recently published health and social care delivery plan disappointingly has little to say about tackling health inequalities. It fails to acknowledge the notion of health in all policies highlighted by a number of submissions so far to the Health and Sport Committee's inquiry. The importance of a cross-departmental approach to health was also highlighted by the Christy commission when it published its report in 2011. It stressed the need for community planning partnerships to have an understanding that health inequalities aren't purely a concern of our national health service. Christy called for the strengthening of democratic accountability of a joined-up public sector leadership approach and given public sector staff the freedom to develop approaches in accordance with local circumstances rather than a top-down approach. The extent to which that has happened is debatable, given that the most significant reform that we have seen in the management of public services in recent years was the establishment of centralised police and fire and rescue services. The reality is that tackling health inequalities has to be put at the centre of all-government policy development, for example carrying out health inequality impact assessments for all policies and plans. All-government departments in public services need to play a key role in reducing inequality whether that's delivering accessible public transport, affordable sport and leisure facilities, decent, damp-free social housing or properly funded local services. There's a need to get serious about a more joined-up approach to the delivery of services and the pace of change needs to be increased. When the short time I have, let me give just one brief but simple example, the co-location of money advisers in GP surgeries. We know that primary care is the access point for the majority of people in the NHS, but not everyone needs to see a GP. Having additional services in GP surgeries helps to take pressure off our already overstretched GPs. With £2 billion worth of benefits unclaimed in Scotland and the cost of co-locating a money advice specialist in a GP surgery just delivered £1,500 with an estimated return on investment of £39 for every £1 spent, that is exactly the type of practical measure that recognises the clear link between inequality, poverty and health. Crucially, as is clear in the evidence so far to the committee, there's also a need for a relentless focus on the early years from pre-birth onwards. Stimulating learning in very young children and preparing them for primary school is essential to help break the cycle of health inequality. While tackling health inequality and therefore preventative health is a cross-cutting issue, there's still very much a role directly for health and social care. In public health, we know that Scotland faces an obesity crisis with two-thirds of adults and almost a third of children classed as overweight or obese. The current obesity framework isn't working and if the Government, when refreshing that strategy, proposes a bolder, more radical replacement which includes tougher regulation on the current promotion of unhealthy food over the healthy option, it will get Labour's backing. There's also a need for a revised and tougher tobacco strategy setting out the priority actions and clear targets along the way to measure progress towards the Government's ultimate welcome aim of smoking prevalence below 5 per cent by 2034. With Scotland continuing to have the highest level of alcohol consumption and harm in the UK, the need for a new alcohol strategy is also clear. In all those areas, obesity, smoking, alcohol-related harm, there are inequalities with people living in the most deprived areas most likely to be affected. Ultimately, with any strategy, it is the implementation and resourcing of that strategy that will be crucial, which is why the issue highlighted by Alex Cole-Hamilton, namely the recent decision by the Government to reduce funding for alcohol and drug prevention, is one that is deeply regrettable. We need to have an honest debate about how we resource our NHS. We all accept that we have an ageing population and more people with more complex needs. Despite the growing demand for services, local health boards are being hit by significant health savings of £1 billion over the next four years. Those savings come at a time when the NHS is also struggling to recruit and retain staff, a problem that is exacerbated by the number of unfilled trainee and specialist posts. One in four of our GP practices report a vacancy. There are 350 consulting vacancies and more than 2,500 nursing and midwifery vacancies, including more than 300 unfilled mental health nurse posts. If we do not stop those cuts and have sufficient staff, it will make all the more challenges for health boards and integrated joint boards to shift the balance of resources from reactive to rented of spend and to better focus resources and priorities on health inequalities. This Parliament has the powers to stop those cuts to make different choices to be progressive. To say that if we want decent health and social care, we need to ensure that we fund them properly. That means being honest with the public and saying that those with the broadest shoulders should pay that bit more. We now move to the open debate. I suggest that we have plenty of time to take and make interventions. I call Emma Harper to be followed by Brian Whittle. Before I begin, I would like to remind members of my interests. I am co-convener of the Lung Health Cross-Party Group and I participate in other cross-party groups that are health-related as well. I too recognise the importance of the work that the Health and Sport Committee in its inquiry into the preventative health agenda is undertaking. I thank the convener and members and the clerks for their hard work. The local health delivery plan guidance says the nature and scale of the challenges that our NHS faces, in particular the challenges of an agent population and the challenges of dealing with health inequalities mean that we need to change the way that our NHS delivers care. The plans recognise that we must prioritise the actions that have the greatest impact on the service delivery and focus on three areas, often referred to as the triple aim, better care, better health, better value. The Christie commission estimated that 40 per cent of all health spending was spent on interventions that could have been prevented. The commission insisted that focusing resources on prevention measures must be a key objective. Obesity, diabetes, coronary heart disease, stroke, cancer, mental health, dementia and alcohol-related diseases are major issues affecting people in Scotland and more so in lower socioeconomic areas. We are already seeing a reduction in the mortality for the big three, cancer or non-respiratory cancer, coronary heart disease and stroke, due to the targeted multidisciplinary teamwork that has been implemented across Scotland. In the chief medical officer's annual report realising realistic medicine, it showed between 1994 and 2015 there was a 36 per cent reduction of all causes of premature mortality. There is a graph on page 48 that clearly shows the mortality reduction for the big three. NHS boards and teams of professionals working together have been able to achieve that. Today I would like to focus on Scotland's lung health. It has been 10 years since the ban on smoking came into force on March 26. Banning smoking in cars with children as passengers is a move that has been commended recently by health professionals across Scotland and my former colleagues in the respiratory team at NHS Dumfries and Galloway. The number of deaths attributed to respiratory disease has flatlined and there has been little change over the last 20 years. The reason for the fall in mortality in other groups is due to a concerted effort with Government support to target the big three in Scotland. At the Lung Cross Party group, I have the privilege of meeting specialist doctors and other multidisciplinary professionals who have the prime directive of improving the lung health in Scotland. Representatives from the British Lung Foundation, Chest Heart Stroke Scotland and Asthma UK also attend. The BLF published the battle for breath. This document looks at lung health across the UK. The big picture is that the UK lung disease mortality is among the highest in Europe. The overall cost for lung health in the UK is £11 billion a year. It is £1 billion in Scotland. The BLF paper makes recommendations for similar investment and attention that cancer and cardiovascular disease have had. Across Scotland, there are wide variations in the care given to people with lung conditions like asthma, lung cancer, COPD, idiopathic pulmonary fibrosis, mesothelioma and more. However, there is great work already being done. Action is already in place to prevent unscheduled hospital admissions, which contribute significantly to higher costs of overall care. Patients are taught to self-monitour their vital signs and use a scoring system that triggers action based on the severity of the score. Patients recognise the symptoms of exacerbation of their lung condition and can act by getting an antibiotic prescription instead of a hospital admission. NHS Lothian has a light-touch, telehealth person-centred approach to prevent or reduce unscheduled admissions. NHS Dumfries and Galloway's multidisciplinary team is testing a community respiratory early warning score or cruise score currently. Fewer exacerbations lead to fewer admissions and a reduction in costs. However, more could be done. We have a national respiratory advisory group, the NAG group, which is chaired by Dr Ian Small. They are working on a respiratory quality health improvement plan with the intent to it being delivered across Scotland. The current document is being created and is based on the Welsh and Northern Irish respiratory improvement plans. I would like to suggest that the respiratory experts need Government support to implement a national respiratory quality improvement plan or an ARCWIP. A strategy with some Scottish Government assistance, with co-ordination and support so that the deaths from lung disease can be reduced and hospital admissions can even be reduced. Presiding Officer, this is what I would like to ask the Scottish Government for, to consider supporting the respiratory advisory group to create a short-life working group or a task force to, number one, agree on a national ARCWIP and then, number two, help roll it out. I would like to call on the Scottish Government to consider support in the next steps for healthier lungs for those affected in Scotland. The work of the Scottish group would not be an uphill battle. The template has been created already and the battle for breath has already begun. I have Brian Whittle to be followed by Bob Dorris. Thank you, Deputy Presiding Officer. I start by thanking the Health and Sport Committee for its work to date on the issue of preventable health agenda and bringing it to the chamber to debate and discuss. As most of the chamber will be aware, it is a subject that I have a particular passion for. In the short time that I have, I would like to focus on the relationship between physical activity, food and nutrition and how they can contribute to the preventable health agenda, especially when early intervention is possible. It is widely acknowledged that having a healthy diet and an active lifestyle will certainly stack the cards in your favour when it comes to preventing many conditions like cardiovascular disease, stroke, type 2 diabetes, degenerative musculoskeletal issues, certain cancers, heart disease among others. We must also include poor mental health as a condition that can be prevented in many cases by an active, healthy and inclusive lifestyle and is certainly useful in many cases in the treatment of mental health issues. The AMH has stated that prevention and treatment of poor mental health should include inclusivity and physical activity. In fact, so sure are they of that, that they are helping to fund the Jog Scotland programme. The fact that a general lack of physical activity and poor diet is leading to a BCD epidemic with many above conditions increasingly appearing as comb oriddy problems, disproportionately so in the more challenging areas. Access to opportunity is certainly a main area that we need to explore and to ensure that opportunity to participate is available to all irrespective of background or personal circumstance. Incidentally, we must also understand the differences between physical education, activity and sport. All are intrinsically linked, all are crucial but all are very different. Getting active as early as possible should be the goal. With the advent of 30 hours of free school childcare, we have the opportunity to use those hours constructively in an active play framework. As I have said many times, the physical and mental pathways for life are mostly set at the preschool age, so focus should be on this age group. Having an active healthy lifestyle in the early years is likely to set the foundation for an active healthy lifestyle for the rest of their lives. Following on, we need to ensure that when children reach primary school, the active framework continues into active games and on into activity and sport by secondary school. Access is the key. Tackling barriers to participation to give opportunity for all. One of the solutions is surely to keep schools open after 4pm. If children need to go home from school and then go somewhere else, the drop-off rate will be high. While they are in school, they are a captive audience and with the right opportunity and encouragement, the physical activity uptake will be more likely to increase. A Child Poverty Scotland report suggested that some children from families with more challenging circumstances are saying that they are not interested in participating in sport and activity, rather than asking their parents if they can take part knowing that they are likely to be told that they can't. Surely by opening up extra curricular activities at school, that barrier can begin to be addressed. The other issue in terms of participation that I would like to raise is that of having enough appropriate teachers and coaches to ensure access to opportunity. That is borne out with the increasing waiting lists at clubs in many sports. There are solutions out there, however. Perhaps we should be looking at that section of the population that has life and work experience aplenty, those approaching retirement and already retired. When I was the manager of the Glasgow athletics development scheme, we had 43 coaches on a rotor working with school children who came from all over Glasgow to the Kelvin hall. All of those coaches were retired. Intergenerational social interaction, purpose and activity, quite a few boxes ticked here. There are always options worth exploring. Poor diet is an area that the Scottish Government has a direct input into. From nursery education right through to primary and secondary schools, in our hospitals or even our prison service. When doing some investigation into public food procurement policy through the Scottish Government Excel contract, I discovered that a size over a proportion of food that can be produced by our farmers is in fact sourced from outside Scotland and the UK, and much of it is reduced quality from that that is locally produced. I welcome the Deputy Minister's decision to investigate the nutritional quality of food serving schools as a result of this report. However, I would also encourage the health secretary and the justice secretary to do the same for hospital food and food serving prisons. By ensuring that the highest quality food sourced locally is available from nursery education onwards, the Scottish Government can have a significant impact on diet, especially in the earliest years. Neil Findlay. In relation to his contribution, what we are looking here and we are debating about is a whole Government approach, a whole societal approach to improving health, particularly those of children. How, for example, does the UK Government's social security policy contribute to that? Ryan Whittle. I think what Mr Findlay is alluding to is the inequality of income. Obviously that has a bearing, but I think also what we have to acknowledge is that there is the cost of participation as well as an impact. I think that we have got to be really careful here because they are both intrinsically linked. I recognise Mr Findlay's desire to tackle that issue. I have been in committees with him when he said that. I think that you have an answer that you are trying to get to and you are trying to find a question that will get you there. I think that what we have to have is a much more open mind into a much wider, as has been stated in the chamber already, a very wide issue. By ensuring that the highest quality food source locally is available from nursery education onwards, the Scottish Government can have a significant impact on diet, especially in the earliest years, where intervention will have the greatest long-term impact. It is also important to note that the good nutrition plays in mental health as well as physical health. According to the report by the Mental Health Foundation, Food for Thought, nutrition is a factor for mental health in the same way it is for physical health and plays an important role in prevention, development and management of diagnosed mental health problems, including depression, anxiety, ADHD and dementia. In establishing the activity levels of Scotland and the potential impact of top-level sport and increased participation levels, it is important to note that, within those figures, the increased waiting lists for sports clubs are not included, nor the people who are inactive and would like to be active but do not know how to or have the means to do so. Do not throw the baby out with the bath water here. It is crucial that we recognise that investment in physical education, physical activity and sport at all levels is crucial if we are going to seriously tackle health inequality. The truth of the matter, Deputy Presiding Officer, is that preventable health agenda is primarily an educational intervention, not a health portfolio intervention. I once again thank the Health and Sport Committee for giving us the opportunity to debate this in the chamber. I call Bob Doris to be followed by Monica Lennon. Thank you very much, Presiding Officer. I am delighted to speak in this afternoon's debate and I commend the Health and Sport Committee on a constructive and proactive approach to its inquiry. As a previous deputy convener of the last session of the Health and Sport Committee and with Labour's Duncan McNeill as convener at that time, I certainly know he'd be pleased that the approach to current committee is taken and I have a strong interest in this area as well. As I tend to do in those situations, Presiding Officer, I want to talk about how, by getting such cross-party and cross-pallant support, you can really derive change. In the last Health and Sport Committee, we got significant change in relation to accessing new medicines and medicines for rare conditions and regulation for care for older people. We achieved that by coming together not in a tribal way but in a cross-party, constructive and proactive way and we drove real achievement there. Sometimes you get that cross-party approach in committees, but not always in this chamber, so it could take transfer over to this chamber from time to time. I know of the privilege of convening the local government and communities committee in this Parliament and housing is a huge part of our committee's remit and then police housing is contained within the terms of the motion before us this afternoon. Housing has a key role to play in preventative spend. Health and social care integration is a significant step forward, as we've already heard, in the journey for joining up services locally. In Glasgow, for instance, there's been a significant progress made in tackling delayed discharge from hospital. However, pressures do still exist, as there's additional progress needed in supporting vulnerable residents in their own homes or in the most appropriate homely setting. I should commend Glasgow on including housing within its integrated joint boards. That's a real positive step and it's the right thing to do. I'd be keen to know how many integrated joint boards across Scotland have included housing and what consideration the Government would give at some point in the future to making that a statutory requirement of success would start to be evidence-based in relation to that. I'd like to outline some of the issues with regard to housing in my constituency within Mary Helen Springburn. It can be difficult to find an appropriate housing and care solution for many individuals and families in my constituency, particularly sometimes when an older person is failing health in their own home. My constituency has a number of low-income homeowners, often elderly but have to say not always whose health is failing in the suitable adaptions at their home or the alternative accommodation. Let me give you some examples in relation to that. An elderly lady that I'm working with is seeking to get a housing association to buy back her property. It's on the second floor and, without a ground floor property, she'll be isolated and she'll be housebound. We have to ensure that social work services are rather health and social care board. What's collegiantly with a housing association to make that happen and make sure the financial models that underpin that both suits the care at home services that that person needs and that it's seamless because that individual can't sell the property and not an appropriate place to go to. There has to be a seamless entry to support for that elderly individual. Another elderly constituent of mine who is also a homeowner is unable to return home at present, the property would require significant adaptions and the best outcome might even be an extension to that property. That puts huge challenges on budgets, of course it does. It puts huge challenges on how adaptions criteria at a local authority level can meet that. Do we need new funding models to make that happen? There's equity in properties there. Do we have to think more carefully about how we get a joined up process and a joined up system so there are opportunities there if we think proactively out of the box and how we can take some of those things forward? I'm trying to give a flavour of how I hope the local government committee perhaps may seek to work in partnership with the health and support committee in relation to some early intervention work because, as we know, if a person stays at home with the appropriate support for longer, they're not only happier and healthier, they have a slimmer care package and the cost of the public purse in the long term is reduced, everyone can be a winner in that situation. It's getting the model right to make it happen. Can I say a little bit more about some of the debate around preventative spend? Quite often we get into a statistics war in relation to more money being spent in the community in terms of the acute sector. I think that the Scottish Government is accounted for some of its spend unwisely. I think that the acute elective surgical centres that are going to be opening up across Scotland puts money of investment in the column of acute services showing that we're going in the wrong direction where we all want to see more money put into community services but I can't think of a more appropriate preventative spend than giving people the hip operations, the knee operations, the cataracts operations that they need to stay in their own home. If they don't get those quickly and timeously, the slips, trips and falls is a huge issue. By that investment that the Scottish Government is making, it's actually making the situation look worse than it really is. This is a positive preventative spend investment and I don't think that we account for it properly. Maybe I'll say another thing that comes up when we looked at this in the last committee quite a lot, and that's in relation to the inverse care law that comes up quite a lot. That tends to be an argument to move away from universal services to target those living in poverty. I think that it would be unwise to move away from universal services. In the last committee I was convinced that you must be wed to universal services but look at an additional uptake drive for the areas. It's not just the worried well and more income well-off areas that are making use of those universal services but do you have time, Presiding Officer? Neil Findlay. Mr Doris will be familiar with the principally proportionate universalism where there's a universal service but the areas that need it most get more. Does he not agree with that principle? Bob Doris. I thank Mr Findlay for that intervention. I think that that's the direction that the Government is hoping to move in. We have to put the financial models in place to underpin that. I was going to go in and look at the GP's practices that are within the deep end areas, many of them in my constituency. To a degree, they are very well resourced but if someone is going in there with multi-marbidities with five, six, seven things wrong with them, that 10-minute or 15-minute appointment, you don't get enough opportunity to get the support compared to someone going into a GP surgery in an area with one health condition or for a preventive health measure that they are seeking support of. The final thing that I want to say if I have a little bit of time in hand is that you can do health to people as much as you like but what we have to do is empower people to make positive choices in their lives. That links into the Scottish Government's community empowerment agenda and it links into proper local regeneration initiatives and it's only right that I should name check in my constituency Royston, a deprived community where the local authority was doing no regeneration but they did their own, they got their own regeneration plan and they now have taken land which was wasting away back to be redeveloped for the community and they've got money for a local community centre but it was the community's priorities, not the council's priorities and in Springburn there's an eyesore called the talisman pub. What's that got to be preventative spend? Well that pub has been sitting there withering away for generations now. If the community saw that demolished and something happened to that land they might just buy in a little bit more to community regeneration and you have to get that right for everything else to be right as well. It's about community empowerment, not just doing health to people but asking people what they want for their communities. That would make a huge difference as well. Thank you very much Presiding Officer. We do still have some time in hand. Monica Lennon followed by Alison Johnson. Thank you Deputy Presiding Officer. I'd also like to echo colleagues in committing the Health and Sport Committee for its inquiry into the preventative health agenda. In my role as an equality spokesperson for Scottish Labour so much of the work that I've been engaged in since being elected last year has been focusing on highlighting the causes and solutions to complex health inequalities. Whenever we're talking in this place about health inequality or how we can address Scotland's ill health problems in the long term the conversation always seems to circle back to preventative spend and action. Dealing with health problems after they've already occurred is much more difficult and costly to us as a society than it would be if we had taken preventative action to stop preventable health issues from arising in the first place. We know this but we also know that the prescription for preventative health care is not as simple as it sounds or as politicians would like it to be. Preventing health inequality which is so often ingrained in the first days of life requires cross-cutting action across Government, right across housing, education, the environment and more. There is certainly no one easy fix but that's why it's welcome that the committee has taken the time to conduct its inquiry and to build on the work of the Christie commission from previous sessions. In taking forward the findings of this inquiry I welcome the focus on the cross-cutting nature of preventative action and welcome the BMA's suggestion of a health and all policies approach. Such a policy is certainly an intriguing idea and further investigation by the committee of how this could be achieved would, in my view, be very worthwhile. In the time that I have today there are two particular aspects to the preventative health agenda I'd like to draw attention to. Having mentioned in my opening remarks about the importance of cross-cutting intervention an issue that I've consistently been raising over the past few months requires exactly that. The question of how do we improve the mental health of people in Scotland and how can we achieve this in a meaningful cross-portfolio way? Tackling Scotland's mental health problems needs urgent investment in the early years and adolescent support because failure to intervene at that crucial developmental stage only leads to storing up further problems later in life and we know that half of all mental health problems start before the age of 15. We know that there is a current crisis in waiting times for CAMHS with over 300 children waiting more than a year to be seen last year and thousands more waiting for months upon months for help. Even then we know that several hundreds of those children are being rejected for treatment with no further explanation or clear pathway to alternative support. More children coming forward for help with mental health struggles might well be a welcome sign that stigma surrounding mental health is reducing but it's also a sign that investment to make sure those who require medical help can receive it must also be coupled with preventative action to provide support for those whom CAMHS is not always necessarily the most appropriate destination. That's why Bernard Rose Scotland recently backed Scottish Labour's plan for an independent review of rejected referrals. It's welcome that the Scottish Government have indicated a commitment to an audit of referrals in the mental health strategy but I was also disappointed alongside a number of mental health charities including the NSPCC and SAMH by the lack of ambition and lack of detail on funding and timescales in the strategy when it comes to other preventative action. Most notably that there is still no concrete commitment from the Government to back the plan for school-based counselling. Having a qualified counsellor in every school would be a welcome step that the Government is cognisant to the importance of prevention. It would be a clear, targeted action to improve the wellbeing of our children at the early stages and could be a crucial link in spotting and preventing mental health problems in their early stages by providing support to young people quickly at the right time and in their own environment. That's why I've been consistently pressing the Government for further detail on how the dedicated mental health minister is working with the education secretary but despite some reassuring and welcome words the fact remains that the lack of action in the 10-year mental health strategy is disappointing. That type of preventative cross-cutting action is the bold vision required to transform Scotland's mental health services. Early prevention work like that is vital to reducing the harm of poor mental health, which in turn could have a transformative effect on reducing the pressure that mental health problems can have on other public services. That brings me to the second aspect of the preventative health agenda that I hope to draw attention to, the impact of alcohol harm and how we can reduce that also. The Scottish Government has pledged to bring forward another strategy on this later this year and I agree with the view of Alcohol Focus Scotland that that presents a unique and excellent opportunity to set out the actions that we need to reduce alcohol harm in Scotland. I hope to see the Scottish Government commit to some bold preventative action including a commitment to tackling marketing of alcohol to children and licensing regulations to reduce the availability. The effects of alcohol harm are most acutely felt in the most deprived communities with those living in the poorest areas up to five times more likely to suffer an alcohol-related death than those in the least deprived areas. Given that the funding for alcohol and drug partnerships that others have mentioned today has reduced by 22 per cent in the last financial year, a cut that is being maintained in the current budget, I think that it would be a welcome move for the committee to investigate the impact of preventive spending to reduce alcohol harm more widely. Given the cost of alcohol harm across many portfolio areas, it would have a significant impact. In closing, driving forward the preventative health agenda will be crucial to the development of health policy during the lifetime of this Parliament. The health and sport committee's work on the topic so far is promising. I look forward to seeing them take up further investigation on preventive spending. Alison Johnstone to be followed by Marie Todd. Thank you, Deputy Presiding Officer. I'm glad to contribute to this debate and to reflect on evidence that the committee has heard so far as part of our inquiry on the preventive health agenda. It's a timely inquiry which questions our public health spending priorities and challenges assumptions about shifting the balance of care. I'd like to thank all of those who've submitted evidence to inform the inquiry and provided briefings in advance of this debate. I'd like to thank our clerks and researchers, too, for their on-going support. The committee's motion rightly stresses the cross-cutting nature of health inequalities. We need a decisive focus on health from a range of portfolios, including housing, education and the environment. We need to tackle serious systemic threats to public health like air pollution. It causes as many deaths as lack of physical activity. Research led by Professor David Mewby at the University of Edinburgh and British Heart Foundation, 12 miles away from here at the Royal Infirmary, has demonstrated that particulate matter from traffic has a serious impact on our cardiovascular health. Urban air pollution presents a serious risk to young children, to pregnant women. It's been linked to premature birth, decreased lung function and even neurological disorders. The House of Commons will lead an unprecedented joint inquiry on air quality, including the Environmental Audit Committee, the Environmental Food and Rural Affairs Committee, the Health and Transport Committee, and I'd really like to see equivalent joint-up action here in Scotland. Friends of the Earth show that air pollution causes over 2,500 early deaths in Scotland every year, but I don't believe the matter is taken seriously enough. My colleague Mark Ruskell will soon be putting forward his bill to change the default speed limit, which will be a great step forward. Presiding Officer, I'd like to emphasise the fundamental importance of income and the impact that poverty has on health and wellbeing, because we won't make real progress in tackling health inequalities until we take real steps to reduce inequality of income and wealth. NHS Health Scotland has laid out clear evidence that inequality damages our health and recommends introducing a minimum income for healthy living, more progressive taxation, and building a more vibrant democracy. Those are all Scottish green values, and we believe that preventative approaches to healthcare don't simply mean providing some services at a slightly earlier stage of illness, but fundamentally rebalancing our approach to public health. The state of child health report published by the Royal College of Pediatrics and Child Health shows that we need a transformation in our approach to child health. There's a particularly urgent need to tackle child poverty because of the lifelong effect that growing up in poverty can have on health and wellbeing. The Social Security Committee, in which I also sit, has heard how the Healthier, Wealthier Children income maximisation programme developed in NHS Greater Glasgow and Clyde raised over £13 million over the last seven years for families in poverty, and it increased the uptake of healthy start vouchers, too. I'm glad that the cabinet secretary has agreed to roll out this approach across Scotland. The child poverty action group has welcomed this, and they would welcome further details about how the extension will be implemented and funding. I believe that the Scottish Government's proposed reforms to maternity services, including individualised anti-natal care for all women, presents an ideal opportunity to embed income maximisation across all maternity services. A clear commitment to this must appear in any delivery plan leading from the child poverty bill. I also believe that this is the right time for a right to income maximisation services to be put on a statutory footing. Those actions are crucial because, sadly, child poverty throughout the UK is predicted to rise. The UK Government's decision to scrap child poverty targets was shameful and limiting tax credits to a family's first two children is wrong. Beggars believe that women are expected to prove that they have been raped to receive tax credits for other children. I cannot begin to understand why anyone would ever think that it is acceptable to put a form like this in front of anyone, and it is shameful that the Conservatives support it. Policies like this are hugely damaging to physical and mental health. We want to provide more support for financially vulnerable families, not less. That is why the Scottish Greens have been calling for a £5 child benefit top-up, which the child poverty action group also recommended. We need to strengthen our focus on tackling health inequalities and child poverty in particular. I have concerns that they are being lost in our debates about preventative spending and shifting the balance of care. The Scottish Government's health and social care delivery plan only mentions the phrase health inequalities twice and does not use the words poverty or income at all. Improving access to primary care and addressing unmet need should be absolutely key to health and social care integration, but there is a lack of clarity about the Government's plans for primary care. We know that the Scottish allocation formula has been reviewed, but the commissioned analysis has not been published and a further review of GP pay and expenses is under way, but details are not available for public scrutiny. The Scottish Greens have stressed the need to ensure fairer funding for GPs and primary care specialists working in areas of high deprivation. There is a case for adjusting the Scottish allocation formula in a way that ensures practices in deprived areas are properly resourced and ring-fencing some funds delivered through the formula for patient care and practice development. The need to strengthen primary care in areas of high deprivation has been recognised for a long time, but progress to achieve this has been slow. The care report stated that resources should be selectively targeted to deprived areas to ensure that patients in those areas have enhanced opportunities to be seen and have their problems dealt with at an early stage. It is time for the Government to provide clear information about its plans to improve primary care in areas of multiple deprivation beyond link workers. They are warmly welcomed, as are the welfare rights advisers who are working in some practices. It is absolutely crucial, that our health services are equipped to meet the needs of an ageing population, but we must not lose a broader focus on families and child health. Mary Todd, followed by Jeremy Balfour. Thank you, Presiding Officer. It is a pleasure to participate in this debate today as a member of the Health and Sport Committee. I take the opportunity to remind everyone that I am a pharmacist registered with the General Pharmaceutical Council. Part of the challenge that we have, as others alluded to in debating this issue, is that there is no single definition of a preventative health agenda. There is general consensus, though, that the preventative agenda is inextricably linked to the health inequalities one, but there remains a stubborn tension between the need to tackle issues and problems that face health and social care in the present and the view that the focus of preventative spend should be on the root causes of health inequality, the upstream socioeconomic factors, mainly the uneven distribution of wealth. Some of the most potentially significant public health interventions that Government and health services can make might take decades to produce measurable financial outcomes. For example, the measures that successfully reduce levels of overweight and obesity in children, which we all care so passionately about, and young adults might not lead to financial savings to health services until those children reach middle to older age when weight-related health complications would otherwise be more likely to occur. Where improved health outcomes are identifiable, it can also be very difficult to attribute particular outcomes to specific public health policies. For example, a variety of policies have been introduced to try to reduce tobacco consumption, but this multi-stranded approach can make it very difficult to attribute success to any particular policy intervention. That makes measuring the cost-effectiveness and efficacy of individual approaches a challenge. It is a real challenge for those of us whose job it is to scrutinise Government spend. A number of the submissions to our enquiry highlighted the false dichotomy between reactive spend and preventative spend, and I want to explore that a little bit with regard to my own profession. There are lots and lots of statistics published that illustrate the need for a more preventative approach to pharmaceutical care and the scope for improvement. Over half of the medicines that are prescribed are not taken as the prescriber intended. More than one in four hospital admissions for older people are related to medication and considered preventable. If we look at asthma, according to asthma UK, there were 1,143 deaths from asthma in the UK in 2010. Approximately 75 per cent of the hospital admissions and 90 per cent of the deaths which then occurred were preventable. Non-adherence to routine medicines has been estimated to cause approximately 48 per cent of asthma deaths. Would more investment in pharmaceutical care here help? Certainly, I hope that it is clear that the better treatment of illness can be considered preventative spend. That illustrates the notion that preventative health agenda is not care cut, nor is it an area where there is universal agreement about approach. In Scotland we have been really bold at times and a recent example I want to take the opportunity to welcome in the chamber today is the approval of PrEP. Scotland has become the first part of the UK to approve a drug which reduces the chance of HIV infection. The daily pill known as PrEP has been approved for use in the Scottish NHS by the Scottish Medicines Consortium, the SMC, and it reduces the risk of getting HIV from sex by more than 90 per cent. Among people who inject drugs, it reduces the risk by more than 70 per cent. As Robert Mackay, the national director for the Terence Higgins Trust, Scotland said, not only will this make a life-changing difference to individuals by protecting them from a life-long and stigmatised condition, but for every person that would have become HIV positive without PrEP, NHS Scotland will save £360,000 in lifetime treatment costs. We have also been bold in the many different measures the Scottish Government has taken to change our cultural attitudes to tobacco and alcohol. One of the questions posed to us at committee was why is there a reluctance to use the most cost-effective forms of prevention the most likely to reduce health inequalities. Measures that use fiscal and regulatory or legislative levers to encourage behaviour change, such as minimum unit pricing or tobacco taxation are very cost effective. But politicians do tend to favour less effective forms of prevention and less effective forms of prevention. Politicians do tend to favour less effective methods perhaps because of the huge pressure from multinational companies which the less effective methods increase inequalities such as individual behaviour change or education on lifestyle and they should only ever be a small part of a comprehensive approach. In Scotland we have taken a comprehensive and bold approach in alcohol and smoking and I would say that we need to take a comprehensive approach to obesity and tackle the quality of food that we eat. We live in an obesogenic environment and we need to make it easy for people to do the right thing and in my opinion this will include using fiscal, regulatory and legislative levers to change culture. I want to finish my contribution by mentioning welfare reform as others have. An inquiry by the UN into the actions of the last Government of Conservative-Lib Dem Coalition found that their austerity policies amounted to systematic violations of the rights of people with disability and with this Conservative Government it continues disabled people losing motability cars means that they cannot work the introduction of universal credit in the highlands has caused severe hardship because of the delays in processing applications and just in the last couple of weeks the introduction of the two child cap for families claiming tax credits why on earth a child with more than one brother or sister is less deserving of state support I cannot comprehend the callousness of the rape clause I'll finish with a quote not from me but from the BMA submission inequalities have remained persistent and cuts to welfare support in particular have undermined progress that might otherwise have been made in this area We do still have some time in hand I call Jeremy Balfour to be followed by Alex Cole-Hamilton Thank you Deputy Presiding Officer and can I thank the committee for the work that they have put in in regard to preparing the support and welcome the debate today where we can air a number of different issues As my colleague has already said early years intervention is perhaps the most significant area where we can help individuals and society if we can intervene to help young children and their families live a healthy lifestyle then we are more likely to have less health implications later on good habits picked up in early life doesn't impact reducing the future of ill health to the NHS loss of economic output and can reduce the chances of risking individuals coming part of crime prison and all the associated costs with that it can impact the quality of learning of life an individual has I am aware as a local councillor here in Edinburgh that within three or four miles of my ward the life expectancy will be five or ten years less that seems unacceptable to me in Scotland today we need to work with all areas of society where we put the money and the resources to help the most vulnerable noble prize winning economist James Heckman who argued that the returns for investments made in early years greatly outweith those made in any stage of education he says optimal investment strategy is to invest less in the old and more in the young I think that is a challenge we face today and when we talk about the young we are not talking about those in nursery or in school we are talking about from zero to three years old it is helping families to set patterns at the earlier stage that will give us the biggest improvement certainly Marie Todd I thank the member for taking the intervention I would ask the member again to reflect on his current theme on supporting the youngest of children might fit with the policy from the Conservative Government and Westminster of not providing tax credits for more than two children and one family Jenny Balfour what we are looking at here is how we can help families generally but we are also looking at how Government both nationally UK and here in Scotland local authorities can direct that help to help individuals and we are the Government and this country has made a decision that we should put that limit on and I think it is a very sensible measure I wonder if I can move on I had this morning the privilege of visiting Dr Bell's family centre here in Leith Dr Bell's family centre has been going for many years here in Edinburgh helping children living in Leith and North Edinburgh where they can get encouragement, support and advice in a very relaxed environment it is there to support and help vulnerable and disadvantaged people from different cultures within that area one of the things that they provide is a dropping centre for nurseries 48 per cent of those that go along to that have English as their second language now sadly Edinburgh City Council and SNP administration has cut the budget for that centre and they are now affecting services that they can provide giving money to that type of centre I think would be much more advantage than a token baby box going off to well of families what we need what we need is to put the money where it helps most and that type of centre is to provide a match so we need to help absolutely excuse me which person were you taking Mr Bell what are you both oh well we have plenty of time for that let's go for Eileen Campbell first I guess going back to the intervention made by Marie Todd which I don't think the member properly articulated I wonder how he can square the fact that he's criticising the baby box which is giving families and giving all children the best start of life with the policy of limiting tax credits to more than two children does he not see that those two comments are contradictory and actually that he should take the opportunity to distance himself from the policies of his UK Government Jeremy Balfour I wonder whether the minister would accept that reducing the amount that is given to local authorities particularly here in the capital city is affecting the amount of money they can then give to third sectors who are doing the most benefit and perhaps the minister would like to reflect that perhaps if the Government supported local government better we wouldn't have these issues I'm happy to take the second intervention as well Stuart McMillan Thank you very much Mr Balfour for taking the intervention The question that I was going to pose was posed by the minister but your response to Mr Balfour also highlights further questions one of which being if Mr Balfour is so concerned about the level of money going to local authorities what did Mr Balfour actually do to lobby his UK counterparts and the UK Government to not cut the budget coming to this Scottish Parliament Jeremy Balfour I think that Mr McMillan must be living in a slightly different world than I am because the money that we got from Westminster Government was more than we were getting last year and it is a decision by the Scottish Government where to give the money that is the choice of this Parliament or this Government and we have given less to local government this year than we had in previous years so I think that the issue is not a Westminster issue it's a Scottish Government Scottish Parliament decision If I can conclude that the time has gone just to re-emphasise the point that I am making that early intervention will help longer term in all areas and we need to look at that very carefully thank you very much Alex Cole-Hamilton to be followed by Ivan McKee I would like to start by expressing my thanks to my fellow members of the health and sport committee for their work in this inquiry and indeed to the clerks who have been able to serve that committee in its work In his forward to the 2011 report in the commission on the future of public services Dr Campbell Christie said that experience tells us that all institutions resist change especially radical change however the scale of challenges ahead are such that a comprehensive public service reform process must now be initiated involving all stakeholders whilst this insight was offered to the micro-institutions that make up our public sector I'm sure if he thought about it he would have ascribed it to this institution as well For a great many years the idea of rhetoric and since the beginnings of devolution we have seen each of us employ the language of prevention but not necessarily the structural and financial investment and culture shift required to see upstream funding reducing negative social outcomes that continues to evade us and nowhere is the cost of that failure demand as has been described by Campbell Christie more evident than in the continuum that represents our health service now it would be easy for me to spend the entirety of my time poking holes and pointing fingers at the failures in command and conduct of this administration's efforts in this area however I believe that one can only offer such criticism with any meaningful credibility if credit is also offered where it is due and as marita Todd has already articulated since we last met in this chamber a Scottish Government through SMC have made the prophylactic HIV medication prep available on the NHS this is a tremendous victory for campaigners and a welcome recognition by this Government that the problem of HIV is still growing serving as it does in many ways is something of a vaccine the widespread availability of prep will help to dramatically lower infection rates at risk communities and also prevent future failure demands for the NHS in terms of the lifelong HIV medication that failure to prevent infection can lead to would that this foresight could be replicated across the board I talked earlier about our health service as a continuum that does not exist in a state of flow but upward pressures exist at every level in that continuum which acts to disrupt that state of flow a shortage of GPs leads to conditions becoming more acute and diagnoses being delayed a lack of appropriate social care provision can lead to patients like my own constituent I've raised in this chamber many times George Ballantyne languishing in hospitals for 150 nights or more after being declared fit to go home for wanted provision and bed blocking in turn sees the cancellation of elective surgical operations like that of Dr Patrick Statham the consultant neurosurgeon at the western general in Edinburgh and in turn we can see severe delays and discharge from A&E into the wider hospital due to there not being an available bed something that is manifest in statistics we see every week in missed A&E waiting targets now we mitigate these blockages through prevention at all stages of life and in all demographies and communities of our society we understand the key stones of prevention but singularly we fail to meet that understanding with preventative spending particularly in addressing health inequalities if we've heard many times in this debate John Mason I thank the member for giving way I just wonder how you could explain where the money is all coming from in this because should we take money away from the hospitals to put it into provision because presumably we can't spend the money on the hospitals and the preventative spending Alex Cole-Hamilton Absolutely I am coming on to the ways in which we can recalibrate the front loading and pump priming of a health service to meet exactly that demand within existing resources so despite a measurable increase in drug related deaths and a causal spike in HIV infection in Glasgow this SNP government has reduced funding to drug and alcohol partnerships by as much as a quarter a cut which totals nearly £1.3 million a year in our nation's capital and despite the cabinet secretary's assurances these cuts have not yet bitten so we have not yet seen the impact on outcomes in our elderly population despite the excellent work resultant from the 2014 falls framework which has put on much to reduce falls in care settings amongst our older population this government has yet to act on the mandate it received from this chamber earlier this year to bring forward a comprehensive fall strategy to tackle what has become one of the biggest causes of anxiety for older people and with good reason given its demonstrable relationship in terms of protracted hospital stays and mortality but as Monica Lennon said it is in the challenge that our nation's mental health particularly among children and young people that this government has been arguably found the most wanting with delays in waiting times that have spanned years and children in abject crisis being turned away from tier 4 beds due to lack of available staffing in her first speech to this Parliament following the election the First Minister was very gracious inciting my party as the catalyst for the appointment of Scotland's inaugural Minister for Mental Health I do not doubt the integrity with which Maureen Watt seeks to launch a brief and the revelation that despite a protracted delay the nascent mental health strategy with spanned 10 years was greeted with great approval from the sector but such transfer was however short lived with such targeted and stretching aims and as I quote support for an increase in support for the mental health of young offenders and yet a further delay of our expired suicide strategy we might start to doubt the condition in mental health and many do with professional bodies greeting the new strategy with this May citing it as unambitious under resourced and profoundly lacking in detail there can be no greater frontier for us as a legislative body to push forward in the healthcare arena and in the preventative agenda than in mental health because with suicide is the principal cause of death in men under the age of 50 with over 600,000 days lost to the workplace due to mental health each year and most crucially for that interruption in flow in the continuum of the health sector that one quarter of all patients who present to appointments in GP surgeries around Scotland do so with an underlying mental health condition Presiding Officer the stewardship of the health of our nation must not be measured by the treatment or absence of symptoms but what we do as a Parliament to keep people well in mind and in body to stabilise chaotic lifestyles to reduce health inequalities to protect vulnerable communities only then can we possibly hope to meet the challenge before us. I have Ivan McKee to be followed by Alison Harris. Thank you Presiding Officer I'm glad to have the opportunity to speak today on preventative spend and the health and sport committee's inquiry into this important subject this debate allows members to make inputs into the committee's work and I hope many will take that opportunity and there are three specific areas that I intend to focus on this afternoon firstly the scale of the task before us we will not provide a modern fit for purpose health service for the 21st century by continuing to do things as we've always done them the need for change is compelling secondly the solutions that are available to us in particular drawn on the work of the Christie commission which has been mentioned several times already and thirdly the imperative to shift the political discourse from the language of inputs to the language of results and outcomes health services across the UK and across the developed world are facing unprecedented challenges indeed advances in health provision have been the victim of their own success an ageing population and technological advances in new medicines and equipment means that health inflation the cost of just standing still estimates range from 4.5% upwards and let me put those numbers into context the Scottish government has committed a health service spend of 500 million over and above inflation for the lifetime of this Parliament more than that committed by any other party however it represents an above inflation increase of less than 1% a year on the 13 billion annual health budget around one third of the increase necessary to match health sector inflation and it's an easy sound bite to call for tax increases to fund this but even easier to see that this isn't a sustainable solution the sums just don't add up matching health inflation of 4.5% for just 10 years would require an annual spend increase of more than 3 billion above inflation by year 10 the equivalent of increasing basic income tax by 7% and this isn't a particularly Scottish problem all health services face this challenge the English NHS has gone down the route of increasing privatisation and 7% of its services 10 times a level in Scotland and is delivering poorer services a gap of more than 10% in any waiting times compared to Scotland and these challenges are real but the direction of the solution is also clear and it isn't cuts to services and it isn't privatisation the Christy commission report of 2011 identified four principles to underpin reform of public services firstly the integration of service provision reducing silo working and the integration of health and social care is a good example of that secondly empower individuals and communities and the Scottish Government's community empowerment bill is a welcome move in this direction thirdly the need for public service to become more efficient through technology or the adoption of operational best practice Christy calls for delivering more with less and the need for prioritisation of spending which prevents negative outcomes Christy went as far as stating of public sector spend was due to fixing problems that could have been prevented by more focus on preventative spend this is a significant number some £5 billion across the health service alone and while it may be ambitious it gives us a view of the size of the prize a country the size of Scotland is well placed to deliver on the Christy agenda big enough to support a full range of specialist and high technology services yet small enough to ensure rapid development of best practice it is also recognised that technology is a double-edged sword better medicines and equipment cost but they also enable efficient solutions in meeting the challenge be that through the use of advanced communications remote diagnosis, IT or advances in operational management processes these must be embraced it is also important to recognise that not all preventative spend actions are effective a robust process for data-driven evaluation of preventative spend proposals is necessary taking into account upfront spend and projected time phase cost savings calculated on a net present value basis and I make no apologies for the use of accountancy alignment in this debate because to be effective the preventative agenda needs to be constantly evaluated in terms of returning investment and here we encounter another problem that data is not as good as it needs to be in general is a surprising shortage of data-driven policy proposals and I would take this opportunity to urge third sector organisations not just to produce policy wish lists but to focus on generating fully costed preventative proposals which deliver measurable results we should also recognise that while some preventative spend decisions cost money others, often the most effective consider smoking or drink driving legislation are free decisions on health promotion legislation also needs to take into account savings accruing to the public purse flowing from improved health outcomes and finally we need to take into account to change the political discourse a much needed move away from a focus on inputs towards a focus on outcomes it is often easy for politicians to announce extra spend on public services but outcomes are what matter to service users the preventative agenda has is its core the concept that we can do more with less that the relationship between inputs and outcomes is not linear otherwise this discourse is pointless a continued political focus on inputs and outcomes serves neither service users nor taxpayers this will not be an easy transition for us as politicians to make but it is one we must I hope in my remarks to have outlined the scale of the challenge before us and offered some pointers to the way forward the preventative agenda offers much to be positive about and improving outcomes and managing cost challenges we need to embrace this agenda with some urgency Mr McKeith, call Alison Harris to be followed by Richard Lochhead Mr Lochhead is the last speaker in the open debate there is time in hand Deputy Presiding Officer problems caused by the abuse of alcohol, tobacco and drugs are major concerns for public health in Scotland and ways to prevent or even reduce that will impact will have very substantial benefits not only for the individuals affected but society in general all three can lead to a variety of social problems including family tensions, antisocial behaviour absenteeism from work and financial difficulties but today it is mainly the impact that they have on health and wellbeing that I wish to speak on over 60 medical conditions are linked to alcohol use alone alcohol is classified by the international agency for research on cancer as a group 1 carcinogen the same grouping as tobacco and asbestos around 4% of all cancers diagnosed in the UK are caused by alcohol for cancers of the mouth and throat it is the second biggest risk factor after smoking alcohol is often a factor in coronary heart disease and is a commonly seen factor in the development of anxiety, depression and other mental health issues not only can excess alcohol lead to damage to essential organs such as the pancreas it also has an adverse effect on fertility alcohol related brain damage is another reason why the issues of overindulgence need to be tackled head on it is estimated that at peak times 70% of admissions to hospital acts in emergency are alcohol related it contributes to over 1,000 suicides a year and almost half of violent crimes are committed by people believed to be under the influence of alcohol over 50% of all domestic violence incidents are in the UK are carried out by people who have been drinking Deputy Presiding Officer very often dependence on drugs, alcohol and tobacco is highest among those who already have health issues through poor diet and lifestyle they are major contributors to health inequalities in Scotland the Scottish health survey in 2015 found that alcohol related mortality is not evenly distributed throughout the population but is highest among those living in the most deprived areas and there is a clear correlation between levels of deprivation and the rate of alcohol related admissions worryingly the misuse of alcohol and the start of potential associated health problems can begin at an early age the trend for people to drink more at home rather than in pubs is to reduce children to alcohol although often in a responsible way but sadly not always Youth culture too often links alcohol with having a good time getting drunk is now far too often the desired effect of an evening out it is clear that work needs to be done with this age group to counter the alcohol industry's promotion of alcohol to the youth market Stuart McMillan on that last point regarding working with younger people but Alison Harris agree that this is not a new issue this has been an issue that has been there for some time, it's been there for decades and it is a difficult nut to crack and I think we would all accept that but I think Alison Harris should sit and generally recognise it's not a new issue and I think all parties of whichever hue should certainly attempt to work to try to get successful solutions in this particular area Alison Harris I would like to thank Stuart McMillan for his question and yes I don't think it is a new issue it is a very long standing issue I think it is an issue unfortunately that is getting worse in society nowadays and it is crossing more and more problems sadly to those that sometimes you know are not so well off in society but I do think it's very important as you say we should all work together with a view to going forward and trying to sort this out once and for all so as I was saying with regard to youth culture perhaps in a way of actually trying to help the youth understand what's happening would be through the wider circulation of the excellent leaflet produced by alcohol Focus Scotland and the NHS alcohol and healthy living which warns of the dangers caused by drinking alcohol in excess of the sensible drinking guidelines the harmful effects of smoking are even better known than those of alcohol Thankfully over the years the number of smokers have steadily declined to around 20 per cent of the adult population and the ambition of a tobacco-free Scotland by 2034 is very much a work in progress 34 per cent of adults in the most deprived areas of Scotland still smoke compared to 9 per cent of those in the least deprived areas 29.3 per cent of pregnant women in the most deprived areas are smokers at the time of their first anti-natal appointment compared to 4.5 in the least deprived areas a child born in a more socially deprived area of Scotland is much more likely to be growing up around smokers and figures show that children born into a family that smoke are far more likely to become smokers themselves and so just repeat the cycle a cycle that imposes on our poorest citizens the financial burden of smoking as well as the health issues NHS Scotland advise that smokers from deprived areas get less encouragement and social support to quit smoking and I'm sorry can I just keep going for a minute please and are less likely to be aware of the harm of smoking and of second hand smoke and are more likely to be heavy smokers thus having a stronger nicotine dependence in my remaining time I would like to touch upon another aspect of the preventable damage that drugs can cause my colleague Douglas Ross has today highlighted that the number of people on drugs drive dying at the wheel is now the same as a number of fatalities who test positive for alcohol whilst the powers available to the police and courts in dealing with the drug drivers is far less clear than for dealing with drink driving drugs, drink and tobacco can shatter lives break up families and cause untold health problems many of which lead to premature death sadly the burden of misery caused by them falls heaviest on the poorest in our society the need to improve public health is one that we all agree must be addressed and I recognise the importance of the work being carried out by the health and support committee on the wider preventative health agenda and I thank Neil Findlay for his motion this afternoon thank you very much Ms Harris I apologise for the minute clock stopping but I'll be restarting now for the next speaker a call Richard Lochhead please thank you Deputy Presiding Officer that's a relief for your comment there in terms of this debate I suspect that the spotlight that was shone upon it is not quite as bright as what may have been otherwise the case had not announcements not been made elsewhere in the UK today but I expect the general election if it goes ahead as we all expect will feature many of the preventative measures that may be required to be addressed to tackle health inequalities and other social ills in this country and at least the fact that according to the Institute of Fiscal Studies a three child family will lose on average £2,500 per year while families with four children or more will lose £7,000 per year and four million families across the whole of the UK will see entitlements fall as a result of UK welfare policies so I guess the two issues in the news today hopefully this debate and the opening of our UK general election are very much interlinked and I very much welcome this inquiry by the health and sport committee of course as many members have highlighted during their speeches at the very crux of this debate is a dilemma it is how can you feed the insatiable appetite of the NHS for more resources as more drugs are developed as people live longer and so on but at the same time we find the resources to address the preventative measures that we need in the first place to lessen the burden on the NHS and that dilemma I do believe is at the crux of this debate I don't pretend to have the answers because we know that given the current financial climate there's not a lot of spare resources out there but it is something that politicians in this Parliament elsewhere have to wrestle with we can't ignore it and I hope the inquiry will hopefully find some solutions to that dilemma and also the fact that this is a multifaceted issue there's no silver bullet it's such a complex issue and many members have addressed many of the different complexities during their speeches today but I think what we can all agree on hopefully is to address the issue of preventative measures being essential that we do need bold and ambitious interventions from Governments it is obviously easier for ministers often to stand up and deliver more resources to the NHS than deliver controversial measures which can come sometimes lead to difficult headlines in terms of some of the preventative measures that perhaps have to be taken in society and as a member of the Parliament back when we debated the smoking ban I recall at a time how controversial that was and in many ways divisive but of course here we are in 2017 looking back and talking about how it's been such a successful policy and as the health survey that was published last year showed in terms of people who say they currently smoke 28 per cent of the population in 2015 it was 21 per cent albeit smoking is still a big issue it's responsible for 128,000 hospital emissions and 13 and a half thousands smoking attributable deaths as well and as other members have also mentioned lung cancer is expected most common cancer in the years 2023 onwards I want to use the time available to touch on two issues close to my heart today one is food and the other is the need for more sports facilities in Scotland in terms of preventative measures if we look at cancer research UK's recent news release since September 2016 and they highlighted again as other members have mentioned obesity is the UK's second largest single preventable cause of cancer after smoking and they said that junk food advertising and price promotions are among the issues that need to be tackled in terms of food the charity called for junk food marketing to be restricted along with price promotions and multi buy offers on unhealthy food and it then says if left unchecked obesity will lead to a rising tide in ill health including cancers and become a crippling burden on the NHS and there's other statistics in here that we can't ignore such as Scottish households spend more than any other UK nation on soft drinks at £2.60 per week compared to the British average of £1.90 so I think there's a lot of difficult decisions and challenging decisions this Parliament hopefully with more powers in the future over some of these issues we'll have to take but I do welcome the fact that the Scottish Government are committed to a good food nation bill and the Scottish Food Coalition of course have been leading the campaign as to what should be included in that bill they want a statement of food rights and responsibilities they want to establish a principle sustainable development which ensures the needs of the present are met without compromising the needs of future generations and they want to establish a statutory food commission with a civil society participation mechanism to promote involvement in policy making ensuring transparency and collaboration across Government departments so food and tackling some of the issues around Scotland's food culture is at the heart of preventative measures and I'm delighted in this parliamentary term we're going to debate what should be in that food bill and make it forward according to the food coalition legislation that needs to be addressed there's the high levels of food insecurity and the reliance on food banks low wages and insecure working conditions in many parts of the food industry the on-going challenge of diet related illnesses particularly diabetes, cancer and heart disease and the impact of these illnesses and health inequalities including child attainment and quality of life and of course other issues about the food system and the global environmental crisis of climate change by diversity loss and so on so there's plenty for us to give the pun to get teeth into in terms of what should be in the food bill all of it will be related to preventative measures and there will be tough debates and tough decisions to take but I hope that as a parliament radical we're bold and we're very ambitious the final thing I want to address is the issue of sports facilities the health survey I referred to earlier on published in 2015 the Scottish health survey said that just under 2 thirds, such 63 per cent of adults in 2015 met the guideline for moderate or vigorous physical activity a similar level to those seen since 2012 so not much progress in 2015 just under 3 quarters 73 per cent of children met the guidelines on physical activity a similar proportion to that seen in 2008 71 per cent not much progress and around 2 thirds, 68 per cent of children have participated in sport in the prior week a similar level to that seen in 2014 but lower than 2008 and I turn to my own constituency where at the moment we have the Murray Sports Foundation trying to raise the funds for a Murray Sports Centre and they argue that in Scotland average there's one sports centre per 33,000 people and Murray there are none not one designated centre to develop sports for a population of over 95,000 and a Murray council survey carried out in 2014 found many worrying statistics in terms of access to sports provision in the area so in terms of preventative measures I think as a Parliament as a government we have to do a lot more to promote sports facilities the Commonwealth Games have been and gone and yet we have these statistics at the moment sports Scotland give grants I understand limited to £200,000 if a company wants to come to Scotland invest in creating 30 jobs or under jobs we offer millions of pounds when it comes to building sports facilities to serve 95,500 people the grants available are £200,000 this is not just the issue of the Scottish Government policy at the moment this applies to previous historic policy but it's something perhaps we have to grasp if we want to be serious about preventative measures and make it easier for people to live healthy lifestyles and access physical activity so I urge ministers and all Parliament and all parties to grasp some of these issues we know there's a competition for limited resources but we have to be radical, bold and innovative if we really want to take seriously the whole issue of preventative measures and I do hope Neil Findlay and his committee congratulate him on his owing speech address some of these fundamental issues to advise Parliament about how to move forward and give the people of Scotland a healthier, better quality of life thank you very much before we move to closing speeches I've noted that Monica Lennon who took part in the debate doesn't have the courtesy to hear her colleagues in summing up she's obviously got better things to do with her time, no doubt the front bench will advise her that this has been noted and I'll call Anne Sarwar to close for Labour Mr Sarwar up to nine minutes please noted Deputy Presiding Officer and I'll ignore what the minister said in my ear ingest I hope can I first of all start by agreeing with Richard Lochhead I think we do need to be bold and radical when it comes to preventative policy and when it comes to tackling inequality I would like to believe that all of us would have been excited by Scotland listening to a really important debate in Scotland today in this Parliament about prevention rather than talk of another election but sadly for those of us who came into politics to talk about inequality we have to accept that perhaps today's debate is on the back burner while we talk about politics elsewhere can I start by thanking Neil Findlay and all members of the Health and Sport Committee for bringing forward this inquiry I know this inquiry will have support from members right across the chamber and indeed from all political parties and we look forward to hearing the final findings from the inquiry and thank them for allowing the debate in this Parliament today for all of us to contribute to that process as Neil Findlay said in opening this debate today this is an issue that cuts beyond just the health and social care portfolio it has relevance yes to health and social care policy but also to inequalities it has relevance with housing with welfare with poverty with education and so much more so I hope that this is a debate that is listened to and indeed a report that is reflected on not just by the Minister for Health and Social Care but actually ministers right across the Scottish Government I think that we have made good progress around preventative measures I think about behaviour and lifestyle we have made progress a good example being the smoking ban which has been a transformative effect in Scotland and something that was replicated across the rest of the UK I would though repeat what Emma Harper said that doesn't mean there's not still continued challenges particularly around lung health so there is more that we can do to take on the effects of smoking we made progress on alcohol but we still have 12,800 cases of cancer-related alcohol across the UK each year we've seen the sugar tax which has some impact on fizzy drinks but I do think that we have an opportunity to tackle what I think is the next big public health campaign which is around obesity and diet and that's why we look forward to seeing the Government strategy and we would encourage the Government to make that a bold and radical strategy and if it is bold and radical we will have the full support and that obesity and diet strategy as set out by Cancer Research UK who have done so much work on this issue needs to look at a number of areas one around physical activity which I know is of particular interest to other members in this chamber but we also must look at price promotion particularly on junk food we must look at advertising particularly on children's channels around junk food we must look at portion sizes and also what more we can do in confectionary and other products too I would note though Alec Cole-Hamilton's point around cuts to alcohol and drug partnerships which I think is a concern and I would ask the Government to please reflect on that decision again I mentioned inequalities and I would say to members on the Conservative benches to Donald Cameron, to Brian Whittle to Jeremy Balfour and to Alison Harris I agree with Donald Cameron when he said that we need to be honest but as part of that honesty we also have to say that decisions that are made by Government do impact on inequality and do have a negative impact on people's health as well and I think that they must reflect on that in terms of decisions made by UK Government but also must say that members of the Scottish Government benches must also reflect on decisions that are made by the Scottish Government and how they impact on inequality and what impact that has on health and what impact that has on society is still on the rise Income inequality has got bigger not smaller across Scotland and indeed across the UK we do have tax powers in Scotland we could choose to use those tax powers to have a more progressive tax creation system as was mentioned by Colin Smyth also by Alison Johnson and touched upon by Marie Todd we could use the levers that we have in this Parliament to tackle income inequality and help to drive resources towards and help to lift inequality we still have a postcode lottery in Scotland where your postcode determines not a child's life chances but also a child's life expectancy as well while that continues that will continue to be a stain I think on our politics and our society and we all must redouble our efforts to challenge the postcode lottery that exists we've got to accept that child poverty sadly is also increasing in Scotland we have the powers in this Parliament to tackle child poverty around education, housing, welfare around health, education, the criminal justice system and we should get on with using those powers so that we can tackle child poverty here in Scotland and I should also touch upon fuel poverty although we've come out of winter and we're heading into the summer there's no doubt that the quality of housing and the high levels of fuel poverty that still exist also impact on health outcomes as well as something that we have to really challenge my colleague Monica Lennon who I wish was in the chamber today she's just come in no doubt she's penning some apology to me she has some apologising to do to the Deputy Presiding Officer I'm sure she has heard that and I'll pass that on for you again but as Monica Lennon mentioned as also did Alec Cole-Hamilton the importance of mental health when it comes to inequality and prevention is so important we have a generational opportunity to have mental health in Parliament so it wasn't even recognised as being equal to physical health we are now changing that but we still have work to do so we should use the opportunity of being able to make a generational shift around putting school councillors into our schools to make sure that we're supporting children who may later on in their life go on to have mental health issues quite often children are mental health issues at the most important times of their schooling time can impact their access to college their access to university and indeed the access to the job market for the rest of their adult life so what we can do around mental health I think is an important issue I want to touch more on two final issues which are around budget structures and then around workforce I think that we all have the right intention in terms of challenging prevention but we have to recognise that decisions that are made in here but also decisions that are having to be made that will have a negative impact on patient care, on services and indeed on the pressures that we see on staff Ivan McKee touched upon health board budgets in his contribution and the reality is that the £1 billion of cuts that health boards will have to make over the next four years will directly impact on services will directly impact on staff and will directly impact on patient care and undermine the preventative agenda that we all I hope are signed up to as the RCN briefing that was sent to us all for this debate also pointed out the pressures that are on integrated joint boards has meant that they are using resources to cover other areas when indeed there are issues around recruiting community nurses who in many times actually lead the preventative work so how we actually have the operation of the health boards but also the IGBs and how they choose to use the budgets will again have a direct impact on how our healthcare professionals actually deliver prevention on the ground a specific issue in terms of Glasgow was mentioned by Colin Smith and his contribution around welfare advice and benefits advice we have a direct issue in Glasgow where £600,000 has been cut by the Scottish Government for benefits support advice in the city of Glasgow which again I think has a negative impact on income equality and then leads on to other health issues as well and I would ask the Government again to please consider that impact on the city of Glasgow and on community care there is no doubt that the GP practice and community care is the entry point for the majority of people into our NHS how we overcome the one in four practices reporting a vacancy how we filled the vacancies that we have and the shortage we have of GPs how we use the GP contract process to get more auxiliary support services into general practice how we use the inverse care law which was mentioned by Bob Doris to give more support to the more struggling practices yes there should be a universal access to a service but we should also recognise if we believe in tackling inequality that there are some areas and some practices that will require additional resource and additional capacity to help to challenge that inequality and I think the inverse care law and Professor Graham Wat's work addresses that head on I just want to end by saying this I realise that I'm short of time is I'm not short I've got loads of time I don't think our generosity in the chamber extends to hearing you adding for an item thank you very much everybody's being officer I'll just address one final issue which is around workforce again the RCN and indeed other trade bodies and trade union bodies for the NHS workforce are addressing the fact that we don't have enough staff for them to do the jobs properly one in three NHS staff saying there's not enough of them to do the jobs properly and that their work has increased in terms of the pressures that they face and again the vacancy rates that have seen two and a half thousand nursing vacancies across the UK 300% increase in long-term vacancies in our NHS that all has a direct impact on the ability of existing staff to actually have the time to care for their patients and I think we have to get a grip of the workforce crisis because that again has a direct impact on how we can deliver prevention on the ground so in closing I would hope that we all have the right intention to close inequality and promote prevention right across this chamber but we must recognise that we have a duty we have the powers in this Parliament we have the duties in this Parliament to actually deliver on closing inequality and actually making that the difference I think that that should be the mission of this Parliament is tackling inequality head on whether it be wealth inequality income inequality, child poverty inequality because only by that collective working and using the powers of this place can we actually make sure that every child no matter where they are born, no matter their social status, no matter their gender is able to maximise their life opportunities and maximise their life chances thank you thank you Mr Sarwar I had no doubt you could use the extra time can I call now Miles Briggs please close because we could serve to have equally generous with you Mr Briggs thank you very much that's a challenge in the light of Mr Sarwar I'm pleased to close today's debate on behalf of the Scottish Conservatives and I'd like many others in the chamber to thank the many organisations that have provided briefings for today the large number of which are a sign of a level of interest in the work of the Health and Sport Committee on the preventative health agenda there have been some very good speeches from across the chamber and consensus in a number of key areas and on key issues as my colleagues have set out already in their contributions the Scottish Conservatives are supportive of the principle of preventative spending and early interventions that can prevent negative health outcomes later in life those investments in tackling the causes of ill health have the potential to save significant amounts of public spending over the long term and help reduce health inequalities none of us in this chamber want to see our country continue to have such a bad reputation with health having the widest reality inequalities in western Europe suicide is three times more likely amongst the poorer Scots cancer survival gaps of those living in the most and least deprived parts of Scotland haven't really closed and stoke mortality rates is at the highest in some of our deprived communities it's not a record or a reputation any of us in this chamber want to see our country have and we recognise too as they seek to shift health spending away from acute care towards preventative investment does prevent many just present many challenges I think Ivan McKee made some very important points during his contribution while preventative spending should in time help reduce the demand for acute services there will clearly have to be a crossover period where full spending is required on both preventative and acute services and that is a challenge for all politicians in this chamber I agree with RCN Scotland who have said we need to have a more informed public debate about the fact that spending on preventative health may mean redistribution service redesign and investment in the benefits of primary prevention which may take many years to come to fruition and show that these decisions taken can make a huge difference my colleague Brian Whittle talked about diet and physical activity and I want to back up the points he said on this as a convener of the Parliament's cross-party group or co-convener of the Parliament's cross-party group on cancer I'm very much aware that more than 40% of cancer diagnosed are attributed to lifestyle environmental factors a point made by Cancer Research UK's excellent briefing ahead of today's debate as Donald Cameron said earlier the cost of obesity in Scotland the single biggest preventable cause of cancer after smoking has now been estimated to add up to over £600 million a year with wider economic cost of more than £4.5 billion a year one point which has been raised by a number of speakers today is a need for cross-portfolio working and I think it's time that we as a Parliament also reflect on this and how we can improve the workings both of Parliament and the development of policy on a cross-portfolio and cross-committee basis I still as a relatively new MSP don't see how we can influence the work of each other's committees good enough to be able to make that difference when it comes to policy development and I think that's something as we look towards reforms of this Parliament I hope we will see taking forward a focus on promoting exercise and a healthy balanced diet excessive calorie consumption is vital and perhaps the best example I've seen of an organisation outside of this Parliament working on a cross-portfolio way is Jog Scotland Jog Scotland has a major success story to tell involving almost 40,000 Scots in hundreds of local groups across our country and I share the concerns of many constituents who've contacted me about the Scottish Government's regrettable decision to stop funding this programme I'm pleased to say that Sam H and Athletic Scotland have stepped into the void here to help secure the future for Jog Scotland recognising the links between good mental and physical health but it seems very wrong that a Government that is reviewing the effectiveness of this policy that says that it wants to boost physical activity in the population looks to remove the support for a scheme that has successfully encouraged a cohort of inactive people to actually become active Yes, certainly I don't know whether the member didn't see the £2 million that we announced to go to our governing bodies which will of course benefit Scottish Athletics but I wonder if he would join us in our cost to the UK Government to work out how they improve the way in which national lottery monies can be improved so that sport doesn't have to feel the pinch on that and the management of the national lottery from the UK Government As is always in the case of this Government the devil is always in the detail I'm delighted if the Minister would like to have another intervention to confirm if any of that money is for Jog Scotland A Government money to Sport Scotland for the governing bodies to make sure that they can continue with the programmes that are increasing participation which will include of course looking at Jog Scotland Mr Briggs There's two words missing from that I think it was Jog Scotland but maybe the minister would look to actually outline whether or not this is filling the cuts which the Government put in place to Jog Scotland's funding Anyway I'd like to make some progress on this It's also helped The work of Jog Scotland's also helped to reduce health inequalities by encouraging more women to participate in physical activity Other colleagues including Alex Cole-Hamilton and Alison Harris have talked about their real concerns about the reductions in funding for drug partnerships and I agree that the Government needs to also look at this area for too long I think drug and alcohol partnerships have been the Cinderella service and I have my own real concerns in Edinburgh at how we are developing our drug and alcohol partnerships where they will actually be placed within the health service as in some cases even they don't know where in the future they will be and that's something they need to plan for a better services I wanted to use the time I had today to talk about preventative health in terms of mental health and I have emphasised before in this chamber the importance of building resilience in our young people and the vital role that youth organisations like to if I have got extra time Mary Todd Thank you for taking the intervention As you know Miles Briggs that I worked in mental health for 20 years and in the time that I worked in mental health the most significant impact I saw on the health of the people that I worked with was the welfare reform brought in by your Government by the Tory-Lib Dem Coalition between 2010 and 2015 I saw people made significantly insecure in their situation tipped into poverty and frankly made sick by the treatment of the Government will you be addressing that in terms of mental health Mr Briggs In terms of the powers which we have coming to this Parliament I don't know from anything which I've heard from Mary Todd here on the health committee what plans her Government are bringing forward in this area there doesn't seem to be any thought going on in this area at all but as I was saying I've emphasised before the importance of building resilience in our young people and the vital role that youth organisations and the life skills that can prepare them for difficulties later in life support for youth organisations is essential and we want to ensure that every school pupil has access to these groups and all parents are provided with a list of these local groups in their area early intervention in terms of providing swift access to support, counselling psychological and talking therapies for people with minor health mental health problems is essential too as we are developing into more severe ones that is why I have consistently been calling for more action to reduce waiting times for psychological therapy treatments something that remains a big concern for many constituents I represent trying to access these services in NHS Lothian and I think looking back on 10 years of an SNP Government Mary Todd would maybe like to consider why is it that my constituents here in Lothian take two years in some cases being seen by a specialist and for children up to a year that is this Government's record and something which I think they should start to look at in more detail to conclude Deputy Presiding Officer today's debate is welcome and has been largely constructive the challenge will be to take forward the consensus which I do actually think does exist around preventative health policy and to see the good will implemented in practice through policies that cut across as the BMA has rightly said ahead of this debate public health interventions are more likely to have an impact when they are long-term and substantive I urge Scottish Government ministers to work closely with this health and sport committee as we continue our inquiry into preventative health and to listen to our committee's findings as the Government and Parliament take forward policy developments in this area Thank you Eileen Campbell to close for the Government Minister up to 11 minutes please Oh gosh, right, thank you very much Presiding Officer That didn't sound if you were very keen I'm sure you are I'm delighted, thank you very much for the additional time I commend like others the health and sport committee for today's debate and I welcome what has been a very mature and considered range of contributions from members across the political divide as we all seek to create the fairer and healthier country that we seek a tone very much set by the convener of the committee and while I know he and the committee will seek to scrutinise Government as he is right to do I look forward sincerely to the committee's report and working with the committee as they prepare their recommendations and findings We all understand the challenges that Scotland faces many members have articulated them today we have an ageing population a country that continues to have an unhealthy relationship with alcohol and is now more common to be overweight than not and a country that needs to increase its activity levels and what exacerbates and magnifies all of these are deep, unfair and persistent inequalities that are driven in part by the harsh consequences of austerity and welfare reforms and where there is challenge we must seek opportunity because we have enormous potential to transform Scotland's health and wellbeing and there have been improvements October's Scottish schools as a lessant lifestyle and substance use survey showed that smoking, drinking alcohol and drug use among young people are now amongst the lowest level record and I hope that that gives some comfort to Anne who made some contributions around the young people in her remarks but we know that the pace of improvement is simply not quick enough and in times of a challenging fiscal climate the ability to simply power plough more resource to fund increasing demand is not an option or as Donald Cameron put it we perhaps need to a challenge established orthodoxies and be frank and candid about how we marshal our public finances because the challenge of what the late Campbell Christie wrote in his report is still relevant now we need to not only reform our services to cope with the fiscal climate but also reform services so that they improve the quality of public services to better meet the needs of the people and the communities that they seek to support we need to prioritise prevention reduce duplication and we must empower individuals and communities trusting our communities to find their own solutions and just not be those passive recipients very much in line with what the previous CMO articulated Harry Burns and certainly very much in line with the current CMO's realistic medicine agenda and we must also again tackle those established orthodoxies as Neil Findlay, Bob Doris, Alison Johnson and Ivan McKee properly outlined by ensuring that the preventative health is not seen solely as the preserve of the NHS this is about housing, it's about education it's about justice, it's about environment and it's about transport and a whole host of other disciplines, professions and portfolios it requires us to work together and in a country of just 5 million there is no excuse not to do so Bob Doris, on a very local level spoke with clear examples of how working together at that local level can also make real and transformative and tangible differences it also requires us to be bold and innovative because when we do all those things the progress and the improvement is tangible and with regards to alcohol and tobacco Scotland has frequently led the way this Parliament passed legislation that would allow for minimum unit pricing for alcohol the Scottish courts have found that lawful and it is with some regret that we must now go to the Supreme Court on a matter that would save lives in the last 3 years we could have seen over 200 fewer deaths and over 4,500 fewer hospital admissions and I'll certainly be taking forward a refresh of our alcohol strategy and we'll be looking forward to the outcome from the Supreme Court similarly our efforts on smoking have been bold and remarkable progress across different administrations has been made illustrating again that when we take an ambitious Scottish approach we can bring improvement moreover our cancer screening programmes are among the best in the world these programmes play an important role in prevention by detecting cancers at their earliest stages and under our 100 million cancer strategy we are investing up to 5 million to reduce inequalities and improve uptake particularly amongst those less likely to participate in screening and the important point others have made about obesity and cancer are well made and again will be very much in my mind as I bring forward our obesity strategy and we're also seeing real progress and successes with our vaccination programmes and achieve some of the highest uptakes in Europe around 3 million vaccines are administered annually in Scotland which helps to protect against a wide variety of disease and it's hugely effective to prevent the programme second only to clean water and their value to disease prevention and again loosely related to that I also echo the comments made by Marie Todd about the welcome progress on PrEP and with my colleague Maureen Watt here collaboration and innovation has been the hallmark of the approach to our mental health strategy because we must treat mental health with the same priority and drive we give to physical wellbeing intervening and prevent issues developing while ensuring anyone needs only ask once to get the help they need fast and to support our strategy over the next five years we have committed 35 million for 800 additional mental health workers in key settings and in response to Monica Lennon we've also an ongoing review of PSC and we'll investigate what evidence tells us works many members have also called on us to be innovative around what I agree with Anna Sarwar is one of the most interesting public health challenges in Scotland that is obesity and again echoing the comments made by a whole host of members on this topic I sincerely look forward to engaging with all members on this as we bring forward the consultation looking to ensure that we can have that innovation that is needed to address this challenge that Scotland faces and the ongoing health challenges that that presents to our NHS an issue that has also been discussed has been around measurement strongly very strongly articulated by Ivan McKee and he is right about the need for robust data to guide policy particularly when there are challenges around public finances we need to ensure that we can invest with confidence around what works Moreover though we launched in September last year an independent review of health and social care targets and indicators chaired by Sir Harry Burns and Sir Harry will offer an initial report soon his report will begin to set out proposals that ensures our targets and indicators support our strategies for the improvement of health and social care outcomes the future of the NHS and social care services and support best use of public resources that review has taken a whole system approach to measuring health and social care with prevention being part of the agenda focusing on upstream determinants of wellbeing Presiding Officer I wanted to touch on the contributions of both Alison Johnson and Marie Todd who powerfully articulated the damaging impact of welfare reforms and I think illustrated very starkly the cruelty of some of the measures by highlighting the limitation of tax credits to the first two children in a family and the absolute callousness of the rape clause and I mention this because it is absolutely astounding that some members in this debate have had why I think has been the audacity to criticise the baby box which has the aim of giving all children the very best start in life and remain absolutely silent on the issue of the rape clause I think it is hypocritical and it is regrettable in why I think has been a very consensual debate that that has not been two areas of argument that they have not sought to reconcile Monica Lennon Would the minister agree with me that rather than feeling very healthy in this debate would the minister agree that it is not a case that some people have chosen to remain silent on the rape clause, the actual support the cap on child tax credits and the support that a rape clause is a way to address that? I had a lovely note of apology minister I am pleased that Monica Lennon has managed to get back to the debate because I think that the point that she raises is a very important one indeed that actually the issue of silence is not because they disagree I think that there are too many members who seem to agree but don't have the courage of their convictions to simply come out and say it and at least be bold enough to defend what I think is the indefensible and I think that members across the chamber agree with that but we in this bench do disagree with the rape clause and to pay tribute to the work that Alison Thewlis in particular has done on highlighting this issue and this is why the cabinet secretary has written to the UK Government saying that we will not distribute Whitehall guidance as it stands to the Scottish NHS on this issue Alison Johnstone and Mary Todd are also right to talk about inequalities because imagine what we could do as a Government if we didn't have to spend 100 million a year on welfare mitigation but this Government has also taken action on tackling inequalities with our fairer Scotland action plan setting out the things that we need to do to make the changes that we need and decisive action to reduce poverty and child poverty including massive investment in childcare in early years delivering 50,000 affordable homes over the parliamentary term and free school meals to primaries 1 to 3 so overall the health of Scotland is improving and we should celebrate our living longer and healthier lives but the benefits of these improvements are not felt equally what is clear though during this debate is the ambition to do better our ambition is for a fair, smart, inclusive Scotland where everyone can feel at home and where there is genuine equality of opportunity for everyone we must seek to use all the levers at our disposal to improve community health social security, community empowerment housing and education they are interlinked and success is dependent on additional boundaries this is a complex area but the prize of a healthier, fairer nation is worth working hard for and on that basis I look forward to the conclusions of the committee I'm working with them on the aims and ambitions that I think we all share thank you thank you very much I call on Claire Hockey to close for the health and sport committee if you can till 4.59 or thereabouts Ms Hockey speak slowly I will do my best and before I begin I would like to refer members to my register of interests I want to thank you and on behalf of the health and sport committee it is my pleasure to close this debate this has been our first debate since the Easter recess and it is refreshing to witness the benefit the holidays have had on some of the members across the chamber although with the news earlier today some of us might feel much more weary than we did at 9 o'clock this morning we have had a thoughtful, helpful and informative debate during which for the most part there's been a most welcome outbreak of consensus members have spoken on a wide range of subjects during this afternoon's debate Donald Cameron made reference to the health inequalities between rich and poor in our society and we need to work across the chamber to challenge this Brian Whittle spoke about the importance of physical activity a cause I know is very close to his heart and it's a place in improving and maintaining health Bob Dorris spoke about housing and housing that is fit for purpose and its importance in the preventative agenda Emma Harper spoke about targeted interventions that have already helped to improve health outcomes and to reduce mortality and about the importance of team working in achieving those goals Alison Johnstone spoke about the impact child poverty can have on health outcomes and the importance of income maximisation in tackling child poverty and the proven monetary benefits to families of these programmes and she also spoke about the shameful 2 child policy and the appalling impact that this will have on children and on the income of some of our poorest and most vulnerable families Mary Todd spoke about reactive versus preventative spend in particular in relation to pharmacy and the prescription of medications and the importance of education about the appropriate use of medications and also about the impact of welfare cuts on families and how this in turn can impact on health outcomes Jeremy Balfour urged investing more in the young and particularly in the not to three year olds Alex Cole-Hamilton spoke about the importance of treating both mind and body and Ivan McKee spoke about the need for change in health service delivery and he also spoke about the need for our results in an outcome focus in the preventative agenda Alison Harris spoke about drugs, alcohol and tobacco and their causing premature deaths particularly in lower income families and Richard Lochhead spoke of the importance of food and good quality food and of sporting facilities in preventing ill health Miles Briggs I listened to what the minister had to say in her closing remarks and she didn't talk about sport at all because she tried to address preventative health given the fact that funding for sports development in Scotland is likely to be cut by a fifth which will see 2 million less for schools and PE and 1.5 million less for sports hubs how does she think that will impact on trying to narrow the inequalities that we see in sport across our country Clare Haughey I'm not the minister so I can't answer for the minister as you know Miles Briggs and when the committee asked for this debate to inform our work we did so in the knowledge as the convener Neil Findlay said in opening this debate that it's a cross cutting subject and it doesn't lie with a single committee minister or department the need for a preventative approach has been acknowledged from all sides of this chamber in this debate and one key aspect of the need for a preventative approach is the persistence of significant inequalities in our country the stubborn fact that a substantial proportion of the people in Scotland do not share fairly in the wealth and success of the country people experiencing high levels of multiple deprivations experience a number of negative outcomes that are inextricably linked they frequently live in families and communities where poor outcomes are mutually reinforcing reflecting the significant spatial dimension of those inequalities not my words but those of the Christie commission in their seminal report the commission referred to by the cabinet secretary in her speech that led to a clear conclusion that it is imperative that public services adopt a much more preventative approach hence the health and sport inquiry and we want to ascertain how much our health and sport services have moved into the preventative agenda in six years what works and how it can be measured and crucially rolled out but again I remind members this is a cross cutting issue which involves every committee in health and sport we scrutinise every activity and expenditure for the impact it has on health inequalities we agreed as a committee to do that at our first meeting and it stands up front in our strategic plan as members will know I was and still am a mental health nurse and naturally I retain a keen interest in that area mental health was raised in numerous submissions to the committee as it was today by Monica Lennon and by Alex Cole-Hamilton and by others many observed it is frequently associated with health harming behaviours and long term conditions and they suggested that by tackling mental health issues early in or before adolescence often first emerge prevention of health harming behaviours is possible as well as providing a degree of resilience in coping with other long term health conditions and therefore please the new mental health strategy provides a renewed focus on mental health the delivery of the strategy into practice is something the committee will be watching closely and not only for what it promises in preventative terms we need to remember that many of the issues that cause poor mental health are to do with other social factors income, housing and the environment people live in only through a range of approaches across portfolios can such factors be addressed there are a number of support programmes being tried across the country and in the committee's work to date we've heard good reports from the link worker programme we've heard about initial successes and depend practises and we're keen for the government roll out of link workers to be completed as soon as possible we heard last month from Midlothian Integrated Joint Board about a similar type of support scheme a wellbeing service which has been rolled out to 8 GP practices it sounds simple it's about skilled workers working with individuals who are referred by their GP because they have underlying issues it's about focusing on the outcomes the individual wants and helping them to make connections and use a range of different supports that enables them to take control of their lives and we're told that initial evaluation results are looking positive we've also heard about an organisation in Midlothian with a fantastic name, Pink Ladies First which is in effect a self-help group where people use their own experience to support one another in a similar supporting vein I have previously mentioned in this chamber family nurse partnerships as a preventative programme for vulnerable first time mothers until their child reaches the age of two this is another good example of spend intended to be preventative which is being piloted, evaluated and has been rolled out across the country with the aim of improving pregnancy and early year outcomes we've heard today calls for regulation submissions to us made the same point highlighting potential levies on soft drinks and the regulation of formula milk adverts to name but two we've also had comments around the responsibility of public bodies across the board to think systemwide with a community focus in what they should stop doing and an approach which would be in tune with realistic medicine principles the committee are grateful for the opportunity to involve all these issues and we are grateful for the contributions that have been made today and after today we will consider how best we can proceed with this inquiry and identify what we consider to be preventative spend and preventative expenditure how it can be planned funded and measured we will grapple with counterfactuals failure demand and false dichotomies and we will report our findings and suggestions to Parliament by the end of 2017 we will give way Bob Doris You mentioned open to suggestions for things that the committee might look at and sports have been a theme that has come up quite often this afternoon quite often sports investment via proceeds of crime or cash back for communities there are whole pots of cash out there not always at the health and sports committee's scrutiny I wonder if the committee would give consideration to how that money is directed at areas of deprivation and low physical activity because actually I think maybe there has to be more of a targeted approach in relation to sporting opportunities in those areas because I certainly think of local organisations in my area and I'm sure the deputy of the sport health and sport committee's area that would definitely benefit from that Claire Hawke I thank Mr Doris for that intervention and certainly I think he raises a very interesting point and well aware of my own constituency of some of the cash back initiatives and the positive impact that has had on particularly community sporting clubs and I certainly think that the committee would welcome the opportunity to look at that now that you have raised that here in the chamber and part of the reason that we were having this debate today was obviously to encourage debate and sharing of ideas across the chamber from members of different committees who may not be able to input directly into the health and sport committee so I thank Mr Doris for that intervention Presiding Officer, in closing I again thank all contributors today and thank our witnesses who have assisted us orally and with written submissions I can thank our researchers for their support and most of all thank all of those who work in our health and social care services looking after our citizens of Scotland we owe them a huge debt and the least we can do is to ensure that the policies we have identified and agreed upon are directly and fairly and I commend this motion to the chamber Thank you, that concludes the debate on the health and sport committee's inquiry into the preventative health agenda it's now time to move on to the next item of business and the next item of business is consideration of business motion 5181 in the name of Jo Fitzpatrick on behalf of the Parliamentary Bureau setting out a revised business programme I would ask any member who wishes to speak against the motion on behalf of the Parliamentary Bureau request a sweet button now and I call on Jo Fitzpatrick to move motion 5181 formally moved thank you and no member has asked to speak against the motion therefore the question is that motion number 5181 in the name of Jo Fitzpatrick be agreed are we all agreed we are all agreed and there's a single question today but we'll just wait for a few seconds 4948 in the name of Neil Findlay on behalf of the health and sport committee on its inquiry into the preventative health agenda be agreed are we all agreed we are all agreed and that concludes decision time we'll now move on to members business in the name of Christine Graham and we'll just take a few moments for members to change seats