 Mirele commemorates everyone. Welcome to the second meeting of the health, social care and support committee in 2023. I have not received any apologies for today's meeting and the first item of today's agenda is to decide whether to take item 5 in private. I haveio there an apology other than the first item in private. I should say that the convener has course given apologies. Given that I am convening Felly, rydyn ni'n ddwylliant, ac rydyn ni'n ddwych i'r ffordd i'r five i gael. Felly, mae'r next item on our agenda is an oral evidence session with the Cabinet Secretary for Health and Social Care on three public petitions, which are PE1845, PE1890 and PE1924. The petitions all relate to rural healthcare, and I welcome to committee this morning Hamza morning, I'm the use of the Cabinet Secretary for Health and Social Care, Susan Gallacher, the Deputy Director of Primary Care Strategy and Capability, Sir Louis Ritchie, Professional Advisor and Dr Gregor Smith, the chief medical officer at all from the Scottish Government. The Cabinet Secretary will make an opening statement and then we'll move to questions. Thank you so much, convener, and thank you for being so accommodating with my time. I'm grateful for the committee shifting this slightly to help me with some childcare issues. I was having some very grateful for you being so accommodating to me. I'm also grateful for the opportunity to be here today to respond to the committee on questions relating to the public petitions that will be discussed today. Let me begin perhaps once again, as I did last week, by restating and reiterating the fact that we are currently experiencing extreme pressures within our health service. That is, I think, by any estimation and has been the most challenging winter that the NHS right across Scotland and indeed across the UK that we've ever faced. Our NHS and its committed workforce is facing a perfect storm of intense pressures, which are leading to difficulty, they're leading to disruption and delay right across the service, including, of course, in remote and rural communities who often face their own significant challenges and many of them I suspect we will touch upon in the course of today's discussion. As I outlined in Parliament last week, we've clearly advised health boards to exercise their own judgment in relation to their own localities and what action is necessary to overcome, at least mitigate, some of the challenges they're experiencing. I'm absolutely aware, as I say, of the challenges facing rural Scotland when it comes to healthcare having visited all of our boards, but spent a significant amount of time in our health boards that have remote, rural and indeed island communities within them. I'm determined to ensure that our remote and rural areas are not left behind as we continue to invest and reform our health and social care systems. Community, I expect the NHS boards that serve remote and rural settings to take account of the particular needs of their communities. Ensuring services are developed in a flexible and innovative way, recognising local population concerns and, of course, those significant geographical challenges. A blanket approach for a country is geographically diverse, as ours is simply not appropriate. Frontline workers are, of course, the absolute foundation of our health and social care services. We've committed to growing that foundation and overall staffing levels have increased by almost 3,000 permanent whole-time equivalent roles in the past year. That builds on our strong track record of delivering 10 years of consecutive growth, almost 30,000 additional whole-time equivalent staff working in NHS Scotland compared to 2006, around about 28,900. We're making nearly £8 million of funding available to boards to support the recruitment of up to 750 nurses, midwives and AHPs from overseas this winter. That will, of course, include boards with remote and rural localities. We're creating opportunities for our initial 250 band for assistant practitioners across acute primary care and mental health. We continue to expand the number of trainee doctor posts in line with medical workforce modelling. 725 additional training posts have been created since 2014, including 152, which I recently agreed and will be recruited in 2023. We know the importance and, again, I'm certain, committee will discuss the importance of training posts being available in remote and rural health boards. I recognise that GPs in remote and rural areas also, of course, have very distinct challenges. That's why we've invested £7 million of funding since 2019 to take forward a range of initiatives to support rural general practice, which includes support for recruitment and retention. That includes a golden hello scheme to attract new rural GPs, a £20,000 bursary to recruit and retain GPs, GP trainees in hard-to-fill locations, and, of course, Scotland's first graduate entry medical programme Scotland provides a graduate entry medical degree with a rural focus and a pilot scheme to recruit experienced GPs to provide support for rural practices. The father's programme has seen 52 students graduating—in fact, I think that the CMO was at that graduation—allowing them to progress to foundation year one posts. We're also supporting a recruitment campaign. Many committee members will have heard of it, Rediscover the Joy, which aims to recruit experienced GPs to provide support for remote and rural practices. As we go into committee, I'm happy to give some of the detail of how that particular programme has assisted. NHS Education Scotland has also developed a credential in remote and rural healthcare for doctors that recognises the very unique skills that are required to work in those challenging regions and provides a route for upskilling in those environments. We're working very closely with NHS Education Scotland to scope a national centre for excellence for remote and rural health and social care. Again, a piece of work, Sir Louis Ritchie, was absolutely involved and a bit leading. I'm grateful for all the work done in this regard. It will have an initial focus on primary care, but I imagine that it will be of interest to those right across health and social care. The centre will be a resource that boards and health and social care partnerships will be able to utilise in support of the responsibilities for providing rural health and social care. Our aim is that the centre will identify, celebrate but, importantly, pull together the many examples of innovative work already going on and promote excellence to address those long-standing issues, particularly in relation to recruitment and retention in remote and rural areas. We remain committed to growing our nursing workforce in remote and rural areas and look forward to welcoming new pre-registration nurses to the University of Highlands and Islands in 23-24 academic year. Since the programme was established in 2017, we've seen a fantastic increase of 34 per cent on the intake. While we're committed to investing in reforming the NHS and social care systems nationally, we're fully aware of the challenges of rural health care and we're responding to them. Women's health is a key priority for this Government, which is why Scotland was the first country in the UK to publish a women's health plan in August 2021. Our ambition is for Scotland, it is for Scotland where health outcomes are equitable across the population so that all women, regardless of where they live, enjoy the best possible health throughout their lives. There has been substantial progress since the publication of the women's health plan. There is now a specialist menopause service in every mainland health board and a buddy support system in place for those island health boards. We've initiated new research on endometriosis, launched a new women's health platform on NHS Inform, and we've increased access to bridging contraception in community pharmacies, but of course there's still much to do. I hope that those are important welcome first steps. While a formal review of NHS Highlands gynaecological services is under way, the board has set up additional capacity for both outpatient and theatre treatment. That will provide much-needed capacity across Keith Ness General Hospital, Belford General Hospital, Lawson Memorial Hospital and Regmo Hospital. In conclusion, I thank our exceptional health and social care staff who make such an incredible contribution to keeping us safe, especially under the current challenging conditions and especially where those challenges can be exacerbated by remote and rural geography. I'm grateful also to the petitioners for taking the time to bring those petitions to our Parliament. Of course, I'm happy to take questions on those matters and any others that you wish to ask this morning. Thank you very much. I'm very grateful to the cabinet secretary for his opening statement, helping to set the scene for many of our questions. I think I'll begin this morning just with a couple of broad questions and then we'll move to colleagues as we go along. Obviously, the petitioners have outlined the various challenges that exist in terms of geography, access to services, availability of staff and much of that that you have touched on, cabinet secretary. I suppose that if we think about the wider structural challenges within how the NHS is set up and operates in many of those communities, has there been any thinking about structures and how the NHS operates at board level in many of those communities? Do we need to look at, for example, how those boards operate? Do we need to look at devolving more power down into local communities? Has there been conversations around that? A lot of what the petitioners have asked for is a lot of that decision making perhaps to be more localised as well, so I don't know if there's a comment you want to make on that. I think that it's an excellent question. I'll often go to a remote and rural health board and let's just take an example, the one that probably covers the largest geographical areas of the NHS Highland. Of course, as you know, it's convenient that it also covers Agailin butte, as well as North Island. I will often go to either North Island or Agailin butte, and they will say, well, the challenge is here, there may be some similarities with what other parts of the NHS that they are facing, but we also have very, very unique challenges in Agailin butte and particularly the islands, for example, that they have within their geography. So absolutely a conversation about devolving further, and that's why when I visited, let's just take chat, for example, the campaign group around Caithness hospital. It was very clear to me that they felt, and it came across very strongly, that there was a disconnect between the community in Caithness and what they were saying was coming from the health board management level. That was a message that they communicated to me and obviously I took back to the board, and now I'm pleased to say that there's regular meetings that are scheduled and diary between chat and that particular campaign group and health board. So absolutely, as far as our health boards absolutely can devolve some of that, if it's not direct decision making, certainly really important to have that engagement at a local level. Again, that is important actually both for urban but I would say even more important for remote rural island health boards. Where I would perhaps draw a line at this stage is that we're not looking at wholesale structural review of health boards. Given all the other pressures that we're facing, we're not talking about breaking up health boards into smaller health boards, certainly not at this stage. We have the structure in place that we have at the moment. Disrupting that in its entirety at this stage would probably take a lot of focus away from the significant challenges that we're facing. All of that being said of course, we have the NCS bill going through Parliament and I know that every member around this committee table knows that healthcare and social care are so integrated and therefore there is certainly a conversation to be had about the interaction between health and social care with the current system but certainly with a view to a national care service coming into play too. Thank you very much. I wonder if I could move on to a question around something you referenced which is the national centre for remote and rural health care and the work that's been done on that. I suppose that we'd be keen, I think, as a committee, to understand how our success is going to be measured in terms of that innovation. I think that it would be useful to have an update if we can on its development and where we are in terms of the progress with that and perhaps Sir Lewis may want to comment as well but I'll come to Cabinet Secretary first. I'll bring us Sir Lewis shortly. Again, it's a good question because essentially what we're asking the centre for excellence to do is we know that there's multiple good pieces of innovation going across a number of health boards in remote and rural Scotland and actually pulling together that work and doing that work more collaboratively might bring better return for those health boards and having the centre almost having that multiplying effect on that innovation and those innovation practices across remote and rural Scotland could be really helpful. As I say, Sir Lewis might be able to talk more about it because he was deeply involved in the idea of a centre for excellence. I think that sharing effective practice, sharing data, sharing that evidence, supporting boards to deliver a stronger collaborative response to some of those concerns which, by and far, the biggest concern that I hear from health boards in remote and rural locations is workforce, workforce, workforce recruitment and retention, which tends to be the biggest challenge. So I think that the centre for excellence can absolutely help in that regard. Where are we? Nes, National Education Scotland, have agreed to host and be the host for the centre. I think that makes sense given again their remit around education, around training, etc. It makes a natural fit for them. I suppose that the big question is about funding, which is an understandable question. As you know, convener, we are very much in discussions around the 23-24 budget. I am not pre-aimed the conclusion of that budgetary process, but I have asked for a proposal for how much the centre would require in 23-24 in order to make progress. I am still waiting for that information to come back from Nes, but I would expect it very, very shortly. I will consider that with an open mind, but if you do not mind, I will pass the solutions as they have been deeply involved in the centre. I thank the cabinet secretary and the convener. I might frame my initial response. The cabinet secretary mentioned the enormity of the challenges in remote and rural areas, and I am reminded that 70 per cent of the Scottish population stay in remote and rural areas. The land mass of that is about 98 per cent of Scotland, and that brings unique challenges clearly to service delivery, both retention and recruitment of staff and the fulfilment of equitable care across Scotland. The centre was born out of one of 12 recommendations that we made to the Scottish Government in relation to how to improve the delivery of the 2018 GP contract in remote and rural areas, and that looked at the future of contractual arrangements and how they could be modified for the better going forward. It looked at recruitment and retention. It looked at infrastructure, which clearly is important, both physical infrastructure and also delivery infrastructure. One of our recommendations in that regard was that there is considerable scope for digital innovation going forward. As to the centre itself, I would use three summary words if I may. One is the centre should be a centre of excellence for education, it should be a centre of excellence for innovation and also evaluation. Too often in the past we have implemented models in not one of the remote and rural areas, but across Scotland, where we have not done the due diligence of evaluating the benefits and costs of these models. If we get this centre in its best position, I would expect the centre not only to benefit remote and rural communities within Scotland, but also for it to have an international profile so that others can learn from us and the good things that we do in Scotland. I heard a lot about recruitment and retention, staff and those are all very important when it comes to our rural areas. I would like to know directly the impact of the £65 million cut to the GP budget and how that is affecting primary care in rural areas, which is already struggling more than in the central belt. Difficult to evaluate because we are obviously in the midst of the current financial year, but Dr Goharry will know that we took a very difficult decision in the EBR largely down to UK Government's mismanagement of the economy, meaning that my budget was worth £650 million less than when it was set last December. Obviously, on top of that, we have put forward our record pay deal, 7.5 per cent, which is far greater than any other country in the UK. It has put forward for its NHS staff and obviously means that Scotland currently is the only country not experiencing nursing or, indeed, any NHS strikes this winter. It is a really difficult decision that we had to make because of decisions that we have taken around the workforce, because of the mismanagement of the economy. That means £400 million having to be re-profiled. No easy decisions in that. Mental health, primary care and social care are not areas that any health secretary I suspect in the world looks to try to make savings from. The impact and the full impact of those savings, whether it is in primary care, social care or mental health, will only be realised, I suspect, as we get towards the very end of the financial year. Fair to say, we have been working closely with our GP services to see what we can do—not just GP services, everybody in primary care to see what we can do to try to mitigate the impact. I suspect that one of the biggest areas of concern that was highlighted by the BMA in the response to the re-profiling of funds was around the sustainability funding. I am keen to try to do this next financial year in the year 2023-24 to ensure that we do not lose focus of the increase that we have seen in multidisciplinary team staffing, which has helped in all GP practices, whether it is urban or rural, but there has been a significant benefit for remote rural GP practices in relation to spreading that workload, where it is a bit more difficult to recruit and retain GPs, being able to recruit more of the multidisciplinary staffing, the advanced nurse practitioners, the physios, et cetera, the pharmacists. All of that can make a significant, significant difference, but I am not going to sit here and pretend to you that a cut in primary care of the scale that we have made will not have an impact. It is just about evaluating some of that impact, but ensuring that we mitigate it as best we possibly can in 2023-24. With that answer, we are also missing the fact that vacancies are on an upward trend. If we look at the AHP vacancies, for example, 1,252 whole-time equivalents are required. We look at medical and dental, 392 whole-time equivalents are required. Nursing midwifery, 6,319 whole-time equivalents are required. This is an upward trend that happened before the cuts. My real concern here is that we are going to see rural and deprived areas really struggle when it comes to their primary care services. This is something that is going to affect them more than it will be with the central belt. I am not hearing a solution to help. Let me try to give you a few solutions if I can. Dotac Annie is right. Workforce and recruitment plus retention of that workforce is exceptionally important. A few things that we are trying to do first and foremost, we have a good record on recruitment and staffing. I referenced some of that in my opening statement, but I am not in disagreement with Sandesh Gohani that the vacancies are far too high. I look at nursing and midwifery, the AHPs, wherever the vacancy rate is, particularly around nursing and midwifery. That is far too high, so we have to work to try to resolve that. I have often said in the parliamentary chamber that we have to look at recruitment and retention, although interlinked is looking at them as separate work streams. There is no point filling the leaky bucket, so our recruitment record is good. We have to make sure that our retention record is just as good. We start, as I say, from a strong position, that 28,900, increase in staffing since 2006, more GPs than head than anywhere else in the UK, higher nurses per head than other parts of the UK. What are we trying to do about it? You talked about solutions. I always think about recruitment, and I will come to retention shortly as having a three-pronged approach. One is the pipeline, so we are making sure that our pipeline of graduates coming through the system is going to match what our demand is for the future. We have made, for example, the medical workforce. We have made commitments in fulfilling those commitments to increase them 100 per annum over the course of the parliamentary term, so 500 by the end of the parliamentary term so far, not just meeting, but exceeding 10 consecutive years of growth that I mentioned in terms of the numbers. Pipeline is one. By domestic recruitment, across the UK, we have a very proactive campaign under way to try to recruit GPs, particularly with a campaign focus on remote and rural Scotland from other parts of the UK. I make no apologies for that. Scotland is a very attractive place. I think that remote and rural parts of Scotland are very attractive places to work in Scotland. The third is the international recruitment piece. I will ask about solutions. There is £8 million to try to recruit 750 nurses, midwives and the HPs. I am not the panacea. I will sit here and suggest that international recruitment is going to resolve all of the challenges that we face around workforce. However, as part of that three-pronged strategy, it can make a difference. Certainly, in my engagement with the remote and rural health boards, they believe that the international recruitment piece is one that we can absolutely get more advantage and we are currently getting particularly in remote and rural areas. The retention piece is a lot that we are doing and can do. I attended a nursing roundtable with the RCN. A couple of members are on this table. Gillian Mackay was certainly there. Gillian Mackay will remember that one of the comments that came from the RCN and the nurse was about retiring and being rehired. The inflexibility that existed meant that she was just going to leave the health service altogether, which was a huge loss. She had well over three decades of experience, so that was fed back to the chief nursing officer, who I am glad to work with. The RCN and others have got an updated retire and return policy in place, and it has been welcomed by much of the workforce. The REC scheme—again, it was a direct call from another trade union or professional body, the BMA, who had been calling for a recycling employer contribution scheme to be brought forward to deal with some of the pension incentives that are existing in the system. The REC scheme was very much in our gift, so we have devolved that to health boards. REC schemes have gone live in health boards across the country since the end of December. Obviously, there is more that can be done on pensions, and I welcome what the UK Government has done thus far, but the call from the BMA is for them to go even further and we support that call. I think that I have taken a fair bit of time and answer right enough, but I can speak to more that we are doing on the recruitment retention side and much of it geared towards helping our remote and rural health boards. Cabinet Secretary, it will be aware that I have written to him on a few occasions about specific issues in remote and rural Dumfries and Galloway, such as Strunrar. I really appreciate your responses, so thank you and thanks for being here today. I am interested in the centre of excellence for remote and rural health and social care. Sir Lewis, you talked about being education, innovation and obviously collaboration. I am interested in if there will be a role to help advocate for people who are in remote and rural areas, because those folk can access the self-help groups, the people that are in more urban areas. I know that people are engaging in using Zoom and all that to engage as well. Is there a role or a place in this agency where advocacy can be supported or delivered? I know that in Australia they have a rural commissioner for health as well. I am interested in that kind of aspects of the centre for excellence. If I may just reflect back on a comment that the cabinet secretary made earlier about rediscovering the joy, which is a scheme that has been able to promote 65 vacancies temporarily being filled in Scotland by GPs. I just wanted to flag that in the passing. As far as the centre is concerned, the exact nature of the centre is still being scoped out, and that has been done by NHS Education Scotland. My personal view is that the centre would not have a particular advocacy role. It would be involved in educational development, as you said earlier, in innovation and evaluation. That would be its prime concern. You also mentioned the rural health commissioner in Australia, which I flagged to the petitions committee as part of my response and written evidence when they asked about my views about the petition that they were considering. That post was established in 2017, and the first commissioner published a report in 2020. The particular role that that health commissioner has is one of advocacy in relation to service development and in relation to educational development. In terms of advocacy, a rural health commissioner, if considered, might be a post, an office that might be able to advocate for remote and rural matters. I am happy to add to that that the Government is in agreement with the position that the centre of excellence probably would not have an advocacy role given Sismith Nees and what the original thinking behind the centre has been. I do not think that it would fit into that advocacy role. In relation to the rural health commissioner, I think that it is an idea that is worthy of merit. We have obviously been focused on what the centre's core purpose will be, as opposed to the consideration of a rural health commissioner, but the idea, as Sir Lewis has already said, which you can see in a number of other countries, is certainly worthy of merit in consideration. However, the first and primary focus has to be getting the centre for excellence established and up and running. Advocacy role, just because for more than 20 years now we have been trying to look at cancer pathways in Stranraer, for instance. People go and get their radiotherapy. In Edinburgh, it is 140 miles compared to 87.2 to go to Glasgow. If we are looking at helping to support people to get their care closer to home, I realise that the south-east cancer network is where the people in Dumfries and Galloway go, but nowhere in Dumfries and Galloway is in the south-east of Scotland. How would we have opportunities to look at relocating the service for cancer pathways for people in Stranraer, for instance, to go to Glasgow instead of the 140 miles to Edinburgh? It is a valid question that I know you have raised before. Forgive me, I do not have the most up-to-date position, but I can see entirely the logic that MRPR is deploying in relation to Stranraer and feeling like it would make far more sense to be part of the west of Scotland cancer pathway. If MRPR does not mind what I will do, I will take a look at the latest position, because I had raised it with the health boards involved. I remember the response at the time that many patients could travel to Glasgow, but if that is clearly not the experience, I want to find out why. On that specific point, I will come back to our perhaps through the convener to Emma Harper in writing. On the more general point, as I say, the issue of a commissioner is worthy of exploration. I think that the difficulty would be given just the volume of correspondence that I get in my inbox. I think that it would be very difficult, even if we were to establish a commissioner, the expectation of that commissioner to then have to advocate for every single patient with every single challenge or issue that they have with the health service. We have obviously patient rights embedded within statute and guidance. We also have robust procedures in place to deal with complaints, but we probably just need to take a bit of time before we consider any further commissioner, advocacy or individual who will advocate, or indeed an organisation that we will advocate on patients' behalf. I know that Jeane Freeman has done work on this and basically ensuring that people are offered a choice because they might want to go to Edinburgh for radio therapy if they have family in Edinburgh and they can stay overnight with them. Choice is what Jeane Freeman was advocating for at that point. It is just on-going challenges in how to support patients and manage expectations, because I understand that sometimes people have to go to other centres that will deliver radio therapy, for instance, because there is no ability to do that in the new hospital in Dumfries, so I would appreciate some further follow-up. I will get you the latest position. Choice is only good if people are offered a choice. We will move on to questions on the wider involvement of service users from Carol Mawkin. I am very interested to explore the experiences of people in remote and rural areas and how they interact with services in this Government. They often repeat their commitment and engagement with service users and people with lived experience. There is a sense from the petition and other action groups that that does not happen particularly well. I wonder if the cabinet secretary could just speak a little bit about how he feels that is going on. I know that there is a responsibility on us to do that and that Health Improvement Scotland monitors that, but just how you feel in remote and rural areas and in relation to that petition, how you feel that engagement has gone? I am always of the opinion that you can never have too much engagement. Engagement is positive in visibility and it can be tricky. I know, for example, that I had last week a council meeting with the fantastic women's hub in North Highland and much to their annoyance—understandably so—because of the certain pressures of the parliamentary schedule that I had last week. There will always be times when that engagement can end up being disrupted for understandable reasons, but what frustrates me slightly—I will not mention any health board because it is an issue that all health boards need to be cognisant of—is that they can often feel like there is a disconnect between the health board management and health services and health provision locally on the ground. My instruction to all the health board chairs and chief executives is one for them to be visible in all the management, the board to be, senior management to be visible. Secondly, to ensure that that engagement is happening on a regular basis and not just engagement, but what can we do to make people feel like they are being heard but what proactive action can be taken in order to show and demonstrate that we are listening? We are not going to be able to do everything that everybody wants, that is just the nature of what we deal with. I would say that engagement has gone well, but there is certainly more to do and I would encourage boards to make the best use of technology. I know that it is not always possible to travel around the vast expanse of NHS Highland, for example, but there are many others. NHS Orkney, Shetland and many islands are not always possible to get everywhere all of the time, but making the best use of technology is certainly one of my instructions. I was going to come in at this point because I think that there are signs of some areas that are beginning to do this really well. If we take the example of the recent opening of the community hospital in Avymor and the community engagement that sat round about that involvement of the community both in the planning of how that would work, the services that would operate from it and continued thereafter with the service providers who operate from that. It then becomes almost what we would refer to as an anchor institution within that community, as a place where people can begin to coalesce, discuss their ideas and look for that wider community engagement. I think that that is a model for the future that we need to begin to exploit more and more particularly as we are bringing on some of those wonderful capital projects and to begin to have that act as the ffulcrum for that engagement that you are speaking about. As I said, Avymor is a very good example of how that has gone about. I think that it is only fair to ask directly about the petitioner's request for any agency in terms of engagement with service users just to find out exactly what the cabinet secretary's view on that is. I was very interested in the discussion that we had with Emma Harper on the rural commissioner which might be useful to discuss with the petitioners as well, but what is your view on that sort of agency? One thing, like everybody here on this table, is that the creation of agencies, new organisations and institutions is not something that we do lightly, partly because we do not want to clutter a landscape that you could argue already has a fair bit of bureaucracy around it. There are obviously financial resource implications that you have to be very alive and alert to, which we all are, particularly given current pressures. I am very invested and committed to the Centre for Excellence, which she has spoken about already. I think that that can help us with some of the real challenges that we are seeing in remote rural Scotland. I have already said that I do not think that it would have an advocacy role. I would not intend at this stage to create an agency that advocates for patients, although I would say that we have committed to a variety of commissioners already in this parliamentary session. She will know the work that we are doing around patient safety and patient safety commissioners in that respect. I know that that will be a disappointment to the petitioners. I would not at this stage be looking to create a new agency that particularly works around the advocacy piece, but I think that to help us with remote and rural healthcare, the Centre for Excellence can play a really critical role, but I will maybe pass this or lose it. I was indicating that he wanted to say that I am an advocate of public involvement in service provision. Those who receive services are entitled to shape them, in my view. In order to do that, you need to consult and meet with those who seek to shape services. I have been privileged to do a number of reviews, and always as part of the process of these reviews, I would have had a number of meetings both with those who provide the services, clinical colleagues and support colleagues who are sometimes lost sight of in that regard, but also the public as well. I am, as I say, a firm believer in advocacy at patient level, individual patient and public level, but also what I call and has been described as co-production, which is those who receive the service working with those who provide directly to make better services in localities across Scotland. We are going to move on now to further questions about accessibility of services and, indeed, regional and national planning. Sandesh Gohani will lead on this section. Thank you. I have a number of questions that I would like to ask, but I just want to pick up on something that the Cabinet Secretary said to me earlier. You mentioned that your budget was worth £650 million less, and I know that you have said this in the media and in chamber. Can I ask how you arrived at this figure? Are you happy and confident that it is correct? Yes. It is given to me and provided to me by some of my financial experts and analysts that we have within the Scottish Government. As I say, they will look at what the inflation level was when the budget was first set and what it is at the time we made that statement. Obviously, inflation fluctuates, but the figure that arrived at my inflation was at its peak. I am happy to provide more detail to Dr Gohani if he wishes, and we can give him the full analysis breakdown of that £650 million, which our budget is worthless. However, I am confident that it is correct. On to this. Have you ever personally driven the A96 between Elgin and Aberdeen? Yes. I have done it as well, and I did it on a sunny day. Imagine this. It is winter, it is cold and it is dark. Your pregnant partner is in the back screaming because it is time to go to hospital because your baby is due. Is that a position we really want to be in, given that Dr Gray's maternity consultant-led service is no longer running? Is that safe because we have had many times been told that people have given birth in labors? Yes. It is certainly not a situation that I would want to find my wife in. I certainly would not want to be in that situation myself if I was driving. My wife and she was pregnant on the A96, and that is the same for, and I am sure that we will touch on, Cathness 2. It would be the same for those in Cathness, and let us consider what the weather is like there just now and has been over the last few days. I would not like to be in that position. However, for Dr Gray's, it is important—it is worth me saying at this stage that I do not think that there is another local matter that I have spoken more about in the chamber in terms of ministerial statements or debates than Dr Gray's, so it gets rightly so significant attention for me as the cabinet secretary and rightly from the Government. I will not rehearse the latest position. I think that I may have been in the chamber in the last debate, if not he will have certainly appraised himself with the latest position. The safety of women and their unborn children has been at the centre of our thinking in relation to Dr Gray's. At the moment, we could not, in good conscience, have a consultant-led service tomorrow, because if we said that and we said that all women in Elgin and all women in Murray should be able to give birth to Dr Gray's from tomorrow, from next month, from later this year, we would be putting women at its serious harm, and there are unborn children at very serious harm. Part of that discussion can be understood if we look at the issue of what Ray Robertson's report on Dr Gray's referenced as low-risk electives. I am very aware that I am talking to a doctor who has far more clinical expertise than anybody around this committee table, I suspect. He and you will therefore be the first to understand that the term low-risk elective c-section can quickly turn into a high-risk elective c-section potential for bleeding, hemorrhaging and therefore needing blood transfusions and other such things. The facilities that Dr Gray's, for example, would not allow that to take place. Even what is termed a low-risk c-section, as it was in Ray Robertson's report, actually requires significant investment in the facilities and the workforce. We have a plan in place. As you know, NHS Grampian has recently come forward with a plan for the return of consultant-led medical services. Sooner than was previously predicted, I know that a number of people in the chamber have referenced the 10-year timescale, seven-year timescale, but he will know that the timescale brought forward by Grampian is far shorter than that and by the end of the parliamentary term. It is so positive in that sense, but I would not underestimate the challenge that it will take to get there. That is why the workforce and recruitment and retention issues will be at the core of this. The investment in the actual capital infrastructure, to me, is not the difficult part, is the recruitment and retention. Forgive me, it is a longer answer to the short question, but I do not feel that, at this stage, that if we were to instruct that all women in Murray should be giving birth in doctor grades, that would be a safe position for the women or, indeed, the unborn children at this stage, given the challenges around the workforce and the facilities at the moment that I have made closer to that, given his clinical expertise, if there is anything to add. I think that I was just going to emphasise that final point, which is about the assessment of the safety of the service just now that would be able to be provided in that way just now. I know from recent discussions that I have had with the medical director and with others in Grampian during a recent visit there that their intention is certainly to move forward as quickly as possible with the plans, but their assessment in the environment of risk that we find ourselves in now when we practice medicine is that they could not offer a service that they would be content to be able to pass in terms of their risk assessment. Can I ask? So, talking about accessibility of services, we unanimously passed the Transmaginal Mesh Bill. What progress have we had when it comes to women who are in rural areas throughout the country, but we are focusing on rural areas, that want to move and get their service from Glasgow, from somewhere else in the United Kingdom, or even from worldwide the United States. Where are we with that process and have women come through this? The member might be aware that we have a debate later on this afternoon committee debate on the mesh issue. It is focused on largely on hernia mesh, which I suspect will segue into the issue of Transmaginal Mesh. I can give an update, fuller update, if also the member wishes a written update, I am happy to provide that. He will know that we now have the contracts in place, both in terms of the contracts for other providers in England, such as the Spire Clinic in Dr Hashim, as well as the overseas contract with Dr Veronica's and the Missouri Clinic under way. I have to be really careful what I say here, because we do not want to get into the territory of patient identification, but it is fair to say that patients have travelled to those providers. I cannot tell you locality, but it began for patient identification, etc. I had a meeting with a number of women who have been affected by the Transmaginal Mesh issue, a number of them from remote areas. They made the point of telling me that there were definitely things that we could do to improve the service for them. I will not say which health board she was from, but it was from a remote rural health board who told me that she was perplexed that she was offered a 9am appointment in the complex mesh service in Glasgow. She was travelling many hundreds of miles and being offered a 9am appointment, to me that made no sense, either. Now the health board, in some circumstances, Sandish Grunhane will know that we will pick up the cost for travel and so on, but that is only in certain circumstances. Why make somebody even go through that? They are willing to travel, but they do not want to have to leave the house at 6am, or whatever else, to make sure that they get to the appointment on time. I have fed that back to the complex mesh service in Glasgow and I understand that that feedback is being taken on board, but I will regularly engage with the women who have been affected by Transmaginal Mesh and some of the campaign groups. If that is not being implemented on the ground, I would be pretty concerned, so there is definitely two weeks that we can make in that regard to support women who have been affected by remote and rural health boards. We come to supplementaries now, and there are a number, but I will start with Tess White. Cabinet Secretary, since June of last year, I have tried repeatedly to ask the Scottish Government when a women's health champion will be appointed. The Minister for Women's Health and even the First Minister has deployed every delaying tactic in the bulk. It has just been kicked down the road, the can has been kicked down the road, but the petition on the services in Caithness and Sutherland really does underscore why a women's health champion is so important to Scotland. Why is that not a priority for the Scottish Government? Can you say today when an appointment will be made? I would say to Tess White that we have tried to approach this issue whether it is the First Minister or whether it is Marie Todd or indeed myself. With as much openness and honesty and transparency, I do not share her cynical world view or certainly the view of the Government that we have been trying to kick this down the long grass or kick the can and so on and so forth. It may well be her characterisation, but it is certainly not the approach that we have taken. We have always said that we have wanted to get the right person appointed, so important, because we envisage this women's health champion being in place for a long period of time. We do not want to get the wrong person, and we understand also that the people who are and you can imagine the calibre of the people who have applied for this position are also people who have many other commitments, so we have got to be absolutely sure that the one that they are able to provide the time necessary for what I think is an exceptionally important role. There is also a discussion to be had about the time commitment involved and there are other commitments. Everybody that is applied and everybody that we have interviewed for this role is somebody of incredible stature, incredibly busy and has other commitments, so we have just got to work around that so that they understand what our expectation and all of this in this regard would be. The second thing that I would say is that the women's health champion is absolutely important, but it does not hamper our progress in the women's health plan. I could give you a whole range of initiatives that we have taken forward. I know that the women's health plan had 66 actions to it. I could give you a range of actions. We have already progressed and I think that I have already referenced some of them in my contribution, but I could give you a list of a number of actions. I will not do so all perhaps again if you want that further information. I am happy to write to you. I do not think that a women's health champion hampers us from making progress, but we are able to make progress. The very last point is the direct answer to your question. We would be hopeful within the Government of being able to make an announcement on the women's health champion within weeks, as opposed to months within weeks. We are very close to it. As I said, there are just some eyes that need dotted and some tees that need crossed with the right person. I think that we have an excellent women's health champion, potentially if we get this one over the line in place. That would be the intention to get it over the line in weeks, as opposed to months. Just a brief, it is related to Sandesh Gulhane's questions about Keith Nessan, Murray and Dr Gray. It is the same issue since Stranraer again. I hate to just go back on about it, but women are delivering their babies at the side of the road. There are real recruitment challenges for Dumfries and Galloway to find midwives and to have a midwife-led maternity unit at the Galloway community hospital. I am not advocating that we start doing emergency C sections as a former operating room nurse. I have been there in a rush taking babies out of people by crash section, so I am not advocating that we do that in Stranraer, for instance. I know Murray Todd visited Stranraer in October last year to help to engage with the local Galloway community hospital action group and then go to visit the hospital. I know that there are real challenges with midwifery-led units, and I would be interested in it. The cabinet secretary does not have to respond, obviously, today about an update on the work that is being taken forward with NHS Dumfries and Galloway and maternity services being reinstated back at Stranraer. I can provide a written update to Emma Harper on that specific issue. What I would say is that we are very, very alive and alert to the issue around midwives from remote rural Scotland, and she will know the act distance course that we are now running. That came on the back of engagement discussions with rural remote health boards. I was just trying to find the exact figure for Emma Harper, if I can. I think that my understanding is that the new students to the Short Midwifery programme that is running for its second year at Edinburgh Napier University allow students to fully qualify as midwives in just 20 months or a really good course. We will look at the nurses to midwifery. The nurses from remote and rural health boards that are enrolled in the distance learning course was 47 per cent, so almost half of the entire intake was from remote and rural health boards. It has now increased to almost two thirds, 65 per cent. 65 per cent of those students on the Short Midwifery course come from remote and rural health boards. That distance learning is obviously an advantage to them, so that they can remain within their boards. There is a lot that we are doing. That is just one example of what we are doing in relation to the nursing midwifery side of things. On Emma Harper's specific point, let me get her a written update again. I will come in via the convener on that. Obviously, the cabinet secretary shares my view that we should be trying to deliver services as locally as possible. Given that the cabinet secretary mentioned the Lawson Memorial hospital, for example, in Gullsby, it is not the newest building in the world. Having had family members who have had stints in it, it is a brilliant facility. However, how do we ensure that those buildings can keep up with the pace of technology that is being delivered in some of our bigger hospitals in the central belt, where it is appropriate, and how do we make sure that they are fit for services going forward? I will let him come in in just a second. It is fair to say that, in my session last week in front of committee, there was rightly a quite intense focus around the capital infrastructure and a good point to the investments that we have made. Dr Gregor Smith just mentioned that a couple of new hospitals have been built and opened last year, which I was very pleased to be a part of, so it is absolutely a place and a role for, frankly and locally, shiny new buildings that communities will always welcome. They are built to the best standard to accommodate the equipment, the technology, best access standards, etc., net zero ambitions, all of that. Clearly, there is a significant need for refurbishment of an NHS estate. Again, one of the things that might have been test-wide to reference last week was the significant refurbishment and backlog refurbishment that exists. The Government is committed to significant investment in that refurbishment, and that has got to not just be our large acute sites, although many of them need that refurbishment, but also some of those local community facilities. I was privileged to work in a community hospital for almost all of my Korean Peterhead. I also did a review at one point about them to try to improve their potential, and that includes technical innovation. I do think that it is probably time to have a look again at the utility of community hospitals in Scotland, particularly in relation to step down, step up rehabilitation, and the care of those who are in the final stages of their life, end-of-life care. That is all very important. I think that it needs to look at them again, I would suggest, not just about the infrastructure but about the role that they fulfil. I can jump in here slightly on the point that Sir Lewis makes. Many people recently, in the context of our social care challenges, have spoken about that issue, and the potential of going back towards a cottage hospital model in certain areas, or looking at the provision of step up and step down care in a more local sense. Is that something that you would be keen to see more of? I have often been asked about a number of cottage hospitals where we had to, unfortunately, take staff from during the height of the pandemic, and they had to go to larger acute sites. Is there merit in bringing them back on stream to help us with the social care challenges that we face? Actually, that was an issue that I raised with the chief officer on Dumfries and Galloway, in particular. Her response to me was very interesting indeed, which was that the staff that they have taken from particular cottage hospitals are able to offer more hours of care to more people doing care at home. Therefore, instead of being able to look after 10 people at a time, they are almost doubling that to many people that they are able to look after and provide care to, which is important, and of course provide that care to people in their homes. By the way, there is a real important role for cottage hospitals and they play an enormously important role in our health and social care services. I think that those decisions have to be made at a local level around where the balance of benefit is in terms of staffing, but also the care that those staff are able to provide. I think that both colleagues were supposed to come in. I agree with that. I think that we need to look at an amalgam or a pan-a-play of services. Indeed, hospital at home has emerged as a service that was not talked about or delivered much 10, 15 years ago, and now that is online in a way that it has not been in the past. The other point that I would make is that you do not need a new building to call it a community hospital. You could actually have dedicated beds within a nursing home where more advanced care is delivered than nursing home care, as we understand it. We need to think laterally about that and not just think in terms of buildings. Some of the points that I wanted to make here, but I think that it is important that we do not just simply revert to the models that we had of yesterday and bring them back, because practice has clearly moved on in the ways that, particularly multidisciplinary teams work together are very different now than even 20 years ago. Models such as hospital at home, which, as Lewis mentioned, is a really important aspect of the future that we deliver care across communities. Yes, there will always be a need for rural areas to have stepped up, stepped down beds, but I think that the hospital at home model working in particularly these multidisciplinary teams, where we blur what is a very artificial age between primary and secondary care, and have specialists working alongside community teams in that environment, is one for the future, which has an awful lot of benefits, both for the teams who are employed in number, but especially for the patients who are receiving the care. We are going to move on to questions now on the use of digital technology and questions from David Torrance. Thank you, convener, and good morning, Cabinet Secretary, and other witnesses. Digital technology, the pandemic, heightened the use of digital technology, so what impact has increased the use of digital service in remote rural areas? I'm going to roll on the questions at one conciously time, Cabinet Secretary. What are the potential benefits and risks of our alliance on digital services in rural areas? I'm obviously the pandemic necessitated some of not just the use, but the frankly explosion and some of the use of digital technology, and I think that's something that we'd want to retain where it's possible, so often members will speak to me about some of the challenges that they may be facing that are articulated to them from their constituents around access to local GP services. I've always maintained that the GP access should continue to remain a hybrid model. I think that people need to be seen face to face, they should absolutely be seen face to face, but I think that it's no bad thing at all to embed that use of technology, video, telephone and consultations. Again, he knows about the real growth near me, so he'll know that we have a digital strategy, a healthcare strategy, I'm sure that you've seen it, I've often referenced it. In the committee appearances, I commend that strategy to anybody who talks about some of the forward thinking that we're doing in relation to the use of digital tech. If I just take a most recent example, it's a very small scale example, but an important one is the launch of the NHS 24 app over the course of this winter. It's a minimum viable product, but it will be one that will grow and evolve as time goes on, and it can be another tool that we have in the toolbox to try to ensure that people get the right clear in the right place at the right time. I can go on for ages about the importance of digital tech. Clearly, it can make a big difference in remote and rural healthcare, and I can give you numerous examples of how we're deploying digital technology in remote and rural health settings. Speaking to campaign groups, a number of them have told me that that is significantly important to them. For anybody who needs to be seen face to face clinically, the expectation would be that they would be seen face to face. If that is not happening, then clearly I've got a concern if that is the case. On reliance of it, we're very cognisant of digital exclusion, and that's why, within our strategy, we clearly referenced that. We've got to make sure that there are alternatives available for those who are unable to connect digitally. Clearly, the number one priority for the Government is to make sure that everybody has appropriate connectivity across the country and, while that investment is being made, just to make sure that we have those alternatives to digital available. Both colleagues want to come back in with the convener. I think that we should look at digital innovation, not just in terms of service delivery, which I think is imperative. There are numerous examples. To quote one of Skylab and Portree, for example, I've been looking at how best to deliver care nearer to home. There is also the dimension of the learning environment. One of the things that we do know about remote and rural, and I go full circle back to our earlier discussion, we know that those who train and learn in rural and remote environments are more likely to stay there or return there to practice their disciplines. Again, digital innovation will be an enabler for that as well. Two points I would wish to make in this kind of area. The first is about the inclusiveness of the use of digital in the work, particularly with Scottish libraries. It's really interesting here in how you begin to create networks that support people to be able to use digital technologies to engage with clinical and care services more readily. It is one that is really promising. Throughout the course of realistic medicine, we have worked with the Scottish Libraries and Information Committee to try to develop those links to be able to provide people with trusted sources of information in that context so that they are able to participate in those kinds of concentrations using digital technology in a way that is much more productive for them. That's the first thing that I would say there. The second thing is that we probably shouldn't lose sight of the professional to professional supports and benefits that digital technology brings. Some of that might be about education and learning and about how you participate in those types of online courses or meetings in a way in which you are much more likely to feel again part of our community and less isolated, but also in the way that you seek professional advice. So again, during recent visits to Highland, I heard very clearly from GPs and from hospital consultants about the use of some of the professional to professional sources of information that they were now using around about particular individual patient episodes of care so that they could share information, ask questions, all of which was contained within the patient record in a very safe way and was able to then form an audit trail in the background there as well. Those are advances in technology and the use of technology that I think are very much to the benefit of patients and allow often referrals to be avoided because advice is sought in other ways. I wonder if Dr Gregor-Smith could give us more information on that and another time in writing because public libraries are community buildings that are well used and unusually central to community so it would be really interesting to hear about that. I would be delighted to know a little bit of the work that we are doing with SLIC in relation to that realistic medicine and the provision of it, as I said, trusted advice for people, not just in rural communities but right across Scotland. I think that the whole committee would appreciate that, Dr Smith. Thank you. We will now move to questions from Evelyn Tweed on capacity and resilience of services. Thanks, convener, and good morning Cabinet Secretary and panel. How do inter-pressures impact rural health boards differently to urban health boards? You have touched on that, but can they be predicted and can we plan for them? We always do our best to do that, so we will plan for winter, essentially, as soon as we have got through one winter. We will start the planning for the next winter. Of course, the remote and rural challenges can be quite significant, so let's take two aspects that have been central to our planning for winter and before winter extreme pressures that we were facing in the NHS. That is the whole systems approach that we take to both the front door and the back door of really busy acute sites. On the front door, what we try to do is reduce the tendencies. That is definitely having some purchase. We are definitely seeing that that is working. We will continue to see if we can reduce the tendencies even further. That is by ensuring that people get the right care at the right place at the right time, so getting access to other services, such as NHS 24, pharmacy first, general practice out-of-hours, etc. That, clearly from a remote and rural perspective, can be more challenging, because the neediest service might be further away from you. Therefore, if you do not have a car, or even if you have a car, it can be tricky. If you do not have a car, a couple of buses and so on, that can be more tricky. If I am not able to get there, then perhaps the safest option is to go to A&E, because you are worried about your own condition, or your family member's condition. That is one of the real challenges. Our colleagues in NHS health boards and remote and rural and island health boards, in particular, have been working really hard to try to make those services as accessible as possible. Some of that goes back to David Torrance's very good question on the use of digital, and NHS 24 being that service that anybody right across the country can get that clinical advice from. We have a number of clinical supervisors to provide excellent advice via NHS 24. The other is the back door. We know again one of the reasons why we are facing such significant pressure. This winter, again, it was pressure that we were facing before winter as well. It was the high levels of occupancy and the high levels of delayed discharge in the system. Again, if I look at social care, which is so important, critical for us to be able to discharge people who are clinically safe to be discharged, there is no doubt at all that when I look at the landscape of social care that those in remote and rural areas who are social care providers, both care at home and care home, are really struggling. There is a whole range of reasons for that. Often fuel costs, energy costs will be higher in remote, rural and island settings. Again, our local health boards will work with those care providers to see if there is anything that they can do to make adjustments, any additional support that they can give to assist with those particular challenges. To summarise absolutely important and vital and critical that we look at the unique challenges that remote, rural and island Scotland face when it comes to winter challenges. Absolutely is the answer to our first question, which is that there are remote, rural and island partners involved in that winter planning. Of course, I have just given our two examples and many more I could give where there are very unique challenges that face particular geographies in Scotland that we are very alive to alert to and trying to assist during what is a really difficult winter indeed. Are the long-term impacts of cancelling routine surgery understood? What are they and how can they be avoided or mitigated? I will pass a CMO shortly to add clinical expertise to the answer, but it is fair to say that they are well understood. One of the most difficult decisions taken in the pandemic was to pause elective care, and there is no doubt that doing so—somebody waiting list is not benign—people deteriorate and decondition. That is undoubtedly one of the factors of why we see people presenting sicker and with higher acuity, because we will have seen that deterioration and that deconditioning. I speak regularly to particularly orthopedic surgeons and the Scot network, as they are known. They will tell me often that there is simply no doubt that, given the difficult decisions, and I would say necessary decisions taken throughout the pandemic, that people on a waiting list—unfortunately, particularly long waits—are deteriorating and deconditioning is why, when I announced certain targets in the summer, it was focused on those long waits, because we know that those waiting are excessively long for elective care. There is no argument for me that they will come to harm. My goodness, speaking to those who have suffered from chronic pain, you can really understand from their perspective just how detrimental that has been to them, so I am not going to pretend otherwise. How do you mitigate it? I should say that, in the context of the winter pressures, everyone will be very aware of the three health boards that have taken decisions for time-limited pausing of elective care. I stress time-limited, because although those are local decisions, I have made it very clear to those health boards, and they understand this, and there is certainly no argument from them at all that clearly that measure should be in place for as little time as possible, given all the impacts that pausing elective care can have. It is also one of the reasons why we did not move the entire NHS to emergency footing. During the wind tunnel, there were some calls from some people to do that, and I can understand where those calls came from, but if we had moved the NHS to emergency footing as we did in the early days of the pandemic, then instead of three health boards pausing elective care, we would have had every single 14 territory health boards pausing elective care, potentially, if we had made that decision as we did in the early days of the pandemic. That would have had a severe impact on people right up and down the country. Forgive me, it is a fairly longer answer to a short question, but I hope that that gives you an understanding. I will bring in Dr Smith. The first thing that I want to say is that I agree with Cabinet Secretary entirely when he says that the decisions to pause some of those elective programme during the particularly the height of the response to the pandemic were absolutely necessary, and we should not forget just how stark the reality that we were facing at that time is, but undoubtedly it does have a knock-on impact on people. Clinicians across the country are seeing the results of both that impact and the on-going impact that it has for people. Cabinet Secretary has already covered some of the elements of that in terms of deconditioning and deterioration in conditions, but it goes beyond just the elective programme when people think of the work that was paused or displaced by the impact of the pandemic. It is not just about the surgical procedures that were lost during that time, but people responded differently to healthcare during that time. They did not seek treatment just as readily for all sorts of complex reasons that we begin to understand, and treatment was displaced because of the sheer volume of infectious illness that people dealt with. We will see the impact of that for some time yet. We are already starting to see the impact of that coming through with some chronic disease management. That all was foreseen, was anticipated and is now being very starkly realised in terms of some of the outcomes that we are seeing with people's long-term conditions as well. If I could say one thing for the future, it would be that this is an opportunity for all of us to redouble our efforts of focus in a relentless manner to address some of the secondary prevention initiatives that we have had in the past to ensure that not only are we regalvanising our approach to secondary prevention, but that we are ensuring that we do not leave anyone behind as well and that we are making sure that some of those groups that are often harder to reach are finding the ways of reaching them much more effectively and of being able to offer those approaches to them for the future. Can I ask you, Dr Smith? Are people actually coming forward now? You said that during the pandemic, for various reasons, they did not. Are they seeking the care that they need now? Just in terms of the relevance to the rurality and to those petitions, everyone, is it in a rural context? Across the country, we have certainly seen that there is a return to people seeking help, but I do not think that, at this moment in time, when you look at the activity levels that we are seeing in many areas, they have not reached pre-pandemic levels at this stage just yet. I am very conscious of the time that we have a number of questions to get through, so I am going to move straight into questions on workforce. We know that we have an ageing population in Scotland and we heard during our national care service visit to Dumfries and Galloway that they are seeing a higher number of people retiring there as well, which obviously increases pressure on certain areas of service. What work is under way to ensure that we are taking account in terms of workforce of this potential change of demographic, and particularly the potential skewing of demographic with people retiring to certain remote and rural locations? I have touched on some of that in a reference to the round table that we both attended in terms of the RCN, so I will not reiterate everything that I said about the return policy, but I am happy to provide detail to the community who can obviously share it with committee members. That came directly as a result of hearing nurses in particular saying that 20, 30 and 40 years in the profession are now thinking of leaving because of the inflexibility being shown around the possibility of retiring and returning. Many of them want to reduce their shifts, but again the inflexibility of the system is not allowing them to do so, so that is one thing. The second thing that I would say is probably the most obvious point, but I think that it is worth reiterating that clearly one of the significant things that we can do to try to retain our workforce is to reduce that workload pressure. All of us around the table have spoken to NHS staff and again whether it is the nursing or medical or medwifery or any staff working within the NHS will always use the word relentless to me to describe the last almost three years, and they often tell me that in a typical NHS career in a hospital you would be, and this will be the same story in community and primary care, as well as secondary care, that you will gear yourself up for the winter. You will know that you will have a really rough few months and then the pressure will begin to ease and then you will gear yourself back up as you get towards winter. That has not happened for effectively three years, just relentless, relentless pressure, so certainly the work that we are doing to try to reduce that workload pressure. I am notwithstanding how difficult the past few weeks have been, we will begin to see an easing of that pressure. It will not be easy, but easing of the most extreme pressure that we have seen set out in winter. What can we do to try to stabilise the service so that it does not feel as relentless as it has in recent months and years? Pay is important. We can just skirt over that. I think that making sure that people who work in our NHS and indeed social care are appropriately rewarded is really important. I will not rehearse everything that I have said, but we have a fair pay offer on the table. Jenny Mackay will note that, at the end of last week, we also came to an agreement with the three trade unions that were in dispute and had a strike mandate, in which they will pause that strike action. We will enter into negotiations on 23.24 this week. Pensions are really important, too. They regularly come up from the medical workforce, in particular around the disincentive around pensions. I will not rehearse what I have said. We can take some action that the Government has taken and want it to go further as to the BMA. In a rural setting, I think that it is so, so important. It is important everywhere, but in a rural setting, the real big advantage rural settings have got is often the work-life balance that attracts people to go to work there. For retention purposes, we really have to work with our working cross-government cross-portfolio to deal with the housing, education and later life provision for people. That has got to be part of a holistic package. Forgive me, that is probably a longer answer, but I do not know if we can have a solution. I think that we might want to come in. I agree with what you have said. I think that careers used to be linear, but they are now more complex. Our workforce planning needs to recognise that. Equally workforce at one point was perhaps thought to be getting the numbers right. That is still important, but it is not the whole position. We now need to be very more proactive about supporting career development, because that in itself will help retention. Looking to the future, we are in very difficult circumstances right now as the Cabinet Secretary has eloquently said, but looking to the future, we need to be much more alive in career development and recognising that individuals may wish to develop their skills in a different direction with seniority. According to the skills and expertise, they have accrued over many years, so I think that we need to look at this in a number of ways, the number of staff being just the start of that process. Thank you. Do we take Dr Smith? One last point on this. We have not spoken about ScotGem and what it has offered in terms of the production of medical students, new doctors who are much more likely to go into work in a rural environment. Not only has it done that, though, but it has also galvanised the careers of the educators who are providing the education to those medical students and new doctors. The discussions that I have had with the trainers have spoken about how much more they enjoy their careers having now been able to participate in elements such as that. That speaks to Sir Lewis's point about careers that are very complex now, and we need something to sustain them. I had the absolute privilege to visit some school nurses in Falkirk a few weeks ago, and it is incredible the amount of preventative work that they do, and they are hugely passionate and innovative in what they do. In rural and remote areas, their work could be extremely important in terms of preventative health. Given the potential impacts of certain practitioners on keeping people well, resulting in less attendances at acute settings and the importance of this, given some of the distances involved in remote and rural areas, what planning is under way to ensure that we have a diverse mix of recruitment on-going and ensure that we do not lose sight of some really important healthcare professionals such as school nurses? That is a great question. It is why so much of our focus has been on growing that multidisciplinary team staffing in general practice and beyond in terms of primary care and the health service, because our ultimate goal is to ensure that people get treatment as close to home at home if possible, but as close to home as possible. That is just as important, if I would argue, and potentially more important in the remote and rural setting, given the challenges to access to larger health services, secondary care, primary care and the focus on primary and community is exceptionally important in that regard. A lot of our focus has been on growing that multidisciplinary team to more than 3,220 in the past number of years. I think that where we can, on the preventative side, focus a lot on is the absolute investment in the allied health professionals. Clearly, if you get access to an allied health professional earlier sooner before your condition becomes a lot worse, then there may be a lot of benefit from that from a preventative perspective. I am also incredibly impressed and have always been incredibly impressed at how much our advanced nurse practitioners can do as well. Again, embedding them within community facilities and primary care in particular, but community facilities can really help us. I just want to make this final point that I think that McHy also makes on a question, which is often with the health service that you are dealing with the immediate, so let's take the immediate pressures that are in front of us in terms of the winter pressures. What I am very keen is that we never, as a Government, lose sight of the real importance of the preventative agenda. I am focused on that regularly, as you can imagine, but we do not want, for example, the really difficult challenges of the pandemic. We had to deal with those and give those priority. We do not want to lose any focus of the excellent preventative work that we are doing around obesity, around mental health, around smoking cessation, alcohol and drugs, healthy living and so on. Mary Todd leads on that, as Minister for Public Health. You can imagine that she is driving that forward at that pace. I am conscious that we have five colleagues who want to ask questions on the broad workforce, whether that be about recruitment, retention, accommodation or training. If we can try and get through those, that would be really helpful and perhaps more succinct questions and answers. I am going to come to Tess and then Sandesh. Over the festive period, NHS Grampian put out an extraordinary plea on social media for exhausted NHS staff to come in on their days off. Dr Ian Kennedy, chairman of the BMAs, said that the intervention should close any debate that the NHS is broken. It is well publicised how strapped for staff NHS Grampian is. Does the cabinet secretary think that it is going to happen more often? Is it acceptable that that becomes the norm? No, it is definitely not the norm and should never be the norm in Tess White's own articulation of her question. She referenced that this was an extreme measure taken by NHS Grampian. I would never want to see that as being the norm. I think that objectively, if we all take a step back, we can agree that the festive period, in particular those few weeks, running up to Christmas, the Christmas period and then the first week of January, in particular, are probably amongst the most difficult NHS that is ever faced. It is certainly the course of the pandemic, and I would argue possibly even in its entire existence. Really difficult choices, including the pausing of elective care. Before I mentioned it, I do not want to see that happen because of the constituents that write to me and Tess White and everybody around this table who are suffering because of a last minute cancellation on operation. Again, they have already been waiting for a year plus. We do not want the extreme measures and on the workforce, she is right. The workforce is exhausted and I am not going to argue with Tess White on that. I speak to many of those on the front line and they tell me about that exhaustion, so I am very grateful for all that they do and the fact that many of them responded to that particular call, but I would not just be aghast if that was the norm. I would not allow that to become the norm. It is an extremist measure, which I would hope that we would not have to repeat again, but it is so important that local health boards are just given that flexibility to make those really difficult decisions. Thank you. The Scottish Conservatives, through an FOI, discovered people waiting a long time for diagnostic tests. Why is that relevant to rural areas? NHS Grampian was a five-year wait, but NHS Tayside saw a four-year wait. My question is why is there such a bottleneck in radiology and diagnostic testing, which we know has been the case for a long time? What have you done about it and what are you doing about it? It is a really good question because clearly a delay in diagnostics has an impact on an individual, can have the potential to have a real impact on an individual's health outcome, so none of us want to see any delay in diagnostics. Dr Gregor Smith and I were involved in the press briefing yesterday in the issue of diagnostics. It came up in the back of that FOI in relevant articles. A few things I would say, one is that the obvious impact that the pandemic has had, that is not unique to Scotland, that is not unique to Scotland, that is a situation replicated, I would say not just across the UK but across the world. People had to make exceptionally difficult decisions. We already spoke to them, we thought just about the difficult decisions under elective care. I do not think that I would be over egging it to say that one of the most, if not the most difficult decisions taken during the pandemic certainly was the pausing of screening, cancer screening for a very brief period, but even a single day of pausing screening can have an impact, let alone for the months that we had to do that in the early days of the pandemic and never taken lightly, but because of decisions like that, because of the pandemic, the impact that it had on our health service, that is why we see the scale of backlog. I am not here to suggest that there was no delays in diagnostic testing pre-pandemic, but I think that anybody's again objective observation of the figures, the level of delay, would show you that there has been a significant impact in the pandemic. I noticed that the FOI and the resultant information that came from it, that there was a few people, unfortunately, waiting far, far too long. I will go back, I suppose, to what the First Minister said in this regard yesterday, which is, well, first of all, nobody should be waiting. Certainly, as long as five years, I think was one of the cases that was quoted. That to me is an absolute anomaly and we have got to understand why that happens in individual cases, because even if it is just one case or two cases or a few cases where that is happening, that is having an impact on the individual. We have got to understand why, but that is not the norm, that length of wait. What are you doing about it? We have funded additional—this is really relevant for remote and rural Scotland—we have been invested in mobile MRI and mobile CT scanners, six MRI and five CT scanners, but I will double-check the detail of that. Through the investments that we have made thus far, that has provided some additional capacity. What I have done is looking at the winter pressures that we have clearly faced and facing. I have put an additional £1.5 million towards diagnostics and radiology, in particular again from memory between January and the end of March. That will give us in the order—I will correct the record if I am wrong—about 15,000 additional scans, but I will double-check that. I will come back through the figures, but I think that it was around about 15,000. We will keep investing and try to increase the capacity where we can of diagnostics. We really do need to move on. We are very short of time. I take David Torrance and then Carol Malkin. A friend of mine had a position in NHS Highland to go to. After three months of searching, he could not find suitable accommodation. Someone who has strong connections to having more, the residents are really welcome in the new community hospital. Once again, there is no accommodation he had to get unless you want to pay £600 a week for a holiday let. In your opening statement, you mentioned that the Highlands and Islands University had increased its places by 0.3 per cent. Will we not lose him from these areas if there is no accommodation? Do you think that affordable accommodation is the biggest barrier to recruitment and attention of staff? How can we fix that, cabinet secretary? First and foremost, there is no doubt that housing is an important part of this. I hear from many people who wanted to or tried to take up a rural, remote or island post, but it was housing that ultimately was the reason why they could not. Sometimes, in some cases, it might well be education, but it tends to be housing. There is a relentless cross-government focus on this, and I will meet with colleagues who have got responsibility for affordable housing. Together, we are developing, as the member probably knows, a remote and rural and island housing action plan to meet the housing needs of those communities, which is a real focus on retention, as well as attracting people to those communities. It is probably fair to say that where innovative solutions can be found locally, absolutely, and I can see that happening in parts of Scotland, where accommodation has been repurposed for this reason. However, it has to take a cross-government approach, and that is why the remote, rural and island housing action plan is so important. I am conscious that I have about three colleagues who are looking to ask questions. Is the cabinet secretary content in terms of time, given that we have subsequent business? Yes, I mean, I do have topical and other such things, but yes, I am debate. We will certainly work to make that work. Can I take Carol Mawkin, who will be followed by Stephanie Callaghan, and then I will take Emma Harper in our last question in that order, so we will start with Carol. My question is on workforce training, which is quite a wide subject, and perhaps I understand that we will not be able to answer all, but I am very interested to know if there has been a lot of work done in NHS Education Scotland around rural training, clinical places in particular. I am very interested in the notion about those local places, because I believe that there is sufficient evidence to suggest that, if we can train people locally, if we can get people into those areas, those are really interesting jobs and we can retain some staff. There is a wider issue around the different professions, the HPs and nurses, but I am very interested to know what engagement you have had with Education Scotland. First of all, there is no doubt in what Carol Mawkin says that the feedback overwhelmingly would suggest that, if we are able to train people locally, there is a better chance of retention and retaining them locally where we can. Again, I will not rehearse what has been said already around the SCOTGEM programme around the fact that our GP fill rate for those in the north of Scotland is exceptionally good, and I have already referenced some of the at-distance learning that we are able to provide for the shortened midwifery course, so that we are able to keep people in locality while they study to train to become midwives within that shortened programme. There is a lot that we are doing in that space. I have certainly said to health boards that they should be as innovative as they possibly can be for the additional training posts that we have made available in relation to the medical workforce. Again, we are looking to see how many of those training places that we can ensure are filled by remote and rural and island health boards. For the sake of brevity, it is worth me saying that there is no doubting the premise of Carol Mawkin's question. Secondly, there is a fair bit of work going into making sure that we make training places for whether that is nursing, midwifery, GP, medical workforce, and making sure that we have as many of those training places in remote, rural and island Scotland, but I know that we are taking it for time, but I think that that is probably the case for famous expertise. Nes, in particular, is doing good things in specific training programmes, including rural fellows, the ambitions beyond that, clearly in terms of the multidisciplinary team, and also in the direction of social care as well, which I think is essential for an integrated approach to the care of the people of Scotland going forward. There are many good things going on in remote and rural right now. I am hoping that the national centre will amplify that, and indeed Nes' role in that will be very prominent. Already Dr Smith brought up ScotGem earlier on there, and it was great to hear you talking about how it galvanised the career of some of the trainers that you have spoken about. It also made me think back as well, so it reaches your comments around rediscover the joy and the success of that campaign there. We are incredibly lucky in Scotland to live in such a beautiful, amazing country, not least in rural areas. It can be very attractive for students, and I wonder if there are opportunities to further develop ScotGem or to extend that to undergraduate models as well. What opportunities and perhaps what challenges would there be around that? Dr Smith, you are just a second. He has been so integral to the programme. We have actually grown the intake already in terms of the ScotGem programme. We often get calls from other health boards that are not part of the ScotGem programme, and we have them involved. In fact, the convener is one of those advocates for expansion of that particular programme. It is so important that now that we have had the first cohort of graduates, we just ensure that the programme is stabilised. Before we consider additional expansion in terms of additional health boards or anything further that we do in terms of, for example, at the moment that you are right, it is a graduate entry programme, making it an undergraduate. I think that that would be challenging and quite disruptive to a model that we are trying to stabilise. It is hugely popular, I should say, and I think that we should absolutely be open-minded to potential expansion in the future. My own view is that at the moment it should stabilise and ensure that we are getting the benefit from that programme. I will pass to Dr Smith with the convener if he is okay to do that. I will pass to Dr Smith if he is okay to do that. We are obviously seeing some expansion this year in terms of the places offered in ScotGem. I think that that is a positive thing. We have to be careful that we do not grow out too quickly and overwhelm particularly the opportunities for training and dilute the training experience that people get through it. I think that that is an important aspect of it. However, certainly in the time that I have spent with some of the students as they are going through that programme, I was lucky enough to provide a lecture for them a couple of months ago. What I am seeing is very enthusiastic and insightful learners who are really keen to get out there and who understand the challenges that exist within the system just now and are not short of ideas as to how they will go about trying to contribute to facing those challenges. It is a very positive experience to be anywhere near around that programme just now, but it is one that we need to make sure that we grow in time in a proportionate way that we do not dilute the content. A quick education and skills question. The mobile skills unit was developed and in order to deliver education more rurally. I know that the big lorry-sized fan does simulated training for chest tube insertion or even intra-osses needles insertion and things like that. It has been all over Scotland. Is there an opportunity to focus more on that kind of remote and rural education delivery using the managed skills network or the clinical skills network to do that? I think that it would be very brief to say yes. Any potential to use digital, to use mobile technology or to use mobile equipment to do that. I have seen fantastic examples of simulators in our training facilities and it is incredible just how real life it feels. I have to say that somebody is a non-clinician being in there. I can even fear my heart rate racing is those who are training. We are dealing with a medical emergency in that simulated environment, so yes, in short, we are exploring that and seeing what further we can do in that respect. Thank you very much. I thank the cabinet secretary for his attendance and his indulgence in terms of going over the time allotted and to his officials as well for their attendance. Can I suggest to the committee that the evidence that we have heard this morning we consider our next steps on these petitions at a further meeting? Are members agreed? Thank you. We will have a short comfort break. Okay, can I just call colleagues back to order? Our third item is consideration of an affirmative instrument, which is the dentist's dental care professionals nurses nursing associates in midwice international registrations order 2022. The purpose of this instrument is to amend the legislative framework underpinning regulators international registration routes. In particular, the instrument enables the general dental council to set out and change its processes for international registration more efficiently. That includes providing updated powers for the general dental council to charge for services that it undertakes and it allows the nursing and midwifery council to allow more flexibility in the range of international testing routes to ascertain applicants' competence and change rules that set out registration processes to reduce the time taken to process international applications. The Delegated Powers and Law Reform Committee considered this instrument at its meeting on 13 December 2022 and made no recommendations in relation to the instrument. We will now have an evidence session with the Cabinet Secretary for Health and Social Care and supporting officials on the instrument. Once we have had all questions answered, we will proceed to a formal debate on the motion. I welcome again to the committee Hums the use of Cabinet Secretary for Health and Social Care and accompanying the Cabinet Secretary, Rachel Coots, Solicitor, Primary Care, Medicines and Treatments Branch, and Rebecca Wright, Senior Policy Manager, Regulation of Health Professions, Chief Nursing Officer and Directorate in the Scottish Government. Thank you for joining us today and I will invite the Cabinet Secretary to make a brief opening statement. I am keen to take any questions that the committee has. As you have already heard from the last session that we have just concluded, it is so important that our health service is able to meet the challenges, the intense challenges that we are currently under, and meeting those as they arise in this order gives us additional flexibility to the GDC, the NMC, to help the health service to respond to some of those challenges. Since the end of 2020, committee members will be aware no doubt that European law relating to the recognition of qualified healthcare professionals from the European economic area no longer applies in the UK. Current standstill arrangements mean that the UK professional healthcare regulators have continued to automatically recognise EEA and Swiss-obtained qualifications for up to two years after the end of the transition period. The period of automatic recognition ends in early 2023, when the Secretary for State for Health and Social Care will review the approach to registering European economic area qualified professionals. The order is being made under section 60 of the health act 1999 and will amend the DENTIS act 1984, the nursing admin wifery order 2001 and other subordinate legislation. The order will change the legislative frameworks of the GDC and the NMC to allow them to amend the registration processes for international applicants. Currently, both the general dental council and the nursing admin wifery council's governing legislation prevents them from making changes to their registration processes. In the case of the GDC, the current legislative structure makes it quite difficult and quite time consuming to make changes to its registration process. Likewise, the NMC must follow an overly detailed procedure to carry out assessments for international applicants. The order makes a number of changes to the legislative frameworks of the NMC and the GDC's international registration requirements. First, it allows the GDC to apply a range of assessment options to determine whether applicants have the right knowledge, skills and experience to practice in the UK. Secondly, it removes the requirement for dental authorities to use an assessment for overseas applicants, such as the overseas registration exam, known as the OR. Thirdly, it allows the GDC to charge fees to international institutions for expenses and card in relation to international registration, so it can cover the costs of recognising international qualifications that meet UK standards. Fourthly, the GDC will be able to make rules setting out the details of its international registration processes without the need for privy council approval, so that change can be made far more efficiently. Fifthly, a transitional period for the OR, the overseas registration examination, will continue to apply for 12 months after the order comes into force, at which point the GDC will publish new rules for its international registration process. The process is subject to parliamentary approval. The effect of the order is to allow the GDC to use increased flexibility to set out two international registration routes based on an assessment of an application's qualifications, their skills, training and completion of an OR style assessment, and the recognition of an applicant's qualifications where the GDC has assessed that qualification and considered that it provides applicants with the required knowledge, the required skills and the required experience. In terms of changes to the NMC, to the nursing and midwifery order, the NMC will continue to apply its test of competence as the main assessment route for international applicants, which will remain in the legislation as one of the ways that the NMC can make sure that an applicant meets its standards, but the order will bring in other pathways for registration. Firstly, recognition of an NMC-approved programme of education from outside of the UK. Secondly, in limited situations, a qualification comparability exercise which the NMC will then use to judge whether the applicant's qualification is of a comparable standard to an NMC-approved UK qualification. In either situation, applicants will still need to meet the NMC's other registration requirements, such as English language, indemnity and payment of course of the registration fee. In conclusion, convener, I fully support the instrument as a pragmatic solution that will improve consistency and give these regulators much needed flexibility in responding to the changing circumstances and obviously happy to answer any questions that members may have. Thank you, cabinet secretary. Can I invite any questions to the cabinet secretary, Emma Harper? Thanks, convener. It's just a quick question, really, cabinet secretary. It seems reasonable that this order is providing the GDC and the NMC greater flexibility to amend their existing international registration pathway. I know there's challenges with the dentistry, especially in my region in Dumfries and Galloway, for access to NHS dentures. Will that ultimately help us with recruitment for dentists and dental practitioners, especially as a result or a consequence of Brexit? I certainly hope so, because when I have spoken to both the NMC and the GDC in my time as health secretary, they are as excited as regulators tend to get, but they were excited about the fact that the additional flexibility could really assist with that international recruitment. I'm not going to the challenges of Brexit that Brexit has brought in relation to both health and social care, I think that it's well rehearsed, but flexibility absolutely can help with that. As per the previous evidence session, there's no doubt that health boards want to make maximum advantage and use of international recruitment, not the panacea. I'll always quite keen to say that, but it can provide a significant additionality, and there's no doubt that the additional flexibilities in the way that I've outlined in my opening remarks could absolutely help with that, both in terms of the dental workforce and the nursing midwifery workforce, too. Can we move to agenda item 4, which is the formal debate on the affirmative instrument, on which we have just taken the cabinet secretary's evidence? Can I remind committee that members should not put questions to the cabinet secretary during the formal debate, and officials may not speak in the debate? Before I invite you to move it, is there anything further that you wish to say in relation to the motion? Nothing further. Can I invite any contributions to the debate? It is my intention then to ask the cabinet secretary to formally move motion S6M-07061 in your name. The question is that motion S6M-07061 in the name of the cabinet secretary be approved. Are we all agreed? The committee is therefore agreed. That concludes consideration of the instrument, and I thank the cabinet secretary for his time this morning and indeed for his officials for attending also. At our next meeting, we will be taking evidence from Cricket Scotland and Sport Scotland to get an update on their response to the independent review of racism in Scottish Cricket. We will then take evidence from representatives of Food Standards Scotland, and that concludes the public part of our meeting today.