 Welcome everyone to the 19th meeting of the Health, Social Care and Sport Committee 2022. I have received no apologies for today's meeting. The first item on our agenda is to decide whether to take items 3 and 4 in private. Our members agreed. We agreed. Thank you. Our second item today is the first formal evidence session that is part of our inquiry into health inequalities. This session will focus on progress in addressing and tackling health inequalities in Scotland since 2015, when our predecessor committee published a report on this topic. Before we start, I would like to take this opportunity to thank everyone who took part in our formal evidence sessions on last Friday and yesterday. The evidence that we heard at those sessions will feed into formal evidence sessions to take place on the 14th of June, but do not be surprised if it comes up throughout all our evidence sessions. It is a very powerful testimony from people who have lived experience, so I thank Clare Stevens for organising a lot of the people that we spoke to. The voices of people do not need to be heard, so I imagine that, regardless of the session, people will be making reference, albeit names redacted to some of the things that we heard, particularly from the people who feel that they have a lack of access to healthcare. I welcome to the committee this morning David Finch, the assistant director for healthy lives director of the health foundation, who is attending online. I believe that it is a little bit of difficulty getting online, so hopefully, as I speak, it is happening. Jenny McCartney, professor of wellbeing economy for the University of Glasgow, who is attending in person. Clare Stevens, as I said, is the chief executive of voluntary health Scotland, who helped us to organise our informal sessions, attending in person, and David Walsh, public health programme manager for the Glasgow sense of population health, who is also joining us online. Good morning to you all. I was going to ask all of you about the progress that has been made since 2015, and I do want that in the back of your minds. I know that you have all got an opening statement, but I just want to say up front that health inequalities are a massive subject. I think that it would be remiss of this committee if all we did was talk about the problems. I really want this inquiry to be looking at how we can find solutions and actions and recommendations that we can make in areas of devolved competence where we can, so that with that in mind, I will start with your opening statements. Is David Finch on? No, he's not yet. I will go to Jerry first of all. Thank you to the committee for inviting me to come along. To build on the point that you have made, health inequalities are arguably one of the biggest challenges that Scotland faces. Health inequalities here are wider than anywhere else in Western or Central Europe and have been growing over the past 10 years. Widering in health inequalities has been particularly stark since around 2012. Since that date, we have seen that mortality rates amongst the poorest 30 or 40 per cent of areas have worsened in real terms in the run-up to the pandemic. Of course, we are then subsequently exacerbated by the pandemic. We should be under no illusions about the lack of progress towards narrowing health inequalities and the challenge that we face. You have rightly asked us to think of some of the things that have happened that have been helpful over that time. I wanted to highlight three things that I think have made a difference to mitigate that stark problem that I have outlined. The first is the introduction of the Scottish child payment. We know that health inequalities are due to inequalities in income, wealth and power in society and because those income inequalities, wealth inequalities and power inequalities have continued to widen, that is why health inequalities have continued to widen. The Scottish child payment starts to mitigate some of the rises in child poverty that we have seen and makes it less bad than it would otherwise have been. That is important because mitigation can make a difference. It is also worth mentioning the furlough scheme. Had it not been for the furlough scheme, people would have been just without incomes for a prolonged period of time during the pandemic, so that has been a saviour. It is important that we recognise that. There are other things, particularly when we know about rising costs for people that have reduced those costs. Things such as free bus travel for some groups, free prescriptions and free school meals for some groups. Those reduce the costs that are faced by families, so that is important as well in reducing the real effect of poverty in people's lives. There has been a wide range of unhelpful policies, particularly on the macroeconomic scale that has driven inequalities in income, wealth and power. Not many of those are within devolved competence, if we are honest about it. We have continued to have an economic design that drives widening economic inequalities and that, in consequence, causes health inequalities to widen. Arguably, we have been a little bit distracted at times with specific policies to address health inequalities over the past 10 or 20 years. We have had policies such as Keepwell that have not been found to be effectual at reducing health inequalities. We have had a reliance on improvement science approaches and the collaborative to reduce health inequalities, and those have not addressed the fundamental causes and have not been proven to make a difference. There is also a vogue at the moment for place-based approaches, which I do not hold much hope for, because they do not address the gradient. Even if they are focused on the most deprived areas, the health and the gods are seen across the entire population, not just in deprived areas. Most deprived individuals do not live in deprived areas, so it will not target those groups. It ignores the economic relationship between social groups. Instead, it is almost pretending that people's deprivation status is independent of those relationships. In some way, we need to think about how we address the economic design of the country that leads to widening income, wealth and power inequalities. We also know from a big review done by NHS Health Scotland a number of years ago about the other policies that work to reduce health inequalities, and that invariably are the kinds of policies that do not lie in individual agency, so things that involve taxation, regulation and legislation. We have seen really good examples of that in Scotland with minimum unit pricing, the ban on discount buys for alcohol, the ban on smoking in public places. Those are good examples, but we have other areas that we need to think about. What about the food system, for example, and what that does to drive an obesity-genic environment and a rise in obesity in Scotland? Thank you, convener. Good morning, everybody. Thank you for this opportunity to contribute to the inquiry and to being involved in helping to shape the informal events that took place on Friday and Monday. My organisation, Voluntary Health Scotland, with a national intermediary and network for health charities and other voluntary organisations involved in health in the widest sense—a lot of community development organisations, for example—is to work with member organisations and other stakeholders to try to address health inequalities and to create better health and wellbeing for all people and communities. For the past seven years, we have also been the secretary app for the cross-party group on health inequalities here. That is a CPG with over 90 external organisational members and five MSPs at the moment and a mailing list of over 300 additional people. It is a very well-supported cross-party group. If I reflect back to 2015, which is the time of your original or earlier inquiry, that was the year that my organisation first really started to get involved in looking at health inequalities. We conducted research and published research that we called Living in the Gap, a voluntary health sector perspective on health inequalities in Scotland. That report described the widening health inequalities gap from our sector standpoint, giving an insight into people's real lived experience and describing the wide range of positive approaches and interventions that voluntary organisations undertake to mitigate inequalities and to try to prevent and reduce, but largely to mitigate inequalities. We followed up with a second report, the Zuberi report, in 2018, which this time focused on the lived experience of loneliness and social isolation, mindful of Glasgow Centre for Population Health findings that lower levels of social capital and community connectedness are associated with higher levels of health inequalities. I mentioned those reports because their findings are as valid today as they were when published seven years ago, except that, as Gerry has said, the gap is widening, not narrowing and any green shoots are in danger of being cut down by the pandemic and the growing poverty crisis. I was reading some of the written responses that you have had to the inquiry and was struck by Diabetes Scotland pointing out that people in Scotland's most deprived areas were spent half of their lives in poor health, 24 years more than people in the most affluent areas. Throughout the last seven years, our sector, the third sector, has continued to mitigate these impacts by providing targeted services and support, tackling social isolation, loneliness and stigma. We had a lot about stigma over the last two days, building social capital through community development and place-based work and homing in on those who have been simply left behind or overlooked by public policy and services. Voluntary organisations also work upstream, carrying out research campaigns and education to help to improve law, policy and practice and playing key roles in local and national partnerships and community empowerment. They do all of this without reliable or sustainable funding for a great deal of the time and in the face of growing demands and needs, and not least doing this continuing phase of the pandemic. The kinds of upstream strategies that our sector wants to see include investment in wellbeing communities to build, sustain and protect durable community assets, compassionate, non-stigmatising and humane public services, high-quality secure affordable housing, improved access and support to use green and communal spaces for those facing the greatest barriers, easy access to healthy affordable food, improved digital connectivity and affordability for those least able to access it, much more accessible and affordable public transport, measures focused on food, tobacco and alcohol to help to prevent unnecessary deaths from non-communicable diseases, proportionate universalism and active outreach to ensure services are reaching those missing from services or furthest away, and above all across government strategy centred on ending poverty. Thank you, convener. Thank you, Claire, and I'll come to David Walsh, David. Thank you and good morning. The danger of going last or almost last, which is a hazard of having a surname that begins with W, is that you end up sometimes repeating what you've already heard, so I might repeat some of Jerry's points to a degree here. I'll just try and make four very quick points and they all relate to the important issue, which I think is important to be clear about, that there's actually no mystery about the causes of and the solutions to health inequalities. At the risk of sounding rumsfeld-esque, there are more unknowns in this area, so I'm going to very quickly give you four unknowns. The first is that we know very well about the horrific scale and the adverse trends in health inequalities, as Jerry mentioned. Even before the changes of the last 10 years, which I'll say a bit more about, and before the pandemic, we had the widest health inequalities in Western Europe, but those inequalities, again, as Jerry alluded to, have exacerbated massively since about 2012. The second known, which is really important, is that we know very clearly why. We know why we have wide health inequalities generally, and we know why we have widened so much in the past 10 years. Health inequalities are an extension of wider societal inequalities, socioeconomic inequalities. If you have a country with a wide wealth gap, you have a country with a wide health gap. Scotland, like the rest of the UK, has seen since 1979 a massive widening of socioeconomic inequalities and, at the same time, as a clear consequence, a massive widening of health inequalities, the two go hand in glove. In the past 10 years, with the UK Government's implementation of the austerity programme, which has slashed literally tens of billions of pounds from the income of the poorest and the most vulnerable in society, we have, scandalously, in my opinion, seen the increasing death rates in the poorest communities up and down the UK as a consequence of widening of inequalities. Actually, what we have now is a new form of inequality in the sense that previously health inequalities widened because the health of the better off improved faster than the health of the less well off. Importantly, the health of the less well off was still improving. The impact of austerity is now that the health of the less well off is actually getting worse, so we have a new form of widening inequality. The third known is, as important as knowing why we have wide health inequalities, we also know what we need to do about them. As Gerry alluded to, there is a lot of international evidence of the correct policies out there. Indeed, the Scottish Government commissioned Health Scotland, which is now Public Health Scotland, to undertake a review a few years ago of the international evidence of what works and what does not work to narrow health inequalities. It is all there. It is all published in black and white for people to look at. That review talked about the need to address inequalities at three levels. First and foremost, to address those fundamental socioeconomic inequalities in society and the wealth gap. Secondly, as Gerry alluded to, what he referred to as wider environmental influences, so that is about housing and pollution and alcohol pricing and all those things, and there are also issues around individual experiences of inequalities. However, the most important sentence in that report was the one that said, if you do not do the first, if you do not narrow socioeconomic inequalities in society, you will not succeed in narrowing health inequalities. My fourth and final point is that it is really, really important to understand, and it is also really, really problematic for Scotland. To narrow those socioeconomic inequalities, we obviously need the relevant powers. In Scotland we have lump powers, so we can change income tax rates and bans. We have a very small number of social security powers, but it remains the case that the vast majority of taxation, as Gerry mentioned, of social security of other relevant legislative areas, such as employment law, all remains reserved to Westminster. There are some really great things that we can do in Scotland, and they have been alluded to by the other two people in the committee. There are things that we have done that we should be very proud of, but the problem is that it is an issue of balance. On the one hand, if you do all those great things, and then the UK Government comes along and takes tens of billions of pounds from the income of the poorest and the most vulnerable society, then what happens? The bad outweighs the good. There is a need for honesty in the situation about understanding the constraints that we are in, that realistically, in Scotland, we are not going to narrow health inequalities unless either we have additional powers around those socioeconomic areas or if there is a change of policy direction at Westminster. I think that it is important in formulating recommendations, be that from this committee or from David Finch's health foundation review that is happening at the moment, to understand that reality about what we are able to do. Thank you, David. We now have David Finch who has been able to join us. David, we are just at the point where people are giving open statements, so I would like to ask you for yours. We cannot hear David, so maybe we might have to go audio-only. Maybe if it is just speaking through the ether to broadcasting. Maybe if we put David on audio-only, we might have a fighting chance of hearing him. Can you hear me now? Yes, we can hear you now. On you go, David. Great. Thank you. I think I had the wrong microphone attached, so thank you for inviting me to speak to the debate. I think that the health foundation is an independent charity aiming to improve health and reduce health inequalities. We are going to take a range of different activities from giving grants, working on the front line through to funding research and policy analysis. We are currently carrying out an independent review of health and health inequalities in Scotland. Through that review, we are really aiming to provide detailed analysis of health and the whole trend of social and economic factors that influence health. We are going to try to understand why, because we recognise that there is already significant historical work in the area and already significant policies. We are trying to understand why, despite that, we still see health inequalities persisting. Our past research, which includes 10 years on updates to the Marmot review and our Covid impact inquiry, has often highlighted how people's health is influenced by the conditions in which people are born and live and grow and their experiences in their day-to-day lives. That is something that we think will definitely be key things through the review, which we are currently supporting. We really want to make sure that that is considering issues specifically to Scotland. We are also ready to go on the old and moving capturing to use people who are working on the front line, people within policy and delivery roles, and also through some public engagement so that we get a really rounded picture of what is happening. We certainly come into this very open-minded and have no really preconceived ideas about where we think that the review will end and the findings will come out. We very much want to be driven by or led by the findings coming through from the different research trends of funding and also our advisory group. We have tried quite hard to make sure that those are very much grounded within Scotland. We have four key trends of research for funding. One is looking at public health trends and is led by Anna Pearce at the University of Glasgow. The second one is looking at the social and economic factors specific to health, and that has been led by David Icer at the Fraser Islander Institute. We also have two trends, which are really trying to engage us to be holders in the kind of policy and delivery sphere. That is being led by Adam Lang at Nestor and a strand of deliberative public engagements, which is being led by Mark Diffley at the Diffley partnership. We are really hoping that those strands form together and are informing each other through the process. We are planning for those to start to be published in the autumn with a final report of our own set for the kind of following that, which gives us an overview of the findings. We will hopefully give some indications of where we think that there are key priority areas for policy. I would just like to finish by saying that we are very keen that this review is able to help inform the work of the committee and whether that is sharing our emerging findings or some of the policy recommendations, and particularly whether there are areas of interest that are being highlighted through your work and through the inquiry that may be things that we should take a look at with more of a priority as we are at the review keeps developing. We have put you on audio only. Do you have signal improved quite a bit? We might not be able to see you, but we can certainly hear you fine. Just a little bit of housekeeping. Those who are joining us online, the two Davids, if you want to come in on anything specifically, put an R in the chat box and my clerk will let me know that you want to come in. I want to pick up on a couple of things that has been said in your opening remarks. Jenny, you said about the place-based approach. I want to develop a bit deeper into your thoughts on that, saying that putting the place-based approach might not actually, to your mind, have the effect perhaps that you think about. We are hearing an awful lot about that from Government ministers but also from commentators more generally. Can you expand on that? It is a bit of a now-defined approach, if we are honest, but if it means focusing on the areas that are the most deprived and have the worst health outcomes, which I take it to mean on most occasions, what that would not do is address the gradient in health and equality. Even if you had a set of effective interventions that can be carried out at a small community level, and notwithstanding what we have already discussed in terms of the biggest drivers of health and equality, that in itself seems unlikely to be effective. Even if that were to be effective and that was to improve the health of the small communities who are living in the most deprived areas, that would not, by definition, address the gradient, so it occurs across all of Scotland, all of society, all of the UK. We need, as Claire referred to, a proportional universal approach whereby effective interventions are introduced that impact most in the deprived areas but have an impact across that gradient in proportion to that. For that reason, I think that it is unlikely to be effective, but there are also other more technical reasons about the fact that most deprived individuals do not live in the most deprived areas. If you look at income deprivation and employment deprivation, for example, only a very small proportion of the Scottish population who are individually income or employment deprived live in the, for example, 20 per cent most deprived areas. If you simply target those areas with interventions, you will miss the vast majority of people who need them. It refers back to the fundamental causes. The causes of health and equality are the social and economic relationships between social groups, and a place-based approach does not look at that in any way, shape or form. I worry that a lot of energy and attention goes into a place-based approach that will ultimately look back in 10 years' time. It will be another keep well, and it will be another failed very specific health and equality approach, when, in fact, what we really need is an inequalities approach for Scotland that addresses inequalities in the round and health inequalities. If an inequalities general approach is effective, that will generate a Darwinian health inequality specifically. You mentioned those who have been left behind or overlooked by public policy and services. I think that we heard from a lot of those groups in our two sessions. I wonder if you identify, certainly, in the two sessions that we had, we had some marginalised groups, a lot of them with no recourse to public funds. Would you be able to expand on that? Who was in your mind when you thought that policies and services are not getting to these people or not taking these people into account? And which policies and services, as opposed to what I am asking? I think that there is a wide range of groups. We saw a cross-section of some of those over the last two days. I suppose that some people from black and ethnic minority communities, people who are living in deep poverty, gypsy travellers and some disabled people, so that those sorts of groups were represented at the two sessions yesterday and across our network. Dr Andrea Williamson has done interesting work. I think that a colleague now of Jerry's at Glasgow University and a deep NGP is looking at what she calls the missing in health. It is those patients who should be patients of primary care who do not turn up to appointments or do not take advantage of screening and so on. Why do not they come forward? It is because the NHS is a universal service that expects people to turn up and just take advantage of it, but without the targeted outreach or proportionate universalism reaching out to people, some groups just face, some people face such barriers that it is difficult for them to take advantage of that. If there is time later on, I would like to talk about our work in helping to make the Covid vaccine programme more inclusive, because that is a good example of that. I will comment briefly on what Jerry said on place-based approaches. I agree with Jerry entirely at one level, but on the other hand, for my sector and for 40,000 voluntary organisations across Scotland, the vast majority of those work in a single community, not even across a whole local authority. They are getting in at the deep end, at the grass roots. They are reaching communities that are often marginalised or furthest away from public services for whatever reason. They are gaining the trust and confidence of those and working with them. That is very place-based. There is not enough investment in that sort of work. The other element that has been missing from our very important discussion so far about the economy and about wealth is about where people with lived experience themselves sit in all of this. Involving people in the co-design and the co-development of services, for example, is empowering people. That has to be done at a place-based community level often. Again, I have examples from our own work. For example, we sit on the Scottish Government's primary care health inequalities development group that reported earlier this year. Its work was looking at the recovery of primary care and what do GPs and other primary care practitioners have to do to overcome the health inequalities in their communities and reach the people who are missing from their practices at the moment. However, the process that the group went through involved a group of lived experience being involved and checking every step of the way with that. That was through Dr Peter Causton, who is a deep-end GP in Glasgow. We need top-down measures, as we have heard very powerfully already this morning, but there has to be something coming from the grassroots as well and something that works with people where they are and is not doing to people but is doing with people. We have heard in formal sessions of very strongly, do not just consult us, involve us in the decision making and what you have said there about almost kind of road testing things with focus groups from people that your decisions are going to affect was absolutely important. I come to David Walsh. I am picking up a couple of things before I open it up to my colleagues. David, you talked about mitigation measures and the issues that you have when you have things out with your control having an impact on your spending. You talked about austerity measures in particular. What sense of austerity measures have been put in place for those who thought that they were a good idea or to save money? What is the long-term cost of austerity measures when you look at what you just said about the impact on the health of people? Where does the Scottish Government sit in terms of mitigation with a fixed budget? That is a great question. The Scottish Government has done good things. At the start of austerity, when the bedroom tax came in, the Scottish Government basically made up for that through discretionary housing payments to help with that. As Gerry mentioned, it brought in a new social security payment, the Scottish child payment for those on low income. Again, it comes back to what I said about a balance. There are things that Scotland can do and have done, but the sheer scalar of things in terms of the scale of austerity means that those good things can be dwarfed by the negatives. We published in the report last next week with the University of Glasgow and Gerry about all the evidence of what austerity has done in terms of overall health and health inequalities. The evidence is all the same in terms of the scale of it, the cuts to people's incomes, the loss of services and how that has affected people through lots of different pathways. There are increasing levels of poverty, there is evidence there, not just in relation to poverty rates but in terms of the relationship between austerity and food banks provision, homelessness, how austerity has impacted on increased levels of mental health. There are clear links, again evidenced, for the links between mental health and physical health etc. You can trace the effects of austerity through well understood pathways to ultimately and tragically early death. Your question about what is the cost of austerity, the costs are horrendous. There have been some studies trying to quantify this in numbers of deaths and we are doing a bit of work around that, but it is horrific. Again, just to come back to the issue of the cost of life, if you like, and the financial cost. If you think about the amount of money that was invested in response to the pandemic correctly, that came about because of modelling that showed that if the UK Government did nothing about Covid, we would have half a million deaths in the country, which is just a terrifying figure. Other research that we have published with colleagues at Glasgow University has shown that half a million deaths is more or less what you get from inequalities in the UK every couple of years. It is about understanding the scale and therefore if we can find lots and lots of money to deal with one crisis, we need to find money to deal with a much longer lasting crisis that is having a bigger effect. To make the obvious final point is that the UK and Scotland are wealthy countries. It is about the distribution of that wealth across the country and the extent to which it helps the poorest and those who need the most help. Thank you. Sandesh, you wanted to come in, I believe. I just wanted to clarify. Jerry, you said employment deprived. I do not understand that terms, so I wonder if you could clarify that for me, please. The Scottish index of multiple deprivation has several domains for 5, 6, two of which are about income deprivation and employment deprivation. It is about the number of people within each local area who claim unemployment-related benefits. I underestimate the true deprivation of employment opportunity within areas because it is only about those that claim it, but it is what is used to rank small areas by terms of deprivation and monitor inequalities and a whole range of outcomes for Scotland. Yes, I do. It is interesting, Claire Stevens. We spoke yesterday in the session, but I was interested in the comments that you are making around the proportionate universalism. We also were interested in the comments that you made about the GP in the practice of how we can do some more targeted approach and how that might drill down and help us, rather than having a universal approach. Yesterday, the best was to be able to advocate for themselves and get an unfair share of resources with some of the comments that we heard. I am interested in your thoughts on that. Thank you. I am not an expert in proportionate universalism. I suspect Jerry and David will be able to explain this far better than me. My understanding is that with a service like the NHS or education, which is free at the point of delivery and is ostensibly open to all to take it up, the issue is that for some people who face greater barriers to taking up those services, the universal offer is not as accessible. I suppose that you are looking at things like screening. There is some work going on at the moment, as I understand in North Lanarkshire and West Lothian, looking at cancer bowel screening and how and why that is less taken up by people in more deprived communities. Ostensibly, that is open for all people to take up bowel screening, but some people do not. Why do not they? What might help them to take it up? If I could use the example of the Covid vaccine. Last year, when all the blue envelopes were rolling out and in through people's letter boxes, in December or January, as the vaccine programme was starting, the third sector got quite concerned that there would be all sorts of people who might not have a letter box for a blue envelope to come through in the first place because they might be homeless or living in temporary accommodation or they might not have good levels of literacy, English might not be their first language, they might have serious mental health problems or learning disabilities. What would happen to support people to take up this universal offer that would protect not just them but the whole of the community? We were concerned that groups who might be least able or likely or hesitant to take up the vaccine would be those at the highest risk of Covid. We did some research across the sector and got involved with Public Health Scotland and the Scottish Government and what became the inclusion vaccine programme. One of the things that the third sector did in Lothian was to work with Edinburgh and Lothian's health foundation. That is the endowment fund part of NHS Lothian and with NHS Lothian itself and the four third sector interfaces for the Lothians to look at what the third sector could do, very grassroots organisations to support people to understand the benefits of the vaccine, to help them to understand the communications that were coming out from NHS Inform because they were not always easy to understand and then to get to the vaccine. In Lothian they set up a microgrants scheme and the microgrants scheme funded grassroots organisations to hold events in people's own languages, to perhaps get health experts along to debunk myths about the vaccine because there were lots of myths and misinformation going about, to help people physically get to vaccination centres and then in some cases to have outreach to where people were, whether that was homeless shelters or other situations where people actually were. In a modest sort of way, if you like, from a third sector perspective, that is an example of where we think a targeted approach to a public health intervention was successful. We think that it has all sorts of wider implications. You could involve the third sector in that way with screening, for example, but third sector is not routinely involved in planning vaccination programmes, but what a difference that might make if they were, perhaps we could reach more successfully those people in West Lothian and North Lanarkshire who are not currently taking up bowel screening, for example. That is great. Thank you very much. We have also heard from people today about our life expectancy. I think that Jerry spoke at length about that as well in terms of that inequality. We have the lowest life expectancy of the four nations despite higher public spending. Scotland and the US are the only two non-eastern European countries at the very bottom of the life expectancy table, so when you compare us with the other UK nations, you could make the assumption that this is not because of Covid. I am just wondering what you think might be making our perfect storm of issues in Scotland right now. That is a big question. There is layer upon layer of history here. If you go back to the 1950s, Scotland was among the average in terms of life expectancy across Europe and other high-income countries. Slowly, that began to drift apart in Scotland's rate of improvement. It was a little bit slow, but that really became apparent from the 1980s onwards. That is when the real departure from the European means happened. David Walsh led a huge programme of work looking at excess mortality, the higher mortality after accounting for the socio-economic circumstances that pertain in Scotland. Some people have termed that the Scottish effect or Glasgow effect, but we have tried to get rid of that because all that research has now made clear that it really was a political effect. It was about the decisions that were made over that time period, both in the run-up to the 1980s in terms of urban policy and new towns policy and deindustrialisation, but that was all exacerbated by the change in economic policy that led to the widening of income inequalities and privatisation that we have kind of rehearsed already. That is the initial phase. You have the phase from 2010 onwards of austerity that has widened health inequalities more, and David Walsh rehearsed that as well. Covid has then impacted on that once again. We have had three important waves of negative impacts on health. I suppose that what I was trying to say is that the other parts of the United Kingdom have faced the same political policies in terms of austerity, but they are not making the same backwards, they have not seen the same regression. I am just trying to, in terms of us really drilling down and tackling that inequality, we heard yesterday that we have wonderful policies, but I do not get a sense that it is really starting to get under the skin and getting down to the ground and implementing and making the differences that we need. Sorry, I misunderstood the nature of your question. Scotland has essentially become more vulnerable to those kinds of economic policies. If, for example, you turn investment away from council housing and you have a higher proportion of council houses as a country, which Scotland had in the 1980s, you will be more badly affected than the rest of the UK, for example. If you have a particular industrial structure to your employment and that industrial structure is undermined systematically, then, again, you will lose more jobs and you will have worse health impacts. That is why Scotland deviated from the rest of the UK during that earlier time period. We see scarring effects of that on people's health now, so drug-related deaths, for example, are in part due to the scarring effects that we have seen 20 or 30 years ago within the population. All that leaves the population more vulnerable to those kinds of policies. However, I would not be too down on some of the policies that we have introduced, such as the ban on smoking in public places and many other places. Those have made huge differences to outcomes in Scotland and, to refer to some of the services that Claire talked through, we have resisted a lot of the marketisation that has happened in other parts of the UK, which, again, gives us a better shot-and-chance to mitigate health inequalities. The much-quoted Julian Tudor-Hart's inverse-care law—the bit that is less well-quoted around that—is that services are not taken up in proportion to need, especially when market forces operate and where there are a number of barriers. Where you see the most equitable uptake of services, that is where services are taken up in proportion to need. People in more deprived circumstances are accessing more because they need more. That is where there are police barriers, things such as accident and emergency departments. Primary care is somewhere in between, so there are barriers to people accessing that. Claire talked through some of those barriers, but we have more marketisation of services even in Scotland. I am thinking of dentistry, opticians and physiotherapy, where there is a very limited supply within the NHS. Those are much less likely to be taken up in proportion to need, and people in middle classes are more likely to get what they need through those services because of those additional barriers, monetary and otherwise, including all the barriers that Claire talked through. It is a complicated mix of history that explains why Scotland does worse, but I do not think that we should be too down on the mitigation that we do have in place. I will go to Emma Harper for questions. It was just a quick point of clarification, so Jerry answered the question correctly about historical reasons for Scotland lagging behind other UK nations. The question also asked about austerity. I just wanted to make it clear that the effects of austerity have not just been seen in Scotland. The same issues that we have talked about in terms of increasing death rates among more deprived populations have been shown in research for England, for Wales and for Northern Ireland. The same horrific effects of austerity have been seen across the whole of the UK. It is just to be important to be clear about that. I imagine that the point about de-industrialisation is that there are certain parts of England and Wales that have been similarly affected, but it might not have shown up in national data in the same way that it does in Scotland. We did a huge study a number of years ago looking at de-industrialised regions, not just in the UK but across Europe. The general rule is that all post-industrial regions tend to be poorer for lots of historical reasons and therefore tend to have poorer health. Again, it came down to politics. There are a number of areas in the continent, for example, where the national and local responses to de-industrialisation have been a lot better than in the UK and therefore have protected the population's health. It comes down to different political responses at different layers. Good morning to you here in person as well as the people on screen. Just a quick question about upstream causes of health inequalities and the balance between downstream and upstream and how we tackle that. I have a paper here in front of me from the National Institute of Health and Care Research that uses the river metaphor to talk about public health. Downstream interventions focus on things like behaviour change and treatments for illnesses, whereas upstream interventions focus on social factors that contribute to health and prevent illness, such as housing, employment and education. In relation to that, what is the balance between upstream and downstream? Claire mentioned that in her opening. Maybe Claire would be the person to ask about that. I do not know that there is an easy answer to where the balance lies at all. The most important means by which to tackle health inequalities is upstream, but I suppose that the challenge is that that is long term. Getting the political change, getting the change in the economy, getting those measures, the measures that Jerry and David are talking about, is a long term thing. You are talking about preventing health inequalities in generations to come. I suppose that, again, for the third sector, for the voluntary sector, our interest is always the here and now and people who are suffering now or who we might be able to help in the here and now, which is why I suppose some of what the third sector is doing is fishing people out of the stream further down. I think that a balance is difficult, but I think that the third sector has a very keen sense of the need for measures like better housing and employment that is secure and pays well and does not cause stress of much more affordable and accessible public transport. Those are all political decisions and they make a difference. If you cannot afford to get on a bus to get to your appointment to a GP, then that is going to have an impact. That is something that those sorts of policies should be in the gift of policy makers and decision makers today. Changing the economy is a rather, it is a longer term, it is a harder thing. I agree absolutely upstream is where the focus needs to be. Perhaps the difficulty is that you had an inquiry seven years ago, there was the ministerial task force on health inequalities, there was equally wow, there has been all these different, apparently big programmes designed to address health inequalities, but if they only last the lifetime of a Parliament then they are not going to have that traction and make the difference that we know needs made. Introduction of the living wage would be one of the policies that are working. As of April 2022, it is £9.50 an hour, is that something that is basically giving people enough money to manage their families, their homes, that would be part of what would be something that works? Is that a question for Jerry Mibio? Can I come back briefly on that? There was a very interesting contribution to one of the events, I think it was on Friday, there was somebody from NHS Highland who on the health improvement side of things who said of course NHS Highland is a living wage employer and that goes without saying, but that she felt that as an anchor institution in their community and one of the biggest employers, I think along with the local authority they are the biggest employers in Highland, they could be doing much more to promote the living wage to other employers, which I thought was a really interesting take on it, but I think also in those sessions we heard that the living wage alone isn't enough because actually if you're an unpaid carer for example or you're disabled, you've got extra costs then or other health conditions or other things going in your life, the living wage alone might not be enough and we heard a great deal about the benefits system, the UK Westminster benefits system and actually very positive things about the Scottish social security system, so I think the living wage is hugely important, but it's not the only thing. There's some confusing terminology about here, so just rehearse briefly some of this. The living wage in Scotland is a voluntary sign-up scheme that most public sector agencies are either engaged with or working towards. The minimum wage is what regulates all wages in the economy and that comes from the UK Parliament and that has been recently rebashed as a living wage, but it's at a slightly lower level than the Scottish living wage, so just to be clear which living wage we're talking about in different circumstances, it's very much needed and it needs to be higher because the majority of people in poverty at the moment are in work poverty, so either that's because wages aren't high enough or people aren't getting enough hours or their work's precarious, so people are in and out of work or they're not getting the hours every week that they need and then of course the other points that Claire alluded to that the people who are out of work that you know living wage doesn't necessarily impact on, so it is a complicated picture but it's certainly a very important part of the mix to reduce income inequalities in the country. I'm really interested in what David Walsh had to say in his opening statement about how we deal with health inequalities and I want to ask David does he think it would make any difference if we had an overall national strategy to reduce health inequalities given that we don't have overall powers for social security, taxation and employment? Well, I'm a risk of repeating what I said, so I think a strategy would be great in the sense of focusing minds on the importance of the issue and what we can do about it, but fundamentally if the aim is about narrowing health inequalities across society then as I said before you need the relevant powers. It's difficult, this kind of goes back to the last question as well about what levels you do these things and I would refer people to that Health Scotland report from a few years ago because it was really helpful in laying out the three levels that policies are needed at, the fundamental socioeconomic causes, all the wider environmental issues and then individual experiences of inequalities and the things that Claire was referring to. A strategy would be great in focusing minds but it does come down to the balance of what we can do versus what's not in our control. As I said at the beginning, I think there's a need for honesty about what we can do under the current circumstances. Sorry, that's just a repeat of what I said before but it's basically the same question, same answer. Thanks David. Even if we did have an overall strategy we would struggle to get on top of inequalities if we didn't have those devolved powers and maybe Westminster actually looking at austerity in an overall UK-level way? Yeah, so I'd emphasise again, this isn't about my personal opinion, this is me just pointing to the published evidence. So the evidence about, as I've said before, if you want to narrow health inequalities you have to address those fundamental socioeconomic causes of health inequalities and so therefore you look at what powers do we have to address those particular fundamental causes. As I said before, those things we can do, those things we have done, but again it's that balance of if you don't have power over certain areas what can you do. Employment legislation is a decent example of that. Even prior to the current cost of living crisis some of the biggest increases in poverty levels were among those employed, so in-work poverty, and that relates to all sorts of issues that you know about in terms of zero-hour contracts, the gig economy, all those kinds of things. We can't really do very much about that because employment legislation is entirely reserved, so there's one important area. Social security is a massive area, social security should be a safety net to help people when they are in difficulty, not something with which we punish people, which is basically what the UK Government has done in terms of aspects of austerity around conditionality of benefits, etc. It's about big amounts of taxation, not just income taxation but taxing wealth and assets, corporate taxation, all those things with which you can distribute income a bit more. It's about protecting the poorest through a proper, helpful, protective social security system. It's about employment legislation as I've said already, that's where in Scotland we get into difficulty because we only have very small parts of that that we can affect. I just want to be clear, thank you very much for David Freese's contribution and I wholeheartedly agree in terms of austerity, but I just want to be clear that it is about that the current situation with the current Government and Westminster around austerity has had those effects. Of course in Scotland we have very different powers and we can use them in very different ways and we can do that differently depending on what policies we're coming forward to from the UK. I just wanted to ask you in terms of if different policies were happening across the UK, could that be helpful for us in Scotland and then we would be making alternative situations here in Scotland as well? 100 per cent, that's what I said at the end of my opening statement. I said that we won't narrow health inequalities either without additional powers around those economic areas or if there's a change of policy direction at the UK level. If austerity hadn't happened at the UK level then we wouldn't be having these conversations, I don't think, about the horrific scale of increasing death rates among poorer communities. We wouldn't have all the issues around aspects of food banks and homelessness and all the rest that has been put in publish research. That's the reality about where the economic powers around those fundamental socioeconomic causes lie, so if Westminster takes a different direction then that would have an effect on Scotland, certainly. On the whole systems approach that we've been talking about, should we be embedding work to tackle health inequalities across all statutory services rather than just health? And to what extent does the panel believe that this is currently happening or not? That comes to me, I think, to the heart of the matter of our inquiry, Gillian, if I may say so. Can I maybe go to Jerry first of all? I think that the short answer to your question is yes. All public services and indeed other services provided by other providers make a contribution to the things that make populations healthy or unhealthy, whether that's police services, housing or health services. They all matter and they all make a contribution. They all need to provide those services in accordance to the level of needs that people have. So there's a great cartoon that I might try and describe that if you have an equal approach to systems and you have three people of different heights and they're trying to look over a wall, that equality doesn't help everybody to see over the wall but an equitable approach obviously has the biggest box for the shortest person so everybody can see over the wall equally. So that's a kind of visual representation of proportionate universalism that Claire talked through and to a degree all services need to be sensitive to this and that's really difficult when you're running services that are facing sort of overwhelming needs at the moment so health services for example have got this massive backlog following the pandemic of unmet need in the system and that's really difficult. People are really stressed, they're really tired, they're still working in difficult circumstances with people still being off sick and such like and so trying to add in that sort of equity duty and try to help people manage waiting lists and manage demand and need in a way that's very sensitive to that is really challenging because as Claire's alluded to in some ways if somebody doesn't turn up to an appointment that's great that's one off your list but of course those are the people who need that system most and so the temptation to kind of reduce your waiting lists or reduce the scene demand in the system in those ways I'll give a health service example but this applies equally to pretty much every other system that we have so we need to kind of resist those temptations and it's almost the people that don't turn up that you know decline appointments that don't respond they are the ones and greatest needs it's the unseen people who you need to have the most sensitivity towards and make the biggest efforts to to try and encompass and I used to be a doctor a proper doctor if you like and I did six months in psychiatry and I'm going to tell you a short very short story but it's horrific and it embarrasses me but I want to to illustrate sort of some of the the problems of this so when I was on call for a horrifically long shift over a weekend and we saw people who were perhaps intoxicated but needed some sort of psychiatric assessment the way of us managing that demand was to give them an appointment for 9 am and a Monday morning knowing full well that they wouldn't turn up and I'm so ashamed that I was part of that system and I hope and I don't think it would happen now but that's the kind of thing we just need to eradicate from all our public services is to make sure that actually those people who need the system most get the best access okay Claire would you want to come in in this yes that's a very clear thank you thank you thank you yes I think that's an important an important question I mean I think in we heard a lot over the last two days at events about stigma and discrimination in services and I I found that shocking and I suppose I hear a lot of that sort of thing from our member organisations but I found that very shocking and you know somebody somebody said that you know that there is nothing there is nothing in terms of sort of resources or anything that would stop and prevent our public services being more compassionate so yes we know services are hugely under stress workforces have been through the pandemic and everything else that's going on so it is very difficult but there is something I think there's something at one level about you know what what is the art of the doable and having having as red services that focus on people's right to health and that are non-discriminatory and that are non-stigmatising I think is is really important and something that could be done in terms of progress in relation to policy and legislation and opportunities there I think things like the good food nation bill that is going through just now that we're in danger of missing opportunities there I think in terms of what could be done in relation to people's access to healthy food and the food environment and the get this word right the obesity genetic environment that some people live in there's also a public health bill that will be forthcoming the national planning framework for these are all non or some of them are health related but they're not you know they're the they'll be scrutinised by committees other than this one if there's influence this committee can have in relation to the outcomes of those particular pieces of legislation that would be that would be very welcome it comes back to I think our general health committee ethos is that we think that every portfolio should have a health aspect in it because quite a lot of the drivers of health inequalities don't actually sit in the health portfolio I guess that's that that was shown I mean you just have to talk about transport for example quite a lot of the people that we spoke to on Friday and Monday talked about the cost of transport and it was the biggest thing for them or the cost of of food you know and that was having an impact on their on their health and their ability to access services as well I don't know if David Walsh wants to come in on Gillian Mackay's question or nothing specific to add I mean as researchers were forever coming out with recommendations and I remember a previous large report we produced we had a lot of recommendations about using this sort of world health organisations approach to health and all policies and so yeah we would sign up to that but as Jerry's alluded to you know it's one thing the rhetoric is one thing in in in pressed services and that kind of environment doing it is another there's also issues about you know the socioeconomic duty on councils to to always look to the issues about what impact their policies have on poverty etc so these are all really good things it's the the practical aspects of embedding them in everyday managing of policy and services that's the issue. Gillian Mackay you want to come back in? We've obviously been talking about income a lot what to what extent would the panel support a universal basic income or a minimum income guarantee or something like that as a way of tackling some of that income inequality and therefore the health inequalities that result. Jerry. So I need to declare a couple of interests first so I chaired the Scottish citizens basic income feasibility study and I'm on the advisory group I think it's called for the minimum income guarantee work so with those hats sort of on or off I think a UBI is a really promising intervention because it could move more people out of poverty and reduce the precarity in people's income streams and allow people the kind of the security of income security to thrive but there are a number of risks to the policy and there are a number of considerations about how it would be financed and so we had recommended that it be piloted but we don't yet have the cooperation of the necessary UK agencies to allow that sort of piloting to take place so on that basis looking at a minimum income guarantee so using the existing powers within Scotland to sort of shore up the holes in the benefit system to ensure people don't fall through the cracks and experience poverty I think it's a really promising approach that could hopefully reduce the number of people who experience in poverty and all the consequences that has. To have a gremlin in the room someone speaking to us from beyond I'm not sure but we did hear everything that Jerry said. Can I go to Emma? I had a quick question on this before I go to questions from Sandesh Gohani. Emma Harper. Thanks community it is just a quick sub to kind of go back to what Evelyn was saying and what Gillian was saying. Rishi Sunak could make changes in policy that would address cost of living crisis which we're probably going to see exacerbate health inequalities so like national insurance has gone up we've got people in fuel poverty we are seeing people choosing between heating and eating maybe luckily we've got summer weather coming now universal credit being removed or or like a portion of the uplift was taken away so what is the barrier for the finance secretary for like making a windfall tax or or actually addressing some of these issues why is it a political issue or is it just I mean what are the constraints? Jerry? So yeah these are all political choices if we're honest so if you look at the so inflation's not unique to the UK or to Scotland that's happening across many many countries sparked by you know higher oil prices gas prices food prices and different countries are taking different approaches so I gather in Germany for example the costs of public transport have been slashed partly to reduce people's demand for oil and cars to have spin-off benefits for people's incomes as a result and environmental you know positive environmental consequences by reducing car travel so there is just one very specific example of the kinds of variety of approaches that we're seeing across the world so each country you know in each administration will make their own choices about this but it's ultimately a question of priorities and I think if the cost of living and the inflation cost that people are facing is not addressed by policy then it will have massive consequences for the real experience of poverty and as a result will have real consequences for people's health and the trends that David has described in such detail around the the rising mortality for our poorest communities that will get worse and it will get worse faster if these challenges aren't addressed properly. David Finch would like to come in. I'll bring David in. Sure, thank you. I mean I was initially going to comment on the the UK I think but I mean on the cost of living crisis so I mean as Jerry was saying it does come down to choices and we saw through the pandemic that it is possible to put into place some quite significant support at relatively short notice and I guess a concern of ours would be the kind of the remaining resilience of families as well where you've already you know they've already gone through the pandemic and lower income households in particular are more likely to build up debts through that period so then coming into a kind of cost of living crisis where they're also likely to face lower income households and likely to face the higher inflation rates they kind of knock on health impacts of that are are a significant concern but I think that the point is it is it's something that is that can be tackled through or the extra support to help cope with that is something that can be tackled through sort of increased government support whether it's through the benefit system particularly which would be the kind of quickest route to get support to lower income households. Thank you David. Can I go to questions from Sandesh Gawrhani, Sandesh? Thank you convener. So I just wanted to talk a little bit about evidence data and and successes that we have. So was it Scotland have said that we need far more robust data and there seems to be a theme that runs throughout health we just need far more robust data on long-standing health inequalities and you know when I was training at medical school back in 2000 Glasgow was used as a place of great inequality this was back in 2000 so what are the data caps that we have and how can we step up how can Scotland step up to try and fill in this information so that we can get more robust data. So there are different types of data obviously. I think Claire's articulated very vividly qualitative data and the importance of lived experience and I think there's much more we can and should do to gather and feed that into policy making but in terms of quantitative data and monitoring Scotland has the best monitoring system in the world bar none for monitoring trends and health inequalities so every year in March this year the Scottish Government published the long-term monitoring report on health inequalities which is simply outstanding in terms of the detail it goes into in terms of overall mortality trends by different groups and the different trends for specific causes of death well-being measures a whole range of things it's a thoroughly good and clear read and it undertakes a series of statistical analyses to look at gradients gap measures the absolute trends as well so I think we need to keep those really high quality data systems that we have in place so I wouldn't say that the problems we have in Scotland are in any way related to gaps in data however as a researcher and somebody from a university we'll always want more so there are gaps for example around understanding the health of ethnic minorities gypsy travellers other equality groups and there are means by which we could get that through linkages of for example the census with health records and that has been done previously so the scottish health and ethnicity linkage studies the shell study led by Raj Bhopal did that in the past and that uncovered a lot of interesting statistics about the differential experiences of different groups in Scotland so for example in that we learned that white scots had lower life expectancy and all the other ethnic minorities but hospitalisation rates for some specific things were higher for some of our ethnic minority groups so we could do more of that routinely and we could also do more around individual measures of socioeconomic position for example occupational social class or educational attainment or income so in the past we've looked at trying to encourage parliamentarians to include income questions in the census that has always been seen as too controversial but actually that would fill a massive missing gap in what we currently know about the experience of inequalities of all sorts in Scotland it would also be ideal if we could get linkage to DWP and HMRC data so we've been asking for this linkage for more than a decade now and we still don't have this linkage and that means that we can't do individual level studies on the whole population of the impacts of things like sanctions policies on benefits we have to rely on some of the panel services we have like understanding society which take a sample of the population and allow us to look at those impacts but we could look at that on a much more local level if we had that full data linkage and indeed the digital economy act a UK act should facilitate some of that but we're still finding a number of administrative barriers to actually accessing the data and doing those studies. David Walsh would like to come in if I can bring David in from remotely. Yeah I'm not for the first time Jerry's just said what I was about to say I had three points and then after saying I want to come in Jerry then addressed all three of them but just in response to and to echo what Jerry said in response to the question the issue isn't to do with the data the issue is the horrific things that the data are showing that's important to realise that thing. Sandesh Yeah and just looking so Jerry you talked about minimum unit pricing as a as a marker of success there is a bit of controversy about the success of minimum alcohol pricing how good it's been and also whether increasing it or not would make a difference and I'd be interested to know a bit more from yourself. So in my previous job I was heavily involved in the minimum unit pricing studies and they're still underway so we have really strong theoretical evidence that this will have a positive effect and an equalising effect and the early studies do look to show that it is having a positive effect and it is being equalising in terms of mortality and hospitalisations but those definitive studies will be reported to Parliament before the end of the sunset clause and you know that will be the definitive point to make that judgment. What I think you're alluding to is about the the level of MUP so what was set in the original legislation has eroded with inflation over time so the number of products that would have been affected has decreased over time so the effectiveness of the policy might not have kept up with prices so arguably it could or should be index linked or increased at least to try and remove those high strength cheap sources of alcohol and keep them out of the system because they are they are the most damaging to to people's health. I don't know if anyone else would like to come in on this, Claire. Could I come in on the previous question which was the one about data where largely I agree entirely with Gerry but I suppose just to add that you know third sector is a source of very rich qualitative data and it's not taken up and used by any means to the extent that which it could it could be and and made useful so I suppose that that is one sort of point one point to make but I think there's also a question about access to data as well so who gets access to data and how that's used and again I think for our sector if there was better access to data sometimes we would be able to develop responses and approaches and services better and then I think there are there are data gaps in relation perhaps more to the types of health inequalities that relate to service provision and I'm thinking of a particular example and it is work that voluntary health Scotland has been doing for a number of years now with mental health charities and the mental health welfare commission and in fact all that Scotland and the care inspectorate were involved as well looking at the inequalities that people with serious mental health conditions like schizophrenia and bipolar condition face when they reach 65 because for some people they're then moved into geriatric as it's called mental health services and they lose things like their community psychiatric nurse they're overlooked they become missing in terms of the services that are available and we we have been frustrated in our ability to get policy makers to take this serious as an issue because there isn't data and we had NHS health Scotland knowledge services when NHS health Scotland was still around helpers do literature reviews and look at this that the data on older people's mental health simply isn't gathered so there are and that's just one example and I think again across the third sector you would find because a lot of charities will work on single issues or with a particular sort of population group or groups with particular conditions so I think from our sector's point of view the data isn't necessarily always there that would help actually back up what organisations and services experience in in practice on the ground but then haven't got the data in order to make the case to advocate the policy change. Thank you. Can I bring in David Balls? Yeah, it was just to go back to the first question which is about alcohol minimum unit pricing, sorry. It's just the question related to the controversial aspect of it and I think what the questioner was alluding to was an output from a right-wing think tank which had coverage in the Daily Mail about this not being an effective policy and I think it's quite important to say that that wasn't really evidence-based at all and all the robust evidence from modelling and all the work that Health Scotland has since done is that this is an effective policy but as Gerry alluded to, the price level is what's important whether that needs to go up but I don't think it's a controversial policy on the basis of all the evidence and the robust evidence that's been produced. Can I bring in David Finch? Sure, sorry and I'm going to jump back to the data point, sorry to move between them. I mean I agree with what other people said and particularly the administrative data point where we've had research for a funding with the University of Glasgow that's been waiting for three years to get a data linkage with PWP data to link to books and science, drug and alcohol death data which is frustrating but I think the wider point I was going to make is just about the strand of the research within our review is looking at the kind of data that is available and potential gaps there and I think although admittedly as I think David Lawshett has already a comprehensive report published on health trends but I think one thing in particular doing is speaking to people who use the data and more practitioners about the presentation and how they interpret it and whether it suits their needs which I think is a link slightly to I think the point that's been made about the voluntary sector so that's something that we'll be very happy to share when they finish that element of the work. Thank you very much. Sandesh, why don't we get a comment before we move on to questions from Emma Harper? I think it's very important that people don't put words into the mouths of the questions. I was asking a question, I certainly was not referring to a right wing think that tank and I do think that that was very appropriate. Emma, I am going to answer on human rights issues as well but I'm going to leave that to end because my colleagues want to come in on some quite substantive issues. Can I go to health and equality impact assessments? Emma, you want to ask some questions on that in our country, Paul Cain, on Covid-19? Sure, thanks. I will be pretty quick actually. In our private sessions, one of the persons that was given us information said that equality impact assessments are not being made routinely in planning, for instance, and that a wider engagement of thinking about how people access services needs to be considered as well. If you have any thoughts about how equality impact assessments could be done better in order to support tackling health inequalities? Yes, I think I meant to mention health and equality impact assessments in my opening statement and forgot to. I would be interested to know the extent to which health and equality impact assessments are used already and I haven't been able to find that out so if the committee were able to find that out I think that that would be interesting and important because ostensibly, certainly we would say if health and equality impact assessments could be used routinely across the board in decision making and planning, whether that's through the national planning framework structure for example, but other types of decisions as well, any kind of decisions across public services or public policy, public decision making, we would think that that would be an easy thing that could at least be done, but of course the danger is that it becomes a tick box exercise, but I have no evidence really of the extent to which impact assessments are used and how and whether they have been used successfully so other colleagues on the panel might have better answers than I on that, but certainly in principle yes, we would support greater use of them. Do we have anyone else who wants to come in on equality impact assessments at all? I wouldn't press you if you don't want to come in, but Jerry? So my recommendation would be if you're really interested in this to speak to Margaret Douglas at the University of Edinburgh, who's Scotland's lead expert on all things impact assessments, she would be your source of knowledge. Thank you for that recommendation, and certainly with regard to Claire's question, it's a question that we have as well, and it does strike me that if you do an equality impact assessment, it can save you problems further down the line when you launch projects and put policies into action. Emma? I think obviously down the line in our inquiry, we might have more clarity on equality impact assessments and how they are used. Claire's already said that you would support that further use of equality impact assessments as well, so I would be interested in hearing the thoughts on whether it should be a requirement for public sector organisations just to conduct health equality impact assessments and that we would have health as part of every portfolio then. In principle, we would support that. Indeed, in our response to the consultation on the national planning framework, for example, that was the main thing that we called for, and we are not experts in planning. It was a very difficult consultation for us to get to grips with, but that seemed like a very clear ask that we could make. Yes, in principle, but again with the caveats that if it's made a duty, then it has to be a meaningful duty, and I suppose that needs to be backed up with training and understanding in the part of decision makers and services as to what it actually means so that it's a meaningful exercise and not just a tick box exercise. Thank you. David Finch was to come in on this. David? Yes, thank you. I just wanted to add that we have a programme of work called that we call economies for healthier lives, which is thinking about how economic development can be used to help and improve health. One of those projects is with Glasgow City Region and led by Jane Thompson with Glasgow City Council. That is effectively looking at how developing a capital investment health inequalities impact assessment tool, and it's really exploring how that can get just the design of it and also how it can be embedded at the different stages of capital investment projects. I think that it's potentially something that can we'll be able to give you some more information about maybe some of the challenges and doing that and the effectiveness of doing it as well. Thank you. Emma, can I move on now? Thank you. I come to questions on the impact of Covid-19. No Health Committee would be the same without that line of questioning. Over to Paul Cain. Thank you very much, convener, and good morning to the panel yet. I think that we can't escape Covid. We've lived two years of pandemic. A lot of the call for evidence submissions reflected the Covid experience. I think that our informal evidence sessions over the past few days, a lot of the conversation has been dominated by Covid and by the impact that it's had and the barriers that that's created to people improving their health. The first question is what has been the biggest impact? We've obviously seen an impact in terms of people's physical health, their ability to get out and about and access healthcare and things like exercise, but we've also seen a number of policy initiatives designed to tackle health inequalities paused or deprioritised. Is it too early to say what the impact of both of those things have been and perhaps what's been the most serious impact? If I understand the question correctly, it's kind of thinking in the round about the impacts of the pandemic. I'd refer the committee to a paper that Margaret Douglas, who I referred to earlier, led on that was published in the BMG early on in the pandemic, where we did a health impact assessment of the unintended consequences of physical distancing measures. Clearly, there are the direct impacts of Covid, so the mortality, the morbidity of the long Covid that people experience, and then there are the plethora of indirect impacts, some of which are healthcare related, so the postponement of healthcare services or people not coming forward expressing needs for healthcare services, and then through a range of other things, so people's jobs changing, people's experience of education changing, people's experience of childcare changing, people being stuck in the house, potentially with abusers, transport changes, so we saw a massive decline in road travel with really positive impacts on air pollution for a time. We saw reallocation of road space towards active travel for a time in some areas, some places have retained that, other places have removed that. People's finances changed, so some people were able to save for large of the middle classes, other people had their incomes reduced, who were perhaps already in precarious employment, maybe couldn't access the furlough scheme. So that's a complicated pathways. The net impact of course has seen a rise in mortality and a rise in mortality inequalities that peaked previously, things have improved since the worst aspects of the pandemic, and a lot of that was direct Covid mortality, but actually we saw a rise in indirect mortality as well from other causes, and we're not as clear about just quite what's behind that, so some of it might be coding issues where Covid's a contributing factor, but it's not recorded in the process of looking at people's journey. It might be through these other factors, people losing jobs, stress, it could now be the cost of living crisis and the cumulative effects of austerity. So disentangling that and attributing what aspects of the round Covid experience had on specific health experiences is difficult, but I suppose the worry that I have is that if we return to the economic policies that we saw prior to the pandemic, then we can't expect the improvement that we've seen to continue. It will go back to the same flat line that we saw from 2012 onwards, and although we've talked a lot about mortality, healthy life expectancy has been declining for that period, so when you combine mortality experience with people's self-reported health, that's been getting worse since 2012, so I think that's the worry that that continues in that trajectory. It's hard to add to Jerry, so I don't want to repeat. On top of all that, the worry that I suppose in our sector now has expressed over the last six months or so, as things get back to a bit more of normality, is that people are still on very long waiting lists for health care and are still having difficulty in terms of accessing health care, but other services within communities still haven't opened up fully, so some third sector organisations can't reopen lunch clubs and day care and things like that because public sector community centres still aren't open in some cases. On Good Morning Scotland this morning, they were talking about swimming pools for children in Glasgow still not open, so I think there's those wider impacts that do impact on people's health. Voluntary Health Scotland just yesterday was a signature, along with Versus Arthritis, the charity Versus Arthritis to the Cabinet Secretary for Health, specifically about waiting lists, hospital waiting lists for, the letter was specifically about elective care, but I think it goes wider than that. One of the things that the third sector has been looking at, so organisations like Versus Arthritis and British Red Cross, has been how what can our sector do to support people to wait well because things are not back to normal and you have people who've got all sorts of medical needs, health needs that are not being met through the NHS for all sorts of reasons, but what can our sector do to support people to actually self-manage, to manage the mental distress about that and to wait well is the phrase, but yes, thank you. Yeah, I wonder if I can. So I think that that's very helpful in terms of that broader context and I think the important part of any Covid inquiry has to be looking in quite laser focus and a lot of these issues and to try and then understand the impacts and effect. I wonder if I can get a sense of, and I suppose that Clare you've alluded to some of this already, but there were some kind of unintended positives almost that came out of the pandemic and that was probably about communities coming together in a way that they hadn't before, voluntary health organisations in particular really stepping up. How do we measure that and how do we protect that going forward, because I think that we want to see investment in those sorts of software services that have made the difference for people. A really interesting point, yes. I think the community sector and the voluntary sector did a step up and aimed to fill that gap when there were lockdowns and other services weren't necessarily available. I think what's interesting in terms of positive outcomes is that the voluntary sector has had to change a lot of what it does, so in terms of making services available via telephone or via digital internet, which didn't happen anything like to the extent that it does now, a lot of organisations are now doing both because for some clients, for some service users, for some people it actually works better for them or works as well. So I think that a positive outcome has been that there's more options and choice for some people in relation to certainly third sector services. In terms of funding, I think that we saw not least actually Scottish Government, but a lot of independent funders as well. They made funds available quickly to the voluntary sector so that the voluntary sector could pivot, that was the word that was being used, could pivot from its normal services to do whatever was needed to reach out to people and support them. That funding was very welcome and I think also funders flexed existing requirements on existing funding that had already been allocated. So there's a lot of flexibility and what we hear now from our members is that a lot of that, the old bureaucracy is creeping back in in terms of those sort of relationships. I suppose one of the things we would want to see is that spirit of partnership and of trust of the voluntary sector, we were trusted to get on with it and deliver in times of deep lockdowns so can we not be trusted now to carry on with that. You've alluded yourself to the need for sustainable funding, so emergency funding, short-term funding has been very welcome, but longer-term our sector still faces enormous difficulties in terms of sustainable funding and not lurching from one short-term funding package to another. So something in relation to funding would be very welcome, but flexibility in terms of bureaucracy also goes a long way. I said that I was going to leave human rights to the very end because it's actually gone through quite a lot of what we've been talking about in human rights to live your life well, I guess. It's fundamental. Talking about conversations that three out of four of you have not been partied to in terms of our informal evidence sessions is very difficult, so I won't put out specifics there, but it struck me in speaking to people seeking asylum that we spoke to, people who were advocating for family members and friends in prison, we heard about gypsy travellers, we heard about people with no recourse to public funds. The thread that is going through a lot of the conversations that have been made with them is that they don't feel that they are getting access to their basic human rights. I wanted to ask what would a human rights approach to tackling the structural inequalities actually look like and what specific interventions could be made in order to make human rights the thread that runs through absolute delivery of all our services, regardless of whether people have recourse to public funds or not? Whoever it is in society in Scotland, what would that actually look like? Huge question. You can see why I left it to the end, but I'd like to particularly struck by what people told me about our prison population—not getting access to healthcare, not getting access to their medication even though they've got chronic health conditions when they go in prison or come out of prison. That's going to stay with me for a long time and blew my mind, frankly. There are other people who feel that they're not getting access to healthcare that are from marginalised communities, so what do you think that there could be interventions in making sure that those people do get access to the healthcare? That is a really enormous question. One of the things that did come through from those informal sessions was that people didn't know that they had a right to health, so that perhaps needs to be one of the starting points. Why do people not know that they have a right to health? In fact, the work that we published for the inclusion health partnership earlier this year, which was looking at the experiences of Covid amongst marginalised populations, the strong message that came through that as well, was that people didn't know that they had a right to health, they didn't know that they had a right to a GP, for example. There's something about maybe a targeted approach, again, in the way that actually there have been targeted approaches in relation to gypsy traveller populations in terms of helping them to understand they have a right to register with a GP, for example. Targeted approach to helping people to understand their rights, but I suppose that the flip side of that is that service providers, decision makers, all of us, and I would include the third sector in that, not just public sector, and actually I suppose private sector as well. Everybody, wherever you are out in the real world, there needs to be education and training for anybody who's providing a public service of any kind, what people's rights are. I think that those would be my two things that I would focus on. Jerry will know more about this, I'm sure, but there's different frameworks and toolkits and things like the panel principles and the AAA framework and those sort of things that I think would help public services, workforces and public services to understand how to embed a more human rights approach. I think that the starting point, if you've got people understanding, they have a right to health and other rights as well, rights, human rights, that has to be a step forward. Thank you. Can I come to David Walsh? We'll just unmute David Walsh please. Sorry, I was just waiting for the microphone to come on. So just to point you to that there were people in health Scotland before it became public health Scotland who were looking at a human rights approach in relation to inequalities, so it might be worth speaking to them in terms of how that work developed. More generally, in just returning again to the evidence about how you address broader health inequalities, I've talked before about those three levels that have been identified as being important, and the third of those was about individual experiences of inequalities, and that talked about particularly targeting people at high risk, so children in care and the homeless. To that list, I would add the groups that you've mentioned in terms of prisoner population and asylum seekers. Asylum seekers also bring back to the whole politics of it all in terms of the way that asylum seekers and people seeking refuge in this country are currently being treated and discussed, and I don't need to say much more about that. However, it also comes back to the issue of what I've talked about quite a lot, which is social security. Having a social security system as a human right in terms of a system to protect those in times of need, rather than a system that has been attacked in recent times. It's a huge question, but it ties back into a lot of the themes that have come through this conversation this morning. Jenny, I don't know if you've got anything to add to that. I'll be brief. The groups that you discussed all have very high needs, and we need services that are built around those needs and built in deep collaboration with those groups. They don't lend themselves to place-based approaches, which is why sometimes we need to find those equity groups with high needs or different needs, groups that might not find easy to access services, services that aren't designed around them. We need to think about how we meet those needs differently. Every public service and other services that aren't provided by the public sector need to think about that. It also speaks to power inequalities that I mentioned at the very start. Those are all groups that are, in one way or another, made powerless, either by dint of being relatively small compared to majority populations or because they are silenced in some way or other. I guess that the prison population is a classic example of that. The reaction in some arms of the media when we think about even giving prisoners the vote means that, even at the very basic level of hearing the voices and the needs of particular groups, we are not able to hear that. It is maybe a shout-out to think about different models of democracy. We have seen more participatory methods used to discuss where there are trickier issues and where particular groups are more affected. That is perhaps something that could be considered where we are designing services for high-risk groups like that. I probably should not refer to it as high-risk groups with greater needs. That is a better way for me. I am going to round off the session. Thank you so much for the time that the four of you have spent with us this morning. It is very interesting and a very good start to what is going to be a very important and interesting inquiry with some recommendations at the end of it, which we must always remember. Thank you very much for your time at our next meeting on 31 May. We will continue to take the evidence as part of the inquiry into health inequalities, focusing on the impact of the pandemic on health inequalities and the work to tackle them. That concludes the public part of our meeting today.