 First item is to welcome to the health, social care and sport committee. First item is to decide whether to take items 3, 4, 5 and 6 in private. Are members agreed? The second item today is an evidence session with the Scottish Government on the Transvaginal Mesh Removal Costry and Burstence My bronchol locals, ond we have our officials from the bill team who are participating remotely. They are Greg Tramers, the head of chief medical officer's policy division. Sorry, I'm just hearing some feedback, I'm not quite sure why. I apologise everyone, that's better. David Bishop, the mesh team leader. Terry O' Kelly, the Senior Medical Advisor. Bill Cigarland's and Kate Walker's lists from the Scottish Government and I would invite members to ask questions just by, I've got a note of the kind of questions that you want to ask, but I'm going to ask the bill team initially some questions about the specialist mesh removal services. I would like to get an idea of just where we are with that at the moment. We've obviously reached out to mesh survivors around this, and that's a question that they have around the mesh removal services as they stand. I'm not quite sure who I would go to. Would it be Mr Chalmers? Good morning, convener. Perhaps on that question, I might defer it to my medical advisor, Terry O'Kelly. I'm always being closely involved in the service. Good morning, convener, and rest of the committee. Welcome from a very rainy Aberdeen. The specialist mesh service in Scotland was established following work undertaken by a short-life working group consisting of council officers and representative parties. It is funded for the first three years by additional money from the Scottish Government. The centre is housed within NHS Greater Glasgow and Clyde and has been operational now for over a year. You will appreciate that the work of the unit has been inhibited to an extent by the Covid pandemic, but considerable progress has been made. Not only in establishing a fully functioning multidisciplinary team with recruitment of new clinicians—those are both medical and non-medical clinicians—we are now able to offer a truly holistic service for women with mesh-related complications. At the moment, the work is on going. We have a service review next month, and we are looking for updates on patient experience and early outcomes. That is going to be important. There is a service level agreement in place, which we have had a lot of input into. Across the United Kingdom, other centres are being established in England, designated centres in Wales and in Northern Ireland, and centres are being established in Wales. The Scottish Centre is seen as leading. It is leading because of the clinical expertise that is on offer. It is leading because of the public and patient engagement. We are grateful not only for colleagues in Glasgow but for working with the Scottish Health and Social Care Alliance, who are taking that forward. We appreciate—I think that everyone does—the sensitivities involved in the care that the women who have suffered need to have confidence re-established, and we are working towards that. We are working towards not only providing good experience, good outcomes and what we are looking for, but also ensuring that the skills of our surgeon are prudentialed. That is a process that is being established through the Royal College of Obstructions, Royal College of Surgeons and the General Medical Council, and we have been actively engaged in promoting that and ensuring that it moves forward as quickly as possible. Finally, one of the issues that was a major problem previously was information and shared decision making. With the background of realistic medicine, we have been intimately involved in developing the new guidance, GMC guidance on consent, and also engaging with services across the United Kingdom to make sure that we have information, we have patient decision aids and that those are seen to be and are acceptable for patients. Over the years, since the mesh survivors group has been petitioning, there will be a lot of testimony as to what happened to them and where that trust dissolved in the people who had been removing the mesh. How has that informed how the services are going forward? We are talking about the clinicians involved and the surgeons involved and the work that you are doing and the expertise that you have. What learning has come from the mistakes of the past or the practices that the past has led to the point that we are with this bill? We have drawn on the experience of patients very much. That is not only has it been used to craft and mould the service, but it will continue to do so going forward. We heard the voices in Scotland of the women. One has to accept and recognise that the bravery of the women to come forward to keep pressing their points, often when their views and their pleas for help will not listen to. I think that there was that perception. Given the numbers of patients that were involved, there must have been a lot of reality in that. That was born not only here in Scotland, but also by Baroness Cumberlatch and the experience of her committee in Westminster Parliament. We have heard those voices. We recognise that there are lessons to be learned. If we look across the policy areas that are being developed with regard to mesh, those lessons have been learned and what learning is being applied. I am interested in issues around total mesh removal versus partial, but some of the procedures are quite complicated. There might be subsequent surgeries that would be required. Does the bill cover additional, wider requirements for women that need concomitial surgeries? I might start on the bill and then I will defer it to Terry in terms of the clinical aspects of your question. In relation to the point about whether the bill provides for reimbursement when there has been more than one surgery, it does. I think that, apart from that point, in the explanatory notes, we are aware that, as the member has said, the successful surgery can require more than one surgery. We have covered that in paragraph 10 of the explanatory notes. Forgive me, Terry, but you might want to comment on the surgical aspect of that. For some women, the issues that are related to mesh and complications and care going forward are very complex. I am speaking to you as a clinical surgeon here in Aberdeen, Scotland. Those are not really the domain of private practice and private hospitals. Those are the domain of major NHS centres with all the infrastructure and services that can be offered for women. That was the point that we raised through the Accountable Officer and the Short Life Working Group, and it was echoed by Baroness Cumberlatch. This women is dependent on a multidisciplinary team, and we have to be able to offer them holistic care. The bill really covers the primary assessment and removal of mesh. It may be that women will come forward having had further care following that, but I think that the principal aim of the bill is to reimburse women who have had mesh removal, and that act rather than on-going management. With the referral possibilities for care out with the NHS that is being established, that will predominantly involve the physical removal of mesh rather than any reconstructive or additional procedures or clinical interventions that are required, such as chronic pain management or psychosexual, counsellor, etc. Those are the domains of the multidisciplinary team, and they are the domain of major NHS centres. Elsa Garland wants to come in before I go back to Emma Harper. I just wondered if I could just add to what Greg and Terry have said, just to clarify that the bill gives power to ministers to make a scheme. As I set out in the bill itself, the cost of being reimbursed will include the cost of the removal surgery itself, but ministers will have power to cover other costs, including if there was more than one surgery needed to remove mesh. We have quite a broad power within the bill to have those things in the scheme, and those are things that can be considered as the scheme is drafted. We heard earlier about a person who needed additional time because of a pre-existing condition that needed to be managed with constrained anti-thrombolosis-thrombolising therapy. If somebody required additional time because of additional health conditions, would that be included as well? I will come back to Elsa Garland. Thank you, convener. Again, this is something that we can consider in the scheme itself, as to what other costs could be included in addition to the main mesh removal surgery. I do not know if the additional time is perhaps a longer period of time in accommodation while treatments are being carried out, but those are things that could be considered as we look at the shape of the scheme itself. We have heard from many women that they have all said that there should be a degree of flexibility because every single person's case, when they have gone for the surgery, whether it has been in Bristol or in the States, has been different. There have been different circumstances, as Emma has mentioned. There may have been different health complications. They want to see that recognised and flexibility. If you do not fit into a particular box but you still have incurred a lot of cost, there is that flexibility. Do you believe that the bill as it stands allows for that? If I may, convener, the bill does allow for flexibility in setting up the scheme. I do not know whether there has possibly been a slight misunderstanding in terms of the costs that were set out in the financial memorandum, which were estimated costs that were used to estimate the cost overall of the bill. I do not think that the intention is that there would be a specific cap for things such as the mesh removal surgery that would be covered in full, and we would look maybe to more to set out what would be considered reasonable in terms of accommodation and travel costs, etc. However, there is that degree of flexibility in the bill, so it is not that, for example, the 20,000 estimate for surgery was just really in order to get an idea of what the total cost of the bill would be, rather than saying that the scheme might say what we are only going to cover up to that 20,000 limit. We might dig into that later. Some members have some questions on the financial memorandum in particular, so that is good to have that to dig into later. I very much welcome Terry O'Kelly's comment on us moving towards a holistic approach. How will you assess success here of the specialist service and how will patients' reported outcomes be collected and reported? We can look at how patients are managed through a process management in an episode, say hospital admission or some other practice of care. You could measure that, set up a pathway and then measure against it. That would be reasonable for things like pain management, and I am sure that that could be done. Similarly, with psychological inputs, etc. However, when it comes down to it, it will be patient experience. When patients engage with a centre, what are the expectations that start? How were those expectations addressed? What was their final opinion? I think that that is really important. We should be able to measure that relatively early. With regard to outcomes, again, there are early outcomes. Those could be patient orientated, but there will be later outcomes. What is the legacy of the care going forward? That is being looked at and addressed across the United Kingdom by an oversight group setting up a database that morphs into a registry over time. That is being led by NHS Digital. We are engaged with that. We have pilots running here in Scotland. Prom is an issue. There are some established problems that are validated. The mesh survivors would not unsurprisingly like one bespoke for mesh and mesh complications. One of the difficulties is that these problems take some time to establish. They take longer time to validate. It is important that, as we go forward, we have an eye on that, something that might be bespoke, but we also try to apply something that is present and exists at the moment so that we can get an early handle on patient-reported outcomes to know and be sure that what we are doing is correct and is addressing what women, not only what they want, but also what they need. That is pretty vital. We have heard a lot from some of the witnesses this morning about the challenges that they have had with the logistics in managing that private sector experience, whether it be in the US or in England. However, the challenges that they have with gaining that trust with the NHS service and an NHS-based service will be much better at managing the anticipated and unplanned outcomes of the complex surgery. What are we doing to reassure and benchmark that we are going to have some of the best mesh removal specialist services in Scotland again? I think that this is something that is very much in the forefront of my mind and actions. We want to change the narrative, but to do that, we cannot just say to women and mesh survivors that we have a great service, etc. What we actually have to do is demonstrate through evidence that we have a centre that is as good as any in the world and that we hope is world leading. To do that, we need credentialing and that we need that as soon as possible. We need the skills of our surgeons to be accredited and we need evidence—hard, really robust evidence—of excellent patient experience and outcomes. At the start of the centre of those experiences, I think that we can look at very early. The outcomes are going to be based on initial measures rather than the long-term legacy, but it is through providing women with hard evidence that we are going to be able to change the narrative and lead them to want to use our centres in Scotland. I absolutely appreciate the lack of trust and the issues with confidence. What we have to do with the service here in Scotland and across the United Kingdom is to restore that. It is not something that is within my gift. What we have to do is provide the information and it will be for women to judge and to value the experiences of their peers who have gone through that service, but the initial measurements experience are extremely encouraging. I encourage women to look at those and speak to our clinical teams and to open their eyes to what is available here in Scotland before they decide to go anywhere else. Thank you. You spoke in one of your earlier statements that you had some new staff coming on board. Where are we recruiting the staff from? What areas of expertise do we have that were not in the team perhaps before in terms of that multidisciplinary element? There are some surgeons who were here in Scotland and working Glasgow, but they have been augmented by colleagues from the rest of the United Kingdom. We are now up to complement with removal surgeons. If a woman chose not to have clinical contact with one of the surgeons who perhaps has been responsible for care in the past, she could state that an elect has been managed by another colleague. With regard to the others, we have pain management, nurse specialists and those are really important additions to the clinical team. I am really interested in how we can support these women's mental health in particular, and whether any consideration within the bill was given to reimbursing maybe private medical costs. A lot of what we heard from mesh survivors earlier this morning was that some have lost confidence in the centre in Glasgow itself and some will probably have lost confidence in the Scottish NHS as a whole and may want to be seen privately for what has been a traumatising event for many of them. I just want to see if there has been consideration given to paying for or reimbursing, for example, private counselling and other things that may be outside just the mesh removal itself but may actually help those women recover. I might start on that and then other colleagues might want to contribute. The bill at the moment in section 1 on the scheme that Ilsa referred to is a concern in the first place with mesh removal surgery. I will be clear to the committee members. As Ilsa has said, we have a scope to refer to other costs in the scheme. At the moment, our intention would be that the main focus is on the surgery, on the necessary preparatory steps towards the surgery and the accommodation arrangements around the surgery. The reason for that focus comes back to the primary intention behind the bill, which is that the Government has decided, as members know, to commence arrangements, to procure surgery in the independent sector. The purpose of the bill is to reimburse people who entered into private costs, essentially not knowing and having no reason to know that the Government was about to do that. That is the primary focus of the bill and that is the reasoning around it. I suppose that acknowledging what the member has asked, it is the case that services of the type that she has referred to in terms of mental health support and other important matters have and have been and will continue to be available as normal through the NHS, whereas, in the past, the mesh removal surgery was not available through the independent sector. There is scope for matters that are connected to the surgery to be included in the scheme, but the general is not the intention of the Government that the whole scope of a person's health needs might be covered by the scheme, even though the way things are connected to the surgery are helpful. What is proposed in terms of the options and making it clear to women to present what the options might be? The bill allows for patient choice that they can opt to have their surgery in Scotland or in other parts of the UK or they can opt to have it privately. How is that going to be made clear to women what the options are and how much is it going to be patient-centred and their choices are respected? I would really like to hear how that is going to be communicated, not just to the patient but also to their GPs. One of the things that we have heard from women is maybe sometimes a lack of understanding about mesh and the complications of mesh at the GP level. I am happy to hear that. Your question can be used for the highlights on what is covered in the bill and what is not. The bill is focused on surgery that has taken place in the past and things that have happened. It is only about reimbursement of moneys already spent. The bill does not cover what you have described correctly as the range of service and surgery options now available to patients in the future. As Terry has already explained, one of the primary parts of those options is the mesh removal centre in Glasgow. There is also now the option developing of surgery in NHS England and potentially the other part of the UK. The work under way now is to make arrangements for the independent sector. Those three options in the present are separate from the bill. Obviously, these issues of course are connected, but the bill is very much focused on the past to ensure that people who have entered the post. The reason that we are asking is that we also want to know about the specialist mesh services. That is why we are asking quite a few questions around that as well as the reimbursement. No, I completely understood, convener. I think that that is a convenient moment for me to ask Terry to talk about the sorts of conversations that you are asking about that will inform which choice people go for. I think that we have to be clear that the needs for a number of patients is complex. It would be foolish to divorce a surgical procedure from a pathway of care that must involve services near to home, as well as those that are perhaps further away. It is important that patients with problems are seen by their local clinical teams. I accept that there may be potential issues around that, but that is really important because it is that local team that will pick up the problems if they occur, which are urgent or occur as an emergency. In discussion with colleagues in the local teams, we have been working with the boards throughout, there will be on-wood referral to the specialist mesh centre in Glasgow. It is reasonable that patients are assessed here in Scotland. There will then be a conversation with the patient about what they want. I speak to you as a commissioner who has been involved in similar issues with managing complex problems with inflammatory bowel disease. Patients want to go to various places, but there has to be a discussion about what is in their best interests and making sure that, by acting in a certain way, care is not prejudiced. We have been clear that the management of any patient must be linked to a competent multidisciplinary team for appropriate discussions and that our primary aim is to encourage patients and show patients the best care that they are going to get is in Scotland. However, that does not prove that we are unable to reconcile issues to allow care to go forward in Scotland. We will then advise that referral to mesh centre in NHS England in Northern Ireland or Wales would be appropriate. That can be discussed and a decision is made about that. All those centres in England will provide similar services to the centre in Scotland, again linked to credentialing measurements of experience and outcomes to benchmark the outcome of pathway of care. The process of care will also be benchmarked and categorised and identified. If, after all that, a woman feels that she just cannot undergo surgery within our NHS, and I think that that is a tragedy but we recognise the reality, then there will be the possibility for surgery either. At the moment of the discussion drawn going, the possibility of surgery is out with the NHS in two places, one potentially here in United Kingdom and one in America. However, that care must be tied into a competent multidisciplinary team. It cannot be that the women embark on management that is not overseen by the multidisciplinary team, we recognise that it is really important, as Baroness Cumberlatch did and the clinical teams do, and I am sure that the women do as well. It is important to ensure that any intervention is part of a pathway of care and does not prejudice what might be necessary or what is present going forward. Can I just ask one other question on this before we move on to talking about the bill to Mr O'Kelly? If a woman who has had mesh inserted into her that she has had problems with and it has been removed by a surgeon, if any of them have a nervousness about that surgeon who put the mesh into their bodies, also being the surgeon who might remove it, is that taken into account and respected? Yes, as I said, it depends where the woman had their surgery but in Scotland, if they engage with our mesh removal service, then yes, there are clinicians there who were there previously, but we have recruited new surgeons, they are well trained, well supported and will be credentialed. A woman absolutely has the right to elect to have care undertaken by that individual. Thank you for being here today. We heard some talk earlier about the importance of trust and mentioning that there is now a full complement of staff and the required expertise at the specialist centres. We heard from women today, some who had already been treated by Dr Veronica, that NHS imaging often cannot see mesh as it is placed behind the bone, and also about Dr Veronica's designing and developing new specialist surgical tools. Have our specialist centres considered those issues in those developments? Have there been lessons learned and incorporated into the processes? I think that that would be a real step in the right direction to re-establishing that trust. I have been involved with mesh since 2014 and Dr Veronica's has been an important figure in development of surgery. He has gained the trust of women, not only in America and the United Kingdom but elsewhere across the world. I do not think that his techniques are unique, and it is inevitable that surgeons develop abilities to undertake procedures. The evidence that we have, published evidence, is that the process and outcome of care offered by Dr Veronica's and other surgeons is no different from those who have expressed specialisation in the type of surgeon that would include our surgeons in Scotland. Dr Veronica's is a high-volume surgeon. He is technically, I am sure, very competent. What we need to make sure is that the care that we offer is at least as good as him, if not better, but supported by all the other services that women need. We also need to offer a service that is responsive to women's wants and needs and can demonstrate that those responses have taken place. Certainly, the initial experience with the new service in Glasgow is that it is listening to what women are saying and responding. That is tremendous. Responding not only in words but in actions. It is an iterative process. As something changes, which was important and improved, something else comes along. It is an evolving service. We would like to see it as an exemplar for how services are developed across Scotland, not only for women's medicine and surgery but for other specialties as well. It is after all the people's service. We are now going to move on to talking about the reimbursement scheme and questions from David Torrance. Thank you, convener. Good morning, everyone. How long will the scheme last? Will there be any time limits on reimbursement? If there is a timescale, how is that going to be decided? Thank you, Mr Torrance. I might start and I might ask David Bishop to contribute as well here. Our present intention is that all the rough timings that are back to mention are dependent on proceedings on the bill. However, our present intention is that the scheme will open not very long after royal assent and that it will be widely publicised to the interesting people. It will not surprise that the committee will be encouraged to know that we have a hopefully now reasonably well-developed system of consultation with interesting people through the health and social care lines that have been very useful in developing policy but also through national services Scotland, which, as the committee will probably know to, has been leading on the implementation of the present mesh fund, which has been in operation for a little while now. We would expect the scheme to offer to open only a few months after royal assent and then be available for a period. We would expect it to be a closing date. We have not come to a final view on what the duration of the scheme being open will be, but it could, for example, be approximately a year. We would hope that, during that time, it would be practicable to bring it to the attention of everybody that is potentially eligible and to give it a very reasonable period to submit an application. As is the case now, with the Scottish Government mesh fund, there will be circumstances where an application needs to be added to or explored a little bit so that the particular circumstances can be confirmed. However, we would hope that that would be possible under that arrangement as well, not least because, as has already been said in the committee, there are a variety of circumstances here. Of course, as we have seen in the bill, it provides for a copy of the scheme to be laid before the Parliament after a royal assent. That is helpful. How will reasonable costs by individuals be defined in the bill? I think that I heard earlier that there would be no cap on surgery costs, but will there be a cap on daily costs? I will start from this, if I may, and then I might bring in my colleague David Bishop, who is in the financial memorandum. I hope that the reasonableness will be looking to the evidence of the situation. The surgery costs will be looking to reasonable proof of what those costs were and that we have some intelligence around the rough costs of that. In terms of the reasonableness of travel and accommodation, in drawing up the financial memorandum, what we have tried to do is to look to the reality of somebody planning travel on their own through their own budgets and through access that anyone else would have to travel on accommodation on the internet. David, you might want to say a little bit about the estimates that we came to in the financial memorandum. Of course, thanks, Greg. I suppose that it is important to say at the outset that they very much are estimates. They were based on the intelligence that we had at the time through the likes of correspondence and all that. In the period since doing that and in drawing up the scheme, which we are obviously still working on at the moment, we have been taking evidence from women who have lived the experience of doing this. We have been getting that evidence via the alliance. Obviously, we will take all of that into account as we draw up the scheme, which, as I say, we are doing at the moment. As part of that, there was a question about capped rates and similar. I would say that what we are doing around all that is engaging with women at the moment to see what evidence they can practically provide to support their applications. Maybe that they have not kept evidence for smaller amounts, whereas they probably do have evidence for the big-ticket items such as the treatment. That is the kind of thing that we are considering around reasonableness and what sort of caps might be applied and whether caps are appropriate at all or whatever. It is important to say that it is very much a work in progress at the moment. We will continue to engage with women as we continue to draw up the scheme. Many of those women who have had to take their husbands, partners or family members with them for support, will the bill include reimbursement of their costs? From what we heard this morning, the biggest issue appears to be with the women having the money up front to fund this, because this is ultimately a reimbursement bill. We have also heard that there could be some significant on-going costs that are unplanned for regarding the removal of the mesh and the surgery and the complications, in particular when they are accessing this through the private sector. Is there something that we can do to help that? It is not a very equal service if there are women out there who cannot have the resources to have the money to pay up front and then claim back, but they cannot then access ultimately what this bill is trying to achieve? What we try to highlight is that, as apologies for repeating myself, the bill here is concerned about things that have happened in the past and people spending their own private money. We are trying to make sure that they are appropriately and reasonably reimbursed for that. In terms of what happens now and in the future, as Terry and others have said, focus is on continuing to improve the specialist centre at Glasgow. As Terry has always said, it is not just about the surgeries but the breadth of services. Of all sorts of different types, those will be free through the NHS as normal. I mentioned earlier that we still have the continuing Scottish Government mesh fund, which is providing help for people affected by mesh complications. That fund remains open at present. Thank you for clarifying that, Greg. Very helpful. If the women who have had the surgery for their mesh removal are not quite gone to what they expect from the outcome, how, when the outcome is not being as successful as they hoped or for and there are still an awful lot of on-going issues, how will that be covered or facilitated in the bill? That is a very fair question, but it is not the subject matter of the bill. Perhaps I might bring Terry on that, because I think that your question is focused on what happens in the press and when any surgery that is happening now is not quite as successful as a patient in search and would hope for. I think that this is where the... As Greg said, the reimbursement bill is about care that occurred previously. What we are addressing through our work and NHS and NHS more broadly is care for women going forward. If patients have had remedial surgery, which has not achieved their expectations and further management is required, this is absolutely the domain of the multidisciplinary team. It is about engagement with patients, understanding what their issues are, what it is that they want and how that can be achieved. In reality, it is unlikely that, if surgery is involved in further remedial surgery, that that is going to be the domain for out-of-NHS care. That is the truth, because we are then into pretty complex engagements that might themselves be associated with risk. Having said that, it may be that there is a bit of residual mesh and it might be appropriate for care elsewhere, but, again, it would have to be, through discussion, sent on what the patient wants, but, importantly, taking into account what the true needs are and trying to align those opinions. I recognise that that may not be what every woman wants to hear and maybe what the committee does not want to hear, but it is the truth. We have to make sure that, in managing patients, we absolutely take into account what they want, but we have to also align what they want to, what is required and what is reasonable. Is that the realistic medicine that you referred to earlier on in the discussion today? Yes, it is absolutely. I think that that is dominating the way that we are going forward in the health service in Scotland. We talk about realistic medicine. People sometimes say that this is cheap medicine, but it is addressing what people want. It is seldom that clinicians ask that question. It is empowering for patients. There are experts involved in all that. There is the clinician who knows about the disease, the processes and treatments, but it is also about the patient. They are the experts about themselves. Sometimes, patient's expectations might be unrealistic, but it is trying to find some way that we can help them to give them as much as we possibly can along what they need. Evelyn Tweed and I have a couple of questions about reimbursement and what it might cover and eligibility and proof. One of the things that I am not quite clear on is that a woman had surgery-involving mesh in Scotland, but when she was opting to go wherever it was privately and have the mesh removed but was not resident in Scotland at the time, but maybe even be back in Scotland now, she is not eligible for this reimbursement. Is that correct? If she was not resident in Scotland at the time of the mesh removal surgery that she has paid for herself? If I understood that question correctly, I will be careful to check the record that I am understanding correctly. I think that that is correct. Section 13b says that the qualifying of surgery is surgery in relation to a person who was at the time the surgery was arranged ordinarily resident in Scotland. The surgery that we are talking about here is the removal surgery. That is the thing that is being reimbursed. I do not know if it ails the surgery. Would you like to add to that if we have understood the community question correctly? The mesh removal surgery, if the person was not resident in Scotland at the time that they were having that, that is not included. To be absolutely precise and answering you, convener, at the time the surgery was arranged, there will be a gap of course between the surgery being arranged and it happening, but if the person was not ordinarily resident in Scotland at the time the mesh removal surgery was arranged, that is not within the scope of a possible scheme. Ailsa, do you want to clarify anything that I have said there? Ailsa? Sorry, I do not know. Am I unmuted now? No, you are not. Thank you. Greg said that correctly. The key point is that when the surgery was arranged, if the person was resident ordinarily resident in Scotland at that point, then they would be eligible to be reimbursed. You have covered some of the things. David mentioned that there might be some smaller expenses that a person maybe had to removal surgery a good few years ago. Things like taxis and mails and whatever, they have not kept the receipt. They never thought they were going to be reimbursed for it. There is going to be a flexibility there, I understand, around that. However, if somebody has raised money to pay for their surgery has been taking it alone, that obviously has an additional cost in terms of interest, is that sort of thing going to be covered by the reimbursement? You are not unmuted if you can ask broadcasting to unmute Greg. I repeat what I said there. I think, convener, we want to give that careful consideration in terms of the exact working of this team. It is a point that we can undertake to reflect upon from your question. We have, for example, in the explanatory materials reflected that, in some cases, it may be that people have received donations through crowdfunding and other things, and that is a relevant thing to take into account. Clearly, circumstances where people have the overall financial cost to the person, which will obviously need reasonable documentary evidence to be available if there is a large amount of money, is something that we will be happy to reflect upon in the drawing of the scheme. A person has applied for reimbursement, and they are not satisfied with the level of money that they have been given as a result of their application. What avenues might be open to them to challenge that? That is the potential to cover that in the scheme that is addressed in section 2, H, of the bill. It will be the intention that the scheme covers a route of review. David, you might be able to clarify that. I think that that is a route of review at the moment in relation to the present Scottish Government mesh fund. There is, yes. We are working through the detail of the reimbursement scheme and how an appeal process might work, but we are looking at including one in that as well, so that is something that we are giving consideration to. Thank you. Evelyn, you had some questions around this. I have one question left, because you have asked quite a lot. Could I ask if a woman comes forward to use the scheme as set out in the bill and she is unhappy with the outcome? How can she get redress? Where would she go to say, I am not happy about what has been offered, and how could we help with that? As David could have alluded to before, we do intend that the scheme will cover an explanation of how a review can happen. We will explain that in detail in the scheme. I imagine that, in the ordinary course of events, the process of review will be through the body, which in all likelihood will be National Society Scotland, who have been considering the application. However, the scheme will establish a route for somebody to ask for a review or to make a complaint. We turn to the financial memorandum. We are running out of time, but some members have some questions around the financial memorandum. Can I come to Paul O'Kane? Just on the financial memorandum, I think that the analysis of that so far would suggest that there are no unknowns and that we do not have clarity on how many women may come forward in terms of using it. Therefore, the finances are still at the stage somewhat estimated. I am keen to understand, firstly, what contingencies there would be in the FM to account for any increase in the numbers of women coming forward that might have not been anticipated. I suppose that, knowing all along that we do not have to confirm official information about the numbers of women that have sought mesh removal surgery in the past, what we are trying to do to be helpful to the committee, hopefully to the Parliament, is to measure those things in a kind of per diem basis. If there is variation in terms of the number of night stay or the number of people who have been accompanied against those who have not, although our base assumption is that almost everybody going for this surgery will have had a partner or a husband or a partner or companion with them just because of the practical circumstances. What we are trying to do to help the process is to make it as simple as we can in terms of coping with variation as information becomes available. I suppose that it is best to be straightforward and honest in the circumstances in that we policy officials have had a number of conversations with a number of people in different fora over the past little while. We have been offered a similar overall picture about the number of potential applicants. Of course, we cannot know for sure that there are people out there who are just hitting from us at the moment because they do not involve a risk. What we are trying to do in all those estimates is to provide for variation and where there is a plausible risk that somebody is not going to have receipts, a taxi or a lunch, which is perfectly understandable, that we come to some sort of standard approach whereby somebody is fairly reimbursed for those reasonable expenses. So far, I am very interested in just leading on from that question about how we make sure if there are any women out there who do not know about the scheme or do not know how to apply for the scheme, how we make sure that information is very accessible and that the women feel at ease to apply should they have to. Has there been any work on that? It is certainly—as Terry and others have said, we wish it wasn't the case, of course we don't, but we recognise that there is a nervousness of interacting directly with the Government because of the circumstances. We have been throughout seeking to work with the health and social care alliance, which I think is what others have to judge finally, but I think that it has got a lot of expertise in terms of engaging with groups that are sometimes hard to reach and who are ambivalent about working directly with the Government. They have held a number of focus groups over the last little while to inform the development of the scheme, the bill and other points. We will continue to do that. We will continue to work through National Services Scotland, which has established routes. We know that many hundreds of people have already applied for the Scottish Government mesh fund. Although we cannot be certain, we would imagine that anybody who has applied for the mesh fund will include those who might not be relevant in terms of the bill, so there will be that route as well. Of course, I hope that, without saying that the Scottish Government will use its follow-ups channels if the bill gains royal assent to publicise scheme through social media and other steps to bring to people's attention. It might be our final question. I am just looking across my members to double-check. Thanks, convener. It might be that Greg has alluded to this already in the financial memorandum. It says, it is expected upon establishment of a scheme that all applications will be made within one year of the scheme opening. With social media advertising, you will know who has already had mesh implant surgery. Is the one-year time frame quite narrow, or do you think that that is reasonable? We hope that it will be reasonable. I suppose that what we will want to ensure is that we align the activities so that we open the scheme after we have made people aware of it. We would hope that a year will be sufficient and that it instinctively feels that a full calendar year after the scheme opening will provide enough time. I suppose that one thing that is saying is that that period will be a period for applications. As a number of members have said, and I am sure that it will be the case, just because of the complexity of the circumstances, I am sure that there will be a number of cases where the determination of any grant or payment continues up on after that year. There is no date for that, but that will be based on the circumstances of use case. I do not know if Elsa would like to call off anything else out there. No, I am very happy with everything that Greg Scott said. That is as asked all of our questions of you. I want to thank you all for your time this morning and for clarifying certain aspects of the bill and the scheme as you develop it. At our next meeting on 2 November, the committee will continue its scrutiny of the Transvaginal Mesh Removal Costry in Bursamont Scotland Bill and consider some subordinate legislation, but that concludes the public part of our meeting today. Thank you, everyone.