 Welcome to the third meeting of the Health and Sport Committee of 2018. Can I ask everyone to make sure that their mobile phones are on silent and also remind people that, while it's perfectly acceptable to use mobile devices for social media, please no recording and no photography as we have people to do that for us in the Parliament. I've received apologies today from Sandra White and we move first of all to agenda item 1, which is subordinate legislation. As colleagues will know, we have two negative instruments to consider today. The first instrument is the national health service pension scheme Scotland miscellaneous amendments number two regulations of 2017. There has been no motion to annul and the delegated powers on law reform committee has made no comments on this instrument and I would therefore intend that we simply agree no recommendations on that instrument. Is that the view of members or do members have any comments they wish to offer on this instrument? If not, thank you very much and that is agreed. Move on to the second instrument, which is the national health service superannuation scheme Scotland miscellaneous amendments number two regulations of 2017. There has been no motion to annul this instrument either. However, the delegated powers and law reform committee has made comments to Parliament on the deficiency of drafting of this instrument. Can I invite any comments from members in relation to this instrument, which is before you? If not, I would suggest that we have time. The instrument does not require to respond or otherwise by 5 February, which gives us a little time, so I would suggest to members that we write to the Government and ask them how they intend to address the point that has been raised by the delegated powers and law reform committee. Is that agreeable to members? Thank you very much. We move on to the second item of agenda and welcome our several guests who have joined us for the round table and in the public gallery. Given that we have such a large collection of distinguished witnesses, it would probably be helpful if we went round the table and asked people to introduce themselves simply by name and organisation. That is part of our series of round table sessions on the preventive agenda and on this occasion specifically dealing with sexual health, blood-borne viruses and HIV. I am Lewis MacDonald. I am the convener of the committee and I will pass it around to my right. Good morning. I am Ash Denham. I am the deputy convener. Good morning. I am Dr Ken Oats. I am a consultant on public health for NHS Highland in Inverness. Good morning. I am Miles Briggs. I am a Conservative MSP for Lothian and a Conservative spokesman for health and sport. Good morning. I am George Ballyotus. I am the chief executive officer of HIV Scotland. Good morning, everyone. I am Alex Cole-Hamilton, a Lib Dem MSP for Edinburgh Westin and my party's health and sport spokesperson. I am Professor John Dillon. I work for NHS Tayside and the University of Dundee. I am Jenny Gurruth, the constituency MSP for Midfaith and Glanothus. Good morning, everyone. I am Emma Harper. I am MSP for South Scotland region. Good morning. I am Emilia Crichton. I am the deputy director of public health in NHS Greater Glasgow and Clyde. I am Alison Johnstone, MSP for Lothian. I am David Goldberg, health protection Scotland. I am Ivan McKee, MSP for Glasgow Proven. I am Petra Wright, Scottish officer of this hepatitis C trust. I am Mildred Simonia, senior manager with Waverly Care. Good morning, I am Brian Whittle, safety Scotland MSP. I am Duncan McCormack, a consultant in public health at NHS Lothian. Thank you very much. We will move directly to questions before I ask Alex Cole-Hamilton to kick us off. Some of you will have taken part in roundtables at the Scottish Parliament before some of you will not. Essentially, we are looking to obtain as much understanding, evidence and information as we can over the next hour and a half. That is best done by a structured discussion. At the same time, I would want to encourage everyone who has something to contribute to a particular point to indicate to myself in the chair and I will seek to call you on that particular question. If I can ask Alex to ask the first question and then see an indication from any of the witnesses who wish to provide the first answer. Thank you, convener. Good morning, everyone. I should start by declaring an interest that I am the convener, co-convener of the cross-party group on sexual health and blood-borne viruses. It has also been my privilege to have chaired the HIV stigma consortium. My question spans both HIV and Hep C in respect of the fact that one of the biggest barriers that we face in terms of the public health response to both is that identification still proves very difficult. I would like the reflections from the panel as the correlation between rising levels of, well, resilient levels of stigma around both and the fact that that is acting as a barrier to people getting tested or seeking treatment or even admitting to themselves that they might have one or other or both indeed of these infections. I am aware that the World Health Organization is set as a target of an HIV in particular of 1990, which is 90 per cent identified, 90 per cent treatment and 90 per cent non-detectable viral load. I may have got that wrong, but you get the gist. So, if we can open up with the reflection on how stigma is still a barrier to people firstly being identified and then receiving treatment. I am looking to John, please. So, stigma is an issue. My expertise is within hepatitis C rather than HIV, but some of the issues cross across both. The stigma with hepatitis C is usually because of its strong association with drug use and the negative correlations that go with that. The people who are affected by the virus are likely to be in environments where they are fearful of moving out of them because of the fear of stigma, et cetera. So, while we can try and destigmatise the disease, that is going to be a long-term large issue. What we can do is make our services that are relevant to hepatitis C and to HIV embedded in the places where people are already comfortable going rather than sending them to new environments and making them track across new barriers. So, we need to adapt our services to facilitate people's access into care rather than sitting in our traditional ivory towers and making people come to us. So, that is one way around it. Clearly, it is not going to destigmatise it in the same way, but it is a way of working around that stigma problem, and clearly, we need another agenda around destigmatising the disease. But that is the practical issue that we can do today for people who are desperately in need of treatment. I think that that should be the focus of much of the effort, because we are, particularly with hepatitis C, those people who are prepared to come out of the environments that they are in and come to hospital, come to the traditional pathways of care, have largely engaged with treatment and been treated, but the bulk of people who are still engaged with addiction services or other third sector providers, et cetera, where we could access these people, are fearful of moving out of them, and we need to make our services more adaptable and move into those areas. Thank you very much. Dr Crack. Dr Glasgow and Clyde, we carried out research with a view to carrying out a campaign to address the stigma, and that was particularly among our staff. So, what we had was a huge poster you could see from far away that is said the same as you. You could see people being attracted until they came fairly close and they saw I'm HIV positive, and they were swerving away. So, I think the message, the subtle message is that we still have quite a lot to do with our own staff, because particularly in relation to HIV, the long memories are still there. I was working with John's team nearly 20 years ago in Dundee when HIV was an incurable disease and people were dying of it. Since then, HIV is a long-term condition. People have long life, fulfilling lives, but the message has not permeated to everyone. So, we still have a challenge in actually saying this is like anything else. It's better to know, and if you get treated, then you have a fulfilling life and you're no risk to anybody. So, we do have a long journey to go. I just want to speak up for another group of people. I think that the largest group among the undiagnosed are previous injectant drug users, people who may have been infected for 30 years or whatever. Not very much has been done to find them, and I feel that because they're recuperated, if you like, rehabilitated, they're all working and contributing to society, the stigma around hepatitis C stops people from coming forward, even when they remember that they have had risk factors in the past. Normalising of testing instead of just continually targeting harm reduction services might have an impact on reducing stigma. For instance, pregnant women get tested for HIV and hepatitis B, but not for hepatitis C. The number of people that speak to us who presume that they have been tested for hepatitis C before they've had their babies. So, it's an opportunity must. I work for Waverly Care. One of the projects that we work with is called the faith in health agenda. In this agenda, what we are responding to is the particular issue that Professor John Dylan mentioned is about going to where people are and also understanding how people think and how people see the world around them. Part of what we do is we work with faith leaders and we work with faith communities, get the messages from them, how they would want to receive the messages in terms of HIV, understand where they are coming in terms of faith. I think this work began quite early on around 2004 when we recognised that for patients who were coming into clinic for treatment a number of them were stopping their treatment and not adhering because of their faith and you would understand that people see the doctor maybe for just five minutes and they are out of the door and for the next six months they are relating to their faith leader and we understood that from very early on. So part of what we are doing is actually working with the faith leader themselves to talk to their faith communities about HIV and not actually excluding the aspect that faith is actually an integral part of their lives and so if a faith leader is standing up to say let's challenge HIV together, people are more likely to listen to that and I guess also for the NHS and staff working in the NHS this is something that we've continually been emphasising around the fact that if someone says they believe they've been healed what is your response to that and it should be a person centred response and so this is some of what we are we are challenging and when we look at the funding that's out there besides Scottish Government which has been very supportive in terms of some of this work we find that a lot of religion focused work is excluded from funding so there's a challenge out there to access this funding to do the work then again in terms of NHS when we look at volunteers who are visible in the community who are African or who are BME this is lacking we have a push within the NHS workforce to have visibility for Africans or BME communities but when we delve down into the community we are not finding that same effort in terms of getting representatives within the community itself who relate to the community and so this is a push again for our peer to peer work where we are saying other peers in the community will understand their peers and they are more likely to tell the truth about what's going on for them to share the issues and therefore we take these issues as part of the approach with peer to peer take them from the very voice of the community and address them in the way they want to see the solutions not from the point of view of how we want to see solutions though that's what I would like to say just about stigma the whole aspect of how we are tackling stigma right from the bottom route and we would like to see more of this being supported in our work. Thank you very much. Alex thank you for that question to start us off I think it's the most important question because what I think is essential to think about in this environment is Scotland has everything we need to cure hepatitis C and to eliminate HIV we have all the tools treatment works we know that if you have HIV and you're on treatment you will be uninfectious we know that if you've got hep C and you're on treatment that you can cure it we know that we have PrEP which is a an oral daily treatment that you can give people that if they don't have HIV and they take it every day they're unable to acquire HIV we have condoms you might have heard of them they still work really effectively as well so we have everything we need to stop HIV and hepatitis C but we're not getting there and that's because of stigma so I think it's important to begin the day by framing stigma as actually being our key challenge I appreciate that in terms of monetary savings and etc that you want to look at you need to look at maybe some technical things within the NHS but unless stigma is your number one lens in looking at this work we're not going to get to zero and we're not going to achieve anything further we know that from people with HIV once they access treatment at NHS they have really good outcomes overwhelmingly they love their clinicians they love going to clinic or they don't love it but you know it works for them overwhelmingly and yes there's problems here and there but overwhelmingly these things are working what gets in the way consistently of prevention efforts and what gets in the way consistently of treatment progress is stigma so thank you for starting us with that and I mean I could talk a lot more about this and I wonder if the further questions will help us really specify how we can how we can address stigma at every level of the response thank you very much David yeah I totally agree that stigma is a major issue it's of course it's not the only issue but I think we should try and place things in context as well and look at HIV separate from from hepatitis C as far as HIV is concerned we have getting on nearly 90 of the infected population actually diagnosed we're just a bit short of the WHO target we've done Scotland has done extraordinarily well in relationship to HIV I'm not saying there aren't challenges there are challenges still to diagnose that 10 to 15 percent of individuals who remain undiagnosed but over the the last three decades Scotland on the HIV front I think has done has done extremely well and in relationship to injecting drug use and we know there's a small outbreak of HIV among injectors in Glasgow harm reduction services for injectors in Scotland have been absolutely outstanding and the prevention general prevention of HIV among injectors over the last three three decades has been one of the great public health achievements really of all time I think it's been a phenomenal achievement and save the country in terms of human cost and economic cost it's incalculable so I think we've got to place that in context I think we've also got to accept that in terms of HIV and MSM a lot now is being done on the pre-exposure prophylaxis front a lot of work new work is being done to try and reduce transmissions there and so while there are challenges on the HIV front I think we have to recognise that the country and health services government have done an awful lot more to be done though I accept that on hcv different ballgame to really the action plan came in in 90 in 2008 we had 38,000 people infected in the country it's 10 years on we now have 34,000 people infected so the prevalence has come down it would have been much higher than the 38,000 had it not been for the action plan but huge challenge there 38 percent of the infected population had been diagnosed in 2008 now it's nearly 60 percent so in relationship to trying to get in contact with those individuals I think a really good job is being done but a massive job still to be done and I think as John sort of pointed out still a lot of people out there diagnosed really thousands and thousands have been diagnosed who are not actually in services who are not engaged who are not able to take advantage of the new therapies and I think the critical thing is yes it's about making services bespoke for this population group very vulnerable group very chaotic group must make the service bespoke Tayside has done that extremely well and I'd like to see that rolled out to the rest of Scotland there are some islands of excellence and good practice outstanding practice in other health boards but it's not enough we actually have to tailor our services make them user friendly get out there not expect these guys to come to us in hospitals get out there into the community settings make sure they're diagnosed make sure they're treated and that way I think we will essentially handle the problem so yes it is partly to do with stigma but there are other factors that come into play thank you very much and I think David said a lot of my points which I was going to relate to but again I'm sorry again I think stigma is really important but people were talking about maybe have HIV they maybe have hepatitis C but frequently there are also drug injectors their sex workers they're homeless they are poor they're excluded from society in many different ways so the infection itself is not the only barrier they have to accessing and benefiting from services and we have in Lothian we did a review of people referred for hepatitis C treatment and how they dropped out along the pathway which has been done nationally as well and a drop out rate is really high it's about 70 drop out from the first appointment and that's not just because of the stigma it's because of all these other factors in their lives which make it very complicated so I think that's something to bear in mind the other thing is I think again all those stigmas an issue why people don't access services a lot of people do access services and people access services for getting injecting equipment the access services to the GP the access services for addiction treatment and for sexual health treatment and lots of other things and these are opportunities where they could be tested and I don't again think it's stigma which is stopping them not being tested I think it's a lot to do with little barriers like it's not routine practice a lot of staff are very busy particularly in addiction services you know there's a few cuts there if they don't have time third sector staff don't always have access to information to know whether or not the patient needs a test because they can't access NHS records and things so there is the issue of getting people in there's also the issue of when they are in take advantage of that opportunity and testing them and just for Petra I think you'll be pleased to know we are looking in Lothian at starting to do hepatitis C testing in pregnant woman because it's very cheap to do just add it on to the PCR test and we're going to see what the year will be then okay I'm conscious that this is such a general question that we could have a debate around it for the entire session I don't want to do that so I'll I'll call Ken who's not spoken and then we'll ask Alison Johnson to ask a second question which I suspect will allow some of the folk who want to come back to comment further thank you just just a comment I guess about stigma in rural areas of the country where I think it really is a still a significant issue you're you're more well known it's difficult to hide for people and one of the things that we found is a benefit in these parts of the countries to work closely with the third sector we you know we partner with Waverly Care in Highland there are other third sector organisations as well but they do an excellent job and people are more likely to approach them discuss them with them their conditions then go to the statutory agencies like the national health service or the local authority okay thanks very much Alison and follow by Jenny thank you Greg address a specific question to Professor Dylan in the first instance I'd just like to understand why the national health service Tayside using prevention as treatment model is so important so from a hepatitis c point of view it is still transmitted by injecting drug use so even with the availability of opiate substitution therapy with needle and syring provision which has largely removed hiv from the people inject drugs population that it still allows transmission to occur with hepatitis c so in your career as a injecting drug user perhaps you inject for two four five six years before moving on to recovery if you become infected with that virus during that time you will potentially interact with six or seven other people who you will pass the virus on to before your career changes and you move away from drug use if you do the the clears of variability if you can offer treatment at a very early stage while people are still actively injecting who are infected you then reduce when they have contact with other drug users and share equipment with other drug users their chances of transmission disappear because they're not infected anymore so that's the idea of treatment as prevention so it hasn't it's clearly we've got the idea of prep where you can use it before a sexual act to reduce your chances but this is actually targeting the people who are infected and therefore not allowing them to contact or to infect other people within it the impact of that is that rather than waiting at his standard practice at the moment to when people are stable where they've moved on to opiate substitution therapy or moved into recovery and we then treat them there where traditionally that's perceived as being an easy population to treat because they're stable and have moved away from the chaos in their earlier lives it means the bucket is constantly being refilled that new infections are replacing those that you've treated which is in part why all of the treatment activity has had that we've done a hepatitis C has had a smaller effect on hepatitis C prevalence than would have been done if we could cut down the incidence so in Tayside we are trialling a model where we will dramatically increase the number of people who are actively injecting drugs who have hep C that we will treat and will bring the prevalence in that population down from about 30 odd percent down below 10 percent which means transmission will fall from 5 to 10 percent down below 1 percent and that would lead to the extinction of the virus and we think we can achieve that over two or three years if you can take the virus new transmissions of the virus out then all of your subsequent treatment can be used to treat those older people who are stable in the community and you can then move to a situation where hepatitis C is eliminated in Tayside potentially in four years time okay thank you that's very helpful i think doctor Cragman wanted to add a little comment on that Tayside is not the only board in Scotland probably all Scotland would like to use the model and certainly in Glasgow when we were faced with the HIV outbreak we wanted and we still wish to use treatment as a way of preventing the further spread of HIV among the drug injecting population so it remains a desirable way of tackling the outbreak however the addiction gets in the way of individuals engaging with the with the service and the treatment itself and that's why we have put forward additional ways we wish to tackle the issue that we will discuss later so that i don't stay into other thank you very much i supplementary in that point i think from Ivan McKee yes thank you thanks computer it was really just to follow up on the specifics of what we're talking about here in the treatment as prevention and the elimination potential of of hep C and i can see how that model works and i believe you can confirm i'm wrong but i mean the data around that is pretty solid if you do what you say you're going to do the effect will be that it will be eliminated within that time frame and that's obviously something that would be applicable across across the whole country to what extent does the funding mechanisms for treatment cause problems because clearly this is classic prevention what you're saying is that we spend a bit more now we'll save a fortune in future decades because we won't have to treat the problem how much of a barrier is there there in understanding that and directing the resources to the right place and putting the right amount of resources in up front to make that happen and how easy is it for the government to fix that it's clearly a barrier all the health boards are um have difficulty with cash flow nhs tayside has a particularly acute problem that i'm sure many of you are aware of um we have managed to persuade the health board that this is the benefit in terms of financial of health gain dominates the short term costs clearly it is cost saving over a five or a 10 year horizon um but it does mean investing more money now in this year as the drug costs have fallen we're not talking about increasing the overall drug spend we're talking about maintaining it so if you look back two or three years to how much we were spending on hepatitis C when the new active drugs became available the cost of those drugs has fallen substantially and so what we're talking about is still actually reducing that budget but being able to treat within that envelope so the money was there but clearly there are pressures around it also that's the sort of argument and being able to make the argument to the finance director give me this money for three years i will hand back my drug budget and will not ask you for any more there is no clinician that can go to a finance director other than those that are treating hepatitis C and be able to say that are you able to put some numbers on that i mean specifically how much are we spending per year at the moment and how much would you need to spend at the moment to deliver what you need to do for an hs i can give you an hs take side i don't have the figures for old scotland we spent three years ago we spent approximately four million in the first year that the new daa were available this year we're likely to spend two point two million and over the next three years to deliver this elimination agenda we're going we plan on spending two point one million sorry so that a cutting cost per year if you do nothing is how much so we would carry on treating people that were coming through treat through for treatment anyway and that's in the order of one and a half to two million anyway so it's a small additional cost so in terms of numbers of patients you need to treat for the treatment prevention in an hs take side given our deprivation index and given our prevalent use of intravenous drugs is about 350 to 400 people so that's the additional number of people you need sorry i'm not i'm not getting the question is if you before you started this how much were you spending per year and how much extra do you need to spend to eliminate and then how much do you save so i've given you the total because it was four million down so you were spending four million per year before you started doing it and how much extra did you need to spend to eliminate so we haven't eliminated yet but to do that you know the numbers how much so so in terms of going forward to deliver both the treatment of people who have hep C and are advancing have advancing disease and therefore needing treatment and the addition of going in and treating active drug users we're delivering that within 2.1 million pounds okay thanks very much wow perhaps i think they have a goal about me and just just to try and build on on on what john's been saying i s or hps estimates that are probably about 4 000 4 to 5 000 active individuals who inject drugs in scotland who are chronically infected with hepatitis c between 4 and 5 000 so these are the people who have the potential to transmit to others outside of that group by the way the potential to transmit is incredibly low okay it does happen but it's incredibly low probably about 98 to 99 percent of all transmissions of hcv in scotland at the moment relate to injecting drug use okay so we're talking about 4 to 5 000 and then the cost of treatment is what 78 000 or it's in that sort of ballpark and you can do the mathematics there so you're talking about if you were to actually go for that group you're talking about drug treatment costs of getting on for about 30 million but then of course there are all the other costs of actually managing the whole thing coordination etc etc i'm not an easy job but the concept of treatment to prevent on onward transmission is a really good one it's a really good concept it's intuitive i have absolutely no doubts it will help matters it will reduce onward transmission i think the big question is to what extent and for how long and that's why we're doing this research in Tayside to actually examine this because we don't have actually all the answers here it is possible that the actual sort of outcome will be different to what we thought maybe better maybe a little worse we don't we're not sure but we do believe in the the concept intuitively it's right and it's right for i think for hiv as well treatment of infection for the individual is good but it's also good for the population if that individual has the potential to spread it to other people okay i think that opens a wider question as well around cost benefit analysis asked in a minute yeah i just want to ask it's mainly it's following on from ivy mckee's question about this issue of cost benefit analysis so i'll just pull out a couple of comments from some of the written submissions that we received so john dillan you said in yours there's limited health economic input available and that the power of such analysis isn't available really to be utilised for this purpose and david golberg you said that it would be helpful if the framework could call upon a health economist so that's the question really is there should there be a health economist would this enable boards to make better decisions personally i think i think so i think there's no question that the all our activities policy practice has been underpinned by good monitoring systems we do actually have really good monitoring systems in the country so we've got good data and we can tell you how many people are infected and how many individuals have been prevented from going on to liver disease or hiv disease and all that kind of thing so we we actually have really sound data what we haven't got is precision in relationship to the cost effectiveness of interventions i mean there's stuff in the literature i accept that being done in other countries but i do think that scotland would benefit from actually a little bit more precision in this area with health economic support working with us i mean i've no doubt that most of our our interventions will be pretty cost effective but it's ability to be able to demonstrate that that we haven't actually done as well as we might have when you're bidding to an individual health board to make a decision there is models from the literature about the health economics that you can sort of manipulate uh if we did this in this in our territory we think this is what would happen but it's not as convincing as having someone who has personalised the models and the projection or actually done the analysis on the data and um as a clinician appearing in front of a health board saying stuff i suspect it's assumed that i'm being economical with the truth before before i start and that i'm gilding the lily somewhat and so having some personalised specific analysis would strengthen the cases that we're trying to make rather than um me extrapolating data that many of the people around the board don't particularly understand and then trying to apply it to a particular territory or a particular intervention for us any drug before it's allowed to be taken up by NHS scotland goes through the Scottish medicine consortiums and there is both clinical and cost effectiveness that has to be made for the committee to allow excuse me to to allow the drug to be used so past that there is no requirement for NHS boards to carry out additional economics analysis because that is done upfront to allow us to use it when we move on into novel ways or public health analysis we do sometimes make resort to health economists particularly when assessing the new interventions and we go to the boards but probably not all boards have access to health economists as there are there are many of them and there's another issue of actually tracking the impact of our interventions and that goes into the evaluation and economic evaluation of impact of our actions so it's it's a complex thing we could do better there is some already in place that is uploaded so upfront and boards have to be pragmatic in how we how we carry out business so that we maintain our financial envelope so just as a follow-up to that then what would be preventing health protection scotland from carrying out this type of health economics is that a role that they should be playing? In the framework 2015 to 2012 well the framework started in 2011 and in there essentially has its outcomes and then it's basically saying right okay we're going to monitor our performance against those outcomes and we have these outcome indicators and there's a data portal and you can access that data since December the public can access that data portal and see how people how boards are doing in this respect but I think that if we were moving forward 2020 to 2025 or whatever then it would be helpful to have in there not just outcome indicators but perhaps more on cost effectiveness of interventions particularly on the preventative sort of area particularly on the behavioural front the more complex sort of interventions I totally accept the drugs in terms for treatment purposes I have to go through a rigorous sort of process but I think if there was something in there in the framework which is basically saying we don't just want to to know about the performance and relationship to changes and prevalence and incidents and all that we want to actually know also about the the effectiveness and the cost effectiveness of our spend in relationship to interventions. I'll take George Oliotis and then I'll move on to Jenny Gluariff and questions around education. You are echo the comments of my peers but I also want to add an example of good practice. HIV Scotland administered the PrEP shot life working group last year or the year before and what we did in that instance was we used the international literature to where there was good evidence about cost effectiveness of PrEP in Scotland so that work had already been done in the literature we then assembled an expert group that included clinical expertise people from the Scottish Medicines Consortium and academia and we did a cost implications exercise because we obviously couldn't do cost effectiveness and then that report that we generated was used by the SMC when they did their assessment and so they all told that created a portfolio of cost effectiveness. We were able to ascertain what we were able to approximate, how many people we thought would benefit from PrEP and etc so we thought that was a pretty good model in terms of going forward and seeing further cost implications we obviously can't we'll have limitations in how we measure that but also we know it works we know it's cost effective and that model worked for us so just as an example of how we've been operating so far. Okay thanks very much. Thank you convener. I'd like to ask quite a specific question to HIV Scotland and to Waverly Care because you both flagged up in your submission inequalities in terms of educational provision of sex education. So HIV Scotland you flag up that two young people between the ages of 15 and 24 are diagnosed with HIV each month which I find quite shocking and you're asking the Government for specific legislation on this on relationships, sexual health and parenthood because you say you want to be a compulsory component of the curriculum to guarantee equality of access and again Waverly Care also highlight a varying delivery and quality of sexual health education so I did my homework last night and went through the curriculum content for the health and wellbeing curriculum area and there are three pages of content in that curriculum guidance already on dedicated to RSHP from early years right through to fourth level so are you therefore aware of areas in which it is not being taught at the moment and do you have evidence of that? Yes absolutely we are aware of areas that are not being taught we're currently conducting research where we've heard so far from 2,000 young people who are telling us about their experiences of learning. We know that I don't have the actual figures yet because that research is currently ongoing but there are gaps absolutely it's not essential for schools to be teaching these subjects it's very easy for a child to be sick that day and have missed that. So yeah like absolutely we have clear evidence that that's that's not going on it depends on which school you go to it depends on the choices of your parents and your and your school so yeah there's an absolute gap there and we know that because we see two young people a month being diagnosed that in order for kids to get access to their health to be able to keep themselves protected we as adults have to make choices that are in their best interests and this evidence is telling us that they're not getting the information that they need to keep themselves safe so that's why for us is a priority issue absolutely and I think in terms of Waverly Care recognising that very aspect that kids are not getting the sexual health education that they need to part of our for our project called the WAVE project which is in Highlands at the moment that's a project that's funded to actually fill that gap to actually be the people that actively go into schools and teach this because as George rightly says teachers are not you know obliged to teach this they have it but there's no assurance that they are going to do it but if they are projects like ours who can go in and do this and offer to do this for schools schools are are opening up for us to come and do that and I think that's why we are also calling upon consistency with all the NHS boards where they are good models that are working it's we are encouraging you know NHS boards to take this on right now we are in the in the Highlands but it could be a model that could be rolled across so that it's not just dependent on schools but projects like ours can also deliver this just just on that specific point then you highlight in your submission in the share resource which i'd never heard of before so i had a little look at that as well which was developed between yourselves and education Scotland is that correct Mildred yes yes but obviously a teaching resource again is not compulsory much like your experiences and outcomes so is there specific course content which is in that share resource and I don't know if you can comment on this which is not currently in the curriculum content at the moment in health and wellbeing is there something missing there in the curriculum content that you think that the share resource offers I think what I can just comment on is the resource that we have at the moment so the resource that we have at the moment is very interactive so it's different from expecting a teacher to just deliver on a content and ticker box this is about interacting with the children themselves letting them have the discussions ask questions in a peer environment to a non-threatening individual who's just in the school and out so I would just say the resource that we have at the moment works better for students rather than them listening to a teacher who they see in the corridors you know week in week out this is a group of people that come in they are you know they are separate from the school so they are able to solicit questions from students that maybe teachers would not be able to to get from their students and do you recognise that as a strength therefore so for example in my experience perhaps you teach the child english and you then also have to go and teach them sex education do you think it's a strength then having an outside agency coming in and delivering that from your experience oh it is absolutely I think though Jenny there are things missing from the share curriculum because hv has changed like we know a lot more about treatment as prevention we also know about prep now so it's time that that was updated and I believe there is some work undergoing to update that so that has to be done but most importantly we can't be everywhere as a third sector it's important to involve us where you can but actually we need to see some statutory changes here so that every child no matter where she's living can get the same quality of access no matter where she is just a last week question on this point it's actually to David Goldberg with regard to that data gap that we seem to have it says that the last kind of data that we have around about young people's experiences of sex education was done in 2012 with regard to outcome one of the sexual health framework moray conducted a survey no other data is currently available through hps why is that the case and are there plans to do some sort of more data gathering here's my opportunity thank you for asking that question out of scope for hps health protection scotland is infectious diseases and environmental incidents and doesn't cover the sexual health territory which is in fact non non-infections that are related the organisation that did cover that was health scotland and it actually had it was fairly active in this area over sort of many years it doesn't cover this area specifically anymore okay so it'll have it might cover it a little bit in the area of inequalities but it doesn't have a i think a national visible sort of presence in sexual health and indeed there is no national agency in scotland that covers this particular area and i think a change was are you aware i don't know the reason for that change i mean even i think when i think i think i don't want to say any more about health scotland in that respect because i don't have all the facts available to me what i do know is that there is a gap in terms of leadership coordination data at a national level i'm not talking about local i think there are boards which do a hell of a good job in this respect but from a national perspective this is a major gap i've brought this matter up by the way it's not the first time to the executive leads of the sexual health and blood bone virus framework so they do sort of know about it but it's good to be able to air this within this forum it is a problem and so for the territory of sexual health and relationships education and all this yes we can you know i think third sector hiv scotland has done a tremendous sort of job here and other third sector organisations as well but we don't actually have a national statutory organisation that is leading this area do you have a view with regard to who that should be should it be the job of education scotland for example to go into skills and survey pupils about their experiences i don't know in turn that the operational sort of side is one thing i think there's a strategic sort of side which is missing here and that's the thing that i'm really sort of focusing in on i have a supplementary question from allison johnson and then i know dunk in my comic and then we'll get right and both have comments to make on this wider discussion allison yeah i'd just be grateful to witnesses if you could just advise whether i'm hosting an event in parliament tonight and for the royal college of pediatrics and child health it's really sort of looking at the state of child health in scotland and one of the their recommendations is introducing statutory sex and relationships education in all schools and i just wonder if that is something that everyone here would support is there you know is maybe it might be quicker to ask if anyone doesn't support that i think that i think that's a fairly a fairly loud response of a yeah can i just ask very quickly convener miles briggs and i is part of our health committee work recently visited a drug partnership in edinburgh and we heard from a group of people who are now in their 30s all um well it was some in recovery some aiming to be so and you know they said that they'd been but some of them had been introduced heroin for example by family and or friends as young as 13 and they were absolutely determined that we need to get better about introducing people to the subject far earlier than we do and the hepatitis c trust event that was in parliament i think that was last week there was a if you were there petra you know we heard again that there has to be more information reaching people who can make decisions before family and friends perhaps approach them i was just wondering what it is we're doing that's you know what what are we missing here because it just seems very frustrating and when they take uh Duncan with his Lothian heart as well um clearly a relevant similia and then i know there's a supplementary from on the share training i agree completely we need to have people coming in but also having teachers who are trained because the young people aren't they have questions all the time you have to have someone there they can go and speak to who then may go and access more expert advice but need to have someone there all the time but the other thing i don't know what's happening another health board i think not everywhere but in Lothian at least there's a decrease in uptake of condoms in young people and so i'm not sure how this would all work but gets access to condoms without any hassle maybe in school settings or elsewhere it's another issue to think about because it's definitely a problem in Lothian and we're thinking about having access online because we don't like the paperwork and all the traditional ways of getting condoms thank you very much first and foremost we need to highlight the successes in sexual health in the last 20 years so how much what happens now it's a it's the consequence of the previous successes health Scotland now um has revised their strategy indeed they decided to move on into the inequalities as opposed to covering all the health education topics so the sexual health it's now part of the curriculum as Jenny has said that means everybody does a variation of what they they see fit so there's also additional top-up training and the the sexual health health improvement networking Glasgow is the one that actually provides additional training for schools but again it's not a compulsory we're going and see every school it's it's again a matter of relationship and who asks and where we see the need the other major success has been the reduction in teenage pregnancy so we use that as an indicator of what happens in sexual health but it's not we're not there yet we still have a lot to do a major concern right now with the sexual health services being passed on to the AJB in Glasgow in particular we see a revision of the provision and we're going to have more cuts and money taken out of the service therefore we are concerned about what is going to be available in the future because unless you have a major crisis there's no issues so we need to put in the curriculum but we need to ensure that we monitor and have additional ways of engaging people because I completely completely agree with Meldred teaching out of the usual curriculum is really valuable for individuals particularly those at risk and to pick on Alison's point you know being introduced at the age of 13 or well a teenager to drugs alcohol and so on what can we do the only evidence we have from the world is what the Icelandics have done and that was actually getting the families to spend time together empowering the young people to actually look at alternatives to actually being out hanging on the street and drinking and smoking and doing other things so it's having sports cultural activities spending time with your family and it's a whole person approach that actually works and it's the only work the only thing that works thank you very much a pretty supplementary from alex it's more of a reflection but perhaps other panel members would like to come in on it it's about in respect of bringing sexual health and education in schools under a more statutory footing we covered this to a certain degree in our equalities and human rights committee inquiry into school bullying particularly around homophobia and one of the things that came up and and i've experienced this in my personal life my wife teaches in roman catholic primary school but i have spoken to many roman catholic teachers in the conduct of that inquiry that whilst there is no uh dictator or anything like that from within the roman catholic church within schools there is still an anxiety and a tension that exists for teachers within the roman catholic sector around this area because of the tension that exists between what is normal healthy education around these issues and church doctrine i think we need to be mindful of that and perhaps legislation this way would give teachers cover within that context so that whilst there is no and i should stress this i don't want to cause a controversy there is no pressure within the church for teachers not to talk about this but there is a tension that exists because of the clash that exists with church doctrine okay i don't know if any witnesses want to comment on that at this stage or it may be something to comment on in association with other uh answers uh miles did you want to to um pull together some of the discussion we've had around hep c and specifically looking at um those in treatment so i think for 2016-17 there's just over 1500 new cases were diagnosed and 1700 commenced treatments now given that low level what work is actually being done or what should be being done to try to extend that opportunity and looking at the government's target of elimination for 2030 we're no way going to meet that so my question really relates to some of the evidence we've received with regards to identifying new patients and certainly the work which this committee did around prisoner health showed a real lack of opportunity there when mandatory testing not in place meant that many people weren't having any tests within prison and so therefore the opportunity to start on a treatment pathway was just not being realised so i wondered from the panel today if they had any specific views on on that comment on our prison work we've been delivering a project with people in prison especially people who inject drugs and our services really been a link service where we are actually take handholding actually people from the prison setting when they are going into the community and continuing that support i think what's been missing is that link where if someone is tested in prison what happens to them let's say they've got a short stay but also that's also changing also because of the shorter treatment cycle that's now in place i i just feel that a lot of the time when people are tested in prison the follow-up is lacking so people then get lost along the way so our project in a sense in Waverly Cair has helped to engage people throughout the treatment pathway and i feel maybe this is something that also could be extended to other areas as well so that there is that link in terms of treatment and care right from the start of the right from diagnosis up to completion of treatment i think this point also touches on what Tayside's pilot is doing around that whole handholding through the process of treatment because sometimes it's about the attendance for appointments if people are accessing their treatment it's okay but we know we are dealing with chaotic people with chaotic lifestyles Waverly Cair has found value in then handholding people through that process and i think even when we are looking at the cost benefit analysis looking at that part aspect of actually handholding people in this pathway would also be helpful so i think in response to that looking at our prison work as an example this is something i believe in terms of the work that probably is limited when you're looking at whether we test people or not whether people opt in or opt out the opportunities there when we look at people who can handhold people through the process so that's the comment that i would like to yeah i would just like to say that testing people using hand reduction services isn't compulsory either it is something i would actually like to see everybody accessing hand reduction services got a bloodborne virus test i don't really see why not i mean that would take some of the stigma as well for that population but there needs to be more testing done in other areas as well like i say pregnant women in other sort of places people are known perhaps to have rheumatoid arthritis many other health conditions thyroid problems that sort of thing maybe we need a list of conditions that people could present with with hepatitis c that could indicate that they need to have a test along the lines of what happens for hiv not only risk factors but to look for other health things as well and i really think that it should be written into the service level agreement say harm reduction services that they aim to test 100% of all their service users and refer 100% to those positive direct clinical specialist services uh historically there were issues where the drug worker would test the person deliver the test and then decide that the person wasn't ready to be referred to hospital to engage um so i'd like to see it being compulsory of David Goldberg and then so we estimate between 20 and 30 000 of the 34 000 infected chronically infected people with hepatitis c are either undiagnosed or essentially lost to lost to follow up or maybe never never in follow up so there's a huge challenge um Government in 2015 did ask hps to look at the cost effectiveness of birth cohort screening this is the um this is something that the United States have recommended the sense of disease controls recommended and it's being implemented um in part across the United States they've got a mixed problem you know i think part of their probably about half of their infection is is um healthcare associated um and the other half is injecting drug use associated um we did look at this in association with Glasgow Caledonian University and we looked at it at a time when the cost of therapy was really very high you know it was um certainly around about the 30 000 pound mark per course of therapy and um the cost effective analysis cost effectiveness analysis didn't look particularly promising but things have changed very very dramatically we're down to under the 10 000 mark and um it may well be now that there is a very very compelling cost effectiveness case to be made for universal screening of a certain age group or a certain age band in primary care settings but possibly confined to certain geographical areas because we know that most of the hepatitis C in Scotland is located in areas of of deprivation and that's a so that but there are challenges here so if we come up with the cost effectiveness analysis which says this is really going to be cost effective here it's still there's still an investment here you still have to put money into that you've got to actually work with general practitioners you've got to invest in that sort of area so it will be costly but i suspect um and we'll produce the data very very soon that it will come out highly cost effective as a consequence of treatment costs coming down but the critical thing is that once you diagnose once you diagnose you've got to be able to offer that treatment there and then in the primary care setting and one of our problems is that we have a limit well government understand that set minimum the minimum treatment targets and this to a certain extent has hindered our ability to go down that particular path and be innovative in these settings because once you diagnose you want to be able to do the next bit and then but at the moment you've got to think well if we diagnose we might not be able to do the next bit and so the two things are linked together but if we were to agree that a universal sort of United States type model I think we could make real inroads into hepatitis C. Thanks I have Duncan McCormack and then John Doe. To say in terms of opting out opt out testing I agree it's really the best approach to take there's lots of challenges though because people might choose to opt out there's sort of people get discharged from prison very quickly before they've had an appointment to get the test there are things we're doing in loathing which I think probably elsewhere people are doing as well things like or a quick which are the rapid test so in police custody for example where people really do leave quickly they can have the result pretty quickly and then they can go home with that knowledge and maybe get more motivation to link into services also in terms of being out in the field testing people we have a portable fibre scanner which we have two now which we're going to buy and we have bought and so that's as a sort of like to get people in for testing if you get a fibre scan result you can look at your liver and get your test you sort of start to sort of get a bit more engagement with the whole process but I think it's a challenge to do that. Just the other thing in terms of cost benefit and you mentioned it was I think we need to do look at the whole wraparound service of people not just the cost benefit of the drug pharmacological part of the treatment it's also how to maintain stability the primary prevention the other areas of stigma and difficulties that people have there's sex work and homelessness and poverty and that kind of thing so there's not much cost benefit analysis of these kind of interventions at all anywhere particularly with groups of people who happen to be a female drug injecting sex workers homeless so I think think about these kind of really vulnerable groups and cost benefit analysis of things that work for them to keep them in treatment is the important so the clinical networks across scotland's each health board who are who deliver the care I have an individualized health board target based on the overall scotish minimum number with the financial constraints the health boards face the minimum number as often of the target treatment number has often become the minimum number plus one for that health board which has led to a constraint and David makes a valid point that if we're bringing patients people into diagnosis and then saying yes you've got this nasty transmissible fatal disease but we're not going to treat you is exactly the wrong message to be telling them particularly if they're vulnerable particularly if we want to bring them and engage them in a wraparound holistic point of care because we shouldn't be viewing hepatitis C treatment or HIV treatment in isolation it should be encouraging other healthcare behaviours in this group of patients and sort of drug-rated deaths that many of you will be aware of in our own work in Tayside we've seen those people who have hep C and have engaged in care their risk of drug-rated death falls dramatically and in fact that's the biggest life-saving benefit in the short term rather than prevention of death from liver disease so that's important we have had treatment pathways have largely been set up based on interfere on treatments and then we've had the joy of these new very effective drugs that are easy to give and we have if you like cleared out all those people that were waiting to rise to the challenge on the targets the government has now committed in the last week to increase the treatment targets from 1800 to 2000 in the next year 2500 a year after and 3000 a year after that that puts us back online to start to move to elimination by 30 30 we would like to have had the 3000 target now but it is taking some health boards time to adapt their pathways because we do need to move out into much more integrated pathways of care where we can reach into people there is a short life working group that's been brought together to try and highlight the best practices from across the world and in Scotland and come up with the toolkit for each health board to develop because there are differences between the different health boards in terms of where their distribution of patients is and how their services are organised and we need to be integrated into their services and equally we need to take away some of the medicalization and the gear that went with hep C treatment when we just had interferon therapies because the field has changed these drugs are very safe and literally it's sort of almost a treat and forget. Thank you very much and before I bring Dr Crown back in again I think that Brian Whittle wanted to follow up the line of question and again. Thank you. Good morning to the panel I think. From all the evidence the link between HIV and viral hepatitis and the drug community is obviously very prevalent so I'm wondering whether where the pressures are within that environment vis-à-vis drug rehabilitation units, what is the cross-referencing being done with other agencies that are working within this environment and is there a correlation between the pressures on their budget and the rise of HIV and hepatitis and how do you play in between those agencies and how does that correlate? So in the original action plan we acknowledged the overlap particularly with hepatitis C and the drug agencies and the drug treatment services so it was a requirement that we had to have integrated treatment services so that hepatitis C treatment services had to be available within addiction centres that's worked well in some areas less well in others. Clearly the loss of budgets associated with the ADP alcohol and drug partnerships last year has put more pressure on the drug services etc so when we're trying to get them to be more holistic about the way they work with their clients because if clearly if they've made a point of contact to move from injecting on-topic substitution therapy or interacting with drug services to be able to offer them treatment around their hepatitis C is an advantage it means that client doesn't have to go elsewhere doesn't have to face new barriers and new stigma it can be delivered there. Equally the treatment around drugs is often relatively confrontational around the addiction but moving on to hepatitis C treatment is neutral ground if you like both the person infected with hepatitis C and the worker views them as a good thing to do and that helps build relationships and trusts so we need to convince our partners in drug services that there is a win-win situation for them here where if they're offering more services they'll get more buy-in to the whole treatment point of view where that's worked well it has been really successful and we've had huge uptakes and part of the success of NHS Tayside in having the highest diagnosis rates in Scotland and some of the highest treatment rates has been because of those integrations with drug partnerships I think that's the way we should be going. I must advise the panel that I actually am the vice chair of the Glasgow ADP and in that role I've been leading on the work looking at the addiction needs for individuals for HIV positive part of the outbreak that work has given me a lot of insights that I have never ever had before what it became very clear is that there are a group of individuals that shift in between prison homelessness are addicted to drugs have experienced multiple trauma in their childhood and it's very difficult to actually find a way to bring them into mainstream services and keep them there what we have found is that they know that their HIV they know about HIV they know that they are hep C positive they continue to share equipment drugs needles and they actually say I I know I'm hep C positive so are you and it makes no difference the priority for them is the addiction unfortunately and as services we have pulled together the homelessness the addictions community justice in Glasgow we're all working together and we still haven't cracked it we have Health Scotland on with us we have academia trying to create additional insights but there are some difficult issues these individuals face and until we work with the users and understand their true needs it's very it's going to be very hard to actually deliver the services I must say that the budgets are an issue because we do have very very aspirational and challenging treatment numbers that the government wishes to for us to deliver in Glasgow we are looking at actually finding massive savings as an NHS board so we're looking at every single budget line that could be could be reduced so we need to find a way of treating individuals who are most in need we need to be mindful of the re-infection that we have seen already in individuals who have been treated for hep C and we need to live in the financial envelope and address the needs of the users and these users are some of the most vulnerable people in the society and the academic debate and the education means nothing to them it's just we need to to be where they are and take them with us. One of the key successes I feel of the hep C programme initially was the way it was funded so it was ring fence funding it was to deliver an action plan it was easy for health boards except another partner agencies like Come Alcohol and Drugs partnerships to utilise that money there's been a drive in the last few years in the NHS to simplify funding so that it all gets lumped in together and something called the outcomes frameworks of health boards are now allocated a massive sum of money to do a whole bunch of stuff instead of having ring fence programmes and I know there's diverse views in this but I think that that is very detrimental to the likes of these vulnerable people vulnerable groups in society that had protected funding for streams of work before like through alcohol and drug partnerships harm reduction services the so-called Cinderella services because inevitably what happens with NHS when it's looking at global sums of money is it prioritises acute services it prioritises waiting lists where all the political and media focus is and Cinderella services so-called lose out and I would say that you know alcohol and drugs addiction services harm reduction services the things that we're utilising to tackle these vulnerable people and their problems are going to miss out and have missed out in the last two or three years because of that funding mechanism and I would make a plea that that we look again at that and see whether actually for these vulnerable types of people and for specific programmes of work on homelessness etc that we need to target funding at that within the NHS and council streams not just give a global sum of money because if we keep doing that they'll never get funded they're always the first to be cut thank you very much I'm aware of time I'd like to move on now and ask Emma Harper to thank you convener the multi agency approach is something that I'm interested in and the framework and update highlighted the importance of effective interagency working and Dr Emilia has already mentioned that just now and Dr Ken Oates talked about the third sector being really important in the highlands you know I'm sure that the rural south of Scotland it's really important to have third sector involved so are the agencies working together appropriately effectively or is the health and social care integration process still at an early stage where we haven't got the buy-in from the ijbs or the engagement so I'm interested in comments about that yes thank you I think the agencies are working together as well as they can at the minute we work a lot with the third sector waverly care and cgl change group live in various organizations what's been a challenge there is data sharing so for example in there we try to do some work to look at homeless people who are drug injectors the homeless database and the city of Edinburgh council doesn't record this fact as like drug injecting sex work violence this kind of thing so it makes it very difficult to to join services up and also third sector I think potentially they could do but they don't have access to some of the NHS data such as last hepatitis c test and that's a very simple thing that if you can check that you can then say okay you do another one I'll give you it if you can't get that information it's more difficult so I think data sharing but in my experience have been a very big issue certainly the Glasgow agb has completely bought into it there there was massive commissioning in terms of third sector provision for for individuals and what they have done they have pulled everything together so there's now a head that actually is in charge of addiction homelessness mental health so we are we are trying to work together better data sharing indeed has been an issue the Glasgow needle provision service has actually been cutting out testing but again all that data sits in their nests so we we know if we look there what the situation is we look we know if there's there what the situation is right now in NHS Scotland through the MRC we're going to carry out a big study that is going to link various data sets between the addiction services the homelessness the mental health so the results won't be available until 2022 but it's really exciting because for the first time we're going to have a clear view what actually other needs and what's happening in this population but in the meanwhile what I can see is that there is there is the right direction of travel by getting all together but we'll need the money to deliver and address what the users truly need because just us working together without taking the users is not going to get us anyway so I'm assuming that you know which integrated joint boards are performing really well and the ones that might need a wee bit of help but that might be something to explore maybe like away from away from today in a separate type of engagement. Certainly an important question. David Stewart. Thank you, Gwyr. Can I just reinforce the point about information sharing? I think that that's certainly a theme that came through the evidence for example GP's not been able to share with pharmacists or third sector groups but it's interesting in the evidence that the information commissioner suggested there was more leeway than is often thought and also I think it's important to know that there is obviously new data protection regulations that are coming to force which also affect our thought processes on this issue. I think that that's why I've been interested in our comments yesterday David Goldberg. I think from a national level and looking back at national networks and leadership over decades actually I mean in this area third sector being fantastic integration there that from national perspective absolutely amazing and hugely important. Local authorities have been really difficult. I mean I can hardly remember anyone representing local authorities at a national level being on our committees and our networks and possibly not for the want of maybe it was a it was a just a logistical sort of issue who would actually be the representative. There are so many local authorities but believe you me it has been a real struggle and in the action plan there was an action around local authorities to get local authorities embedded in there and it was one of the few actions I think we failed on. So I do think this is a problem of course we've got the new public health Scotland agency just over the horizon and one of the things there is to try and make sure that it's integrated but certainly my experience so far is that this has been a problem area. Are there other comments on I think these are important questions? Yes, Peter. It's just when I pick up on something David was saying there about the various networks and things in the framework and also talking about the third sector there was initially a third sector network meeting that happened maybe four times a year now there hasn't been one for three four years so who's up there representing patients and their views I've got no idea and also the information doesn't come back from those who do represent us at these meetings back to the third sector so I just don't know the reason for that. Okay there's a question that perhaps other witnesses might be in a position to assist with Dave Goldberg. Just to say that there are other national networks and I mean John chaired the hepatitis clinical leads network yesterday had clinical leads from throughout Scotland all the health boards and in there was hepatitis Scotland representing the third sector and the same applies to other national networks with HIV Scotland well integrated but Petra is right in that there was a network specifically for the third sector and from my understanding Petra it was a very difficult one to to run and it was to do with the dynamics within because I mean I don't I don't know the I don't know the full story but if the third sector said to health protection Scotland which runs the all the networks in relationship to the framework if it said look we want this third sector back up and running we will do that there is absolutely no problem but it's over to the third sector to actually push for that. It's just that nobody had actually communicated to me that it had stopped even. Well I think we can I think we can claim an early achievement for this committee meeting then if we can see progress on that ask moving forward. It's just in terms of networks I think the gap I've experienced in the last couple of years is really around opiate substitution therapy and harm reduction and either a prevention non-sexual prevention part of this the hepatitis C network that doesn't really link into the opiate substitution therapy part the national organization for that pads to me as somebody in the boards appears rather obscure and maybe a bit exclusive because I'm not clear the representation of all constituencies that's there such as third sector you know frontline workers local authority and so on so I feel that's a gap in terms of joint working for me at the board level. Dr Criton and then George Saliotis. The the third sector is certainly represented on the ADPs the ones that work well beyond that I cannot comment. George. On a policy level because that's where HKB Scotland operates we have various interactions with IJBs the the best example that we've had recently is with Glasgow looking at the closure of the clean needle program and we had fantastic exchanges with the local authority there in Glasgow but of course this for me really points to the challenges that you have looking at the prevention agenda because to get prevention right you need to get treatment right because it's almost the same thing for both hepatitis C and HIV but when the focus is only prevention that's where we've had challenges in engagement because how does it seem relevant perhaps to local authorities who have many other things to do I think David you pointed to the challenge that we have which is representation is a real challenge because there's so many people so when there's a challenge something specific that needs to be done we have really good exchanges but in general when we're just looking for policy brainstorming that's where we do have some challenges I also just want to add something on confidentiality and information sharing one of the main issues that people with HIV raise when they ring HIV Scotland with a concern is how the information is being dealt with and so we've published guidelines on this we've done a lot of work on this because it's a priority issue and just as an example we often get a call that might be someone saying my GP has just found out that I have HIV how can I get her to take that off of her database so people's control of their information is at a whole new level of concern when it comes to HIV and I think that's really important to keep in mind when looking at information sharing thank you very much any other comments on that I think I think that the whole general issue around whether ijbs are helping or hindering which emory is I think we've heard some answers to it but I think also some useful suggestions about renewing some of the contact that's there across sectors David Stewart I think you had one final question thank you a computer could I just ask about future strategy for sexual health what do the panellists think about are we adapting enough to changes in society for example social media and use psychiatric substance or sexual health folder people is that already incorporated in a strategy or do we need to adjust for the future who would like to take on a couple of a couple of important questions there about some of the issues that have arisen recently and how well prepared we are for dealing with those I think that the sexual health and bpv programme is well set up and it empowers a lot of people within the boards and the adps to do what they think is necessary and so from my perspective on losing we've identified actually people aging people with hiv as an issue through the one of the groups which actually is chaired by Waverly care so it's got a good role for third sector there and we're doing some work to try and identify what those needs are and how we should change the services so I think probably across all the boards there is an opportunity to take on that work where you think it's necessary thank you very much Amelia Crouton in terms of mentioning social media the the Glasgow sexual health health improvement have been using the social media for a long time so they have targeted campaigns aimed at particular groups more and more we are moving towards understanding which groups of society use different media so the young people we know that the only way to get in touch with them nowadays is use the appropriate social media but also there were a lot of successful campaigns aimed at men who have sex with men there will be the group that actually has been the subject of debate this morning and that's the socially excluded with multiple social issues that will be completely out with the social media or any other interactions so we need to be mindful of them the older people again and the how we tackle the living longer we need to be savvy about that because there's always a need to keep up to date and update our messages to the needs of individuals but yes we are considering all sections of society we need to prioritize our resources and adapt the communication to them in terms of the wider drugs Glasgow again through the ADP has had a big event last summer looking at the issues around particularly new drugs that we're not called psychotrops anymore because it's beyond psychotrops and thinking how the different things come together so it's drugs sex alcohol multiple risks behaviors and how we actually segment different individuals and bring a harm reduction approach to tackling with these issues. I think it was Jenny you pointed out that it was a report in sex education wasn't it 2012 2012 and that was just a sort of one off and if you look at the data the frameworks data portal you find really strong data on infection HEPCHIV the STI is really really strong data so we know what's happening out there and then when you actually get to I mean there are five outcomes one to three seem absolute are fine outcomes four and five which are the sexual health outcomes there's just no infrastructure there and what I mean by that no data at a national sort of level which is I mean there may be data at a local level and I think there you know that some health boards will have will have the information but a coordinated approach to monitoring doesn't exist and also there's no coordination sort of infrastructure there's no that that can deal with this and that goes back to my point that my earlier point about sort of the leadership sort of territory I think this is something we really need to address okay thank you very much I'm looking around to see if I have any colleagues anxious to have one last question but if not can I thank the witnesses very much for your attendance this morning it's been an extremely instructive session we will consider it in some detail later on and well I will now briefly suspend the meeting to allow witnesses to this meeting of the health and sport committee our third item on the agenda today is consideration of petition PE 1611 in the name of Angela Hamilton on mental health in scotland members will be aware that we considered this at previous sessions and considered it as part of the work the committee undertook on mental health and the previous work that the committee did included writing to Sir Harry Burns in his role as the chair of the review into targets and indicators to make him aware of the petition and its request to reduce mental health weight in times and also of course we have heard from the Scottish government on their mental health strategy members will have seen the paper from the clerks which invites us to consider whether to close the petition in light of the commitment made by the Scottish government in its mental health strategy to a change of approach to the development and to the development of a system of indicators for mental health provision can I invite any comments from members and ask if that is how you are minded to proceed allison yes I suppose convener I'm not entirely clear on whether or not the government's refreshed strategy and Sir Harry Burns work have answered the petitioner Sir Harry Burns review simply said that waiting time targets should be subject to clinical prioritisation and his review hasn't called for any change to those targets and I'm not entirely clear that the government the government is obviously increasing the level of investment it's spoken about having 800 more workers and its commitments include a change of approach to the development of a system of indicators for mental health prioritisation I'm not clear that that's going to impact on waiting times as yet that's that's my concern about closing it I'm not entirely sure that it's being addressed elsewhere understood Alex I share Alex Johnson's concern about closing this prematurely I think that whilst the rhetoric from government and indeed tying in as it did with the review of targets by Sir Harry Burns is welcome I think we need to keep a watching brief on this I think the petition still stands we are not reducing mental health waiting times if anything they are going traveling north and I think for example in the budget you know I raised this at the last committee meeting that £17 million is certainly welcome additional spend but it's trying to do rather a lot at the same time it's going to pay for that initial investment towards that 800 members of staff I reminded committee that 800 members of staff will cost you £20 million a year and yet still also deliver a quote unquote transformation in child and adolescent mental health I'm not entirely convinced that it will I hope to be proven wrong but I would be very reluctant to close this petition until we see some tangible progress against these waiting times the direction of travel is very welcome I think all the rhetoric is very positive but I think before you can close the petition you'd have to have some sort of indication of outcome yeah I think from my perspective I would rather as is considered have a bit more of a watching brief prior to so that we understand that the direction of travel is actually being adhered to and is actually having some sort of impact so I would be reluctant to have it close at this point I mean the petition specifically makes reference to reducing the mental health waiting time target from 18 weeks to 14 weeks you know for adult therapies you know the government I would imagine are not going to do that therefore should we keep I just wonder whether if that's not going to happen if the government have responded to saying what they are doing which is to try and improve the outcomes you know they're existing already with regard to the targets we already have harry burns obviously suggested maintaining the targets as they are currently not making any changes to them 12 weeks for your child and adolescent mental health services and as we know that five health boards including five are not meeting that 18 week target are we not better to try and say hang on a second and to try and hold the government to account on the current numbers which they are not meeting so I think there's a judgment here about how we proceed because clearly I think members have indicated that the what the responses on this area have been broadly positive but not have not yet reached the point of decision but there is a there is a judgment on whether I think everyone would agree with the point that we want to keep the government's propositions on mental health treatment and treatment times under review I think the only question is whether this petition which is somewhat dated because of the development since it was submitted whether this is the right vehicle or whether we should close this petition and look forward to finding other means for maintaining that on-going review in the months ahead Alex I think Jenny Gilruth made a very good point about the fact that we're not achieving the 18 week target so let's focus on that and that that's a fair point to make I think though that this petition represents a reflection of public expectation about where they would like to drive this agenda still further they throw our metaphorical cap over the wall as it is and I think that we are we do well not to lose sight of that and be reminded of what the public would like to see in respect of these waiting times irrespective of the fact that we're not even meeting the government set waiting times I think that that's even all the more reason to hold on to this. Are there other views? I would just like to point out a previous letter from the committee to the minister the committee said that we don't make a recommendation on reduction to 12 weeks as we think the target needs a fundamental rethink I'm not entirely sure that that's happened however we've also said as a committee we cannot see the justification for a continuation of different waiting time targets between mental and physical health conditions I suppose I'm reluctant to close it in case you know it's just seen as we accept the current situation. The fact that we aren't meeting the current waiting times is I'm sure it's a huge concern to everyone sitting around this table you know I don't think any young person having to wait for the weeks they're being asked to currently is good enough and clearly I think most of us would agree that being seen within 12 weeks is not exactly a speedy service so probably at the moment I would be hesitant to close it. The issue that I've got is obviously if you're going to do this stuff targets and indicators you need to do it in a structured coherent fashion you can just go picking this one picking that one based on whatever petition comes in that day and we've kind of gone through that process and maybe we need that process to get more ways to run in terms of what targets and indicators should be there but I think that's the format we do that rather than focus fine and random stuff and grab 100 of these things on any old indicator and we'll be sat here all day saying should it be this, should it be that, should it be the other. Emma, followed by Brian. I mean I'm aware that NHS Frees and Galloway are 95 per cent meeting their CAMHS targets so they're actually doing really well so I think that there are people that need to perform better, there's people that are doing okay and I am not sure that keeping a petition open like this is the way to proceed to hold the Government to account. I think that Ivan makes a point about there could be lots of petitions looking at targets but we've already been flagged about looking at targets and we're not meeting the targets already so I'm not sure that this is the best way to proceed but I still think that we need to keep an eye out on a process for analysing the information. Ivan McKay's point, I think that when you look at petitions the reducing of the target times is one part of that petition and it's probably the part that I'm least engaged in to be quite honest because we're not hitting the original targets but I think for me it's more an understanding or getting some sort of feel that the direction of travel that the response to the petition has had from the Government and agencies is actually becoming to fruition in that we're moving in the right general direction. I think that for that reason particularly I'm kind of hesitant to let it go. I just want to see that there's been a lot of really positive indications from the Government and welcome but I would like to see some sort of movement. I hear there are clearly different views around the table. I guess the difficult or the question I would put back to members is if we don't close this petition what else do we need to do with it because it seems to me that this petition as a vehicle for raising questions has been well used and has kept allowed the committee to keep a focus on this issue for some 16 months which I think is credit to the petitioner and the petitioner but I wonder if there is anything further to be done with this petition as opposed to further steps to hold the Government to account on its strategy and on the priorities that it's going to set in the period ahead. Alex? I think that that poses a wider question convener to the committee and to the wider Parliament about the use and life of petitions. The thing that I'm struck by is I think a point that Alison Johnstone made to say that to close it now almost either is an admission of defeat that it is unachievable or that we feel that we have done all that we believe possible to do in this area. I'm yet to hear an argument from around the table about what the negative consequence of keeping this petition open are. If we agree as a committee to revisit it in a year's time to benchmark progress against it and if we're closer to achieving the aims of petition then perhaps I would welcome the opportunity to close this petition as a sign that we were, as a nation, doing something tangible to close that gap that the petitions are about. We're not there yet, so I don't see the cost of keeping it open and I think it's important to, as a demonstration of will, that we don't think that this might be a progress made. Yeah, I mean I think your point is a valid one in the sense that there is no negative consequence. I think that the only negative is the sense that I have that this is a petition that was raised before the Burns review and before the strategy was published, and therefore I'm not sure it's the most useful basis on which the committee can have future consideration of mental health strategy. But of itself keeping a petition open does no harm, but as time proceeds and as those things roll out, the petition will become less and less related to the circumstances that we currently have. Emma. As we continue to hear from the NHS boards about their performance directly and I'm sure we'll have Minister Maureen Watt in front of us in the future as well so that she can directly answer about targets. I agree about that there is no negative issue around keeping it open, but what is the best process then as we are assessing mental health, physical health, health and wellbeing, it's all part of what we've heard this morning. I think we're coming close to a consensus. Alison, did you have a last comment? Well you know here we have someone who's gone to the trouble to raise this with the Parliament and I think I'm not entirely sure how the Government has said that they'll develop new mental health indicators, but I can't see how developing that new system of indicators relates to any clear commitment to change these targets. And you know, Sir Harry Burn's review hasn't, it hasn't called for this, so I think I would like the committee to have more information on what the Government do intend to do. You know, will those new indicators impact on those targets? At least then we'd be able to answer the petitioner more clearly instead of just closing it. In light of what members have said, I would suggest that we do not close the petition today, but that we do await developments over the development of the indicator. I don't think that there's any great advantage in getting ahead of ourselves on that. Let's see what develops and what is produced, and then ask those questions, which I think we do have to ask. In any case, Alex's suggestion that we use this as a benchmark to return to in January 2019 if we aren't satisfied that progress has been made by then seems a reasonable one as a benchmarking exercise at that time. Miles? I would like to make a point on that. One of point three with regard to a review, a progress review in 2022, I think that was something I was specifically concerned about, given the fact that, yes, it will be halfway through a 10-year strategy, but there are already issues being highlighted to MSPs about the Government's current strategy, so I think that that should form part of our discussion as well whether or not we can see an earlier progress review to make sure that we're maximising its effectiveness. Okay, that's helpful. I think that if that's agreed around the table, then we'll proceed on that basis and we will continue to keep a working eye on all of these matters. Thank you very much. That concludes the public session of the committee, so we will now move into private session.