 Dwi'n fawr i'r 30 yma yma yma o'r gweithio eu cyfnodau hefyd yn 2018, rwy'n meddwl i gyflogau ymdd與fod ymdd i'r Oeddon Bryn Whittle. Felly, rwy'n meddwl i'n fwy o'r gweithio yma i'r cyfnodau hefyd o'r oeddon, a ddod i'r ffiliadau, rwy'n meddwl i'r gweithio'r yma o'r ddwyllteisio'n ddysgu'n eu cyfeirio. Fy modd i'r oeddon yma yma yma mae'r gadael i'r ystafellu rhagorauau eich UK Parliament legislation for which a legislative consent memorandum has now been lodged and which we anticipate will be formally referred to this committee in short order. The bill was introduced in the House of Commons on 26 October 2018. It is one of a series of bills intended to adjust UK legislation for Brexit in addition to the European Union withdrawal act, and it is intended to allow the UK to maintain reciprocal health arrangements with the EU and its member states after Brexit whether or not a withdrawal agreement is reached. The provisions of the bill are not limited to arrangements with the EU, and the UK Government has stated that the bill would also allow the UK to strengthen existing reciprocal healthcare arrangements with countries outwith the EU or to reach new ones. To give evidence on that, I welcome to the committee Paul Gray, director of health and social care and chief executive of NHS Scotland, Shirley Rogers, director of health, workforce leadership and service transformation, Liz Saddler, deputy director of planning and quality division, Ian Davidson, head of constitution and UK relations, and John Patterson, divisional solicitor. Can I start by acknowledging that Paul Gray has let us know that he intends to step down in the coming weeks and allow me to record the committee's thanks to Paul for his leadership over the last five years within the NHS in Scotland, and personally my own thanks for his leadership in health and care over an even longer period. On behalf of the committee, Paul, I wish you well in your future endeavours, however it falls to this committee to interrogate you one last time, at least. I invite you to make an opening statement. I thank you for your kind words. I have certainly felt that it is a great privilege to hold the role and also to appear before parliamentary committees, which I regard as an essential component of public service and being held to account. I am pleased to be here today with colleagues to discuss the legislative consent memorandum for the UK healthcare international arrangements bill, which was lodged in the Parliament and published on Thursday 6 December. On leaving the EU, the reciprocal healthcare arrangements currently in place may no longer apply in their current form, and UK legislation is required to provide for future arrangements. In broad terms, the bill gives powers to the Secretary of State for Health and Social Care to fund and arrange healthcare outside the UK and to put in place reciprocal healthcare arrangements between the UK and other countries or international organisations such as the EU. Scottish ministers in the UK Government agree that the bill impacts on the devolved function of health and as a result it requires the consent of the Scottish Parliament. UK Government officials have indicated that the bill will be amended to recognise the responsibility of the devolved Administrations. The current proposal is to introduce a requirement to consult the devolved Administrations and enter into a memorandum of understanding with them before regulations can be introduced to impact on devolved matters. In the event of a deal between the EU and the UK, the EU withdrawal bill will allow the current reciprocal health arrangements to continue during the implementation period. However, in the event of no deal, this legislation would be needed quickly to put new arrangements in place. The committee is no doubt aware that, in June this year, the UK Government proceeded to pass the EU withdrawal bill, despite the refusal of the Scottish Parliament, to give its legislative consent to relevant provisions of the bill, and UK Government ministers expressed the view that Brexit is not normal and felt within the exceptions applying to the Sewell Convention. Since that bill, the Scottish Government has taken the view that it should not seek formal legislative consent from the Parliament for Brexit bills, but the Scottish Government has, however, made clear that it will co-operate in developing bills and in supporting this Parliament's scrutiny. It has lodged LCMs on the trade bill, the agriculture bill, the fisheries bill and now this healthcare bill. Scottish ministers have also said that formal legislative consent could be sought for Brexit legislation in exceptional circumstances. The Scottish Government believes that there are exceptional circumstances for this bill, given the need to provide reassurance to Scots who access state healthcare in the European economic area under the existing reciprocal schemes, and the Government will therefore lodge an LCM for this bill. On reciprocal healthcare more generally, my letter of 4 December to the committee indicated that six NHS boards were not participating in the UK Government's EHIC incentive scheme. That number included NHS Greater Glasgow and Clyde. We have since received further returns than November statistics after I wrote to the committee and I am pleased to report that Greater Glasgow and Clyde now has recorded EHIC activity and has recovered £120,000. I am meeting the health board chief executives this evening and I propose to take up with the remaining five boards the question of why they do not participate in this scheme. Finally, convener, we have sought to anticipate in those we have brought the range of questions that the committee might ask, but clearly the subject is broad and could attract questions from members on many aspects. If there is any information that I do not have today, I will give an undertaking to the committee to provide it at the earliest possible moment after this session has concluded. Thank you very much, convener. Paul, that is much appreciated. Can I start off, and you rightly say that it is a very broad subject, and I think that the committee is very keen to understand the scope of the current arrangements and how they operate? Can you explain what currently happens if a visitor from outwith the European economic area wishes to register with a GP? My understanding is that we encourage GPs to establish persons country of origin, but we do not wish to deprive them of primary healthcare services, so we have not so mandated, but Liz could perhaps say a little more. There were recent guidelines on GP registration generally, which includes a section on overseas visitors, which encourages but does not require GPs to establish the country of origin. As Paul says, that is primarily to ensure that people can access primary healthcare if they require it. I am afraid that I do not have any more details on that, so that is something that we will need to write to you about. The regulations that do make clear that people from outwith the EEA are required to pay for healthcare and that those we expect GPs to be able to establish where people from country of origin are. I am interested in that reply, and I wonder if you can tell us if Scotland in this respect differs from other parts of the United Kingdom in respect of not requiring evidence of either residency or nationality for registration with a GP. I am afraid that I do not know that answer. Given the nature of the bill that is before us and the implications that it may have for Scottish NHS finances, it would be very important to understand the implications of what you have described. If a person with no entitlement to free treatment is able to register with an NHS general practice without evidence of being entitled to free treatment, they could then very easily go through the entire healthcare system without being recognised as ineligible for NHS treatment. What could cover people from within the EEA who are entitled to free healthcare under the reciprocal healthcare arrangements? Non-EEA people are not eligible for free healthcare, so this bill would not impact on those individuals. Are there separate arrangements set out in the regulations relating to the payment of healthcare for people from non-EEA countries? Yes, I understand that point. The point is that the bill will presumably apply to citizens of EEA countries. Are the same rules that apply to non-EEA visitors in the event of leaving the European Union without an agreed arrangement? Is that correct? Is that broadly the principle of the bill? The Government's policy is that the reciprocal healthcare arrangements for EEA people should continue in force. Therefore, they would continue to in the event of an agreement, which will continue under the existing arrangements until the end of the implementation period, in the event of no deal, there would be a need to put in additional provisions straight away to enable that to continue. That would only apply if there was no agreement to continue reciprocal healthcare. I have understood your question correctly. The point is that, because we do not oblige general practitioners absolutely to determine the country of origin of someone seeking treatment from them, it is possible that someone who is not within the EEA could still get treatment from a general practitioner without so declaring. That is the point that we should write to the committee about quickly, just to make that distinction that you have made and to be clear whether we are doing something about that distinction and furthermore to be clear about whether this is a different system from those elsewhere in the UK. Have I understood the question? That would indeed be helpful. The legislative consent memorandum appears to say that the bill is intended to go beyond the EEA and to allow for reciprocal health arrangements with other countries—third countries, we have already some with Australia and New Zealand, for example—so it is pertinent to know what the scope of the current arrangements may be. Particularly in addition to the point that you have come back to me with, the question of whether there is no check at the point of registration with primary care on origin and nationality, does that mean that checks have to be made by hospitals when a GP refers a patient or is it the case that there are essentially no checks throughout the system? Yes. There are certainly checks that are formed if acute services are required, but it would be good for us to be completely clear about that stream with the committee so that we have put that on the record for you. I am interested in any consultation that has occurred between the Scottish Government and the UK Government as far as developing the scheme. Was the Scottish Government consulted as part of the introduction of the scheme? Do you mean that the bill is new or that it is the e-hick? The e-hick, in general. Liz, what has been discussed with the Government on e-hick? The current arrangements have been in place for some time. In anticipation of Brexit, we had discussions with the UK Government earlier in the summer at a very high level about what the future might look like, but since then, there has been very little interaction, despite regular prompting from us to ask for further information from the UK Government. We were informed at official level on 22 October that there would be a bill, but it was not until—we were informed on Friday, 19 October, that there was going to be legislation and we were given a copy of it, but it wasn't until Monday 22 October that we were informed that the bill was imminent. The Cabinet Secretary had a conversation with the Permanent Under Secretary of Health on Wednesday, 24 October, when he confirmed that the bill would be published and that there was a requirement to consult the Scottish Parliament. Since then, we have had some limited conversations with officials in the Department for Health about strengthening the bill to recognise the devolved implications, particularly around consultation or, ideally, seeking the consent of the Scottish Parliament to amendments to any legislation passed by the Scottish Parliament. There hasn't really been much connection with the health secretary in Scotland in order to develop the process, but now there is a commitment to engaging with the Scottish Government. The current arrangements have been operating effectively for a number of years, and there has been a lot of consultation and engagement with colleagues around that. What we haven't been involved in, to any great extent, was the development of this piece of legislation. We would expect to be very closely involved in any implementation around putting in place new reciprocal arrangements, because that does impact on the NHS in Scotland. Can you briefly describe the reciprocal arrangements that currently exist with the UK Government under the current arrangements? The reciprocal arrangements are provided for EU member state level, so the UK Government administers the arrangements on behalf of the UK. There are three main schemes, S1, which is around the provision of healthcare for UK pensioners who have chosen to live in another EEA country or Switzerland, and that covers the cost of their healthcare. A lump sum of €4,000 per year is paid by the UK Government for that provision. S2 is the provision of planned treatments where an individual can request through their health board to go overseas for elsewhere in the EEA to receive a procedure that is provided the same as they would get at home, and that we understand from the EU returns, the returns that go to DWP around 10 people from Scotland a year use that scheme. Then there is the EHIC, which is obviously the part of the agreement that most people know about, and that enables individuals to receive medical treatment if they become ill or have an accident in the EEA in the equivalent of the state healthcare system within that country. Some EEA countries do not have as comprehensive a healthcare system as within the UK. In those circumstances, people may have to pay something towards the cost of their treatment, which they can claim back from the DWP when they come home. It is not that EHIC should not be seen as a substitute for healthcare insurance because it only covers the cost of the treatment. It does not cover any additional costs such as the need to repatriate somebody home, additional costs for family and friends, family to be with the person or for rehabilitation periods. I also add to what the convener said and offer my congratulations to Paul Gray on his imminent retirement to having worked with Paul for a number of years in the Scottish Government. It was clear to me that Paul contributed in all sorts of areas of government policy on a regular basis and was often the person that ministers went to, especially during SCOR, and other crises to get something fixed. I think that you have a great deal to be proud of, Mr Gray, and what you have done for the public service in Scotland. Just to help you out with my last pre-retirement gift, my question will actually go to Mr Davidson if it can. A lot of people say that Brexit has not really impacted so far, and yet we look at the range of senior highly-paid officials here today and the work that you have had to do in terms of preparation for this. The fact that, as Emma Harper highlighted, we are doing things at breakneck speed, we are not having the proper consultation carried out, we are having to agree things about having seen them first of all. Obviously, Brexit is having an impact and it is mainly because of the possibility of a no-deal scenario. Can I ask whether all that work going on in this directorate would have changed, had it been the case that the amendment that would have been discussed today at Westminster, which has ruled out no-deal, were you aware of that? Would it have been the case that that kind of parliamentary guarantee that no-deal was not going to happen would have stopped this work, or would you have had to continue doing it as a contingency in any event? To be honest, I think that that is a very difficult question to answer. My particular expertise in relation to those matters is about the relationships between the Governments on legislative co-operation and, obviously, together with Shelley and many others across the Scottish Government, some involvement in the wider preparations. The Government has at all the stages taken the necessary steps that it is believed to be appropriate to prepare for all circumstances before us. I do not think that anything in relation to that has changed, but as uncertainty grows and we get closer to the potential of the 29th of March, those preparations need to step up. I do not think that I am precisely answering your question, but I am not sure that it is really possible to do so, other than to give that general indication that all the work that we need to do proportionately at different stages that we are doing. I would hope that if there is a prospect, and who knows what is happening in that complete shambles, but if there was a prospect that something was going to rule out the need for this work, that the Scottish Government doing the horizon planning that it should be doing would take that into account in the system work that is going to be unnecessary. A more specific question, and it may be for somebody else on the panel, is, and I could be getting this wrong. If it is the case that the Secretary of State for Health will have the power to increase the fees, so say three years hence, we want to increase the charges that are made to other EU countries to keep these reciprocal arrangements. The limit on that just now, I assume, would be if you did it within the EU that other countries would get quite annoyed about that and maybe take action against it, I do not know. However, that limit would no longer apply in this circumstance. My concern is that, would it be possible for a future UK Secretary of State to increase the charges that are made because of budget pressures or whatever else, and if that is the case, what possible detrimental impact might that have on the Scottish NHS, if you can follow? As I said in my opening statement, the UK Government officials have indicated that the bill will be amended to recognise the responsibility of the devolved administrations. In the particular point that I would draw the committee's attention to is the requirement to consult devolved administrations and enter into a memorandum of understanding before regulations can be introduced that impact on devolved matters. The distance that I can go based on what we have and bearing in mind these are proposals is to say that the current proposal is that there is a requirement to consult the devolved administrations before regulations can be introduced. To that extent, we would have influence over the decisions that were made. Of course, reciprocal arrangements work both ways. That is to say that if we were to increase substantially charges levied on other administrations, whether within or beyond the EU, then clearly that would work in the opposite direction. We do benefit quite substantially from the current arrangements in place, so under the S1 scheme that Liz Saddler mentioned, for example, around £15,000 state pensioners from Scotland benefit from this scheme cost of £48 million. If something was to happen to increase these costs, that would not be a positive step. Just one last minor thing. I just noticed the list that we were given of non-EU countries with which the UK has a bilateral agreement. It may just be an odd sample, but it seems quite idiosyncratic. Australia, Falkland, Ireland and New Zealand, perhaps you can understand, but, because of all in Serbia, are there particular reasons why? I could not comment on why the UK Government had particular relations in particular places. No, I do not think that I would go any further than that. In terms of the payment for treatment of Scots in those countries with which we do have reciprocal arrangements, who pays that and how is it paid? In terms of the reciprocal arrangements, does the UK Government pay that? It does not recover it from the NHS in Scotland. That is helpful to understand. Alex Cole-Hungton Can I echo colleagues' comments about Paul Gray's service? Paul has always been very generous of his time and, indeed, his patience, particularly with lowly backbench opposition MSPs like myself, so good luck, Paul, on whatever is next. I just wanted to ask a couple of questions about recovery and the mechanisms for recovery of e-hick moneys. First, how was money recovered prior to 1415? That is under the e-hick scheme. Prior to 2014, there was just an expectation by the department for work and pensions that health boards and trusts in England would inform them of people who had received treatment under the e-hick scheme. The DWP then claimed that money back from the person's country of origin. There was very poor take-up across the whole of the UK because it was seen as a bureaucratic process with no benefit to the healthcare provider because they were not getting any of the money back. The scheme that was introduced in 2014 was an attempt to encourage people to report that they had treated people under the e-hick scheme. 25 per cent was seen by the UK Government as a sufficiently large amount of money to encourage the people to do that, but since then, the number of people reporting has increased significantly. As Paul said, there are still five NHS boards who are not reporting activity. I think that you have in part answered my next question, which was about 25 per cent from the DWP. Was that a cash incentive to encourage health boards to more readily record their e-hick activity? Obviously, it is still not perfect. Five territorial health boards are not reporting activity. Some who regularly have delays and the rest of it. Is there any way that in the future, particularly in respect of the new arrangements, that technology could make life easier in this regard? It just feels a bit clunky and unnecessarily bureaucratic? My understanding is that it is a relatively straightforward system to use. There is a secure portal that the boards input the information on to. Undoubtedly, improving technology would help, but we do not know why people are not reporting. Some of the boards are smaller, so they may not have very much business. Even at 25 per cent recovery, it is considered that it is too bureaucratic and costs more than they get back through the 25 per cent. As Paul said, he is meeting the chief executives this evening and is going to speak to the five relevant ones. Can you give us an idea of who those five are? I am sorry to put you on the spot like that. Do not worry. Listen, that is not hugely important. My final question is how much of this do you think is about just culture on the ground, that people are not readily asking where the patients that present before them are from, or that they are not thinking to make that connection to say, actually, that we need to recoup money easier? The five boards are, Dumfreton, Galloway, Fife, Forth Valley, Lanarkshire and the Western Isles. I think that, within acute care, there is a requirement for people to establish where non-UK residents are coming from. I do not know why those five boards are not, whether it is a cultural matter or an administrative matter. Just to answer Mr Cole-Hamilton's question in a slightly different way, the culture of the NHS in Scotland is to provide care to people who need it. I will almost ask questions later. I am not ashamed of that. I think that we should recover money where we legitimately can, and we should observe the regulations and provisions that are in place. What I am planning to do this evening is to make sure that we are doing all that we can, because the NHS in Scotland should not do without money that it legitimately has access to. As I say, I think that our best foot forward would be to treat the person who presents with a need and seek the recovery afterwards. I fully endorse that, and I think that it is a culture that we should be proud of. I think that my desire to get those five names on the record in terms of the boards that we have who are not collecting was to bottom out whether there was a corollary between that and just the propensity for them to treat non-UK citizens, if they are particularly remote or not necessarily on the beaten path of the tourist trail. I do not really get that from that list, so it does strike me as odd. Anyway, no further questions. I wonder, Paul Gray, if you could tell us why the decision was taken, or when it is, and why the decision was taken, that this would be our responsibility of boards dealing directly with EWP and not something provided by the Scottish NHS in order to have a standard approach across Scotland? It is because it is a UK Government scheme rather than a Scottish Government scheme, but I think that, nevertheless, the questions asked by this committee highlight an anomaly that I intend to pursue. In which direction do you intend to pursue it? I intend to pursue it in the direction of consistency. It is clear that there is money to which health boards could be entitled, and therefore it would be sensible for them to have it. If any of the health boards can advance a case that says that they only treat two such patients a year and therefore the bureaucratic cost of doing it would be higher than the recovery, I will listen to that. However, I think that I would want to be assured that that was actually the case rather than that a source of funds was being overlooked. It is in terms of consistency of application by boards rather than a structural change in the way that the matters are managed, and in terms, presumably, of a consistent approach to the registration or treatment of patients from outwith the UK and outwith the EEA. That is correct. Thank you very much, convener. I wish you well in the future. I reciprocate what everyone else has said. You have always been open door to people who want to ask any questions, and it is basically diplomatic as ever. That is what I will say. Just to go back to the situation with the health boards. Obviously, there were six at the beginning of the recent gallery for Farley, Greater Glasgow and Clyde, which you have mentioned. I have just joined five NHS Lanarkshire and the Western Isles. As NHS Greater Glasgow and Clyde is one of the biggest ones, it was a concern that they had not joined in particular, but you have said that they have just joined and they have got money back of £120,000. The papers of evidence that were given by health boards said that the reason they did not participate was because it was too much bureaucracy. It cost them more money to get staff to look into it, so that was concerning as well. It certainly outwead the income, so I understand what you are saying, Paul, about various health boards in that respect. You mentioned that the scheme has been running for a number of years. I think that it was the end of 2014 that it came in. Has any analysis been done on the cost benefits of belonging to the scheme and not belonging to the scheme? That is one of the things that I intend to pursue with the chief executives today. Actually, in a very simple way, we just ask those who are recovering money to say to their colleagues, well, this is why we do that and this is why it is worthwhile. The fact that NHS Greater Glasgow and Clyde have recovered £120,000 for one quarter, if you multiply that up, that is nearly half a million pounds a year. It is not a trivial sum of money. Now, the sums may be smaller for the other boards in question, but I think that it is very important that we establish, as I say, a consistent baseline of activity. My judgment is that the best way to do that will be to get the health boards who are recovering money to explain to their colleagues why that is worth doing. I will certainly be looking by the end of this financial year to have a consistent pattern across all the health boards. If there are to be any exceptions to it, it is to understand it in a way that can be properly described. You would say that, basically, of the five health boards that are just now mentioned, the fact that if it was too much money to put staff in, it is reasonable to expect that they would not join in the scheme, but can you tell me why Greater Glasgow and Clyde health board decided that they would join the scheme all of a sudden? Is it because they have seen the benefits? Yes, it would be because they had seen the benefits of it and recognised that there was an advantage to them in doing so. I think that it is not so long as well since Greater Glasgow and Clyde got a new chair and a new chief executive. I do not think that I know that they have been looking at their governance arrangements and seeking to refresh those and strengthen them. All of that will have contributed to their decision to take this offer up. If I am being frank, being asked by the committee why you are not will have prompted some of them to think about it. Obviously, £120,000 is not a drop in the ocean, but for the size of Greater Glasgow health board, as you say, it could be half a million pounds or whatever it may be. What I want to say was that it mentions in the papers about back money, so I do not know if £120,000 is part of back money, but how far back can health boards claim? As far as I know, they have to claim as cases arise, but my sadler could say a bit more. The scheme is administered by the UK Government and we would need to investigate that further on right to you. It does say in evidence that you can claim back money. I think I wrote it down here. It appears that the claims can be back dated and that NHS Greater Glasgow has been collecting data on HIC since 2014-15. Would it just go as far back as when the scheme came in? Yes, it will only go back as far as the scheme started because there was no mechanism for that to reclaim any money. We could expect to get some information in regard to that. Non-residents have been treated. Do the boards still collect data on that? Do the health boards collect data on EIA? This is non-EIA? Yes, non-residents. Non-EIA people? Non-residents, I think, was what Sandra. All the actions. If they were resident here, they would be entitled to treatment in the ordinary way, but is their data collected from those EIA countries who are not resident here? Yes, my understanding is yes. Could we deduce from the fact that Greater Glasgow has been collecting this data for several years, but not making a claim to the DWP to recover costs? Could we deduce that the other health boards may well be doing the same? Do we have any idea what has been done with that data since 2014-15, if it has not been used as a basis for recovering funds? That is what I want to find out from them, because they should be collecting it. We have all agreed that. I want to know what they are doing with it. Further to Sandra's question, can we be confident that boards know who it is that they are treating who is not either a UK citizen or an ordinary resident in the United Kingdom, whether they are EIA citizens or otherwise? We touched on that in your initial questioning, convener. As the matter of general practitioners and primary care, I would like to write to the committee about that. Given any guarantee that I can be absolutely certain of the millions of people who are treated every year that we are perfectly sure about each single one of them, it would not be helpful to the committee, frankly. I would rather get what we know and give it to you in short order than try to speculate. Okay, thank you very much. Good morning to the panel and just to add to your blushes poll, can I also put on the record my thanks? Particularly, I think, as an opposition politician for the behind-the-scenes work that you have often helped to assist me with, and I think that for politicians across the Parliament that has really been valued, especially for individual constituents that we have been trying to get support on. I wanted to pursue further issues around British-born nationals being resident in different countries but maybe coming back to UK for treatment, and I wondered if there was any collection of that sort of data when people are potentially returning home to the UK but resident in different countries for treatment. We do now. I am just scanning my paperwork here of people who come. Under the S2 scheme, we know that fewer than 10 patients from Scotland choose to travel for treatment in the EEA, so in other words fewer than 10 choose to go out of Scotland for their treatment. But those that come back, we probably do not collect that because they will be Scottish citizens and they will come back from spending six months a year in another country and have treatment here, so no, it is very unlikely that we would collect that. So we do not know a picture around that currently. In terms of—and that leads me on to my next question—in numbers of Scottish pensioners who are living in the EEA currently and other countries, do we have any data around that and how many potential EU or EEA pensioners are living in Scotland currently? So I can tell you that there are 15,000 state pensioners from Scotland who are benefiting from the scheme, that fact we do have. Now, in terms of pensioners from other European economic area countries, do we have these data? No. So the 15,000 Scottish pensioners is extrapolated from the UK figure in terms of how many UK pensioners live in the EEA for which the Department for Health pay €4,000 a year for their healthcare. The amount that the UK—and that costs in total—sorry, I have not got that—but there are significantly more UK pensioners who live in Spain, Ireland, France and Cyprus than EEA pensioners who come to live in the UK. So the UK pay out significantly more than they get back in payment from other countries for their pensioners who live in the UK. Further to Cole-Hamilton's line of question, is there any mechanism around that from people who are resident in other countries then? Or is it the S1 scheme, S2 scheme—sorry, you mentioned—or are people, when they return to the UK, we're not necessarily sure where they're resident in the EU and the numbers receiving treatment? So we can't tell if someone who would ordinarily be treated in Scotland comes back to Scotland, we simply can't tell. Mr Briggs, I think you're asking, but if someone who would ordinarily be resident in Spain, let's say, a Spanish citizen, where to come to Scotland and have treatment, would we know? And I think that's the point I was going to write to the convener about, which is how do we know and on what basis and how many have we counted because I think we should assemble these data for the committee. So we would know through the EEHIC scheme how many people had access to care using an EEHIC card. For an EEA resident who came to live in Scotland as a pensioner, they're entitled to free healthcare, but it's in their interests to make sure that they are registered for that free healthcare so that they—and then the UK Government—claim the cost back from their country of origin. There are very small numbers of people in that category, and we would only have the number for at a UK level, I think. Finally, one issue that I wanted to pursue, which is kind of away from this, was around people when they die living abroad or die on holiday abroad and the repatriation around bodies. Do you think that there's opportunities to improve that? Because I certainly know from my time as MSP that it's one of the areas where I've had a number of constituents who you've had to support in making that happen. Do you think that there's an opportunity to improve that internationally, not just necessarily EU-wide? It's not, as far as I know, covered in the proposed legislation that the committee is considering today. That's why Ms Sadler made the point earlier about the importance of people also having the appropriate levels of insurance, because that is not something that is covered by the EUIC scheme. Now, where Governments—plural, here and elsewhere—agree to have some mutually or receptacle repatriation scheme, that is something that could be agreed, but it's not on the face of the legislation at this time. At the centre, it would be a piece of primary legislation in a new area of law. Effectively, I think that's right. Just a quick supplementary, convener. Anybody that presents for healthcare in Scotland without a community health index number, a chi number, are traceable. Is that correct? People coming from England without a chi number, we'd be able to know where their residence is or the fact that they're not resident in Scotland. That's so, but, again, this comes back to the point about the extent to which GPs would insist on such information before providing treatment. I'm using general practitioners as an example. The same would apply if someone was, you know, suffered an accident in the street and was collected by ambulance and taken to A&E. We wouldn't focus on finding out who they were and where they were from until we had administered the definitive treatment that they needed, particularly if it was very urgent. In my experience as an operating room nurse, it's handy to have a chi number, especially if you're going to cross-match for blood and things and just labelling and labs and just the whole system communicating. People are assigned a temporary chi number if they pitch up in the emergency room. It's just trying to get my head round the traceability aspects of people who show up for emergency treatment. To be clear for the committee, I do regard it as highly desirable that we know where people are from. The more backgrounds you have on an individual, the better the treatment for them is likely to be. There will be certain diseases prevalent in some countries that are not prevalent in others, for example. Again, just knowing all that and depending on the circumstances will lead to a better diagnosis and a better treatment and better care. However, as I think we've already established, our principle is to provide the treatment that's needed. I would support that as well. Keith Brown. It's a very quick thing. It's just that we were given before of 15,000 people from Scotland, I think, being an estimate of or extrapolation of UK figures. I'd really quite be interested to know more about that, whatever information the Government might have, and I'll also ask Spice for it as well. I suppose that my intuition would be that there'd be smaller numbers of people from Scotland, the north of England, Wales and Northern Ireland, living permanently overseas than there would be from the south of England. That's just my intuition, so I'd be interested to know what that 15,000 figure relates to. I think that it's probably also true, or my intuition would be that there's less people from overseas living in those parts of the UK, but I'd be interested to know what that is. My substantive point was on the point that was made by Paul Gray earlier about the culture of the NHS. 70 years of not having a vision of the NHS, which is a cash register by a bed, I think is probably quite an important thing. It would be useful in his pursuit of consistency if the value of that was kept in mind at the same time as looking to properly see reimbursement for services. We don't regard individuals as a source of income, I think, is the way I would put that. Nevertheless, the NHS in Scotland denies the principle of kind to the officer of a duty to recover such funds as may be available to us. My point is that the idea, the culture behind the NHS of free-at-the-point-of-use or treating people who need treatment has a value itself, and that should be borne in mind in my view when you're looking at the straightforward accounting of these things. Further to Emma's question, my understanding is that UK citizens who do not have a kind number, who are not registered with the NHS in Scotland, may not be able to access, if they're working abroad in other parts of Europe in particular, may not be able to access care in England if they're returning to England, but may be able to access care free of charge in Scotland. Is that an issue that has come to the attention of yourself or any of us? It's not an issue that certainly is one that presses on us, convener. We in any case treat patients from England on reciprocal arrangements, particularly across the border between Scotland and England. I'm happy to follow up your question to see if there's any evidence of that. I can see in the abstract how it might happen, but we wouldn't routinely be denying people treatment if we thought we needed it. Absolutely, and again that's not the suggestion, but merely to establish if there are any anomalies that may be impacted upon by this bill or may be carried forward into this bill between the different levels of eligibility in different parts of the UK. David Stewart Thank you, convener. I again add my best wishes to Mr Gray and all the work that you've done over many, many years. I think that I'd echo the positive comments from my colleagues. Can I touch on the final questions on contingency and planning? Someone of colleagues at Miles Briggs already mentioned the 15,000 Scots who live in the EEA outwith the UK. We know that figure taken from the UK figures. If we had a scenario where the reciprocity of health ended and that would be the S1 route, have you done any analysis of what the effect would be for the Scottish Health Service? I seem to remember the previous cabinet secretary talking about the number of extra beds that were required if those 15,000 Scots came back. Obviously, you've mentioned earlier that you don't happen to know if individual Scots who are in Spain come back for a one-off treatment, but you will know if the reciprocity ends and you will know that those 15,000 need healthcare in Scotland. Has there been any detailed planning done on that specific aspect? Given that this bill is before us and given that the Government has indicated that it regards it as exceptional, that is a core part of our contingency planning. However, I do not know if Shirley Rogers wants to say that a little more. Shirley has been leading for us on the consequences of Brexit for health. It might be helpful for the committee to hear some of the breadth of planning that is under way around anticipating the healthcare requirements. I suppose that it links also to Mr Brown's question around what we are planning for and how does that work. At the moment, we are planning for a no-deal scenario on the basis that, if that is as bad as it is, anything that is not that will allow us to recast those planning assumptions. We are planning on the basis of medicine supply, of medical devices and clinical consumable supply, reciprocal healthcare of which this is an element, workforce and all of the impacts around workforce potential supply and our existing EU 27 workforce, mutual recognition of professional qualifications and those are the arrangements under which we are able to use those medical and other professionals who have qualified in EU 27 nations. Research in clinical trials, legislative deficiencies, contingency planning, readiness of NHS boards and social care, bodies for operational impact, interdependences with critical supplies, in particular food and fuel and communications. I use that to illustrate the breadth and depth of the planning that is currently under way for EU through. That is very useful, but I can just press you on the specific. Let's assume a scenario in the current climate. Obviously, it's very difficult to know what the next steps are, certainly after the fiasco we've had in the Commons yesterday. Let's assume that we don't have reciprocal healthcare. 15,000 Scots need healthcare who are living abroad. They are coming back to Scotland. How many more nurses, how many more beds, how much more spend are we going to require in Scotland? We don't have that information at the moment because we don't know the extent to which those 15,000 people are unwell. If those reciprocal arrangements are an issue whereby they've come back because they needed a particular surgical operation from which they have recovered, then the answer may be zero. If, on the other hand, those patients are people with long-term on-go conditions, then we obviously will need to factor those into account. It depends on the nature and severity of the disorder from which those patients suffer. We are working up a range of scenarios, but I don't have a percentage number for you at this stage. However, there is a potential scenario where there is no reciprocal healthcare that your department is planning this detail. We are doing some scenario work to plan for that, yes. Can I just move on? I think that Mr Gray has already mentioned this, but just so I've got this on the record, you'll be aware of the new EU directive on patient rights and cross-border healthcare, which is effectively an enhanced S2 route. It means that, if I required a hip operation in Scotland, I could go to the EEA either in the private sector or in a non-planned way or in the public sector, get that done and charge it. That's the new directive, which has only recently been brought in, although it's 2011 stroke 24 just for the record. You may not have this information in your head, Mr Gray, but do you have any general information on that? Has it been used by Scots going abroad, or has it been used by other EEA members coming to Scotland to get the treatment done here? We do receive an annual return on the use of the directive. On average, around 30 Scottish residents use the directive each year to travel for treatment at a cost of around £50,000 per year across Scotland. The directive allows people to get the treatment covered at the same level as it would have been cost in Scotland. If the cost is higher, they only get the cost of Scottish care, and it doesn't cover any additional care such as travelling and any additional hotel accommodation, etc. The directive is not part of the bill, and we understand that the Department for Health is considering the future of the directive and how it should work, but we don't have any further details on that at the moment. As it's not part of the bill, if there's not any further legislation brought forward on that, we would cease for decades. It wasn't included in the terms of the withdrawal agreement, so it could potentially stop at the end of March. It's not alone in that aspect, if it's certainly. My take, and other members may have different views, is that I'm not surprised at the low take-out, because frankly it's not very well known generally. My final question is a UK Government issue, but Mr Gray may be familiar with it. I read in the press just the other day that for non-EU migrants coming to Scotland, particularly in health service, which we're all interested in, that the NHS levy has doubled to 400 a month. The scenario would be a nurse on over 30,000 a year coming from Ukraine to Scotland would have to pay this NHS levy to pay for the costs of accessing health service in Scotland. Is this something again that's been scenario planned in terms of workforce management? It's slightly beyond our legislation today, but, since I've got Mr Gray captive probably for the last time, it might be useful either today or perhaps in a written answer, because that does affect recruitment. Certainly, the health service unions and professional associations have been very concerned, because there's also a big cost to the employer as well, but that's another issue. No, we will write to the committee about that, because I think it's an important question and we should give you a proper answer to it. I want to thank Shirley Rogers for the list of the amount of work that's being done. We're coming to the nub of the frightened part of Brexit, if it is an odd deal. Dave Stewart mentioned about the 15,000 people in Scotland in their reciprocal healthcare, if they all came back from wherever they are. If there's an odd deal, and it's to say that there's no reciprocal healthcare, you're talking maybe 10 times that amount coming back to England from abroad. How is that going to affect if we've got reciprocal healthcare UK and obviously DWP are working on this bill as well in reciprocal healthcare there? How is that going to affect the healthcare in Scotland when it is reciprocal if they couldn't get the healthcare in England and they happen to come up to Scotland? I know it's a scenario, but it's quite frightening when you think if there is no reciprocal healthcare, we could be looking at the use of our tsunami, but of people coming back. We'd first of all have to assume that they all did come back, and given that some may have made their lives elsewhere for many years, they may choose to take out insurance arrangements. As Mr Rogers has said, there are various detailed scenario plans that we are doing, but the likelihood of 15,000 people all returning on mass to Scotland is probably quite low. What I think may be more likely is that people would be less likely to choose to live abroad in future if they thought that their arrangements were less favourable, or that they would have to take into account the insurance requirements that that could attract. However, I think that I wouldn't want to miss the point that the bill that's before the committee today is there in preparation for whatever scenarios may emerge, and therefore, if the bill—and I'm not presuming on this Parliament at all—were to be adopted, given consent to, it would resolve some of the issues that you described, Ms White. Thank you very much to Paul Gray and to the officials for your evidence this morning. Thank you also for the offer to come back to us with additional information. Can I say to put one further burden on you that if we, as a committee, are in a position to conclude our consideration of the LCM at our next meeting, we would require that relevant information to be with us by close of play tomorrow? However, I recognise that some of the things that we have asked you to provide are not directly pertinent to consideration of the LCM. If there are matters that you're able to reply to us within that timescale, that would clearly allow us to move ahead with the LCM, and the other matters that we have raised may require a collection of data, among other things, in due course. We'll certainly give you everything that we have by tomorrow night, convener. Excellent. That's much appreciated. Thank you very much. I'll now suspend for a couple of minutes, and when we resume, we will resume in private session. Thank you.