 Good morning, everyone. Welcome to the 12th Meet of the Health and Sport Committee. I can ask everyone in the room to ensure that their mobile phones are in silent. It's acceptable to use mobile devices for social media, but please don't take photographs or film precedents. The first item on the agenda is subordinate legislation. We have one negative instrument. That instrument is the general pharmaceutical council amendment of miscellaneous provisions and rules order of council 2016, SSI 2016-108. There has been no motion to annul and the Delicated Powers and Law Reform Committee has not made any comments on the instrument. Could I invite any comments from members? If I may, convener, I think it is the case that previously only pharmacy professionals from outside the EEA were required to demonstrate appropriate knowledge. A new legislation has extended this requirement to professionals from European countries. I just want to say that I fully appreciate that there is strong support from the health professions for this requirement, and that patient safety is at the heart of it, but I just like to note that the law society has previously raised concerns. It noted in 2014 that the proposals for language controls for health professionals raise equality and discrimination issues and may give rise to issues of direct race discrimination, which can't be legitimised through the principle of proportionality. I just like to put on the record that I hope that this requirement comes along with the adequate support for these professionals to learn English if required. Thank you. That is now on the record and hopefully that will be taken on board as this goes forward. Any other comments from members? No. Can we agree to make no recommendations? Thank you. That is agreed. The second item on the agenda is our third evidence session on mental health, and this session will focus on adult mental health services. We have a cast of thousands this morning, so I will begin by introducing myself. I am Neil Findlay. I am the convener of the Health and Sport Committee and MSP for the Lodians. If we could go in this direction and people just briefly introduce yourself, not your biography, just a brief introduction. I am Bob Leslie. I am the chair of the Social Work Scotland mental health subgroup representing Social Work Scotland, and I manage mental health officer services for Renfrewshire Council. I am Claire Hawkey. I am deputy convener of the Health and Sport Committee and the MSP for Rutherglen. I am Tom Arthur. I am the MSP for Renfrewshire South. I am Caroline Lockhead. I am the public affairs manager at SamH. I am Miles Briggs, concept of MSP for Lodian. I am Chris O'Sullivan. I am from the Mental Health Foundation. I am Donald Cameron, MSP for the Highlands and Islands. I am Andrew Fraser, director of Public Health Science at NHS Health Scotland. Good morning. I am Alex Cole-Hamilton. I am MSP for Edinburgh Weston. I am also the Lib Dem Health spokesperson. I am Alison Johnston, MSP for Lodian. Good morning. I am Richard Lyle, MSP for Oddingston and Belsil. Good morning. I am Colin Mackay, chief executive of the Mental Welfare Commission. I am Marie Todd, MSP for the Highlands and Islands. I am also a pharmacist specialising in mental health. I am Lucy Mulvey, director of policy and communications at the Health and Social Care Alliance Scotland. We are co-conveners of the Health and Social Care Action Group of Scotland's national action plan for human rights. I am Mia Collins-Smith, MSP for South Scotland. I am Alistair Cook, chair of the Royal College of Psychiatrists in Scotland and of the Scottish Mental Health Partnership. I am Ivan McKee, MSP for Glasgow Provin. I am Wendy McCoslyn, who will join us when she arrives. Alex, would you like to begin? Good morning to everyone. Thank you for joining us this morning. At the end of last year, our earlier mental health strategy kind of expired and we have been treading water with that ever since. We have now received a draft strategy that is being consulted on. I wonder if the panel can give us their reflections on what the opportunity cost has been of the delay in producing a draft strategy and whether they think that this answers the challenge of mental health in our society in terms of what they see in the draft strategy. Who would like to kick us off? I will start. I think that we have worked with a number of partners in looking at the strategy over a good period of time in the Scottish Mental Health Partnership. I think that the delay is probably less of a concern to us than at the moment our perception of what was in the engagement document as a lack of ambition within the proposals that have been brought forward by the Scottish Government. I think that we would rather see time taken to get a strategy that is really right for the time that we have now in Scotland and that produces a transformation in where mental health services are going in Scotland. At the moment, I think that the engagement document has tended to focus as previous strategies have on how we make mental health services as they exist at the moment better and absolutely behind that and I think that that is really important that we need to do that. I think that the partnership and stakeholders across Scotland would want to see if we are genuinely looking at a 10-year vision for mental health. Something that takes us beyond good mental health services and starts to look at how we improve the mental health of the population of Scotland and how we begin to identify what we can do at the local and national level to produce better mental health across our whole communities. There are a whole lot of things that can help us to do that. NHS Health Scotland has co-produced with COSLA the document Good Mental Health for All, which is a really helpful document in directing in some of the way. The other area that we would push for in terms of the strategy is that if we are going to do some of this, then we need to be really thinking about whether there is a commitment at government level to resource that mental health strategy as well as produce that. There are a couple of opening areas that we would be keen to discuss. If I am making a follow-up on that, I am grateful to you for that. I think that everybody would agree that we do not want to rush out a strategy if it is the wrong one. That lack of ambition that you describe, is that primarily characterised by the barrier of resources? Is this a cash issue? No, I think that it is both. I think that there is a lack of ambition in a sense that what was set out in the consultation document at this stage was a series of actions, most of which we would support, but that did not have an overarching aim or objective behind that. I think that the lack of resource is a particular pressure. Of course, it is a pressure across all health services at the moment, but what we are seeing certainly in recent years has been that in terms of efficiency savings within health service and local authorities are being applied across the board. The new money that has been identified that is coming into mental health services goes nowhere near matching the efficiency savings that are coming out. Boards naturally tend to respond to the pressures that are placed upon them to where the urgent need for money is. That tends to focus in on the acute services. Overall, we would see that the proportion of spend within health and social services on mental health certainly feels like it is dropping. I do not have the figures to give you that ideal, because it is difficult to get accurate figures around that, but certainly there is a sense that the proportion of spend is dropping across mental health and social care services. If I am right, the proportion has dropped from something like 12 per cent five years ago to nearly nine per cent now. Do you have a sort of figure—the GPs ask for 11 per cent— that you would have in mind on that? No, I do not have a specific figure in mind. Can I bring in Carolyn? Just in terms of the question about whether this meets the challenge of what we need from a new mental health strategy, I think that there are things that are looking positive in the draft that we have seen before the election. We asked for a 10-year strategy. We have had three-year strategies in the recent past, and we were pushing for a 10-year strategy, which we have got and are very glad of. I think that the eight priorities that were in the engagement document were good and we would support them. There are additional things that we would like to see, which we will no doubt get on to. Particularly, we are keen to see something more on employment, more on primary care and more on psychological therapies, particularly. I think that the approach overall that we are really looking for prior to the election, we talked a lot about the idea of an ask-once-get-help-fast approach, and that came from when we spoke to people who were in need of a mental health service of some kind. Often what we hear is, do you know what the service is generally quite good once you get into it? That is not uniformly the case, but it is something that we hear quite often. It is actually getting to the right service or the right support that is the difficulty. That is why we, Alistair, mentioned the need for more ambition and more of a vision, which we definitely want to see a clear vision for this strategy and for us. That should be about transforming the culture of mental health, not just in services but really broadly, so that at any point when you need help, whether that is in a health service, in school, in employment, you are able to take that ask-once-get-help-fast approach so that you do not have it. It takes a lot of courage to seek help for a mental health problem, and you should not have to summon up that courage more than once. You should be able to be rooted to the right source of help when you first ask. We hope that this new strategy will really help to transform culture so that that becomes the case. In the NHS Scotland evidence, they say that estimates suggest that only one in four of the significant symptoms of mental health problems are receiving treatment. Clearly that is not happening. Chris. Thank you very much, convener. Thanks for the question. What are the challenges that we foresee in that? I should explain to the committee. We are a national charity focusing on prevention in mental health, and one of the great opportunities with a decade-long plan is that you can play the medium to long-term game, and that is where prevention sits. We firmly believe that addressing mental health across policy areas is a skeleton key that can unlock quite a few of the challenges that we face in Scotland in the years going forward, and I know that the mental health partnership shares that. A jewel in the crown of doing that should be equitable, accessible mental health services, which are based on a human rights-based approach and enable people to get help and move through that help on to recovery. You would think that that was a simple ask. It is not necessarily, and we have worked to do that. Equally, we would very much like to see a 10-year strategy which focused both resource and ambition across policy areas, including places like justice in children's work, taking forward some of the excellent progress which has been made in the likes of GoFec and others, and in some of the strategies in relation to ageing and working life, and orienting those around mental health. We felt to an extent that mental health policy has been somewhat orphaned in the last two iterations of policy within a very specific set of civil servants within the government, and we would like to see a strategy that firmly placed responsibility for addressing mental health across government as an asset for Scotland going forward. Andrew. The building on points that we have heard already. This is not so much a mental health strategy, it is a mental health service strategy, and as such it is quite adequate. I think that more could be done on primary care, but if we are looking at a mental health strategy, we need to go upstream to the prevention elements. We need to widen the vision. Just as Chris Smith said, we need to look at other areas. There are plenty of other areas where if we built on them or we took seriously and went about the business of implementation much more enthusiastically and comprehensively, we would yield mental health gains, such as parenting interventions, serious attention to bullying in schools, and heading on through the life course, good work and fulfilling work and policies that are in light in their social inclusion at the community level. Back to Chris Smith's point about justice, some people who are in serious trouble where we have good evidence that support for people with complex co-occurring problems, including mental health problems, is effective. Homelessness, I would highlight too. People at real risk there with vagrium health indices, and the flow of human rights underneath it. I think that the strategy could borrow but also build on some of these elements from policy areas other than health in order to create a vision that is ambitious. Just to come back on a couple of points that were made in terms of the time that's been taken, I would agree with people that have said, that we welcome the fact that the strategy has been extended to 10 years, although ideally it would be even longer than that, given that mental health is something that we want to address through the life course. The other thing that we welcomed was the really quite explicit focus on human rights and the rights-based approach. I think that that is very welcome, given that it was only one of the commitments in the previous strategy. I think that if you are to look at achieving transformational change and a rights-based approach, we need to nurture that and that will need to take some time. One of the things that we have picked up on is that we are a bit concerned at the focus in the strategy on only two particular elements of the rights-based approach. Some people use the panel principles, participation, accountability, non-discrimination, empowerment and legality, and in the vision document that they particularly pulled out, only a couple of those. One of the things that we would think is that they are interdependent on the five elements of a rights-based approach. Particularly in mental health accountability is incredibly important, as well as the legality aspect. I know that in the commission's response that you have picked up on points around the mental health legislation, and again we would think that in the future one of the things that the strategy could look to doing is to advise mental health legislation to be more in line with international human rights standards. For example, the Convention on the Rights of Persons with Disabilities. I echo some of the sentiments around the table. Social Work Scotland feels that the strategy whilst welcome is not really transformational enough and is very service-led. Despite having an integral role in the support of people with mental health, social work is not mentioned in the strategy nor is the role of the mental health officer who has a very important role in protecting the rights of the individual at very vulnerable times in their life when they may be about to be placed under statutory measures of care. As has already been said, some of the key groups in society such as those involved with the criminal justice system are sadly not mentioned. Equally, the strategy is not embedded in current policy and legislation and links to things such as GERFIC self-directed support. The integration agenda of health and social care will impact its ability to be delivered in its current forum. Many of the IJBs the strategy is intended to inform the help and strategic planning for the IJBs but many children's services and criminal justice services sit out with the structure of the IJBs and our colleagues in Highland Council and NHS Highland have a completely different model of management and structure so there are a number of challenges around and that's really just an open position from SWS. Go on. Thanks very much. I'm still going to come with anything new after that. Obviously we generally agree with those that make a couple of points. One about how you do the strategy if you are genuinely talking about a 10-year vision and I think I would generally echo the view that there's quite a lot that's welcome in this but it does feel like a three-year mental health services plan rather than a 10-year vision and in a way that's not surprising if you're going to sit out to produce that in a matter of weeks because it's a difficult thing to do to produce a 10-year vision and it almost seems a constitutional point if you're genuinely talking about a vision a transformational vision that's going to survive two or three parliaments it doesn't seem to me to be right that the current Government produces it more or less within St Andrew's house and then says is this okay guys that actually what you need to do is have a much more substantive dialogue and engagement with people who use mental health services the wider community and the people affected by the things and people mentally unwell such as poverty and so on and in fact the Government in other aspects of its work has done a lot to commit to broader public engagement recently Scottish Government is at the United Nations joining up on developing citizen participation and it doesn't seem that that approach has fed enough into this it does feel like something that we can commit to doing something transformational over a long time frame and that should be done in a different way the other comment I'd like to make initially is just picking up on the rights point which Lucy particularly mentioned and all policies should be rights based and I think there's a lot in the SHRC submission on a human rights based approach which I think is very helpful in terms of fleshing out the kind of ideas about the panel approach that we'd actually entail but I just want to make the particular point that this is the only group of people for whom who live in the shadow of coercion and I think that's really really important when you're talking about a mental health strategy that ultimately some people will be given care and treatment that they don't want or didn't ask for and that's different from everybody else who accesses health and social care and you can't have a mental health strategy which doesn't actually acknowledge that and there are elements in the current document which we say something about that but that's an area where I think and we might get a chance to expand on this later but just briefly say Scotland about 10 years ago Scotland was probably world leading in terms of rights based approach to mental health care and treatment genuinely world leading and you would speak to people in Northern Ireland people in Australia people in Canada who say we all learn from what Scotland did in the early 2000s we're not world leading anymore and I think you know if you look at something like Northern Ireland it just passed very radical mental health and capacity legislation there is a chance for us to be world leading again but if you're looking certainly if you're looking 10 years out I would find it difficult to imagine that we say in 10 years time the legal framework that was devised in the late 90s is actually what we want in the light of the UN Convention on the Rights of People Disabilities and other things so part of a tenure strategy I think has to be looking reasonably fundamentally at what the framework is for compulsory care and treatment Colin, you I'm looking around the table who would know this but I'm looking at you in terms of the the draft was that produced by somebody sitting in an office in St Andrew's house or was there a working group where you people consulted beforehand before that draft saw the light of day there was engagement I think it's true that the Government discussed with what's engagement some engagements last a while others last a while as I understand the process and certainly as we were involved in the process I think officials from the mental health division came out and spoke to various people of events I remember an event in the hotel opposite St Andrew's house so there were a couple of general events involving some stakeholders and I think some one-on-one discussions and as I see some of what Is that what you would have expected to have happened? I think that's helpful but as I see in the context of a tenure vision I think I would have expected something a bit more structured and substantive than that Defensive of the division but they are saying that the document produced for consultation at that point was very much an engagement document there was some input leading up to it I understand that they've had well over 600 responses to that document and are now working the way through those but again are producing a draft strategy based on that information rather than a further process I understand that we still expect to see this strategy before Christmas We would always expect any draft to be commented on and critiqued but it does seem as though this one has missed the mark pretty widely Colin Smyth Can I touch on the issue of waiting times obviously the Scottish Government has set a maximum waiting time target of 18 weeks from a patient's referral to treatment for psychological therapies and obviously the aim is for that to be met in the case of at least 90% of patients now for the quarter end in June 2016 the figures show that it was it was only met in the case of 81.2% of people so can I ask the panel why they think that that target was missed and do you support the call that was made by SAMH for an inquiry into the failure to meet those particular targets and just one final point later in the agenda we will be considering the petition which calls for the target to be reduced and I'm interested to get the panel's views on whether they think that the target should be reduced Colin Smyth Thank you The target to see people who've been referred for psychological therapies 18 weeks is a really important one and it's one that currently only 81% of people are being seen within that target and that figure has been broadly static for quite a while there's five health boards who are currently meeting the target there's a lot that we can learn from looking into those statistics a little bit more for example we know that Glasgow and Ayrshire and Arran are dealing with quite notably more referals per head of population than other health boards are and I would like to see you won't be surprised to learn that we support the call for an independent inquiry into why these targets haven't been met given that we made that call but beyond that I think there's a lot more that we can learn these stats come out very regularly so we would like to know more about why are particularly Glasgow which is one of the health boards that is meeting the target why are Glasgow able to do that given that they are dealing with more referals per head of population we would like to know more about specifically what therapies are being provided we did some FOIs a couple of years ago now and what we found was that the majority of health boards couldn't tell us much about for example equality's data so we don't really know if different equality's groups are getting more or less access to psychological therapies and we would question why health boards aren't collecting that at least aren't aggregating that in a way that they can then review they weren't really collecting again at an aggregate level details of the therapies that were being provided so they couldn't really tell us what they were providing and obviously that is recorded at the individual level but again if that's not being reviewed at a board level we would question well how do you know what you need to plan for so I think there's a lot more information that we would like to understand in terms of what's the good practice that's happening now and what we can learn there is good practice happening in England the increasing access to psychological therapies programme seems to be getting good results I would note that they are seeing 61% of people within 28 days they have invested in creating 3,000 new therapists there's quite a lot of funding going into that so there's a lot that I would like to see us look at in terms of what we can learn the draft of the engagement paper rolling out computerised CBT for people as part of helping to meet the target which is important computerised CBT has an evidence base and can work for many people but there are also other approaches that have an equivalent evidence base such as one to one CBT such as things like behavioural activation and in the interests of choice we would like to see those approaches that do have just a strong an evidence base being rolled out so there's a lot we can look at we know that there are a lot of people who were waiting at the end of the last quarter I think it was 18,000 people were waiting to start treatment at the end of the last quarter so there's a lot of people waiting for these services there's a lot that we need to learn we would like to see the target come down to be 12 weeks so that it is more in line with other health service targets we're not sure why it should be higher in mental health and just to address your last part of the question about do we support that the target continuing we are doing a bit of policy work internally at the moment to inform our position on the target's review which you took evidence on recently so we haven't reached a final view on that at the moment we are wary of the idea that we might lose targets in mental health because they do drive investment and they do drive improvement but we accept that there is possibly something better that we could do if we took a wider approach particularly on the psychological therapies target where we know a great deal about how long people are waiting for the points in the journey that they go on but we don't really know does anyone feel better at the end of it and what's helped and what hasn't helped so we think the target could be improved but we hope that we don't move away entirely from it without giving it some careful thought I think it's pretty comprehensive interesting to see what others think I just wanted to pick up on it a couple of points that Carolyn made is that I think we're encouraged by the new national targets review in the sense that they say they're going to take a wider approach rather than looking at just sort of a numbers and percentages games of waiting times because of course while waiting times are incredibly important it's also incredibly important to know more about what the quality of the care is what people are actually receiving once they do get access to support and services and what the outcomes are for them so we're very keen to see that they're increasing measurements around personal outcomes approaches and so on and again I know probably a bit of a stuck record in this but we do think that taking a rights based approach and actually if we were looking at taking a transformative approach to mental health and building it on a framework of rights then that would be something that would actually help to underpin a lot of values based around outcomes empowerment of people participation in decision making and things like that rather than just a narrow focus on percentages and numbers Alison Did you want to come in? It wasn't particularly on that issue Okay we'll come back to you then Any other members on this issue Miles Okay Ivan Yeah we're just on that area around about targets to focus on this 18 week target I suppose my question is around the panel considering that in the round is that the right thing to measure should we be measuring other things as well for example what we hear is that if there was more focus spent on what's happening at tier 2 you might be fixing a lot of issues there in advance and they don't get as bad and they don't have to go to tier 3 Is there an issue around about if you divert resources to having that first appointment but then the rest of the process through tier 3 should be is there something in there the quality of the outcome is always important all these things can be measured you can use numbers to measure them ensure that you have a broader range of number driven targets on some other aspects in addition to what's there at the moment I think we've welcomed over the last decade actually since these targets were first talked about and brought in through delivering for mental health the fact that there are targets in mental health what that has done is it's brought mental health on to the agenda at health board level and in other places I'm not sure that the current targets are sophisticated enough to be able to drive the sorts of change that we want what they have done and they've been hugely successful in this is increase the numbers and availability of psychological therapies and of CAMHS therapies but as a gentleman to my right here said what we've seen in CAMHS in particular is that there's an expansion in the tier 3 services but that's meant that it's more difficult for CAMHS services to be able to do work with schools and do other things which is actually a huge part of what they ought to be able to do in terms of psychological therapies we see fewer psychologists and others with psychological therapy skills working in our community mental health teams with individuals with severe and enduring mental health problems because the resource within psychological therapies services is very much moved towards meeting the target because that's the priority so while supporting the need for targets within mental health because it keeps it on the agenda I think that we need to be much more sophisticated in how we look at those targets and really start to think about how they improve outcomes rather than focusing so much on the numbers I think that the focus on targets is a good thing in some respects because it has driven access to certain services that there was a problem with however the danger with the target is that we do see the delivery of services almost on a wide basis of one-size-fits a programme of CBT or a particular intervention in an area and that's what people get offered and it actually doesn't address the individual's individual need and outcome that they're looking for and I think we have to be cautious about targets that they don't always deliver what we might wish them to deliver Chris Very briefly just two things one we would certainly support an equity in mental health and in other areas of health because it reduces people's perception of mental health being somehow different and secondly at both ends of the prevention scale access to psychological therapies is very important it's important that people get rapid access at a first episode of a mild to moderate mental health problem when they need it because it enables them to continue in their job, in their caring responsibilities and all the other things and helps for example workplaces to see recovery from a transient episode of mental health problems critical at the other end of the spectrum as well though and not just in terms of first access and we need to also understand how people with ongoing mental health problems have access to psychological therapies and how they're used and I think there's certainly scope within a 10-year strategy to do some real user journey research about how people use services of all kinds at different points and how that interacts with the targets that are set from time to time Okay So at just one point in relation to targets and stuff you know if we want to change things what should we be reporting on and measuring and counting Yeah Colin Well I think this is the thing about rights and outcomes because of course all targets will as I've gone and started to measure access to one particular kind of intervention may or may not be the right intervention for you I mean my sense of a kind of 10-year vision is actually the role of Government and the role of the kind of Parliament is to set a kind of ambition in terms of outcomes in terms of what we want to change in people's lives now exactly how that change is delivered will change over time and there may be different ways in which you achieve outcomes for people and some of that may be about people having greater choice for themselves about what would help them so you know it may not be that you know a particular psychological therapy is the particular thing that's going to make a difference for a particular person and I think targets certainly have a use if you're saying there's clear under investment in a particular area of care in the health service or in the social care system so therefore we as a Government or we as a Parliament are going to make sure that there's a change in that I mean that's a legitimate short term aim to set a target in terms of the broad ambition is a sense of what the outcomes are for people and get the system to work out how to deliver those outcomes and to do that in a way which actually responds to what people want and this is where some of the things that have been tried over the last few years like self-directed support are all about that they're all about people saying this is what would actually make the distance for me this is the thing that would actually allow me to live a flourishing life rather than just live some kind of fairly impoverished existence but actually some of these things like self-directed support although people with mental health problems could be the ideal customers of those because their needs can be quite individual they can fluctuate they haven't really worked for people with mental health problems because problems around access and the way that systems are designed so I think if you set an ambition which actually is about services responding to people's own sense of how they can get well and how they can maintain good mental health that would allow the system to be more responsive rather than just responding to centrally set targets I don't know if you meant to say customers or not but that just sits very wrong with me that we regard people with mental health problems as customers but anyway could it say customers and I wouldn't say customers you might be inadvertently say that sorry could I raise just a couple of things if if three out of four people weren't being treated for a broken leg and if so many people were dying decades before they should would there be an outcry if it was a physical condition I don't understand why there's not an outcry around these figures and are those the things that we should be measuring people's life expectancy and access to services three out of four the submission from Collins organisation saying three out of four are not getting the treatment I find that absolutely astonishing so is that the type of things that you think we should be recording and analysing Lucy I would agree that it is absolutely outrageous and I just wanted to come in on the question of what should we be measuring and I think the thing is sometimes when we talk about rights and recovery they can seem like quite a theoretical level things or they're to do with courts and legal action and so on but actually there are existing tools that have been created at an international level but for in-country use around how you can indicators on rights and recovery within mental health service settings for example there's the world health organisations quality rights toolkit and also the UN the United Nations has come up with a list of sweet indicators that you can use to measure people's enjoyment of the right to the highest attainable standard of health the right to an adequate standard of living health housing etc etc so there are things that already exist out there that we could be using and adapting for a Scottish context to take into account the realities of our national situation here so just wanted to contribute that Chris I would certainly agree with you convener it would be wonderful if we could monitor the absence of outcry and to produce that outcry and actually on your previous point many many moons ago when Vox was first set up the conference we put together to co-design Vox was called User Consumer Survivor Refuser because of the different senses of identity that people with mental health problems have in the world and one of the challenges we face is giving a voice to some of the most voiceless people in our society people like me who have mental health problems agency and control and education and can come and stand before committees is one thing but there are legion people experiencing compound inequalities, complex trauma who have no voice and are furthest away from agency so if we could begin to monitor some of their experiences some of the injustice that people experience probably through some quite detailed and quite intelligent research that could be extremely useful and Colin brought up self directed support that we've tried self directed support is something which is in law people are legally entitled to self directed support and yet we find time and time again that people with mental health problems are unable to access self directed support either because they don't meet eligibility criteria or because in some cases they're told that self directed support doesn't apply in mental health and that to me smacks of systematic discrimination and that needs to be addressed and it comes back to the point that I made earlier on that is extremely important and that is that your experience of mental health services and the support that should be available to you should be consistent no matter where you are in Scotland no matter which board, no matter which local authority and indeed if you move between boards and are mobile between things and there are some places in Glasgow where you can move between two boards very easily there are places in Edinburgh where you can move between two streets and move teams and you get completely different experience and we need to have a certain set of consistency across the piece Implicit in the strategy, returning to the strategy for a moment it does want mental health mental health care to take its place alongside other types of health and disease so I think implicit in its ambition is a wish for it to move up to be to live alongside physical health conditions and you know for that broken leg to be just every bit as important to treatment for mental health conditions to be every bit as urgently and confidently addressed I think the question to us is how and yes there are all these service responses we've been talking about access to services, the right services the right style of services but I think we need to look in a strategy also at the causes of these illnesses and it goes back to what we want to achieve back to points made earlier about outcomes as well as access and experience of services but also these reasons why people become ill and are unable to climb out of despair or distress because we know the scale of these things, we know ways out of them I think we need to apply that as part of a broader strategy than looking at the health and sometimes social care implications Clare Thank those who contributed those organisations that contributed written reports to the committee this week they've been particularly helpful in particular the NHS Scotland report which looked at health inequalities and the impact of social determinants and health and as you might be aware one of the strands of this committee's strategic plan is to test health policy and health strategy against inequality and how it helps to address health inequalities and we've heard about we need to address this, we need to do something but I'd like to hear what witnesses suggest can be done to help reduce some of the health inequalities and social inequalities experienced by those who have mental health problems and I have to declare an interest here in that I am a registered mental health nurse and it's me again but we've set out in our NHS Health Scotland submission a number of these areas I think the challenge that we've been set by people who've looked at it is not just as of areas of high level intent and ambition but what are the things we're going to do and I think that that's assuming people are familiar with what we've said what can we go on to say about the interventions and I think we cannot dodge the issue of people's means there about income and poverty and the stigma that comes along with not being able to afford things for yourself or for your child we've done things like the cost of the school day now that may be loosely related to mental health but if you can't afford to have your children go out to school and have other children do and be able to afford the basic things that other children do that's not good for mental wellbeing and that's only the start we're dealing with school age so we need to look at fundamentals like that I've mentioned before things like the school ethos the effectiveness of schools we're dealing in other areas of policy with attainment and I've said before about bullying so there are specific interventions about around school and then we get into working age and older age and so on there are things we can do to prevent mental illness occurring on a very large scale if we get things right for the whole population now we are aware that mental illness is banked up amongst particularly the poorest in our society but it's not only there it is amongst all areas but particularly represented in the poorest people with least means and feeling they've got power over their lives in their circumstances so we need to put mental wellbeing in that context so that was the basis of our submission but I think we do need to rise the challenge as an agency along with other colleagues who are service providers as well as policy linked people to see what is that going to be what is that going to look like and close the vision with interventions towards outcomes that really mean things for people I think it would be hugely helpful if as part of a 10-year strategy we had a name to reduce that gaff in life expectancy between people with mental health problems and people without that and it would drive a whole load of behaviours but if you start to think coming on to Claire's point about how that actually works you actually need to go quite far back so we're talking about preconception we're talking about support during pregnancy we're talking about then perinatal period we're then talking about childhood and what can be done in schools and it begins to touch on your issue about so what about the three quarters who aren't seeking help in a sense what we need to be able to do is to develop in our communities a much greater confidence and resilience so that people are more able to self-manage if they can't prevent some of these things so there's very much something about general education within our population about awareness of mental health we all have mental health all of the time just some days it's better than others and for some people it's worse for a long period of time and needs to be supported so it's a general level of population awareness but then also targeting specific groups where we know there are risks so high-risk families as I say children as they go through the school period and then identifying people who are developing serious mental health conditions at the earliest possible stage so that we can help them with we know that the early mortality is largely caused by excess smoking, obesity and drug use within those groups as well as some impact of suicide in other areas that's where the early mortality comes from we need to intervene early before those hopeless and helpless behaviours set in with people with serious mental health problems so early intervention childhood stuff, perianatal and greater community awareness of mental health across the piece for where we should go in the next 10 years Alison I'd probably like to address my question to Dr Cook in your submission you say you've touched upon it there too we need to consider how we plan our communities with a view to improving mental health and what support employers can offer workforces in improving mental health and we know how workplace stress affects far too many people and that welfare services need to be designed in a way that respects the needs of mental health difficulties the other committee I sit on in Parliament is social security and there's huge interlap between those services so could you just expand on what you'd like to see happen in our communities in our workplaces and with welfare services okay it's already been touched on by other members who've come along today is that bit about we need to get much greater mental health awareness across all policies in particular I think there'll be opportunities coming through the community empowerment act which means that we're starting to look at how community planning partnerships function and work I'm not sure how much I don't get a sense that community planning partnerships really have much awareness of the mental health impact of what's happening in local communities so we could start to look at that which would certainly be when looking at any work that those planning partnerships do with employers and think how mentally healthy policies within those employers should be encouraged and supported and similarly then as we look at the welfare situation so it comes back to that bit if you look at almost any policy area you will find that there is an impact and a potential impact as well as negatives on mental health it's about identifying that and using that I think Dr Fraser you touched in your submission on limited control being associated with an increased risk to mental health and I think that can be about if you're on a zero hours contract and you've got no control over your working hours or if things are being planned for your community and your view that that hasn't really been taken account of clearly we're ignoring the impact of some of these decisions and life circumstances on our mental health is there anything that you'd like to see this committee particularly highlighting to government as we go forward and one other thing you also speak in your submission about introducing a minimum income for healthy living I think that would make a huge difference on that point too We will all sum up at the end at the point to meet about the one thing or could we maybe do that and around at the end is that to give people time to think about To address your two issues issue of control analysis already touched on community empowerment and the values within that I could touch also on the consultation on social security which is going around at the moment the values underneath that are laudable it is operationalising these things to say what does that mean at day to day level we we recognise that the fundamental causes of health and other inequalities are around income, wealth and power and power is the most difficult one to sort of operationalise if you like but it is about at the individual level feeling as if you have a say in your treatment at community level feeling you have a say in the wellbeing of the community that is a basic level of assets around it so that you can engage and build on them at democratic level that there is local and national democracy and accountability there but it is the general value of accountability in services which Lucy pointed out under the human rights framework we lock the key to power empowerment if we created that value in services and supports for everyone but particularly people who are most vulnerable intensive intervention we have evidence intensive intervention for people of complex problems are cost effective and lift people out of the position they are in on your other area of interest minimum income yes, if people had had sufficient income to set their children out to school confident that they would cope materially with the cost of the school day as we call it that is just an example of how people can get on with life if people can socialise and know that they can take their place in social situations supported by a minimum income which is more than we are talking about at the moment in terms of minimum income we would see mental health gains we would see health gains generally because it would mean the evening up of income and differentials and it's not just about narrowing inequalities, the health dividend there is undoubted really just to come back on the point that I was making earlier on about health inequalities and I suppose you have addressed a little bit there Dr Fraser about what was going to ask about what measures we can put in place to reduce the inequalities in terms of the mortality rates for people who have mental health problems and perhaps some of the other members of the panel would be able to expand on that and Dr Cook spoke about alcohol and smoking as one of the main issues I've got a number of people who want to come in so can I have Lucy then, Carolyn just to pick up on the point about inequalities and reducing mortality and pick up on some of the comments that Alistair made there's increasing focus here in Scotland on something called ACEs, Adverse Childhood Experiences which is a trauma informed approach which has seen incredible results in America for example and there's increasing interest in it here in fact Health Scotland are running a national conference on Monday next week that's been chaired by Sir Michael Marmot on ACEs and looking at various evidence little projects here and there around the country that's doing it and what that does is it basically looks at what happened to you as a child, there's a set of I think 10 questions in the basic questionnaire depending on where your score is in that it then can kind of say well your life chances of acquiring diabetes, cancer or whatever, irrespective of the then very natural so-called risky behaviour that you might go on to take such as smoking using alcohol and drugs as a natural response to the trauma that you've had in childhood but coupled with work as Alistair picked up on working around strengths and resilience and asset-based approaches and again there are some great examples in Scotland of work being done in those areas we can look to try and overcome this but it is an intergenerational approach and it will take time it's also a very good approach because it seeks to address a whole person not just within health and social care services or within mental health services but it's also about tackling it in schools in the criminal justice system in local community centres and so on so I think that's one thing that's one practical thing that we could do another I think is co-production as a rights-based approach co-producing responses strategies such as the mental health strategy strategies that are going to address other inequalities actually meaningfully actively engaging the people who are affected by this in listening to their experiences and basing our responses to them on what works for them already in a meaningful way again I think there's another practical thing that we can do by encouraging signs in the social security consultation for example that there's been a heck of a lot of engagement going on in that but co-producing is more than just engaging or consulting with people it's about getting people in a room sitting down with them and they draft this thing alongside the people in the civil service or on various committees whatever so I guess I would say what can this committee do take more evidence from the people who are at the sharp end to what's happening in their lives and what's important and what works for them Two points from me on the issue of tackling inequalities so they are employment and stigma we know that in general good work is good for your mental health most of the time if you are well enough to work and that's something that we would really like to see a lot of in the next strategy so in the draft, the discussion document it does talk about making sure that the new employment programmes in Scotland reflect or involve mental health but we think that we need to see a lot more on that. We know that if you have a severe mental health problem you are very likely to be unemployed about half of the people who are on employment and support allowance receive it on the basis of a mental health problem and we know that if you are employed in a job where you have a reasonable amount of control and a sense of satisfaction it would be good for your mental health as long as you are well enough to work so we think that's a really important area for the mental health strategy to focus on not just in links into the new employment programmes although that is really important we need to make employment a health issue we need to be having conversations about employment in the primary care sector in the secondary care sector where people are well enough to do so we know that there are some good programmes on employment in Scotland so we know that the individual placement and support programme which SAMH and others run has extremely high success rates of getting people into employment and staying in employment the equalised review in six European countries found that the IPS approach is cheaper is twice as likely to get people into work they stay and work for longer they have better outcomes and currently IPS is only in 15% of community mental health teams in Scotland we think that there is a bit of an open goal there in terms of something that we can do we are already doing it, we know it works and it will help to give people more opportunities more income which is really important more of a sense of control and start to reduce inequalities so we really hope that there will be a big bit of work on employment in the next strategy and then secondly on stigma which isn't a great deal about in the discussion document that we had earlier in the year SAMH with the mental health foundation we are proud to be one of the managing partners of CME, the anti-stigma campaign which is doing excellent work and has had really good support from the Scottish Government but we think that stigma needs to be tackled not just through the programme through the CME programme but also at all levels in the mental health system it continues to be difficult to talk about your mental health and the fact that you may be having problems with your mental health it is hard to seek help for a mental health problem and everyone that you might encounter on your journey to try to get that help understand that and to be committed to helping you to dismantle the stigma that you might have encountered and we think that that is really important in tackling the inequalities that we see OK, class then Colin Sure, just briefly on the employment front we've just done a new piece of research on the experiences of people in work and a bit of an economic analysis on the impact and contribution made by people with mental health problems in the workforce and we didn't get much media coverage because we went with a positive angle the media always wants a negative angle but our economic analysis showed that the value added to UK GDP by people working with mental health problems was £226 billion or 12.1% of GDP as compared with a cost if you like of around £26 billion now cost and burden and drag is always something you hear in the public narrative about mental health problems and I'm going to link that quite cunningly into the call that I would have for the committee we would love to see this committee recognise and call out mental health inequalities as a mainstream inequality that is faced within Scotland which links to all the other areas of inequality and back in 2011 with the Christie commission report into the future of public services Christie called for an assumption on addressing inequalities a systematic approach to addressing failure demand and co-production as a means forward but I still can't think of three better ways to address mental health inequalities as we are and failure demand is the one that we haven't really touched on in this debate today and we are at great risk with the pressures we currently face in the fiscal environment we are in creating a new generation of failure demand so if we do what we should do to address inequalities which is early years support which is perinatal which is starting at the beginning of the life course and experiencing an adverse childhood event somewhere in this city has 80 years or probably more likely 60 years given the challenges of life expectancy ahead of them a failure demand and we can't forget that either Colin and Marie I'm probably reinforcing a couple of points on making one new point and certainly around life expectancy which we started off talking about a while ago and I think again in terms of what do we do this is actually a classic wicked issue we don't quite know what to do what things you would have to do so I think the role of a tenure strategy is to actually say we're going to do this in tenure time we are going to reduce by half the difference in life expectancy it's like climate change we don't know how we're going to reach the climate change target but we set an ambitious climate change target and we're going to actually change systems in order to meet it and that's what we should be doing around life expectancy and we've done it in the past around suicide I don't think we've set a suicide target we're going to get the numbers down but we did get the numbers down quite substantially so it's about setting an ambitious goal and working through over 10 years how you actually make that difference and it will be a lot of different interventions I mean the failure demand I mean I think it would be very helpful in a strategy because we know we haven't got any money to think about where money is being wasted in public services and that's where people end up in the justice system costing the police or the courts or the prisons vast amounts of money when they could be supported in crisis in different ways and I think the point about people in crisis is a classic area where lots of different public service actors get involved and spend a lot of money but we don't actually help people in crisis very well and that would be an area of focus and finally just on inequalities I do think it's important that we look at inequalities within mental health as well and look at who with mental health needs actually does worst out of the current mental health system and that would be people like people with borderline personality disorder people with autistic spectrum disorder and the investigations we've done it tends not to be people who have bipolar disorder which responds to medication which gets the medication who are the tragedies it tends to be people who come to services don't meet their needs if you look at a couple of investigations and we really need to do better for people with those kind of labels who come from services rather than to support them Marie Thank you very much I'm particularly interested in your submission which was about the mention of the legislative framework so we've heard from a couple of people about the difficulty that folk with mental health problems have accessing or utilising SDS we've also heard about how power is really important and fundamental to our health and I just wonder if this issue as you say this unique issue where there is non consensual care is maybe part of the fundamental problem I know that's a real bag of words but I'm very interested to know what your thoughts are and how we could improve that One of the issues which is currently being debated at the UN level is the UN Convention on the Rights of People with Disabilities that's a very challenging document because some of the people behind the UN Convention would say we shouldn't have coercive care at all and we're not sure we can get there quickly but I think one of the things that underlies that is how do we actually take decisions for and with people with mental health issues or other mental disabilities and we recently published a document around support to decision making and the fundamental kind of change that that's about is historically we've had I suppose a system which is based on the idea that you lack insight into a condition therefore we're going to have to take a decision for you and we will decide what's best for you and you'll just have to take it now that's a caricature but that's the way the law is ultimately framed supported decision making is actually about saying we will maximise the extent to which you have some say in your own care and treatment and what matters for you and this is happening across healthcare generally that doctors are saying it's not for us to decide what's good for you it's for you to decide what works for you and I see the mill and principles in the mental health act are already supporting that and things like advocacy which is already the mental health act support that but we haven't really done enough to actually make that the lived reality for people who experience the possibility of coercion as I see at the moment within the commission we would say is difficult to do without ultimately saying sometimes people are so unwell we have to take decisions for them but the way that we do that I think could fundamentally change and certainly over the next 10 years we should be working out how to do that Do you want back in Marie? No I think that's good personality disorder so being a particularly area where there is unmet need I just wonder if yourself and other people around the table might want to expand a little bit more on that and why that's particularly so Perhaps it's other people talking about the detail of it because I think people like Alasdair will have much more to say than I do but I suppose historically it's been because there's been a sense that people are labelled as having a personality disorder don't respond well to medication that isn't the answer for them and so it's almost been a kind of exclusionary diagnosis so a way of saying we haven't got anything for you please go away and sort yourself out there are interventions which can support people with personality disorders but our service systems aren't really terribly well set up to deliver those at the moment but others might want to say a bit more about that Chris I'd completely echo what Colin said and I'm sure Alasdair has thoughts too but certainly one of the challenges with increasing access to mental health services is the temptation to provide the simple treatment to the most possible people and we hear timing again and I know colleagues do as well that some of the more complex people particularly people who have had those adverse childhood experiences who are living with profound trauma completely confound the system as it's currently configured and when that system is at a level of overload and when those staff are at a level of overload people who are the most complex and the least empowered are the most let down sometimes by the system that we have and that has to change Alasdair I agree very much that within the mental health system as such that there are some people who are better catered for than others and that people with personality disorders can sometimes very much feel as though that is the bottom of the Cinderella and there is evidence now about things that can make a difference there's increased evidence of the benefits of psychological therapies for people we know that effective care planning can be very useful but at the moment the system tends to where you end up in the system very much depends on where you enter the system so someone with the same level of difficulties could just as easily end up in the criminal justice system or in a secure forensic mental health unit or could be being left in the community being told you don't have a mental health problem and we can't offer anything for you we do have the college does have a working group at the moment looking at making some recommendations about how we can get a consistent approach bringing together and the college's working group has expanded across the personality disorder network which is a multiagency organisation I expect them to report fairly early in 2017 and the college would certainly be looking to have a campaign to improve the sports for people with personality disorder next year but really what they will be doing I hope is pulling together the evidence from the different services that we have across Scotland some of which are producing some good outcomes and that we'll be able to then to use that to suggest to other areas of Scotland how they might proceed I'll go round the other contributors and ask them to give us one thing that Alison requested that we include in the report but I've got one final point to yourself Alison in relation to your submission where you say services are struggling with significant issues created by on-going requirements for efficiency savings and impact on health and social integration budgets if it was efficiency savings then the service would be getting better so are the efficiencies are the efficiencies that are being applied therefore the service is getting better or are they something else that we're calling efficiencies just to use my own day job as an example we'd be in a situation where our mental health service has a budget in the region of 55 to 60 million the health board would apply an efficiency across that last year we looked at 5% in terms of the efficiency across that now we have seen some investment in mental health services so what's coming out is roughly 3 million what's coming in has been something like 1.2 million so we're seeing a 1.8 million deficit in our mental health services this year that 1.8 million deficit isn't applied into mental health services is dealing with the overall health board budget and the same is happening with local authority colleagues and of course the biggest focus for health boards is naturally which they get most pressure on and how they are dealing with unscheduled care, accident and emergency waiting times and the waiting times within the acute sector so all of us on this committee have got our own particular being our bonnet and this is mine so are the efficiencies or are the cuts in mental health there are cuts in the budget to mental health services ok Miles did you sorry did you want in on that? I'm very quickly around gatekeepers for adults in Scotland which we've not really had a chance to touch upon today and specifically I wanted to ask two points for the panel to very briefly touch upon firstly and how do you think the link workers are going to help to improve service and signpost people to the correct treatments and also given the fact that we've seen such a huge increase in prescriptions for drugs to help treat mental health do you actually believe there's people in Scotland being prescribed medications around mental health who actually should be signposted towards alternative psychological therapies? Can I ask when the answer Miles that we all saw so we'll do that if you don't want to answer Miles' question then you can skip that and just give us your one point but if you want to roll it to then that would be really helpful Bob you want to go first you're lucky you can go first thank you Mr Meener yes I think we need to have much more support for the third sector organisations working on helping to self manage conditions but very importantly equal access will support the improved aspirations of people with mental health particularly as we see a revision of the welfare system is currently being undertaken and it's going to have a great impact on those with mental health and mental incapacity and the challenge of helping those caught up in those systems and the impacts of change navigate the very complex landscape that is now emerging in the social welfare field A question of primary care we think the likes workers are really important we think they will help a lot to have people get quicker access to services we would like to see some different models of likes workers tried out whether that's people being a part of a cluster or located in house we'd like to see some different approaches being tested there's a commitment to 250 new links workers the recent theatre Scotland document did mention that only 40 of them will be in place by 2018 we think that it's maybe a little bit slow we'd quite like to see some more in place by then but we definitely think that all GP surgeries in Scotland should have access to a links worker in terms of the second part of your question we want to see better access to things like psychological therapies we want people to have greater choice we do think that medication absolutely has an important place and is really important for many people we often find that the reporting around the stats on particularly antidepressant figures and frankly some of the political debate around those figures is not that helpful people should have the choice to have whatever evidence based treatment and support they agree with their healthcare provider but they certainly should have a very broad range of options and on the one thing that we would like to see we think that the biggest thing that could be done as part of the next strategy is to transform the culture of our mental health services but also our education and employment services so that people really genuinely can't ask once and get help fast Chris I certainly echo Caroline's sentiment in terms of link workers I think that there's a critical role to play in connections to the system for people who don't know how to interface with that system and in young people there's the one good adult theme and that sometimes applies to people who are very excluded or marginalised as adults as well and we see in recovery that often a strong relationship with a good and supportive person regardless of what their professional role is is quite often the thing that helps people forward and I think in the sense that undoubtedly some are necessarily prescribing where people don't feel able to access the other things that are available for them in terms of in terms of our one point well I'm going to say prevention aren't I but I think a critical thing that this committee could do in terms of pushing the direction of the strategies to free mental health from the the constricts of being just regarded as a specialist health issue and anchor it in all policies and compromising the need for innovation and resource in mental health services for those who need them Thanks, on the link workers we are doing some work and evaluating the value of link workers and that will be due out fairly soon the question that I would raise over that is how professional do they need to be I think there's a lot to be said for peer help youth workers not a professional workforce as we conventionally regard them but there's got an awful lot to offer every space behind youth workers is not great but we should do something about that the good adults like that point and I would echo that on the one thing I would say it's a bit of a dodge but I'd say really a full cream implementation of the Christy principles there's a report hanging in there which we haven't really taken on and lived and if we could actually look at the Christy principles and apply them to mental health as we could apply them to other areas of public service we'd get some places and I'd start young young people very young people, young adults they're the ones that we would need to nurture on the link workers we recently did a been visit to people with severe and injury mental illness living in the community and one of the big things for us was that actually the people we saw they were getting their medication they were being kept well enough so they weren't having to go back in a hospital but a lot of people were leading very impoverished lives and they were isolated they weren't in access in the jobs market so it is about thinking more broadly than about are you psychotic today into how do we actually help you flourish and it's about rediscovering some of the values of social work back in the 1960s about actually helping people in community to live flourishing lives that contribute to society and link workers and those kind of things can help with that in terms of the one big thing about the strategy I mean without being sarcastic I'd like it to be a real strategy and I think what if we look at we published a report with the Human Rights Commission on Human Rights and Mental Health Care and one of the things we published that was a diagram of a logic model is that within a few years this is what we're trying to do it's about service users and carers in acting the rights at Scotland we're a care person centred and self-directed free of sigment and discrimination on which recovery is a reality for all and we actually had to set out what are the medium term outcomes that would contribute to that what are the kind of shorter term outcomes that would contribute to that what are the actions that get there and actually do we believe that often about public services it's easy to announce something which isn't a bad thing but if you actually say is that going to achieve that outcome you have to say well don't know or probably not so I think the strategy if it's going to be a tenure strategy needs to have that level of ambition and focus Excellent Lucy Well thanks very much for the question about the links workers because I was hoping for an opportunity to mention them as one of the organisations that's kind of led on the national link worker programme and I'm delighted with what it's achieved and I think the only point that I would add to what everybody else has said is that obviously one of the things about the link worker programme is that it is actually quite a transformational approach to primary care because it isn't just about the relationship between the community practitioner the links practitioner and the people accessing the service and the practice that they're then being directed to it's actually about transforming the culture within primary care itself and the feature of how primary care inverted commas is delivered so it's one of those things again those practical things that we could do to transform our approach to mental health as well as the wider health and wellbeing agenda My one takeaway is unsurprisingly about rights basically we would love it for the committee to call upon the next strategy to be not only explicitly based around human rights the human rights based approach actually developed using a human rights based approach so on a co-production basis for example with people who access services supports and unpaid carers that it's built on a framework of human rights and actually there's explicit reference made to human rights and human rights standards in its commitments and it will be measured against those human rights indicators and also that it might even extend as far as looking at human rights budgeting approaches to how we actually finance and fund the delivery of supports and services whether it's in the public sector or by not forgetting the vast majority of services and supports that are actually delivered by the third sector in mental health and also a lot said already about the link workers I think that we are a time when we need to see transformation within primary care general practice is struggling and that if we can get a better system for accessing mental health services within practices that's going to be hugely helpful for everybody including general practice colleagues. Just mentioned the antidepressant I do have concerns when we tend to look at this in a black and white system and say antidepressants are a bad thing antidepressants are a great thing if they're the right thing for you and so what's really important is that we encourage the identification of mental health problems that will benefit from antidepressants at the same time as offering psychological therapies and psychological therapies and antidepressants can sometimes be the right treatment it's not one or the other we sometimes need both in terms of the big ask from my perspective it would be parity mental health not just we have a law already in Scotland in the NHS act something that says that mental and physical health should be equally regarded and I think that's there but we need genuine parity in terms of thinking about the resource that's applied to mental health the attention that's applied to mental health and our understanding of better mental health in our whole community okay thanks very much I thank all the participants this morning I'm sure I speak for the committee when I say that I found that exceptionally helpful and thank you very much