 Welcome to the 24th meeting of the Covid-19 recovery committee in 2022. We received apologies this morning from Brian Whittle MSP. This morning we will continue our inquiry into the impact of the pandemic on the Scottish Labour market. I would like to welcome to the meeting Susie Fitten, policy manager from Inclusion Scotland, who joins us remotely. Pamela Smith is the head of economy and poverty at Public Health Scotland, yng Nghymru, Professor Sir Aziz Sheik, Professor of Primary Care Research and Development and Director of the Usher Institute and Dean of Data at the University of Edinburgh, who joins us in person, and Jerry McCartney, who is a Professor of Well-being at the University of Glasgow. Thank you for all giving us your time this morning and for your written submissions. We estimate that this session will run up to about 10.20, and each member should probably have about 15 minutes each to speak to the panel and to ask their questions. And for those witnesses who are attending remotely this morning, if you'd like to respond to any issues being discussed, if you could just type R in the check box and we will try and bring you in. I'm keen to ensure that everybody gets an opportunity to speak, and I apologise in advance therefore if time runs on too much I may have to interrupt members or witness in the interests of brevity. Could I please ask the witnesses to briefly introduce themselves, and I'll start with Susie Fitton, please. I'm a policy manager at Inclusion Scotland. Thank you, Susie. Pamela Smith. Good morning, committee. I'm Pamela Smith and I'm a head of economy, poverty and environment at Public Health Scotland. Thank you, Professor Sir Aziz Sheik. Good morning, committee. So Aziz Sheik, I'm Professor of Primary Care Research and Development, director of the Ashrin Institute and Dean of Data at the University of Edinburgh. Thank you very much. Jerry McCartney, please. Good morning, committee. My name is Professor Jerry McCartney. I'm a Professor of Wellbeing Economy at the University of Glasgow. Thank you very much. I'll now turn to questions, if I may. If I can begin with Inclusion Scotland. Susie, if I could ask you a question, and thank you for the very detailed written submission that you provided to the committee. Moving on to long Covid, the committee has a keen interest to investigate this further. The figures that you supplied in your report that nearly 4 per cent of people in Scotland are currently living with long Covid, which is around 202,000, and 83,000 of those people have done so for more than 12 months, and 44,000 reporting that it affects her ability to undertake day-to-day activity. One of the things that I found quite worrying was the early study that suggested that at least half of those with long Covid meet the diagnostic criteria of ME, and we know that ME is profoundly debilitating neurological disease that can affect multiple systems within the body. Prior to Covid, I think that there were 21,000 people with ME in Scotland. I note that the substantial proportion of long Covid sufferers are experiencing similar illnesses, and that will have a direct impact on people's ability to work. I know that you feel that action is urgently needed to address this problem. Can I ask you, Susie, what would you like to see the Government doing to address this problem? While some people with long Covid are able to return to work, particularly when their employers are supportive of making suitable adjustments to support them in the workplace, many people with long Covid have been left in limbo in terms of getting the right advice, information and support to find out more about the symptoms that they are experiencing. Many disabled people and others have reported to us that they have not been receiving any support or advice and have either not been able to work at all or only with reduced hours. It is a particular issue for people whose friends and family members are living with long Covid and they have experienced challenges in combining unpaid caring roles with employment, particularly acute for parent carers of children and young people with long Covid, especially young people who are not able to attend school as a result of their symptoms. We would argue that employers need support and advice on how to make reasonable adjustments to someone with long Covid. We would ask that employability support is made available to people with long Covid if they are forced to leave work so that they can re-enter the labour force. On the kind of things that are affecting people at work, in a recent survey by the TUC of over 3,000 workers with long Covid, nine out of 10 respondents experienced fatigue. There are problems with brain fog, shortness of breath, difficulty concentrating and memory problems. Over four and five respondents reported experiencing at least one of a range of pain-related symptoms with about one third experiencing depression. We would ask that similar measures that have been shown to support people with chronic illness and pain conditions are promoted to employers. That is things like real flexibility in terms of the hours that people are allowed to work. Flexible working in the truest sense has been shown to support people with energy impairments back into work and allows them to maintain work. We would argue that we would like to see flexible working in this rush to get back to normality in terms of renewal and recovery from the pandemic. We are concerned that employers will be less likely to offer real flexibility. There is some concern that long Covid is not yet necessarily considered to be a disability because it is not among the conditions listed in the Equality Act as ones that are automatically considered a disability such as cancer, HIV and multiple sclerosis. The Equality and Human Rights Commission originally said that not all cases—or they could not say that all cases of long Covid would fall under the definition of disability in the Equality Act. It has since qualified that to say that if it has a substantial long-term adverse impact on someone's ability to do normal day-to-day activities, it would count as a disability. We need to ensure that work is affected by long Covid and that employers follow existing guidance when considering reasonable adjustments for disabled people and access to flexible working. If I can move on to start with the link between long-term sickness and economic inactivity, Scotland tends to have a high proportion of 16 to 64-year-olds who are inactive because of long-term sick when compared to the rest of the UK. In Scotland, we have increased to 7 per cent, which is compared to 5.4 per cent of the rest of the UK. First of all, my question is why do the witnesses think that Scotland is comparatively worse than the rest of the UK? On an international scale, how do we explain the continued rise in the UK inactivity figures in comparison to the other OECD countries that see the figures declining? Can I bring you in, Pamela? I think that the first point that I want to highlight is that some of the long-term health conditions and the chronic health conditions are preventable. Many people who are living with the chronic conditions are supported to remain in work and remain economically active. In terms of Covid-affecting inactivity, I think that it is still a pretty new condition in terms of long-term effects and a bit more research is required there. When we are looking at chronic conditions and long-term sickness, we cannot look at that in isolation. We know the intersectionality of disadvantage and inequality manifests itself in poorer health. We know that it is estimated that a third of the individuals who have chronic conditions and long-term health could be prevented through early intervention. Things such as the lack of good fair work that was referred to earlier, lack of access to skills and training for some parts of our community and the continued impact in terms of people living in poverty. It is difficult to identify one reason because there are so many interdependencies and factors that impact on people's ability to move towards entering sustained employment. Health is one aspect of that. I think that there are other reasons for the economic inactivity alongside health, and that may be around the labour market where they live. It may be around other caring responsibilities. It is quite difficult to isolate that health may well be the only factor. We have to look at the individual and their individual circumstances. Health will be one factor. It does not follow just by telling the health alone that you will reduce the labour market inactivity or increase participation. We will need to have a more holistic approach to the disadvantage and the inequalities that the individual is experiencing to get them into that sustainable labour market participation. I know, Gerry, that you want to come in, but if I could just ask a quick question with the comparison between Scotland in relation to the rest of the UK. Do you notice specifically why it is so much higher in Scotland than the rest of the UK? I do not have any evidence to hand that would indicate why there should be a difference. A lot of the studies are self-reported in terms of the cause for economic inactivity. Gerry, do you want to come in? Your question was about why the trends were so bad and why Scotland was comparably bad. I would like to bring to the attention of the committee some of the longer-term history here. In terms of Scotland's health, in comparison to the rest of the UK, it had been improving and improving on average until around 2010 or 2012, albeit that it had always been worse comparatively than the rest of the UK. There are a number of historical reasons for that that were summarised in a report by the Glasgow Centre for Population Health in 2016. Since 2012 onwards, what we have seen is that life expectancy has not improved at all on average. In the poorest areas of Scotland and indeed the poorest areas across the UK, life expectancy has gone down. Mortality and life expectancy is a pretty blunt instrument to measure health, but we can look at other measures such as healthy life expectancy, which combines mortality measures with self-reported health, which starts to get into the experience of morbidity and ill health. We see quite a shocking set of figures that predates the pandemic. Between 2011 and 2019, average healthy life expectancy declined by two years. If you look at the most deprived 20 per cent of the population, healthy life expectancy declined by three and a half years and all that predated Covid. We are quite clear now that the causes of those stalled mortality trends and healthy life expectancy trends are related to the change in economic policy after the great financial crash in 2008. The change towards austerity policies and the implications that it has had for social security benefits, for public service funding and all that sort of austerity packages had a massive impact and all of that has left the population in a very vulnerable state when the pandemic hit. In a sense, it is no surprise that in that context of stalled life expectancy trends and declining healthy life expectancy, a global pandemic impacting on the population would simply exacerbate those trends. I think that Covid and long Covid has probably made an impact on that, but I would also agree with what Pamela Smith has said that austerity has also created a context of poor quality work, of precarious work, of a whole range of labour market demand factors. That means that economic inactivity has become more common as well. There is a sort of poly-crisis of factors that are driving the trends that we are now seeing. Thank you, Gerry. That is very helpful. I am going to move it on to Murdo Fraser. Thank you. Good morning to the panel. Just to follow up some of the questioning from the convener, because I think this is really at the heart of what the committee is trying to understand here in terms of what has been happening in the labour market. We heard some interesting evidence last week from our panel around the reasons for the reduction in economic activity, and whether that was directly related to health, so whether it was people, for example, with long Covid who were struggling to work, or whether it was more about other factors such as people deciding after two years of home working that they were going to take early retirement, for example, because they didn't want to go back to an office working environment. I am interested in getting people's perspectives on that. To what extent do you think that this is directly health-related, or whether there are other factors, particularly among the 50 and 60-year-old age group? Professor, maybe you could start, if you have any thoughts on that. I do not have any direct evidence to draw on, so this is mainly anecdotal, but I think that it is probably going to be a combination of factors. As has previously been mentioned, there are some very important health drivers that are contributing. Most of those were evident prior to the pandemic, so they are largely non-communicable disorders that should be largely preventable through appropriate public health approaches, health promotion approaches, but the fact is that we still have not made that transition as a health system, whether in Scotland or across the UK, so it remains largely a curative health system with a vast majority of funding directed at hospitals rather than at public health approaches. I think that health is a contributory factor, but clearly the pandemic has been a massive, disruptive catalyst for people thinking about their lives in the kind of wider context. I think that anecdotally a lot of people are making choices about having different priorities and trying to live differently, so I think that that is also likely to be contributing. Pamela, do you have any thoughts on this? From a health perspective, we know that mental health and anxiety, depression are the areas of health that are increasing in terms of the economic inactivity, particularly among young people. I am excited more for a reason why people are leaving the labour markets. I think that there are issues around mental health and there is a whole cocktail of factors that are impacting on mental health. People are experiencing chronic stress, and that has manifested itself in other health conditions such as diabetes, high blood pressure, heart conditions and so on. However, it is not all down to the health conditions themselves, because we know that 58,000 people who are inactive due to health conditions do want to work. It is coming back to some of the earlier comments around the flexibility of work within the labour market and the ability to access fair and healthy work. A lot of the individuals who experience the poorest health have the lowest skills level and often enter the more precarious sectors of the labour market. They do not often have the luxury of working from home, and the cost of living crisis is likely to exacerbate mental health and anxiety. I think that there are issues around the types of jobs, the availability of work and the access to that work, particularly for those with poorer health, and the need for more mental health support in work to prevent people from falling out of work. I can maybe bring in Susie Fitton on this, if I can, because in your written submission, you make reference to the Financial Times analysis showing that the UK is the only country in the developed world where people have continued dropping out of the workforce in ever greater numbers beyond the acute phase of the pandemic. There is clearly a specific UK issue here, and that will apply equally or perhaps more so to Scotland. Do you have any thoughts on what is driving that here as opposed to other countries? The analysis last month by the Financial Times of OECD figures and the quarterly labour force survey showed that the rates of chronic illness shot up during the pandemic and continued to climb, with millions of working-age people across the UK now experiencing multiple health conditions, so co-morbidities. The analysis made clear that the number of working-age people in the UK and able to work due to chronic pain had climbed by almost 200,000 in the past two years relative to its former trajectory. The second biggest contributor to the rise in worklessness has been people dropping out of the workforce due to mental illness, and that has obviously already been mentioned by other panellists. I am sure that many of us may want to get into more detail later on in the session. Inclusions Scotland is focused on what factors have contributed to disabled people and people with long-term conditions in Scotland being economically inactive and what are the drivers behind that. All the figures have shown for some time that disabled people in Scotland are considerably more likely than those who are not disabled to be economically inactive. In 2021, over 380,000 disabled people aged 16 to 64 were economically inactive. It is important to realise that, whilst rates for economic activity are much higher for disabled people than non-disabled people, that does not reflect less willingness to work. For example, in 2019, around a quarter of inactive disabled people wanted to work, and that was higher than the proportion of inactive non-disabled people, so less than one-fifth. I wanted to make plain that there are a wide range of factors that contribute to disabled people's economic inactivity in Scotland. Those factors were present pre-pandemic during the initial shock and then also in the phase of adjustment to the virus. Those factors include poor health outcomes in general for disabled people, a mental health crisis that we have mentioned and poorly constructed, and at times underfunded mental health services. We have also made clear that poverty and health inequality are big factors, and that is doubly true for disabled people. The persistence of the disability employment gap in Scotland and the barriers that disabled people experience finding in keeping employment, which can lead to them leaving work or not looking for work, are very important in that discussion. Unfair treatment at work during the pandemic has led that some disabled people to leave work and not look for work. The impact of long Covid, which we have mentioned, and workplace issues that are experienced by disabled people who are at high risk of the virus is also a factor. Okay, thank you very much. I may ask Professor McCartney for his thoughts on this question, and is it about ill health or are there other factors driving people leaving the workforce? Thank you. You are also going to hear from Tom Waters and John Murdoch later on in this today's session, both of whom have done very relevant work here. Tom's done some work with understanding society data sets. John Murdoch has data that has already been referred to. I would highlight our two things here. Even before the pandemic, we had big problems with rising mental health problems being reported across the population, particularly in younger age groups. That is going to drive a withdrawal from the labour market. We have rising levels of poor self-rated health, which we contributed to the healthy life expectancy statistics that I referred to. That is a massive driver. We have that context. Covid is a much more minor in some ways, compared to the decade of problems that we have related to the austerity problems. The pandemic is often seen in terms of the direct impacts of Covid, the infectious disease impact. Of course, there are two other big impacts. We have already discussed some of the social impacts of the changes to employment practices, the changes to people's incomes and the social interactions around the pandemic, relating to periods of lockdown and changing working practices. That will matter for people's health. We have also seen a big impact on healthcare services. As the NHS and social care had to change its model of delivery over the pandemic, and as we have accumulated a large amount of unmet healthcare needs, that is a lot of people waiting for healthcare intervention. It is not a surprise in a sense that that group of people might be less likely to be still in the labour market as they are waiting for their operations, joint replacements, mental health interventions and a whole range of different things. That impact on the health service will also be having an impact. However, I cannot emphasise enough that Covid has just been the cherry on the cake of an awful decade of health trends that are rooted in the economy. It is the economy that has driven poor health, and we are reaping the unfortunate rewards of having that much poor health in the economy so that we have less people available and healthy to work in the labour market. I start with Pamela Smyth. The word crisis has been used a lot these days. We seem to have crisis everywhere. However, if mental health is in the crisis, as Professor McCartney said, it was an issue before Covid, but even now, in terms of long Covid, one of the symptoms that has been described is mental health. Where are we at in Scotland? Do you believe that there is an understanding of the issues around mental health? Do we actually know the numbers of people who suffer mental health? What as policy makers should we be arguing that the Government should be doing? I think that there are figures available, as you know, in the submissions around the increase in mental health as the chronic and long-term health condition. The issues that we need to take on mental health in a number of interconnected ways as well. Often, if mental health is stressed and anxiety, it has been the reason for people to fall out of the labour market. It remains the reason why a lot of people do not move back or into the labour market. I think that there are a lot of good initiatives around that, such as the individual placement service, where Smyth has a model of place and train supporting through community mental health services individuals in that journey into work and towards work. There are very expensive approaches, because they cover different multiple needs and issues that are very person-centred, needs-led, and they often happen within a locality in a place where people live and work. In terms of tackling and supporting mental health, it is not only about health services, it is about all those integrated services that can relieve some of the pressure, some of the stress that exacerbates and contributes to the mental health and wellbeing. The mental health strategy in itself won't resolve the mental health issues if we don't resolve a lot of the consequences that drive poor mental health, and Professor McCartney referred to some of that around the labour market, around the economy, and, indeed, a lot of the precarious employment in some of the sectors that have less access to occupational health services as well. It doesn't help any of the mental health support that individuals might be getting from a clinical perspective. It's an integrated action plan that individuals need, and it's integrated whole systems approaches that we need to look at deploying to tackle mental health and the economy and employment simultaneously. Can I ask you the same similar question? As parliamentarians, what should we be looking at and what should we be expecting from Government in terms of rising cases of mental health, the impact that's having, and the treatment that's either there or not there? Research in lockdown with disabled people across Scotland indicated that disabled people were experiencing a mental health crisis. Obviously, as you've mentioned, the term crisis is used possibly too readily, but certainly our survey findings showed that disabled people were being pushed to the brink by the pandemic and that there was an indication that some of these mental health problems would continue even as restrictions were lifted. We discovered that the social care system during lockdown had basically collapsed so that disabled people had their social care removed or reduced and that they were thrust into caring roles that they hadn't previously had for either themselves or for relatives. Disabled people were worried about food insecurity. They were worried about losing their own job given that the rate of redundancies for disabled people was disproportionately high and reduced hours was also an issue. The indications from lockdown were not good in terms of disabled people's mental health. Disabled people often report poorer outcomes than non-disabled people. Obviously, other panellists have mentioned the impact of poverty and wealth inequalities on health and health inequalities in Scotland. That is now well understood and largely accepted within the health community. Disabled people are much more likely to live in poverty and that has a significant impact on mental health. Nearly half of all those living in poverty in the UK are either disabled people or live in a household containing a disabled person. Disabled people have significantly higher costs that are associated with living with disability. Once those costs are taken into account, half a million Scottish disabled people and their families are living in poverty, which is 48 per cent of the total of all people in Scotland living in poverty. There is growing evidence that the Covid crisis pushed more families into poverty. Disabled people are more likely to say that their finances have been negatively impacted and that they are worried about accumulating more debt. Given that we are in a cost of living crisis at the moment, it is only likely that those factors are going to intensify. We would argue that a whole systems approach that tackles health inequality and poverty of disabled people is absolutely critical if we are going to start to address mental health issues in Scotland for disabled people. We know that people living in our most deprived communities are more than twice as likely to experience anxiety and depression and are three times more likely to die by suicide. Those inequalities have been shown to have been caused in large part by austerity and the drastic impact on the income and health of the poorest and most vulnerable populations in Scotland. Our view is that efforts to tackle poverty and inequality are quite key to efforts to improve mental health. We are obviously concerned about the recent announcements of cuts to funding for mental health provision in Scotland and we are concerned about waiting lists for child and adolescent mental health services, particularly for disabled children and young people. Those are the things that often get talked about, but we would like to see a whole systems approach to tackling the poverty experience by disabled people as a key element in tackling mental health issues. Professor McCartney, I am really trying to say that mental health is increasing right across the population, disabled people and able bodies people. What are politicians, what are parliamentarians and policy makers, should we be looking at here? Should we be, is the data good enough? What actions should we be looking at? I can address the question about what is the scale of the problem and I will try to do that. The best source of data that we have had on the number of people suffering from mental health problems comes from survey data. We have various sources of that, so there is an understanding society survey, which follows people up over time across Great Britain. We have the Scottish Health Survey and other surveys available for other parts of the UK. On that measure, what you see is that mental health was either fairly stable or improving for older adults until about 2010. After that, the number of people who report suffering from mental health problems rose dramatically for those under 65, but continued to improve for those aged over 65. That lasted until 2019. Unfortunately, once the pandemic hit, we have really poor survey data because the response rates to those surveys went down, partly because we could not do the door knocking to collect the survey data. When you have such low response rates or when you do the surveys by telephone, the data becomes so biased that it is difficult to make much of an inference from them. Unfortunately, that is the position that we are in for those survey data sources. The alternative to that are service-based data. You can look at the number of people who are in contact with services for mental health problems. For example, the number of people who are admitted or discharged from hospital, or the number of people in touch with primary care services. However, there are problems with that. On secondary care, we have a limited number of beds, and we reach that threshold quite quickly. It does not tell you about variance in need, because the services prioritise those with the greatest need, and those beds are continuously full. You do not get a picture about whether need is rising or falling, because those beds are constantly in use. In terms of primary care data, we have had a lot of changes to the primary care data sets over the years. The history of variance in GP data collection systems over time has meant that that data has never really been nationally comparable. There has been a lot of work done by Public Health Scotland and others to create a SPIR system that would allow for that nationally-comparative data set, which could be really important in terms of people being more able to access primary care than secondary care for those kinds of issues, but that is still in development and we do not have good data yet on trends in mental health contacts from that data system. That is a very long answer to say that, from 2020 onwards, we do not have great data to allow us to know the scale of the problem, but anecdotally, and that is always dangerous, but anecdotally, you would expect it to be much worse than it was pre-pandemic, for all the reasons that you and other speakers have indicated. I want to make three points. First, I have just come back from Singapore, and I met a team that has been surveying mental health across Singapore, so they are a comparable size country. They have very low prevalence of mental health problems and that has been persistently found, including extending over the pandemic. One issue that, as parliamentarians, you may want to do is just look internationally, and I can certainly make connections with that team if that would be helpful. When I asked them about why they feel that they have such low prevalence of mental health disorders, they pointed to economic prosperity, relative lack of inequalities, low prevalence of substance disorders, whether that is alcohol or drugs, but that is one thing that I think would be important to do to look internationally. The second thing is that, in Scotland, we have the best data sources in the world. I think that this is part of the reason that I have been brought in. We created a platform and we have got real-time data on everybody that is linking across general practice, hospital, social data, those data are housed in public health Scotland. Our permissions are only Covid specific, so if you were to ask us specifically to look into mental health issues and how the pandemic has affected us, we could certainly run that analysis and there are very few places in the world that could do that, so that could be done. It would not take very long, but it would need a specific request and we would not have to negotiate permissions. The third issue that I wanted to talk about was—I think that that links to the earlier question—in Scotland, at the University of Edinburgh, we have the smart data foundry, so we have economic data on a million people, granular data, provided by a network group of 140,000 people in Scotland. Those data are hosted within the national secure data environment. At the moment, no country in the world has been able to link economic data and health data, but we could be the first place to do that in Scotland. That would answer a lot of those questions that we are providing as anecdotal evidence or relying on out-of-date survey data that could be provided in real time. As far as I understand, speaking with the team yesterday, they feel that other banking groups are actually willing to provide data, but again, that would need a specific instruction from parliamentarians. I know that you are leading a long-term study on long Covid. Can I ask what you are hoping to learn from it? This is work funded by the chief scientific office of the Scottish Government. What we are trying to understand is the prevalence of long Covid in Scotland. That is a difficult question, because it depends on how you define long Covid. There are symptomatic-based approaches, for example, which have been undertaken by the Office for National Statistics. I see the kind of evidence that is cited in the papers. That is one approach and another approach is to what extent these are impacting on health systems, so encounters in general practice or on-going referrals to the hospital sector. That is one issue that we are looking at. We are working with different definitions there. The second issue that we are trying to work out is how we can begin to predict who is most at risk of developing long Covid. Just in preparation for this session, I have asked the team to see whether we can begin to look at economic activity. We have data on sick lines that are being issued by general practitioners. We have been able to do a preliminary analysis of that. We have been able to identify some risk factors that are associated with increased risks of being signed off with long Covid in Scotland. That needs more work. There are issues with GPs' reluctance to code for long Covid in records, because long Covid is largely a diagnosis of exclusion, and until we have appropriate diagnostic services up in play in Scotland, that remains challenging. Nonetheless, we have been able to get some indicators as to which factors that are associated with being signed off for long Covid. There is certainly the possibility of doing some in-depth work there. One of the things that I have been sitting here listening last week and this week was asking you the right questions to get where we want to go. As I think you just started touching it there, are we giving the right questions to the panels to be able to get to what it is that we are trying to work out, which is how do we get economic and active people back into the workplace? Are we doing that in this committee? I think that the questions are all appropriate. I think that my kind of slight frustration is that we in Scotland have got absolutely phenomenal data sets now. We are in the health space, but there is no country in the world that has the data that we have. How do we now begin to deploy them, rather than beyond questions of whether vaccines are working or not? That is a relatively straightforward move. We do not have permissions at the moment and we do not have instruction to do this. The reason why we are able to do this in Covid is because the Cabinet Secretary for Health and Sport at the time, Jeane Freeman, asks us to do this. Everything fell into place subsequently, so we need high-level instruction that needs to be done. There are wider questions of whether we can move to whole system intelligence for NHS Scotland. That will be absolutely crucial if we want to improve services and begin to bend the cost curve. The issue of bringing health data and those data are so rich, bringing those together with economic data. That, again, potentially could be done. There are major investments that have been made, but again somebody needs, senior needs, to instruct the country to move in this direction. On the evidence into practice and policies, I think that the committee spoke previously about DWP data and benefit data and the ability to marry some of that. I am probably most interested in how we tackle and identify the individuals because we can have data at the population level. It can tell us certain things, but we know that most of the economic recovery and social renewal actions have to happen at a place. Those places are in the neighbourhoods and communities where people live and work. I am also interested in how the data can vary up to some of the intelligence that is held in local government that will provide and support people in social rented housing, hardship grants through the education system, through social work, through community justice, etc. A lot of the individuals who are economically inactive and who have a lot of the inequalities and a lot of the health issues that we are talking about are engaging and receiving support from a whole raft of public services. It comes back to the point that other panellists around that whole system are marrying up of data, but not only at that high level in terms of population health but being able to drill down and actually know who the individuals are. There were some good examples through the young persons guarantee where the data hub for young people had data from DWPHMRC exported into other data that local partners were able to provide and you could actually get information down to individual level at a partnership level locally to look at how that could then be needs-led, person-centred and place-based. I think that there are different levels of data that we need and different uses for that data in terms of policy and practice. Professor MacDonald said that it is very helpful to bring up a lot of the data that we already have but also to look at what that means in practice if we are actually going to have policies, programmes and approaches that will start to shift the curve for those individuals. You are the head of economy in poverty in public health Scotland. As I was talking about the quality of data that we have in the health system, do you have the same level of data? I know for a fact that, in my constituency, we have 5,155 children living in poverty. That is clear at a granular level. Does public health Scotland have that level of data that could be married into a whole system approach? Yes. There are a number of publications that have a lot of different data, so you know the work that is on going to try and marry up a lot of that data. You know that local government has other data profiles within their systems. The issue is that a lot of the high-level data is fed by a lot of different systems, so yes, public health has loads of data. I also have to say that I am only seven months in public health Scotland and I am more from a policy and practice background taking the data, taking the evidence, taking the intelligence and figuring out what best to do about it to resolve the problem and improve the outcomes. Public health Scotland has a new local working programme, where we are looking to work with all public sector partners locally, looking at those economic and health profiles and looking at how we can start to deliver and develop programmes at work. A lot of that started with the community planning partnership local income improvement plans, where we are trying to integrate a lot of those local actions, so there certainly are through public health Scotland and improvement services and other public sector partners community profile data that touches on a lot of the economic and health as well as other factors that impact on wellbeing. It just takes the time in the ask to look at how we profile them together. Just to answer that specific question, public health Scotland has various departments and it is a large organisation. The group that I work with has data on 5.4 million people across Scotland. Those are GP data linked with unique identifiers to hospitalisation, mortality, prescribing. In the context of Covid, it has been vaccination testing, et cetera. We also now have a linkage to census data as well and a variety of other data sets. We have very granular data. Those data get updated on a weekly basis every Tuesday morning into public health Scotland. If there was instruction, resources and permissions, I could give you data on the question of what mental health looks like in Scotland on a weekly basis, and those answers could be available as long as other things fill into place within a couple of weeks. Just an observation—you can correct me if I'm wrong—is the fact that we've got such an extensive range of data and that Singapore is reporting much lower rates of mental health wellbeing. Is it because we've got the data that we know about it and that Singapore actually just doesn't know about it? No, no, no. Sorry. They're running surveys regularly and their response rates are actually very good to those surveys. This is longitudinal. What I was told by that team was that, even though the rates are incredibly low, their Government officials are not satisfied and they're still concerned. Thank you. I just wanted to get that clarity on record. I've had that time for another question. Sorry for enjoying this, convener. Jerry, I'd like to come to you if that's okay. You talked about this issue that we're looking at just now as predated going back to the austerity policies of 2008. Is there any data or studies that would say how far back these health inequalities have gone in Scotland? Does it only go back to 2008 since the crash or does it go back even further? I'll be living with a chronic long-term problem is the kind of what I'm trying to get to. Thank you. There's various periods, if you like, of issues. If you look at pretty rudimentary data on health inequalities across Great Britain, you find that those measures of health inequalities declined between the 1920s and the 1970s before subsequently increasing. We've got much better data from the 1981 onwards on the extent of health inequalities. They rapidly widened from the 1980s onwards until about 1997-1989, when they started to stabilise. They then widened again from 2010-2012 onwards and have been widening on most measures ever since. On mortality, when you think about other measures of health, you see inequalities in almost all measures of health, whether it's mental health, whether it's mental wellbeing, whether it's self-retail, whether it's admissions to hospitals. You see similar trends across all those measures. On average, life expectancy mortality had been improving until around 2012, and then it's been flat since then on average, declining during Covid. However, inequalities in that have widened. You've got declining life expectancy from 2012 onwards, and our poorest is 30 per cent or so of areas. Mental health problems really start to worsen for the under-65s from around 2014-15 onwards, rising from our prevalence from about 15 per cent to about 20 per cent over that time period. As I said, the survey data aren't of high quality thereafter. From 2008 onwards, the think-it-was-yourself panel said that we had chronic stress issues. Where is that coming from? Is it because of economic problems? Is it because of austerity? Is it because of poverty? What is causing the chronic stress? Professor McCartney and the population health in Glasgow have published some information and data around the austerity and the links with health from 2008. To answer the question around the manifestation of mental health necessity, it is basically linked to poverty and it's linked to lowering from precarious employment. It's all part of that same cycle of inequality. Health inequality has been made worse by anxiety and stress, lack of money, lack of healthy food, lack of diet and exercise to improve health. All comes back to poverty, unemployment and even poor work. We know that most children in poverty have an adult working, so poverty isn't only about labour market connectivity and unemployment. It's about income levels and a lot of that comes back to the economy and how the labour market operates. I was going to say that we've got large numbers of people who are claiming benefits who are in work, so it's not about being labour inactive, it's about the quality of life that they're living. There's two sides of it. A lot of people with health conditions are managing it in work as well, so not everyone who's got a chronic health condition becomes inactive. Again, a lot of it depends on the nature of the job they're doing and what resources and tools and resilience they have to manage some of those health conditions as well. That's great, so Jim Filly won't need to move on for time. Jim Mason, please. Thanks very much, convener. Probably to build on some of the things that have already been asked, but if I could start with Professor Shake, you were saying that we can compare mental health between Scotland and Singapore. Can we also compare, say, long Covid numbers in Scotland and France, or can we compare economic inactivity? Are the definitions the same for all of these things between different countries? With long Covid, clearly we're struggling with definitions internally in Scotland and the UK. That said, I think that there is the possibility for doing comparative work across countries' jurisdictions because these teams are working quite closely together. There's a lot of sharing of information, et cetera, so that could be done. I think that that's an answerable question around economic activity. It's not really my area of expertise, so others are probably better placed to comment. Ms Smith, there's been a lot of comparisons drawn between ME and long Covid and similarities. To be fair, we've struggled with ME over the years to really get definitions to get, and GPs seem to vary quite a lot. Is there a fair comparison between the two? Again, I'm not a clinical expert, but from the information made available to me, a lot of the symptoms and a lot that is self-reported as well. People will report their symptoms of fatigue, tiredness, et cetera, and there's other respiratory conditions as well. As we've heard, it isn't quite clear in terms of the definitions. A lot of the symptoms will manifest themselves in the same way, but it might be different causes. Do you think that it will become clear over time, or are we going to be like with the ME situation, or at least some ME people would claim that we've still not really pinned it down after what have our 30-40 years? I think that there will always be something underlying. It's the same with mental health conditions. A lot of that is self-reported by individuals. Some of that is questioned. People are looking at it as an excuse to opt out of work, et cetera. We have to be clear on the definitions and the collection of the data. A lot of it is about self-report, but it does limit an impact on people being able to participate fully in the labour market irrespective of how it is defined. Professor McCartney, will you come in on that? I would point members towards a publication on 3 November. It was a joint publication between NICE, the National Institute for Health and Care Excellence, based in London, the Royal College of General Practitioners and Healthcare Improvement Scotland. It's a rapid evidence review about managing the long-term effects of Covid-19, and it goes through a series of sections about the identification, assessment and diagnosis, and the criteria for that, the evidence about treatment and so on. What it shows very clearly is the range of uncertainties at each stage of that. There are different definitions used. There is uncertainty in the criteria for pinning it down. There is uncertainty about what works in terms of management and treatment and supportive environments. What it lays out is a really clear research agenda of answerable questions that need to be done. If there was resource to be allocated towards research in that area, that would be a very good starting point. We need to understand how to diagnose it, assess it and treat it. There will be a range of different options and inferences from other conditions that might or might not work, but all of that needs to be tested and we need an evidence base for that, because we are under pressure to act in the absence of evidence at the moment, but that can do more harm than good. It can create a lot of biotrogenic harm, so that is harm from healthcare treatments. We really need an evidence base and an experimental context to learn more about that. I just press you. You have said a few times that we have a number of health issues linked to austerity and the economic factors. Would it not be the case that some issues like obesity and maybe mental health are also seen very much in the better off parts of the population, and those have been problems that we have not been able to pin down and really sort despite that? Both are true. I will briefly rehearse the evidence on austerity. We have evidence at three different levels about the negative impacts of austerity. We have got it through international comparisons of more or less austere regimes over time, country and place, and that shows that countries that have implemented periods of austerity have much worse mortality trends. We have got evidence at local government levels, so councils that have had the biggest cuts to their budgets and the biggest cuts to their services, whether it is health or social care or on aggregate levels, benefit levels, pension credits and the like, have much worse health trends. You can look at it at an individual household level, so we have got evidence from things like understanding society that people that were more affected by changes to benefit cuts or benefit sanctions or changes to the benefit system that reduced their eligibility all had massive negative impacts and often on mental health. We agree that we also have issues around obesity and mental health that are not helped at all by austerity but predate. We had a large rise in the prevalence of the population who were obese from 1995 when data started onwards. That plateaued after 2010, but we see the large defects of that now. Mental health problems actually had been fairly flat on survey measures until around 2015, after which they diverged. You had a rise in mental health problems for people aged under 65 and a decline in mental health problems reported for those aged over 65. The last thing to say is that we need to be careful about some of the inequalities data that we use routinely. Those are area-based measures and we know that the vast majority of people who are deprived of their income deprivation or employment deprivation do not actually live in the most deprived 20 per cent of areas. When you look at the statistics across the population, you need to remember that there is a very crude categorisation of need. It is helpful, because it is routinely available and quickly available, but it does not mask inequalities that you might measure by social class, or by educational attainment, or by income levels. It mixes people up who are more or less deprived by using these area-based measures. That is extremely helpful. That is really interesting. If I could switch over to Ms Fitton, in your written evidence, a few times it comes up about the attitude of employers both towards disability but also towards long Covid. One of the quotes was that workers were faced with disbelief and suspicion, with around one-fifth, nineteen per cent having their employer question the impact of their symptoms. Can you say a little bit more about that and what we should be doing to either educate employers or help employers or whatever? I would say that there is an opportunity to approach participation in the labour market by disabled people and people with long-term illness, so that would, to our mind, include many people with long Covid. We would say that there is an opportunity to approach participation differently as part of a post-Covid renewal. That is going to involve employers and a switch in focus in terms of how we approach inactivity but also how we support disabled people and those with long-term illness into work. Nearly one in four people inactive because of ill health in the UK actually want to work or are seeking work but are unable to start because of barriers that they experience in entering or re-entring the workplace. We think that it is really important that we have a switch in focus and that we ensure that changes that have been made to working patterns as a response to the pandemic, particularly in terms of large numbers of employees working from home, provide an opportunity to look at workplace adjustments and flexibility as a normal part of employment practice, not just as reasonable adjustments to disabled people but as an inherent part of employment, real flexibility. There is a certain irony that changes made to working patterns as a response to the pandemic were adjustments long called for by individual disabled people and those managing long-term health conditions. Disabled people reported to us that they felt that the response to the pandemic was a response to the majority that disabled people are not part of. For years, people with energy impairments or chronic illness have been asking to work from home and employers said that it was impossible. There is an uncomfortable irony in it. That was good evidence of the fact that it was ironic that that had happened. Can you see any sign of employers now thinking differently? We hear that a lot of employers are really struggling to get staff and that would suggest that they might be more adaptable to both people with long-term conditions and disabilities and so on. Do you think that that is happening? Have you seen that happening? As part of our employability work, we offer internship opportunities for disabled people and we have lots of links with employers across Scotland. There are many employers that are very keen to learn from the pandemic to think about workplace adjustments as workplace adjustments rather than just adjustments for disabled people or people with long-term impairment. I think that there is a real opportunity for employers to explore formal and informal flexible working that could support disabled people in terms of remote working, obviously working from home, but also other remote accessible locations offering flexibility in terms of compressed hours. All of the things around flexible working can support disabled people with long-term illness and things like energy impairments or pain conditions and fatigue conditions that may mean that they need to work at different times when they are well. One of the things that we would say is that we need to switch in focus in terms of employability support. For many, many years, for decades, the emphasis on tackling disabled people's economic inactivity and their unemployment has been predicated on the idea that what stops disabled people working is a deficit or a lack of something to do with the disabled person. A lot of that is about supporting disabled people to get closer to the labour market because of a presumed lack of skills or education or a lack of ability to self-manage a health condition. Our view is that what we really need to do is to focus on employers and how inclusive and accessible employment can be. I am sorry, we are running out of time. I think that we have that point, that is great. I just wanted to give a final word to Ms Smith, because you have also said about poor treatment at work. If we have time, the fact that there are backlogs in the NHS, is that affecting people getting back to work? I think that there are certain sectors within the economy, particularly in smaller enterprises, SMEs, where individuals do not have the same access to occupational health services as well. There is work in health services Scotland, and that is available. I think that there is a lot of work to be done with employers and employees around access to support in work. A lot of employability services previously were about people who were unemployed, and a lot of it was about pre-employment support, but we know that there is a lot more required in terms of in-work support to help people to sustain work, whether it is through health to help people to progress in work, whether they need to upscale and to address in-work poverty, so that they can increase their earnings from employment and progression. There is a lot more that has to be done around in-work support for employers and for employees, and how we help to implement some of the ambitions around the fair work action plan. We are going to have to stop now, I think that that is our time. Thank you. That concludes part 1 of the impact of the pandemic on the Scottish labour market. I would like to thank the witnesses for their evidence and giving us their time this morning. If the witnesses would like to raise any further evidence with the committee, they can do so in writing, and the clerks will be happy to liaise with you on how to do that. I will now briefly suspend the meeting to allow a change over of witnesses. We will now continue to take evidence on the inquiry, and I would like to welcome our second panel to the meeting. We have received apologies this morning from John Byrne Murdoch, who is a chief data reporter from the Financial Times. So, please welcome Tom Waters, a senior research economist, and Tom Wernherm, research economist from the Institute for Fiscal Studies, who are both joining us remotely, and Philip White, director of IPP Scotland, who joins us in person. Welcome. Thank you for giving us your time this morning. We estimate that this session will run to around 11.30 am, and each member should have approximately about 15 minutes each to speak to the panel and to ask their questions. For those witnesses who are attending remotely this morning, if you would like to respond to an issue that has been discussed, please put R in the chat box, and we will try to bring you in. I am keen to ensure that everyone gets an opportunity to speak, and I apologise in advance, therefore if time runs on too much, I may need to interrupt members or witnesses in the interests of brevity. If I could just turn to questions to start with, and if I may begin by asking the first question, and I will ask this to you, Philip, if I can, to start with. What are the main health conditions that account for long-term illness as a reason for economic inactivity in Scotland, in your opinion? They are long-standing, and that may be an issue that is going to come out through this session that I think that Covid has potentially exacerbated or shone out spotlights on conditions that have existed due to Scotland's relationship with health inequalities. The gain is very long-standing. Covid did not create it, but as an example, I pulled some stats from the Scottish Health Survey. If you go back to 2008, more than a decade before, you look at the statistics that you have got, high numbers that are not a healthy weight, high levels or a significant number that suffer from cardiovascular conditions, long-term limiting illness, respiratory conditions, general mental ill health. Those are all really long-standing, and I think that it is impossible to separate them out from the fact that health inequalities for Scotland has been an issue that has persisted for so long. You see it in the continued high numbers of alcohol-related deaths, of drug-related deaths, high numbers of comorbidities in Scotland. Those are the ones that have existed for a long time. I do not think that the pandemic may have exacerbated them in some instances, but it certainly did not cause them or create them. If I could ask the same question to Tom Waters, please. I know that we have two Toms with W, so I will have to say your full name. Our focus has been looking at long Covid, so I do not think that I have anything really to add above and beyond what Philip said in terms of why there is a health condition. That is fine. I will move on to the next question, if I may. What can the statistics tell us about the impact of differing policy approaches both pre-during and post-pandemic between Scotland and the rest of the UK? Does anybody want to come in on that one? In terms of response specifically to Covid and the impact on health outcomes, I may be deferred, so I have done a bit of research in the UK level, which might provide some UK contacts if I can then supplement not to put IFS colleagues on the spot. Apologies. Sorry, can you clarify the question? I am not sure I can. Yes, sure, sorry. Can you hear me? Just what can the statistics that we have tell us about the impacts of differing policy approaches both pre- and during and post-pandemic between Scotland and the rest of the UK? With respect to health? Yes. Impact of Covid? Yes. Sorry, I do not have anything to contribute on that. We have focused on the economic policy of the UK Government during Covid and then looked at the impact of long Covid, subsequently, but on health policy. Maybe if I could ask about how can we fully understand the full picture around long Covid when its impact is spread around different statistical sets? Yes, I think that it is a real challenge because for a number of reasons we measure long Covid, understanding the extent of long Covid is a difficult thing to do because it is getting the exact definitions right and the way even things like changing question wording can change the number of people that report having long Covid. Of course, as well known, a lot of the data around long Covid is very much self-reported. It is not confirmed by objective measures. The approach that we have taken, which I think makes sense, is to say that we are going to look at those who got long Covid, who reported getting long Covid. We are subject to those downsides of that self-reported measure. We are going to compare their trajectories pre and post the pandemic to people who, before the pandemic, looked quite similar to them. They have similar levels of income, similar jobs, similar levels of pre-existing health conditions and things like that. Then we look at what happens to their trajectories on outcomes such as employment or earnings. That is the approach that we have taken. One of the issues that the committee is keen to understand is that, to what extent the decline in the workforce post Covid is down directly to health issues such as long Covid or down to other factors such as people choosing to take early retirement. I know that IFS has done quite a lot of work around that, so I am interested to get your perspectives. I will let the two toms fight out between themselves who is going to answer the questions. Just to put that into context, we would hope to have John Byrne Murdoch from the Financial Times this morning. Unfortunately, he is not well, but I just want to quote a couple of things from the Financial Times. He wrote an article in July, basically saying that chronic illness was the main driver of stalled labour recovery, but then there was a more recent article in the Financial Times on 2 November from Delphine Strauss, which quotes IFS research and says, these findings challenge the prevailing idea that ill health is the main explanation for the post-pandemic shrinkage in the UK workforce. There is clearly a contradiction between the two articles and the two outcomes. I am really interested to get IFS's perspective on what is actually going on here, whichever Tom wants to start. Part of the reason that, early on, a lot of people were suggesting that it might be a main driver of what is going on is that looking at people who are inactive, increasing numbers of them were suggesting that health was the reason. However, if you look at the data on who is moving in and out of activity and activity, our colleagues—I think that you will actually be speaking to in a few weeks—have found that most of the people who have started saying that they are inactive due to health reasons have already been inactive for a very long time. They are not the people who are moving out of the labour force at the moment. If you look at the people who are moving out of the labour force, the main reason they are doing so is for retirement. It does not look there as though health reasons are a main driver of the declining activity. Just to follow up, Tom, before anybody else comes in, do you say that people are taking retirement? To what extent do we understand the reasons for that? Is that because there were people working from home for two years and they just decided that they did not want to go back into a workplace environment and they took early retirement? Are there other factors behind that? Do we have enough data to explain this? I do not have much specific evidence to talk about that specific question. I can speak a bit about that. I think that that is a really important question. I think that that is something that is not well understood. You can think of a few possible reasons. One is, maybe you lost your job in the pandemic or you spent a long time on furlough and you kind of got used to or experienced not working and perhaps you liked it more than you thought and thought you might end up taking it at a time. That is what you might think of as a preferences explanation. Other explanations, you lost your job during the pandemic and you are unable to find a new one and eventually at some point you give up and retire. It is fair to say that we do not have definitive answers on these things, but one thing that is important is that most of the newly ineptive people say that they do not want a job. They are not looking for one, that is why they are ineptive, but they actually say that they do not want one. That is quite a large proportion of them. That suggests that it is less of the unable-to-find-a-job kind of explanation. I am not sure what is going on in some cases, but that is not perhaps the primary driver. I think that this is something where definitely more research and more evidence would be really valuable. I will bring Philip in on the second follow-up question. We know that there is a cost-of-living crisis. We know that household bills, energy and food have gone up substantially over the past few months. Is there any evidence that people who dropped out of the workforce perhaps took out their retirement thinking they had enough money that could sustain them are now having to rethink that because of cost pressures and inflation? I think that we are probably getting to the point now where we might be able to see those sorts of effects, just because there is a bit of a lag when we get the data. We might be able to see those sorts of effects coming through. In broad terms, that is the sort of thing that we do have evidence from other similar events. We have plenty of evidence that, if someone loses their job, their partner is more likely to go into work to compensate. You can think of the cost-of-living crisis as making people poor. It is a kind of analysis of that. I think that that is something that we should be looking out for in the coming few months. It is perhaps where we are just about getting to the point now where that might be possible to see in the most recent cuts of data. The IFS has done some of its work on this. To try and get beyond that, what you need to start trying to do is inferring causal links between wider datasets. I would just do one other into the mix. As Tom suggests, we will maybe start to see if the hypothesis is true and start to come through in statistics that we will get from now on when a bit of time has passed. O and S undertook a large-scale survey among those aged 50 to 64 who left the workforce during the pandemic. It did show that among those who left for whatever reason their health was worse. Over and above that, it also asked their views around leaving the workforce. A large number of them said that they were not confident that their savings and resources would sustain them through their retirement. There is clearly something else driving their decision to retire, a significant number on confidence that they will be able to financially survive. That is where you may start to see people come back into the workforce if that comes through. They have not been able to sustain retirement through their savings and assets, but equally, it may start to suggest that there were other factors other than just a pure desire to retire that were driving that decision. However, as both Tom have said, with the stats that we have right now, it is impossible other than to infer causal links. The next question is, what do we need to do to make it more attractive for people to come back into the workforce? What are the barriers to them working? Do we need more flexible working, for example, from employers? Would that help? Or are there other interventions that would be useful? Specifically, in terms of those who have retired or just those who have generally retired, I think that there is a question particularly in Scotland that asks again, this is where trying to draw inferences from UK-wide statistics. Again, I think that IFS's work will show that in particular those who have taken retirement were men who were in professional and ultimately better off occupations. We know that in Scotland, obviously the public sector makes up a significant proportion of the workforce. That means that there is a potential that those who were in higher professional classes are overrepresented amongst that group. Again, it is impossible to start to disaggregate the data. If that is true, then it is very possible that it was a pure decision that I have done quite well throughout my career. The pandemic has tipped me over the edge and I have decided that that is me done. In the health service, that might well be the case. Among those, it is obviously a higher managerial class. If that comes true, I do not know if you are ever going to get those people back. There are those, however, particularly with the abolition of their retirement age. There is a question that also rings through with disabled people. It was talked about in the panel before by Inclusion Scotland, the social model. Whether employers right now are fully equipped to be able to support people who do not fit into the usual mode of workers, are they equipped to be able to help them back in and respond to their circumstances? Again, there is potentially a model of work that we have in the UK that still does not quite work for them. Again, there is a question that we may never get those workers back because they have just decided and their circumstances mean that they have no need to. I do not know if the IFS wants to comment on that specifically. I agree with all that. I just add that it is not always the case that we should not be targeting 100 per cent employment rates. It is not always the case that it is always better for someone to get back into work. The thing that we should be concerned about is when people are able to work and want to work but are not able to find a job for whatever reason. Then you worry about lack of skills, financial disincentives and all those sorts of things. If it is more just a pure lifestyle thing, my perspective would be that that is somewhat less concerning than if it is not able to find a job. I think that that is quite important for that and thinking about what the policy response is. The IFS research has noted that those with underlying health conditions are more likely to suffer from long Covid. Are there any particular underlying conditions that are more prominent among those who suffer from long Covid? That is a good question. I am just looking at Tom to see what he knows. It is not something that we have looked at in particular, no? Yes. I do not know whether it is something that we have known from the previous O&S work on this. Maybe if you can find that, that would be great. Can I also ask then how can statistical comparisons with other countries better help us to understand the root causes of both long-term sickness in labour market and activity and link them back to policy and funding? We talked earlier about those comparisons about some countries. Yes. Precisely because measuring long Covid is a bit of a challenge, doing comparisons across countries has been a bit more difficult. That said, looking at inactivity in general, that is well defined across countries. That is a pretty clear definition that lots and lots of countries get the same measure of inactivity. Now, because our rise in inactivity has been quite large in other countries, the Financial Times articles have pointed out, but because ours is driven by largely driven by people taking early retirement, that drives you perhaps to look a little bit, think a bit about our pension systems perhaps being some of the relevant factors. It might not be the only one, but things like pension freedoms and so on, perhaps playing some role in the uptake that we have had in retirement driven inactivity. That is the kind of thing we should be looking at. I am not sure that beyond the fact that the UK has seen this faster rise in inactivity, I am not sure how much comparisons across countries we have have been done on that. Philip, in terms of different policies in Scotland and the rest of the UK, is there any statistical evidence showing any differences that policies have an approach? Activity, in particular, for all, rather than the long Covid specifically. Obviously, the primary one is employability, which exists in a bit of a complicated and convoluted landscape in the obviously Scotland Act 2016 devolved some elements, and that is what led to the creation of First Art Scotland. Obviously, that service is a sizable chunk of people, but the vast majority who are out of work, for example, or in the seat of benefits, will go through a still reserved DWP Job Sensor Plus. Scotland has obviously made efforts and has been a real focus on employability over the past few years, in particular not least as part of child poverty ambitions. I think that there is a question about whether or not that is at the sufficient scale. You take something like First Art Scotland, it has had over 67,000, I think, referrals since it was created back in 2018, going by the most recent stats. Of those who started a job off the back of being referred to First Art Scotland, it has been just over 15,000, so there is a huge disparity, and more importantly, of those who started 50 per cent drop-outs before competing in the programme. Given that is a programme specifically designed for those who are disabled, have a long-term health condition or are long-term unemployed, that clearly feels like a key driver. I think that the main issue that we have seen right now is just that it is not being delivered at scale. Is there an impact from the introduction of things like universal credit? I think back to before the introduction of working families tax credits, where it was quite common to hear people talk about the poverty trap, that people were worse off getting a job than they were, staying where they were. Working families tax credits certainly addressed that, but we've had changes since then. Has that impacted on people's willingness or ability to get back at the labour market? I don't know if it's impacted. It brings societal issues and it brings what you have seen more, certainly to my least kind of quantitative, if not quantitative evidence, suggests that even just the aura around universal credit has really significantly impacted on people, the conditionality and sanctions regime, has caused really negative reactions for very justifiably good reasons for lots of people. There's also a question of does it actually proactively and positively enable people to be able to find work? You've got 15 minutes with an adviser quite often. They don't have time to go through your specific circumstances. You're then sent off on your way if you have work-related requirements to do 20 hours or so of work-related activity, which is you sat at home by yourself on a laptop looking for jobs. What we really miss is the person-centred proactive approach. Yes, there is a question around the impact universal credit has had in terms of what it has meant, in terms of the amount available to families, the requirements that it brings, the negative connotations that it brings, the stigma that it creates. More than anything, part and parcel law is a system that does not, at times or, if ever, genuinely proactively help people into the workplace, as opposed to putting in place, just instead bureaucratic barriers. Thank you very much, convener. I may be able to follow up some of those points. I may be starting with Tom Waters, if I may. You said that economic activity and so on is well defined and very much agreed between countries, if I understood you. My understanding is that, to be economically active, you only have to work one hour a week. That's somewhat surprised me when that was raised, because I would have thought one hour or zero hours was much the same whereas 35 hours is quite different. Is that correct? To be economic active, you either have a job, which could be a one-hour-a-week job, or it would be looking for work. That's the answer. As far as the economy is concerned, it's much better if somebody is working 35 hours a week than one hour a week. Yes, that's certainly right. It's quite unusual to find people who are in work and are working fewer than 16 hours a week. There aren't that many jobs that are advertised at fewer than 16 hours a week. You're right. In broad terms, it's the number of hours' work that matters more than the number of people. That's certainly correct. A full-time job is roughly twice as many hours as a part-time one. Another issue that came up was that we count people as unemployment, but they might be off quite long-term sick with, say, long Covid in particular or something else. Would that create a problem comparing our data with other countries, or do you think that's fairly accepted internationally? That's a good point. It would depend on how sick pay regimes differ by countries. That could have an effect. In the work that we've done, what we found is that, when people get long Covid, they remain employed and are still literally tired. They have a job that they could go back to, but they are much more likely to work zero hours. They're off long-term sick, basically. They would still show up in the statistics as being employed, as you say. It is possible that, if you had a different country, you might have a sick pay regime, which severs the actual employment link, but you keep getting paid sick pay or something like that. That sort of person might then show up as an active. I'm not saying that I don't know enough about other countries' sick pay policies, but in the UK, someone in this situation who is not actually working, so they aren't producing anything in the economy, nonetheless shows up as employed rather than as an active. The other point was that this whole question of early retirement. From the individual's point of view, if they're well off and they've been a general practitioner or something like that, they can afford it. In a sense, we don't need to worry about them as an individual, but does the economy as a whole not suffer if we've got a lot of 55-year-olds who just stop working? I think that it is true that the size of the economy would go down if that happens. I think that the primary way that you might worry about that would be for the fiscal implications. If you've got a highly paid person who stops working at 55, they were paying a lot of tax before, and now they're not going to be paying very much or not as much tax, and so that has fiscal implications. I think that that's the main dimension in which that sort of thing might be concerning from a societal point of view. If someone doesn't want to work, they don't want to produce whatever it was that they were working in, and they will be paid for it. I see that as being primarily an individual decision, but the tax implications are something that affects everyone. That's helpful. I don't have any thoughts on any of those points. Similarly, on the inactivity point, it's what you make the focus of your policymaking. What we view as inactivity is those people who have literally fallen out of the labour market. The one R is there because it represents that they have fully disengaged, fallen out. That requires a very specific policy response as opposed to those who are in work or actively looking for work. It depends on what you are looking to try to make a policy response to. Are you trying to improve general conditions, which could be primarily for those who are in employment, or are you trying to genuinely find a way to actively encourage people back into the labour market? Again, as both Thomas and I have already suggested, in that inactive population, there is a significant chunk that you just do not want to. Are they just a question about to what extent do you expend your resources and energy in trying to get them back in versus recognising that, for quite often very valid personal reasons, they might never again join the labour market? On the retirement point, it is a loss if those people are disengaged, if they are no longer contributing to the economy to revenue. The important bit is that your economy is built in such a way that there is a healthy supply of workforce coming through after them in similarly well-paid good jobs. It is those structural issues that we have not addressed yet in the UK and Scottish economy to ensure that once your ageing population, which we know in particular Scotland, is at real risk from, falls off a cliff—that is not a terrible turn of phrase—and disappears from the labour market, you need to ensure that your economy is structurally set up to ensure that there is a steady supply of workforce coming behind them. That is the bit that we have missed. You want to ensure that people are not disengaging from the workforce for bad reasons, particularly if they want to stay in. However, if they are disengaging for good reasons, the absolutely vital bit is not trying to get them back in but ensuring that your economy is supporting everyone else coming after them. That is quite interesting because that is a more nuanced approach than we sometimes get. For some people it is better being out of work and for some people it is better being in work. We talked about mental health in the previous session and presumably for some people the mental health problem is that they are working too many hours and they have a bad work-life balance, so that could improve by them either reducing their hours or leaving the workforce. You point about workers coming through. Given that our population is forecast to fall, has that just got to be bringing people in from other countries to bolster our workforce? Are there other answers to that? Again, it has been well recognised that migration is absolutely crucial to Scotland's economy in a wide variety of sectors. There are concerns that the impact of Brexit is going to negatively impact on that. Equally, that combined with ageing population, it almost starts to create a perfect storm that starts to restrict migration, whilst also having an ageing population that is disengaging entirely from the workforce. What are you left with? That is ensuring that you have that supply of workforce ready. Equally, we know from the sectoral impacts that some sectors in particular have been really impacted by the pandemic. Again, as witnesses last week suggested, those are trends that did not begin with the pandemic. They were already there. If you look at retail, people had already started to shift online well before the pandemic. Hospitality, drinking culture has started to shift positively in that it is less of a feature of manufacturing, obviously. There are lots of sectors that we are already starting to see reducing workforce as well before the pandemic. The pandemic might have accelerated that and had a particular plans to effect on it, but it is not entirely clear that those jobs are ever going to come back. What you have also seen is that, while sectoral employment rates have been affected, sectoral inactivity has been affected, but employment has not. Those people are going somewhere, but the important bit is ensuring that there is somewhere for them to go to. Upskilling, re-skilling opportunities, lifelong learning opportunities, ensuring that we are investing in new technologies, which is a huge feature of the Scottish economy to start investing in net zero technology. Again, it is about scale. I do not think that we are there at scale yet. I think that we have made the right noises. We have certainly got the right approach and outlook about it, but the risk is that we are not scaling up early enough to ensure that those jobs and that skilled workforce are there. That is where the crunch point of retirement, potentially migration and Brexit, will start to really hit. Can I just bring Murdo in because he wants to comment on this point, then we will come back to you, John. Thanks very much. Just as a follow-up on this whole labour market issue, one issue nobody has touched on yet is potential rises in unemployment, because the Bank of England, I think for the last week, suggested that unemployment is set to double. Now, if they are right, does not that raise a whole range of other issues, but means that the current tightness in the labour market that is the real issue might flip itself over and we are no longer discussing the difficulty in finding people to do work? We are talking about the opposite problem, which is that we then have people who are unemployed and cannot get jobs. Tom is not right, but we want to talk to the UK picture. Again, in Scotland, that trend has been bucked slightly, albeit whether or not it can rather the potential economic storm still ahead remains to be seen. Obviously, we have ended up that employment was broadly protected through the pandemic. Again, there is a big question about the extent to which public sector employment has insulated Scotland's unwalk, given that it is disproportionately represented within the workforce. However, as you say, Scottish businesses of the four home nations and Scottish businesses are the ones who are least likely to currently face troubles recruiting. Again, the unemployment impact of the pandemic was smaller than in the rest of the UK, as such there was a much smaller cohort of people who were potentially trying to find new jobs and new jobs in different sectors. As the scale of the problem starts to grow, that cohort of people starts to grow. Again, it is not entirely clear if structurally the economy is set up to be able to support those people into new and different sectors or technologies. However, you are right that Tom will have something from the UK. I think that the only thing allowed is the bank's forecast. It is just a forecast, but the bank's forecast is for unemployment to grow and to keep growing until the end of 2025, three years away, which could mean for some people really quite long-term periods of unemployment. That is where we tend to worry more about long-term periods of unemployment, because that is where your skills atrophy and you are not building up your human capital whilst working, so that can have more longer-term consequences for people's labour market prospects. Short-term period of unemployment is not great, obviously, but it does not necessarily have such longer-term effects. I think that that would be as well as the actual rise of employment itself. The length of the time of having elevated unemployment rate is probably just as concerning as something to worry about. Can I just bring in Alex Rowley on this point, and then we will get back to you, John? Sorry, John. Just to pick up on that point, because in a sense we are looking at this as labour market and activity linked to Covid, and we may be making big leaps about assumptions that, somehow, the pandemic has led to this, when you talked about skills and training there, you talked about other factors, the welfare system, the lucky support, etc. So, in your opinion, what impact, if any, did Covid-19 pandemic leave or have on the levels of economic inactivity? Are we barking up the wrong tree here, or what? No, I absolutely do not think so. It is a really tricky one, because you do not want everyone in the country, everyone in the world, to be impacted by the pandemic. You absolutely do not want to make light of it or make it seem like it did not have really severe and significant impacts, in particular for countless people who may have lost their jobs, who their health deteriorated, who are now suffering from long Covid. So you absolutely need to ensure that that is the forefront of your mind and how you protect and support those people. However, there has potentially been a tendency from Governments all over to start to frame what were long-standing issues through the lens of Covid, so waiting lists, unemployment, economic output. There is a tendency to frame that as, in the aftermath of the pandemic, as we recover from the pandemic. That is right, but it cannot ignore the fact that, in a large number of instances, these were long-standing issues. So, again, health inequalities. We know that health inequalities in Scotland have been severe, particularly amongst our most deprived communities. They have not gone away. Again, the pandemic may have exacerbated them, but they still exist. We know that we are setting ourselves up for the jobs of the future, for the industries of the future. Again, Covid impacted on some sectors, but that long-term economic planning should have been happening well before the pandemic hit because I think it was always clear that certain sectors were always going to see a decline and have seen a decline over the last number of years well before the pandemic. I do not think that you are barking up the wrong tree, but I do think that it is absolutely vital that, as well as recognising that there are specific impacts as a result of Covid that, in a large number of instances, these are long-standing trends, which, no matter what you do in response to Covid, need to be addressed as long-standing trends. That is okay. I think that this is another point. It is on that general point and tied back to what you said earlier, because this idea of long-term trends might be that people are doing less retail in town and city centres and maybe less socialising as well. Clearly, that is altogether stopped when Covid happened, and then there has been a gradual drift back. I am just wondering where do you think we are in that process? I mean, our way is what we have got now, especially in city centres, I am thinking of, of what we have got now is what is going to continue, or do we need to wait a bit longer to see will people go back to work, in the offices, in the winter, when it is cold, all that kind of thing? I am definitely not a futurologist, but I do not think that anyone wants to be. After the last few years, anyone trying to predict the future is probably barking up the wrong tree. Again, it is difficult to draw any firm conclusions. Lots of businesses are responded differently. I would be surprised if what you see now is not broadly—it is a settled state but only in the world that we live in. High streets are in decline because you cannot divorce that from the fact that housing developments have moved out of town, because that is where land for house building is, or at least that is where it has been prioritised and invested in. That has got as much of an impact on the decline of high streets than the pandemic, causing lockdown has had even before the pandemic. Again, it is trying to recognise that the pandemic has accelerated some trends, but the way that we have structured our economy means that they were always at risk of happening. You cannot have a vibrant high street if you do not have a vibrant community that exists around about it. Did the city centres deliberately went into the city centres to shop cinema restaurants? Yes, they did, but where you have started to see developments, we know that high streets are in decline, so they are. Again, that has been partly a response to people shifting. It could be that cinemas—obviously, during lockdown, lots of the films started to appear online, while appearing in cinemas. Does that trend continue? I do not know, and I definitely do not want to predict, but all I do know is that Covid has certainly accelerated and impacted on things like that, but again, there have been trends that we started to witness well before the pandemic. Finally, Tom Waters, I saw you smiled at one point. Maybe you are a futurologist? I do not know, but do you think we are where we are going to be, or do you think that things could change quite a lot, especially in towns and city centres? No, I am smart, and I like Philip's response. I am definitely not a futurologist either. Cast my mind back a little bit now, we did see the consumer spending plateau quite early on in the pandemic. Obviously, it fell massively during the first lockdown, then it rebounded, and then it plateaued a bit below its pre-pandemic level. It is still below its pre-pandemic level. I give some indication that things might not bounce back much further. Obviously, it is very difficult to disentangle that from now on. We have high inflation and a cost-of-living crisis having its own impact. Dysentangling all those things would certainly be very difficult. I certainly would not want to make any firm predictions. Philip, I am going to go back to something that you said earlier. I have a feeling that this might be controversial. We have talked about economic inactivity, and there are certain areas of inactivity. Probably before we started, our conclusion was that the inactivity was across all levels, but it looks to be—if we are talking about inactivity—people are just getting out of the workforce, and they are not working, so they are retiring. They are not stopping working altogether. They must be afford to be able to not work if they are getting out of the workforce. There is a suggestion from the evidence session last week where we should not be bothering to pursue those folk. Do we know that the people who are just saying, I do not want to work can actually afford not to? There is a question. It is where you start to try to put together data sets. As I said earlier, all you can do is to an extent for now until the data starts to come through to show the impacts of that. All you can start to do is start to infer some kind of causal things. Again, I pointed to the UNS survey that finds that, whilst people are retiring, they are not confident that they have the kind of financial means to be able to sustain that. Again, people may have retired well before the current cost of living and inflation crisis hit. Maybe that starts to change people's minds that they realise that the small amount of savings that they had set aside absolutely will not see them through. It is really difficult to tell where those people have gone. Equally, the thing that we have not covered off is primary versus secondary reasons. Again, it is impossible to know yet with the data that we have. There are about four in ten of people who are becoming active for a reason other than long-term sickness. They still have a long-term condition. Again, there is that kind of interdependency of it could well be that someone chose to retire or become an active for another reason. That was their primary driver, but again, potentially, this is all anecdotal. Again, we do not have the evidence. It may be that they have been working with a long-term condition up until the pandemic. The pandemic was just that switch that said, you know what, I have been struggling through, I have a long-term condition, but this has made me realise that noise is the time to retire. They retire and their primary reason could be retirement, but a long-term condition has still played a factor. Again, there are just all those variables that we are still unable to really get to the root of so far. Over and above that, I would go back. I absolutely do not take it as they have gone, they are never coming back, give up, because there will be some who do want to come back. We know that highway view age in society still is not great by any means. I am glad that you mentioned that, because I am sitting and looking at it a bit here from Public Health Scotland's submission. Early evidence from the Glasgow City of Region Intelligence Hub suggests that the increase in retirement is due to lifestyle choices, ageist recruitment practices, changes in working practices, socialising in the workplace—we will go back to home working—was an element that kept people in work, and due to their eyes of home working, people have decided to leave the labour market. Ageism is getting away from that socialising in the workplace. Do we need to have a rethink on that ability for people to stay at home, or the requirement for people to stay at home while they are working? Again, it is impossible to do one size fits all model, is it not? It is where you come back to. Again, the social model of disability says that to see what people face is barriers, not because of their disability, but because of the barriers that people put up in response to that. You can spread that out to wider factors, age included. Age is not the thing that stops people from being really successful in the workforce. What is is employers and others who still continue to view that as a limiting factor, or at least certainly an unattractive factor where compared to a much younger worker going for the same job? There is absolutely—I think that Tom said this earlier—that it is not that you give up on them, it is not that you say that they have gone, so they are gone forever, but it is also not that you necessarily have to try and get them back in. What you do need to do is fundamentally shift your employment practices, your structural or societal view, to ensure that they have the means and the ability to come back in if they want to. I think that, particularly amongst the inactive population, that is the key thing. It is if they want to, because we know that so many of them are disengaged that they may not want to ever. Tom Waters, I think, is. Sorry, I have got the wrong glasses on, so I cannot see at distance. I am going to—some of the stats that came back and that were in your submission. Long Covid is increasing the number of people in work but on sick, and it will lead to reduced hours. Do we know economically what impact that is going to have with people who are still regarded as employed, but they are not actually working to the same extent or at all because of long Covid? I might just pass over to Tom Waters on the economic impact of it. I know that he will have that in the better mind. In terms of the total impact of last earnings, it is going to be about £1.5 billion per year, or £1,100 per month per work that is affected. There is also going to be a knock-on cost for employers who are having to pay sick pay and, of course, a smaller knock-on fiscal impact as well with lost tax revenues. I think that the overall magnitude of the total economic impact is not enormous, especially in terms of fiscal revenues and so on. The main concern here is the sort of individual impact on those who do have to go off sick. It is not like this is a massive chunk of people in terms of the overall context and size of the workforce, although it is something that matters still. I think that the main concern in many ways is the individual impact. We know that Scottish Workforce is aging more rapidly than the rest of the UK, and that could be a contributing factor to historically higher levels of inactivity in the Scottish workforce. We are talking about why people are retiring given the fact that more of them seem to be retiring now. Is there a risk that the pandemic will have a disproportionate effect on our workforce here in Scotland, either of the Toms? The way in which I think about the long-term impact of the pandemic is that one of the things that we have been talking about is retirement and activity, but you also have what is the impact going to be on long-term productivity. We have had this period of immense disruption, businesses closing down and so on. I do not know, perhaps Philip will know some of the Scotland-specific members, but my sense is that those kinds of effects can be at least as big as the impact on the number of people working. The OBR thinks that the UK has become permanently poorer because of Covid and that our long-run GDP is a couple of per cent lower. That is because of the sorts of effects that this huge amount of disruption is shutting down. That has long-run consequences for productivity and for the economy. My sense would be how those differences between that in Scotland and the rest of the UK could be important, but I do not know whether Philip has anything specific that he defeated on that. There was a downward trend of inactivity as a result of retirement in Scotland up until the pandemic. The pandemic saw a small uptick in Scotland. It saw a downward trend until the pandemic, a small uptick through the pandemic, but the most recent stats have again that downward trend kicking back in. It was that bit in the pandemic that you saw retirement as a proportion of inactivity going in the wrong direction. Again, in Scotland, actually the main driver in particular has been around ill health. I do not want to make it seem as though I am saying, well, they have retired, they have gone, we do not need to worry about the older people because I am absolutely not, I promise. The trend has been slightly different in Scotland as compared to the rest of the UK. I want to ask you the same question that I asked the previous panel. Are we asking you, as a panel, the right questions to get what it is that we are trying to find out in the first place? That is a good question, but goodness, you do not want to get invited to the committee and tell them how to do your job. No, convener, close your cover of your ears. I go back to what I said earlier. The pandemic has specific impacts, it has exacerbated some conditions, it has exacerbated some outcomes for people, but I think that there is a risk of viewing this issue primarily through or solely through that prism. These are long-standing trends. I think that perhaps what has not come out enough—it has come out, I have looked over last week's evidence session—is the relationship between health and prosperity, which again we know are incredibly closely linked. There is absolutely a question about what we do to restructure the economy. We have seen stagnating wage growth, rising precarious jobs, jobs with less hours, paying less money. There are structural issues that can cause people to drop out of the economy. We need to address that, we need to address ensuring that we have a skilled workforce coming through, we need to address the scale of employability support that we have in Scotland. On the flip side of that, obviously the health system goes hand in hand, and I think that being able to view those two things as more closely related than we perhaps have—we know, again, goodness, it is more than 10 years since Christie commission, so I dread to still continue to talk about prevention, but we are not there yet. We need to see a big shift on prevention and the role that the health service plays in that, and being able to start to address the long-term conditions that we know are having an impact on inactivity and vice versa. I think that that is maybe the bit that focus needs to be put on as the role of the health system in shaping economic prosperity and, importantly, vice versa, because we know that economic prosperity and health outcomes are very closely related. Thank you. Ida Thomas, do you want to add anything before we move on? I think that maybe anything to say is one thing I get. I think you might want to know the answer to would be—we talked a little bit, we kind of touched on a little bit earlier, I think Philip mentioned earlier, the kind of support that people get to get back into work, what kind of support do you get at the job centre? There have been a couple of government programmes, Restart and Kickstart, to try and improve this since Covid, but so far as the increasing activities about older workers, the kind of support that you need to get back into work if you are an older worker is potentially pretty different to if you are younger work. The Kickstart scheme is supposed to think only of those under age 25, for example. Thinking about what kinds of programmes have worked for older workers perhaps in other countries, are there some small pilots or experiments that could be run in Scotland? Those sorts of things might be quite valuable for helping people who do want to get back into work to do so. That would be one thing I think to think about going forward. In terms of—is there anything else you should be asking? I don't know, maybe specifically on the cause of activity, I'm not sure, but in terms of just other matters to do with the labour market and the impact of the pandemic, I suppose, also the questions of on-going productivity and has that been affected, as we mentioned earlier, in terms of people working from home and having an impact, and also just an awareness that many of the impact of the pandemic—this is relating to the point earlier that we bark at the wrong tree—many of them might take much longer than we have had so far to materialise if we are worried about disruption to education or whether people dropping out of work during the pandemic has damaged their human capital and their productivity long-term. That kind of thing, we might not be able to observe it yet, so keeping an illness for the much longer term will be very important. It may or may not be the case that the pandemic has a bigger effect down the line than it has had right now in terms of the impact on the economy. I'm just going to bring in Alex Rowley. Very quickly, Philip. You mentioned Christie. My view is that progress on Christie has been woeful, but has there been any research done to look at it, because we certainly have not got to a position where we are able to shift to unhealth in particular, but has there been research done to look at what progress has been made and why it is so— I'm not sure how in depth it got. It is difficult, because within a fixed budget in particular, there is a trade-off of the more money that you put into prevention, does that mean less money for treatment? It's very clear that we need to see a shift on those. For a bit of work that we did recently, I was looking at this. Again, we know that the incidences of cancer, obesity, cardiovascular disease are all far higher in deprived communities than they are in non deprived communities. As such, there is preventative stuff that needs to happen. That requires funding, that requires a specific focus and deprivation, but then that equally follows through into treatment in terms of early diagnosis and screening. We have both of those things, to an extent. We have action to try and stop smoking and to promote healthier lifestyles. We have started seeing, in particular, as a result of the pandemic, more action on early diagnosis, particularly around cancer, with the establishment of the early diagnostic centres. What I think, again, you are still missing on both of those. You can look through—it's not a scientific way to do it—to do a control F of various strategies on cancer, obesity, etc. You do a control F for deprivation, and other than a sentence that says people in deprived communities are more at risk of diseases and illnesses, what you don't have is any specific actions that specifically target those communities, either in terms of prevention or treatment. That is the thing that we miss. We know where the higher incidences and risk factors are, but, quite often, because of that, if you have a limited pot of money, where do you put it? If you are trying to spread the cost of prevention and treatment, you are probably wanting to spread the cost to everyone, but it feels that, again, we have done a lot of research on the link between health and prosperity. If you want to really start to address, in particular, regional inequalities, you need to get right to the heart of the issues that deprivation causes and within health. Again, I am not a health expert, but that needs to come with a specific focus on the health system and funding, diagnosis, treatment, prevention on those communities, which, again, I just don't think we have seen to date. I thank the witnesses for their evidence and giving us their time this morning. If witnesses would like to raise any further evidence with the committee, they can do so in writing, and the clerks will be happy to liaise on how you do that. We intend to continue this evidence in November before we hear from the Scottish Government on our meeting on 8 December. The committee's next meeting will be on 17 November, when we will continue our inquiry by looking at early retirement as a driver of economic inactivity in more detail. That concludes the public part of our meeting this morning, and I suspend the meeting to allow the witnesses to leave and the meeting to go into private. Thank you.