 Welcome everyone to the Health, Social Care and Sport Committee's 10th meeting of 2021. I've received no apologies for this morning's meeting. Our first item on our agenda is to decide whether to take items 4, 5 and 6 in private. Are we content to do that? Thank you, colleagues. Our second item today is an evidence session with the Minister for Public Health, Women's Health and Sport on her priorities for session 6. I'd like to welcome Marie Todd, the Minister for Public Health, Women's Health and Sport. It's the first time that the minister has been in front of the committee. I know that we've all got this out the way of the welcome to your new role type greeting, but welcome to your new role, your almost new role. Supporting the minister for this session, I welcome it also to Michael Kelly, the director for population health, and Marion Bain, the senior public health adviser for the Scottish Government, who are joining us remotely. Minister, I believe that you have a brief opening statement. Thank you, convener, indeed I do. Over the last 18 months, the Covid-19 pandemic has put unparalleled pressure on all of our lives and on our health and social care system in particular. I want to thank all of our front-line staff, health and care staff for their hard work and commitment in response to the pandemic. Our response to the pandemic has shown a spotlight on new ways of working, and it's shown what's possible in the face of overwhelming need. In relation to testing, to date, there have been over 10 million PCR tests undertaken, and currently we have 55 walk-through testing centres and eight drive-through testing centres. There are over 1,000 pharmacies across Scotland able to distribute lateral flow kits and 3,500 staff involved in delivering testing across Scotland. On vaccinations, we've delivered over 9.9 million vaccines since the programme began. Over 2 million of those are part of the autumn-winter programme. I'm sure that you'll agree that the work on vaccinations and testing has been outstanding. The pandemic, though, has been testing for all of us. The impacts have not been experienced equally. We're all in the same storm, but we're not in the same boat. Covid exposed and exacerbated deep, rooted and pre-existing health inequalities. People from minority ethnic groups, women, disabled people and those living in our most deprived communities have been disproportionately impacted by the pandemic. Our chief medical officer said in his last report that a healthier population could be one of our nation's most important assets. That must be our ambition. That provides a strong rationale for the need to invest in improving population health and tackling health inequalities. It also sets the context for our plans for the parliamentary term ahead. Our long-term goal is to create a Scotland where everyone can flourish and improving health and reducing health inequalities is vital if we're going to achieve that. As we remobilise and redesign our health and social care system, we need to ensure that we understand and address barriers that prevent people from engaging with and accessing health services. We're taking a range of actions. Health screening is one of the most important prevention tools, and it's vital that we ensure that everyone who is eligible to participate has an equal opportunity to do so. That's why we're making concerted efforts to tackle inequalities and uptake of screening. We've exempted all young people under 26 years old from NHS dental charges a first step in removing one of the barriers to accessing high-quality NHS dental care. We are the first country in the UK to have a women's health plan, which outlines ambitious improvement and change across women's health. When women and girls are supported to lead healthy lives and fulfil their potential, the whole of society benefits. We've committed to improving access and delivery of NHS gender identity services. We'll publish a national improvement plan by the end of this year and have committed to centrally fund service improvements. Non-communicable diseases such as cancer, heart disease, stroke, diabetes and lung disease contribute more than two thirds of all deaths in Scotland every year, and sadly most of those deaths are wholly preventable. We need bold, population-wide approaches to reduce the significant harms of tobacco, alcohol and unhealthy food and drinks, and I intend to take a range of actions to drive forward this work. We're going to introduce a public health bill, which will include provisions in relation to restricting food and drink promotions, marketing and displays of cigarettes. We're developing an updated high-impact tobacco action plan to ensure that more people never take up smoking in the first place, meeting our 2034 commitment. We're driving forward our alcohol framework and will consult on a range of proposals to restrict alcohol marketing, improving health information and product labels. We'll continue to invest in our alcohol and drug partnerships, which provide a vital support mechanism for people facing problems caused by alcohol and drug use. I recently published out of home action plan will support families to make healthier choices when eating out or ordering in, and will provide more support to parents and practitioners on healthier food, healthy weight and healthy eating patterns to support children to eat well. We're continuing to support boards to innovate and improve their weight management services by enhancing their digital solutions. The links between physical activity and health are well known, and our vision is for a country where people are more active, more often. That's why we're doubling investment in sport and active living to 100 million a year by the end of this Parliament. Through our Scottish Women and Girls in Sport campaign, we continue to shine a spotlight on the vast amount of great work going on across the sector to support women and girls in sport at all levels. I was delighted to see that the fifth campaign, which was held recently, was such a success with wide collaboration, and that highlighted some of the examples of how sport and physical activity supports girls and women's health from across the country. We need to create the conditions that nurture health and wellbeing, and this responsibility needs to be shared widely across many different organisations, sectors, communities and individuals. The potential impact of that combined talent, expertise and commitment is huge. I am under absolutely no illusions about the enormity of this task, but by continuing to work together and learning from our recent experiences and building on our successes, I am confident that we can make lasting change that will improve the health and wellbeing of everyone in Scotland. When you're faced with something like a pandemic and you're reacting and the health service and the society is reacting to something like this, what you've been talking about, that proactive and preventative agenda, there's a danger of it disappearing. What I would like to know is that you've outlined a range of things in your portfolio that you want to take forward. How is that preventative and proactive agenda going to manifest itself in local areas? What can we expect to see in the next year or so that it's going to really make a difference in terms of people getting that early intervention and that proactive approach to their health? There's a number of significant differences that we'll see, but I suppose that the first thing to do with that question is to reflect on what the last 18 months have given us. Largely, it has been an exceptionally challenging time and it's hard for all of us to think of any positives. But when I think of some of the positives that might have come from the campaign firstly, from the last 18 months firstly, there was a light shone on those pre-existing health inequalities and I feel very strongly that Scotland is unwilling to tolerate those any longer, so we have a mandate as a Government and as parliamentarians to tackle that. And I think we will be able to build consensus and take bold steps to tackle some of those health inequalities. When I think of just how difficult it was, you know, if you think there's new virus hit us and we had no infrastructure and I talk about how much testing we've done and how much vaccination, it's almost hard to remember that at the beginning of this pandemic this is a brand new virus. And what we did time and time again was the impossible and actually I would say as a Government we have a taste for that and we achieved the impossible because we worked together because we turned to face a common enemy. So that is powerful. We have found ways of working together and collaborating that will stand us in good state. We see changes, behavioural changes, significant behavioural changes, not right across the board sadly so there are still inequalities in the behavioural changes that have impacted people in the last 18 months. But what we have seen is people exercising, socialising through exercise, that type of behavioural change, working from home and making sure they took time to go for a walk at lunch time. We need to hang on to those behavioural changes and you'll certainly see work going on to try to encourage people to be physically active during their working day. We already have the daily mile where that is fully integrated into schools, many schools are signed up to the daily mile, we want to be a daily mile nation, we want everybody to have the opportunity to exercise every day. The final thing that I would highlight is that my sense is that there has been an increase in health literacy so people know where to go for high quality information. If you think about NHS inform it was already quite a trusted source of information. It has now become the first point of contact for many people with the health service and I think that will stand as in good state. People are looking at local data for the pandemic, infection rate, making risk assessments so there have been significant behavioural changes over the last 18 months that will stand as in good state as we move forward. As we move forward in terms of prevention, I think about some of the big issues like the non-communicable diseases. We are going to have to take bold steps so if we look at diet and obesity we are going to have to take bold steps to tackle the envisogenic environment. That is going to mean that all of us collectively will have to come together to take steps to make it easy for the population to do the right thing. I think that we will see consultations and work on all of those things. Alcohol, tobacco and diet over the next few months as I said a public health bill coming in the next but possibly not in the first year but you will see work in advance of that public health bill over the next year. I am going to hand over to some of my colleagues. We have got some questions on your priorities in public health. Sue Weber. We know that there is a lot of publicity around the drugs crisis that Scotland is facing but in your remit you have the alcohol aspect of that. People with alcohol dependence also need support and treatment. You spoke a lot about what you were doing in terms of advertising and there is obviously the minimum unit pricing. What does the Scottish Government do to help those people who have that dependence in terms of access, treatment and support? How might that link into the plans for the national care service as well if that is not too complicated? No, that is fine. The drug and alcohol services are often combined on the ground. Much of the work that is going on is led by my colleague Angela Constance in investing in drug and alcohol services on the ground. That will benefit people with alcohol dependence as well. You are absolutely right to highlight alcohol as a priority over the course of the pandemic last year, what we saw was a rise in alcohol deaths which bucked the trend of a number of years. We have done so much work on this front and we were starting to reap benefits of that. Last year what we saw was a 17 per cent increase in deaths which is just absolutely devastating and tragic for those affected by it. We saw that increase right across the UK and, in fact, the increase in Scotland was slightly smaller, so a 20 per cent increase in the rest of the UK is 17 per cent increase in Scotland, which probably is testament to some of the policies that we have in place. Much of the work around alcohol prevention and treatment, we are driving forward our alcohol framework. That is 20 actions to reduce alcohol-related harm and it enables the World Health Organisation's focus on tackling affordability, availability and attractiveness of alcohol. The key aspects of that would be minimum unit pricing. It is a policy that I absolutely, like everyone here, I imagine is an absolutely wonderful, well-targeted and effective policy, but we committed to reviewing it within two years of its introduction. Unfortunately, the pandemic prevented us from holding that review. We are still gathering, but we have begun to gather the information in order to review the minimum unit pricing of alcohol. We are undertaking a range of work to improve alcohol treatment services right across Scotland, including a public health surveillance system and implementation of the UK-wide clinical guidelines for alcohol treatment. Is there anything specific about the access to the rehabilitation services that you have at this stage, or is that still being scoped out? What do you mean? I suppose that if someone was needing support right now, there are gaps. How do they get access to treatment? We have got that rise and death, as you have said, so that means that that would lead me to believe that there is perhaps more people out there with an issue with alcohol and are maybe seeking support and help right now. What we found in the pandemic and what we found all over the UK is that people who drank heavily drank more during the course of the pandemic. I think that that largely explains the alcohol. There are 23 people a week directly from alcohol. We have increased investment. As part of the national mission to tackle drugs deaths, there has been increased investment, which is used by alcohol and drug partnerships all over the country. As I said, those services are not separate on the ground. Alcohol and drug partnerships are there. That is the structure that is there on the ground. The investment to tackle the national drugs crisis supports people with alcohol addiction problems as well. 100 million pounds of additional investment to increase the availability of residential rehab will benefit people with problematic alcohol use. We recognise that more can be done in order to reduce the harms and to increase help with treatment and recovery. Since 2008, we have invested more than £1 billion to tackle problem alcohol and drug use. This year, we are spending £140.7 million on alcohol and drug use. I am a member of the Edinburgh alcohol and drug partnership, and I had a meeting last week. The money is coming down, but it is all being spent on the drug-related aspect. I am just worried that the alcohol element, although it is part of the ADPs, is just getting left behind. I can assure you that alcohol is equally a priority. Angela Constance and I work closely together. We are determined not to introduce further silos in that type of work. It is profoundly unhelpful for the people who are accessing help. That money is intended to improve alcohol and drug partnerships. It is intended to show up the services on the ground that will benefit people with alcohol problems. I am sorry, but my mic did not come on there for a second. You spoke a bit about shining a light in pre-existing health priorities and the drivers of inequality. What I would like to ask you about is that we have had Christy's been around for quite a long time now. What progress has there been towards Christy? You are absolutely right. It is an unwelcome reality that communities experience health, quality of life and even life expectancy differently across our society. That is not acceptable. Improving health and reducing health inequalities across Scotland is a clear ambition for this Government. The pandemic has exacerbated health inequalities and has also heightened awareness of those people whom we need to protect. The solution to health inequalities will not lie entirely in my portfolio. That is the first thing that we all need to be absolutely clear about. Health inequalities relate to inequalities in wealth and power. The solutions to health inequalities lie in improving and tackling poverty, for example, would be a high priority. That is a mission for this Government during this period of time. We absolutely have to tackle the socioeconomic inequalities. Our NHS and social care institutions—I will bring Michael in to tell you a little bit more about how we recognise our health and social care institutions—can be an anchor organisation in tackling socioeconomic inequality and offering good employment opportunities and leading the way in good work practices. We have a fair amount of work going on in that. If you look at preventative, Christy's work was absolutely incredible. It is always important for us to reflect and think about whether we have made the impact that he hoped. I do not think that we have. We have done some pretty impressive work. If you think about the alcohol, for example, much of the effort that we put into tackling the problem relationship that we in Scotland have with alcohol is preventative. Much of that work is bearing fruit. It is just that these are really difficult issues to tackle and it will take longer to feel the benefit of them. I think what happened in the last year with the increase in deaths all over the UK. It is devastating. No deaths from alcohol is acceptable. It is absolutely devastating that there was an increase last year. That slightly lower increase shows that those preventative policies are bearing fruit in Scotland. While we saw an increase, it was not as high as elsewhere in the UK. That could be largely attributed to our preventative policies, such as minimum unit pricing of alcohol, which, as I said, is a policy that every single one of us should be proud of. I will go into that a wee bit more there as well. I totally accept that there have been things that we have been doing etc. What we have heard quite often in this committee when we are taking evidence is about health professionals. Their focus tends to be on the things that they are targeted on. How do we put prevention and inequality in there to make sure that it is suitably prioritised? What the health professionals were saying is that that is something that ends up going to the sides because they have other numbers that they need to hit. We all know about what is measured. I think that that is often a criticism of health services across the world, because they are reactive rather than preventative. I think that there is a lot of work that we can do to make sure that people live long healthy lives and that we prevent illness before it happens so that we support people to stop smoking, that we prevent people from drinking too much alcohol, that we make the food environment easy to navigate so that it is easier to eat healthily than it is to eat unhealthily. All those things are things that we can do, but they do not necessarily sit on the health professionals' shoulders. However, there are undoubtedly actual health issues such as picking up hypertension, for example, and treating it is a really important preventative strategy. I think that there are many much of those lies in primary care. I bring in Michael Boggs. I mentioned the work that we are doing in terms of working with COSLA and the NHS and universities to a whole lot of public services in order to make those anchor institutions in order to change the health of the community that they serve. I think that that is quite exciting work, and it is quite an exciting approach. It takes the burden of the healthcare professionals on the cofies, but it uses our NHS to improve the health of the nation. It is quite a clever way of doing it. Michael Boggs. Thank you for the question. We cannot hear you, Michael. Sorry, can you hear me now? Sorry, convener, I don't know if you can hear me. Can you hear me now? Sorry, my microphone was working earlier, but it is not to be now. We can hear you now. Apologies about that. To pick up on that point that the minister made about anchor institutions, it is interesting that part of my role in working for the minister is to work across portfolios in Governments, working with colleagues in communities, in education and in the economy on this agenda. The anchor institutions agenda is one that has really gained momentum. It is about thinking about the NHS and social care services as well, their powers as institutions. We know more than 150,000 people employed by the NHS in Scotland and many more in social care too. Thinking about those institutions and how they employ people, which people they employ, and how they use their power as contractors for services locally. We are working with NHS boards and health and social care providers around that agenda and doing so in partnership locally as well. That point around NHS institutions working with councils and colleges locally to think about how they employ people and how they can tackle some of this agenda is really important. NHS and NHS in Scotland are pioneering work on the youth academy to think about how they can bring young people into work and training in health and social care who would normally be disadvantaged and excluded from these programmes. There is a lot of work going on there. The other point, convener, if it is possible to make, is to echo the point about the need for further progress on the Christy agenda. We recognise that in the Covid recovery strategy that DFM published recently and the work on the child poverty. There is a recognition that we need to work across Government on those social determinants of population health. We are doing that. I agree with the Minister of Appetite and the intolerance for health and the qualities is something that has been increased by the pandemic and has made this work even more important. Just finally, we have had the recent announcements about the priorities relating to place and wellbeing and the preventive and proactive care. How are we going to go about basing that in communities? Does it involve things like your 20-minute neighbourhoods, where you have all the different services on hand? That is my last one. Absolutely. The 20-minute neighbourhood is a win-win from a public health perspective. People are able to easily access public services but active travel is possible. If everything is in walking distance from where you live, we are likely to have a more active nation as they access public services. If we design public services so that people have to hop in the car and go to a centralised point, that active nation agenda is vitally important. It takes every box. If you think about the priorities for the Government right at this moment of time, tackling inequalities, tackling climate change and improving health, if you think about my priorities, it improves every single one of those. People are more active, we reduce the number of cars on the road, we reduce the level of pollution, we tackle the climate but we also have healthier people at the end of the day. The 20-minute neighbourhood is a very important part of what we are trying to achieve. As ever in Scotland, trick air to achieve in my part of the country, perhaps. As a rural MSP myself, I was going to say that the infrastructure really has to be there to happen in rural areas as well. You might imagine that as a rural MSP myself, my focus is very much on that. We need to make sure that people in rural areas can benefit just as much from that design and thought. There isn't the default setting of centralising public services far away. I want to pick up on the point that you made about the fact that, in reality, inequalities have not changed in 14 years and if anything has got worse. It is quite important to acknowledge that the root causes of inequality are probably the key thing that we have to focus on. Given that, in this session, we have had opportunities to tackle those things around carers' allowances, wages to low-paid workers and the progression of the right to food bill. Those things have not happened. What commitments do we have from this Government that they do acknowledge that the root causes have to be tackled if we want to change health inequalities and other inequalities? What are the Government going to do to work together across portfolios to get those things changed? We are working across portfolios to change those things. You would have to acknowledge that, since 2010, the Tory-Lib Dem Alliance coalition came in and brought in welfare reform. There is well-documented power of evidence that that has worsened inequality right across the UK. Some of those welfare reforms impacted most severely on disabled people. Some of the most vulnerable people in our society suffered from that welfare reform. In the last 14 years, while the SNP has been in government, what you have seen is a UK Government that has systematically dismantled the welfare system and made health inequalities significantly worse. Despite that, the Scottish Government has done a great deal. Most people who look at the UK as a whole say that health inequalities and poverty are prioritised by the Scottish Government. That work to ensure adequate housing helps to protect people in Scotland from health inequalities work like. An awful lot of money is spent, for example, on the bedroom tax that is mitigated in Scotland. That was a tax introduced by the Lib Dem coalition, which particularly punished disabled people. People in Scotland do not have to pay that. If you are looking at what has happened over the past 14 years, you really have to look at the welfare system while you are looking at it. On opportunities to mitigate, the bedroom tax is a perfect example. If the Scottish Government spends money that has four devolved issues on the issues that are reserved, that is less money to spend on devolved issues. There is a limit to how much of that we can do. We spend millions every year mitigating the bedroom tax, for example, which is particularly beneficial to disabled people in Scotland. However, there is only so much of that that you can do. There are limits to how much you can spend. I am very proud that the Scottish Government has introduced the Scottish child payment. I am very proud that, during the course of this Parliament, we are going to increase and extend that to all children. We are going to increase the payment, but there are budgetary limits to what the Scottish Government can do in the face of systematic damage to the welfare system coming from our other Government. Thank you very much for the answer. Clearly, there is a major problem in the way in which the UK Government treats welfare and other benefits. Will the minister commit to feeding back to the committee exactly how far they are prepared to go in terms of mitigating and making sure that we do everything that we can in the Scottish Parliament? Fundamentally, we have heard from other experts throughout this session that the key thing that we can do in Scotland is to change inequalities and that will help us to be able to develop Scotland further and use that budget to its best. Absolutely. I am more than happy to write with more details on the steps that we are taking, but also perhaps a little more detail on what we are up against. Thank you, convener, and good morning, minister. I know that this is not specifically in your portfolio, but I think that it sort of follows on from Carol Mocken's questions. I previously asked the panel or our public health stakeholder session whether they felt a universal basic income approach could help tackle some of the economic inequalities that lead to poor health, and Professor Sahari Burns, amongst others, agreed that this would help. I know that work is being undertaken by the Government on a minimum income guarantee. What role does the minister see this having in the improvement of public health, and are you working with the minimum income guarantee steering group on this? I think that I will bring Michael again to give you a little bit more information about the cross-government work that is going on. One of the things that we recognise very clearly in the Scottish Government, and we always did, but it has become even clearer over the course of the pandemic, is that we cannot have that siloed working. That is not going to serve the citizens of Scotland. There is a great deal of cross-government work going on, a great deal more than there ever was before, and the Deputy First Minister, with his role in Covid recovery, also has a cross-portfolio role to make sure that policies join up across Government. There is work going on across Government on issues like that. The universal basic income, and health inequalities, as I said, are related to wealth inequalities. The solution to health inequalities lies in ensuring that people have adequate income. We need to tackle the disempowerment of individuals, and there are undoubtedly groups in our community that are easy to ignore. It is not as simple as tackling poverty, but tackling poverty would go a long way to tackling health inequalities. My party is very sympathetic to the idea of universal basic income. We are not convinced that we can do that without the full powers of independence. We are exploring ways in which we can assure people a dignified level of income in Scotland, which falls short of a universal basic income. You can see our commitment to that in terms of how we handled, for example, school lunches provision during the pandemic. Very quickly, there was a recognition that getting actual money into the pockets of parents in order that they could adequately feed their children, and that was brought in all over Scotland quite quickly during the pandemic. That was a recognition that that is the best thing that you can do to support families and the most effective way to ensure that children are well fed. Michael, I will bring you in to say a little more about some of the cross-government work that you are involved in. I hope that members can hear me okay. Just to echo what you have said about absolute recognition that poverty and tackling inequalities in power and income and wealth is understood as a central tenant of our approach to tackling health inequalities, just to reassure Ms Mackay that we are working with colleagues across government on that agenda. Tackling poverty generally, tackling child poverty in particular, and also on the explanation, as you said, of the minimum income guarantee. That is what we will continue as a priority moving forward. Tackling child poverty, because the impacts are lifelong in terms of prevention, is absolutely the place to start and the place to focus. It is interesting that you say that because we are going to prioritise and enquire into that very thing about children's life chances and the drivers of inequalities in children's health. Gillian, while I am with you, you want to ask some questions. I am going to be one to the women's health plan, but I will stay with you and you can kick that off. Thank you very much. Like Endermete Trio system, I am really pleased to see the work on that in the women's health plan. Polycystic ovarian syndrome is a condition that women often struggle to get a diagnosis for. Peacoss was only briefly mentioned in the women's health plan. Could you advise how long on average women in Scotland wait for a diagnosis and what work is being undertaken to improve diagnosis and treatment of Peacoss? I wonder if Dr Marion Bain, who is with me here, who was the Deputy CMO and was involved in developing the women's health plan, could give you a little bit more information about Peacoss specifically. What I would say about the women's health plan, I have had a number of conditions suggested to me that ought to have been included and I recognise that it isn't all encompassing. It was developed and those priorities were developed with input from women and those were the areas that were agreed with women with lived experience that we should target first. I see the women's health plan. I mean, I think it's momentous. I love it that Scotland is leading the way on this. I am determined that it will deliver real, tangible change for women, but it's just a start. It is absolutely just a start and there will be more to come in future in terms of tackling the health inequalities that women experience as a whole. The microphone live, yes. I think that your microphone is live, Marion. Right, thank you. Can you hear me? We can hear you fine. Thank you, that's great. Thank you for inviting me in. I had a great privilege of chairing the group that put together the women's health plan. It really was a group that was really passionate about making sure that we do change things in terms of women's health. What would you say in terms of the specifics? Although the women's health plan concentrated on a specific range of items, as the minister said, underlying all of that was how do we make sure that the issues that matter to women, including the conditions that are specific to women, are better addressed in the health service. I would say definitely in that context that that's about all the conditions that are specific to women, and in particular those ones where at the moment women are having to wait longer. That's really applicable. It's really about making sure that our services are accessible to women so that they can get there when they have concerns about their health. And then that we have the specialists who can advise and can treat, and then the third area is the research. All of those are woven through the women's health plan. In terms of taking the women's health plan forward, it should have an impact far beyond just the specifics, and it should certainly have an impact on making sure that women are able to access and are encouraged to access services earlier where they can benefit from them. One of the really key themes within the women's health plan was making sure that women had the information that they needed to understand what are the symptoms that they should be concerned about, and then making sure that our JPs and our specialists have the information that they need in order to refer women on. As we move to the implementation, the similar groups are going to be involved. If I just concentrate on the treatment area that we are talking about, that includes JPs, hospital clinicians and specialists in the different areas of women's health. Between them, it is really about making sure that women, first of all, can understand when they need to go and see a clinician, then they are appropriately referred on, and then that we have the treatments available. The last thing that I will say is about that research area, because what the women's health plan also identifies is that we need to make sure that we do the right research. Sometimes, and certainly, a number of conditions for women are under-researched, and therefore we do not have enough information to really make strides forward, so that is part of what is in there as well. I was going to pick up on the research area. Anybody who has read Caroline Creado-Paris' book, Invisible Women, will know that you have years of lack of research into common health conditions for men and women in which women have not been considered and the implications on women. Just how much of a priority is the Government putting on in undoing some of that injustice in terms of that historic research and going right back to basics with the training of our health professionals into how to—that seems like a substantial piece of work that needs to be done. As you say, that is only a start, minister. It is a substantial piece of work. One of the things that I always say is that you have to understand that women have faced, if you think about the health inequalities and the reasons behind the women's health plan, that is about inequalities in wealth, power and income. Added to that, there has been millennia of mythology and fear about women's bodies. That is not going to be undone quickly or easily, but I think that it is a perfect moment in time to make tangible progress and I am convinced that we can do that. You talk about research. One of the reasons why women's heart health is a priority is that evidence shows that women's heart attacks are under-recognised and that even when they are under-treated, they are less likely to be put onto the battery of preventative drugs that are routine for men who have heart attacks. Women's heart attacks are often referred to as having an atypical presentation. The reality is that for women it is not an atypical presentation. It is a perfectly normal way for women to present with a heart attack. It just does not look quite like men do. That is an insight into the situation that we are facing. It genuinely is a man's world and the world is basically built around the way that men present and the treatment that men need. If I am fair, there are some reasons why that might be. I know that, by profession, I am a pharmacist and there are questions of ethics around using women and childbearing women in particular in participating in clinical trials of new drugs. There are ethical questions around women being involved in that, but most health professionals—perhaps Maryam might like to reflect on her own experience—most health professionals say that, as they went through medical school, the default setting was men's bodies, men's presentations and men's illnesses. I don't know if you want to come back in on that. I'll just get your microphone. Thank you. You can hear you now. I think that that is absolutely right. It is very much a culture thing in terms of what, certainly when I trained, was considered quite normal. When we think about it, it is completely not normal because over 50 per cent of the population are women. I think that the whole change is to make sure that we think about all the population and that there is the focus on how women present and how they respond and the wider aspects of what makes it easier, difficult for women to access information and services. I completely agree that we need a change. Some of that is already happening and, of course, over half of the medical workforce is coming through our women as well. That helps to change some of that in terms of making sure that we focus appropriately on women's health and change some of what was just really regarded as normal. Obviously, it is not, and the things that we want to change as we move forward, especially with the women's health plan. A short supplementary question from Emma Harper. I'll come back to Stephanie Callaghan. There is research that is going on right now about cervical cancer self-sampling screening. I know that NHS Dumfries and Galloway has had a 25 per cent uptake out of the 6,000 default women. That is like 1,500 women who are now part of the cervical cancer self-screening. Can you give a short response about where we are with that cervical cancer self-screening research? You are absolutely right that it is being trialled in Dumfries and Galloway. They are targeting, particularly initially, the women who are not presenting for screening. That is a population who are not taking up the offer of cervical screening and they are having an increase in uptake with the self-screening. That highlights one of the big challenges that women have in terms of accessing healthcare so that they have caring responsibilities that may mean that it is impossible for them to go to an appointment. That is not the whole story in cervical screening. Many people who do not—one of the real problems in cervical screening is that it is such an invasive test and many people, as we all know, have experienced sexual violence and are going for a test of that nature. It is just a barrier that they cannot come through. I think that it will be helpful when that test—I can see that there will be women who would find self-screening at home helpful. The challenges that we have not yet had it validated or recommended by the national body, who says that that is an appropriate screening test to use. As soon as that happens, we will have procedures in place in order to use it, but we are not quite certain of the technology yet. That work is going on. Fries and Galloway is just one aspect of work that is going on right across the UK to assure ourselves that the quality of that test is sufficient in order to use it nationally. I am Stephanie Callaghan. We have so much to cover—this is a thing about public health—so many plans in place. I am going to pick up the pace, because we have members wanting to ask about other plans as well. On the women's health plan, the final question is from Stephanie Callaghan. We will move on to the next plan, Stephanie. Thank you, convener. Thank you, minister, and thank you to Marion as well. I do not think that there is much that I could disagree with on what you say there at all. Women's health—the health plan is not all-encompassing. We have got menopause, hyperthyroidism, endometriosis, which is something that I have suffered myself there. To me, the number one key point that we really need to address is the fact—we have seen that with the mesh stuff coming through—that women are dismissed and that they are disbelieved. I suffered endometriosis and, like so many others, it took over 10 years to get a diagnosis. It was quite severe and I had several operations. I have a daughter and, like every parent, the last thing I want is for her to go through the same thing. She is getting to that age there. What I really want to know is that it is a great training in medical school, et cetera, but how do we propose to change the deeply embedded attitudes towards women who are presented with health issues? A lot of the time, the attitude comes from the top. It is not just male doctors or male consultants that are the issue. Females can be just as bad too. At times, in my own experience, not only is it about women's health issues, it extends to presenting our children with health issues as well. It is that same dismissal in disbelieving what women are saying. I would like to know how we are going to tackle that. You are talking to very broad cultural issues there. The reason that people suffer health inequalities is because of inequalities in wealth, power and income. That power is really important. You will see right across the NHS. If we go outside of the women's health plan right across the NHS, what we are trying to do is provide a patient-centred service. If you look at realistic medicine, that is very much about sharing power between patient and health professionals on coming to decisions together. There is a great deal of work going on in that area, but there is a great deal further to go. Women are more disempowered than most. You are absolutely correct on that. I say it time and time again that information is power. We have put a lot of effort into ensuring that NHS informed has really good high quality information. One of the challenges is the level of understanding about what is normal and what is abnormal and might require help. It is not great in our population. I have reflected a lot on that since I have become Minister for Women's Health. I talk about the mythical status and fear that people have around women's bodies. When I reflect back to when I started my periods at that time, people still talked about getting the curse. The language that was used was so incredibly stigmatised. How could you possibly imagine that that was anything other than a bad thing? How would you know to go and get help if what you were anticipating was a curse? As I said, there are many issues across the board. We are tackling education in schools at every opportunity. There are multiple opportunities through the course of a woman's life to offer her information about her own health. Culturally, we are trying to shift the dial. Some of that is outside my portfolio. Some of that work is like the work to tackle. Incoming inequality for women, close the gender gap, will be really important in empowering women so that they are able to navigate the healthcare system without being dismissed and disempowered in the way that you describe. It will not happen overnight, and much of it reflects our general culture. That is the reality of the world that we live in today, even in 2021. It is still a man's world. I am afraid that we are going to have to move on. I mean, without all of these subjects, we could spend our 90 minutes just talking about each plan. We move on to the best start plan with Emma Harper. My interest in the best start plan is that there is a lot of what is happening that has been presented by the Scottish Government. You have outlined the child support payments and things. I am interested in how the plan is working in remote areas, because, as the convener said, she is rural and I am rural, so are you as well. How are we supporting people who live in rural and remote areas? Do you mean in terms of maternity services? My interest in the best start plan is maternity. It is certainly one that we have issues with. I know in my patch as well. I might bring in Michael to talk about this. One of the big challenges that we have in Scotland is that there is never a one-size-fits-all, because we have such different, I think about my constituency, delivering services in the far north-west Sutherland. Delivering public services is significantly harder, I would say, with the geography, topography, population sparsity compared to a city, but inner cities have their own challenges in terms of poverty and access to transport and all sorts of things. There is, in Scotland, a recognition that one-size-fits-all does not fit all. That is really important. It is important from a patient's perspective as well. One of the things that we are trying to do, as I said, Real Estate Medicine, is about trying to offer people person-centred care, flexible services that work for them. Much of the work on maternity services in implementing the improvements in maternity services had to be paused as we turned and faced the pandemic, but we are starting to pick that work up again. What you will see, I would hope, is a family-centred service, recognising how important the family unit is in a child's health. That is one of the reasons for the payments to support families when they are visiting children in hospital. Partly, there is plenty of evidence that shows the impact that that can have on a family impact. The day I launched that, I met this amazing woman whose child was in a hospital with a long-term condition, and she had to change her job to a much lower-income job in order to be able to continue to visit her child in hospital. She talked about how, almost immediately when she arrived in hospital, the costs racked up on her credit card. That will make a significant difference, but there is a recognition in there that families are not just visitors. When we talk about neonatal care, families are absolutely essential. They are part of that child's care. That is where we see illustrated our most significant strides towards that family-centred approach. Michael, I do not know if there is more that you want to add on that. Thanks, minister. Not too much just to recognise that that work, as you said on implementing the best start plan, has been impacted by Covid, but I know that colleagues are progressing that, as you have said. It is not in my portfolio within the Scottish Government that there is another director in healthy leaps after this agenda, but I know those priorities around continuity of care around personal centre care, around multi-professional working. There will be challenges around how those are implemented in rural areas, as opposed to urban areas, but the principles themselves persist and need to be implemented. It might be minister that I could interrupt the committee with more details around the particular question that Ms Harper asked, if that would be helpful. We will be coming back to this. The minister will be aware that we are doing an inquiry into perinatal mental health and new mother care. I am very conscious of the fact that there is quite a lot to move on. I am going to move things on to talking about the act of Scotland delivery plan and some questions from Evelyn Tweed. I was interested to hear your comments about the pandemic and the fact that, for some, it was a good opportunity for people to get physically active, to get out and about, to make sure that they were having that walk and to see the benefits of working from home. How can the Scottish Government hold on to the progress that was made at that time? What can the Scottish Government do to make sure that access to physical activity and exercise is not too costly? It is a great question. It is one that we are mulling over all the time at the moment because we are trying to harness those benefits but also ensure that they reach those parts of the population that were not able to change behaviour during the pandemic. Physical activity and sport are central to Scotland's recovery. There is a recognition that obesity is a risk factor for severe illness and death relating to Covid. It is even more important than ever that we tackle that. Physical activity and sport are linked with mental health and mental wellbeing. It was already strongly established but many people have recognised that on a personal level over the course of the pandemic. I cannot be the only one who found that opportunity to get outside in the fresh air to connect with nature to say hello to my neighbours, albeit from a two-metre distance. That was the most precious thing that got me through the pandemic on a daily basis. We also see that sports clubs have absolutely done an astounding job and we recognise just how important they are in their community. We have seen across the length and breadth of Scotland many sports clubs stepping up during the pandemic and meeting the needs of vulnerable people in their population. Sport has a reach that we, as parliamentarians or Government, do not have. They reach people that we cannot. We are reflecting on all that and looking at the things that have happened over the course of the past 18-20 months, as you would expect. The relationships between the Government and the sporting sector have been significantly strengthened. That is not to say that it has always been easy, but we have had to work closely together to rise and meet the challenges that the pandemic has thrown at us to try to bring back sport, which is something that we love. We have very strong relationships, which I think will see us through the tough times that are remaining relating to the pandemic, but also into how we work together to tackle the broader health of the nation. We are pretty keen, as I said. It ties in very much with the action on climate change. I have had bilateral already with Patrick Harvie, our minister for active transport. In terms of tackling inequalities, that increase in activity relating to transport is one of the ways that anyone can walk and you do not need special equipment to do it. Making sure that we have 20-minute neighbourhoods that are nice to walk in and that you can access your public services tackling that infrastructure is an important part of delivering that. It will require us to work together and to keep it in focus, but I am absolutely determined that there are opportunities here. In terms of Scotland delivery, we actually do pretty well in terms of our activity levels. We buck the trend internationally in terms of increasing our activity levels, which most people would be surprised to hear, but much of that is about active transport, so it is a place to focus. My colleague mentioned the first that sport has perceived as costly, but often that cost is related to the access to facilities. That cost is associated with the charges that local authorities put on, so I am wondering what we or yourself can do to make sure that the costs to the clubs and the participants are reduced and that local authorities keep those rents down as low as possible. There are a couple of things that we are doing. We are doubling investment in that portfolio area over the course of this Parliament. That will be very much focused on tackling inequalities and making sure that everybody can access sport and physical activity. Over the coming year, we will be working with Sport Scotland on any next steps to ensure that the Active Schools programme, as a first step, is free for all children and young people by the end of this Parliament. That will provide more opportunities for children and young people to take part in sport, but you are absolutely right. Local authorities in many situations have divested themselves of their state and we are quite keen. We are setting up a fan bank to ensure that communities can, in an empowered way, take control of those facilities and run them for the benefit of the community themselves, so there is lots of work going on in that. I am more than happy to provide you with more information on that. David Turans, you have put some questions on this area. Thank you, convener. Good morning, minister. Physical activity and access to exercise is really important in tackling a basically mental health-lonious medical condition like that. There are a lot of key stakeholders out there. How is the Scottish Government engaged with Scottish Government sporting bodies and who have experience in delivering and who could help you deliver that plan? We already work very closely with sports governing bodies and a whole load of stakeholders. Sports Scotland is the organisation that does much of the work on the ground in that area, but over the course of the pandemic it is simply because of the challenge. I am a huge rugby fan. We were not able to go to rugby matches. We had big matches. In fact, Sunday in Murrayfield was the first time they had a full capacity crowd in the stadium. Those challenges in delivering sport—if you think that that is from an elite level, from holding huge events right down to how do we make grassroots levels sport safe for people? How do we make it Covid safe? What are the rules and regulations that need to be in place in order to make sure that Covid transmission does not occur while people are playing sport? We have worked incredibly closely over the past 20 months, and I am absolutely sure that that is going to help us. You are quite right. Sport has a power to reach people, motivate people and inspire people in a way that me telling them stuff does not. We are keen to use that power to tackle all the big problems. Over the course of COP26, I have a couple of interesting meetings and collaborations about how we can use sport to tackle climate change. One of the key things that I am interested in is that I have had numerous reports that there are really good school facilities available, but it is very difficult for communities to access. I was wondering if you have done any work on that. I would intend to look at how communities can access that excellent facility that is already there. I can write to you with more details. I know that there are a couple of pilots happening in Dundee in ensuring that children have access to the school estate out of school hours, not just for sport but for creative and cultural activities. We recognise how important that is, and it is a public space. It is interesting that you should ask about that, because I had a four nations sports cabinet meeting just recently. That is an area of work that the UK Sports Minister is working on. At the end of that meeting, I asked for more detail from my officials about what the situation was in Scotland and what work we had going on across Scotland. I am more than happy to share that with you when we get it through. We are going to talk about the proposed Good Food Nation Bill on Food Standards Scotland. Good Food Nation Bill has been laid on 7 October, according to our papers, but it will be scrutinised by the Rural Committee. Given that nutritious diet and access to healthy food is integral to our public health agenda, our committee is interested in it. I am interested to know, minister, how the Government will work to ensure that public health priorities are integral to the Good Food Nation Bill. As I said repeatedly through the committee appearance, the solutions to some of the real challenges that we face in terms of health inequalities, for example, do not all lie in my portfolio. In order to solve them, we will have to rise to the challenge of working together across portfolio, break down silos and make sure that there is a cohesiveness across the piece to make sure that we deliver. I will absolutely be working hard to make sure that public health priorities are reflected in the Good Food Nation Bill. One of the very basics is tackling food insecurity. It is just devastating that in the sixth richest country in the world we have people who are food insecure, so we will be focusing on that as well as on the broader issues of nutrition. I know that it is a framework bill, so it is not really as prescriptive as other legislation. How will the Government work with local authorities and all the stakeholders to make sure that the bill has the information or the ability to guide everybody to take the Good Food Nation plan forward? I must admit that I am not sure that Michael wants to come in here, because it is not my bill. My level of detailed understanding of exactly how it is going to work is perhaps not what it would be if it were my bill. I understand that there are duties on local authorities and that there will be a requirement to, for example, procure locally issues like that, which I think will deliver benefits on a health basis to the population. Michael, perhaps you can help me out here. I will do my best. Again, it would be useful for us to write to the committee with more information. What I can say is that colleagues in my directorate who are responsible for leading on challenges around obesity and diet work closely with colleagues who are leading on the bill and colleagues in Food Standards Scotland as well. We see that as an important vehicle to help to deliver that agenda around better diet and health inequalities in this area, but we can provide more information to the committee if that would be useful. We know that that has increased because of Covid or food bank usage. Will the bill have a strategy to end the need for food banks? Absolutely. As I said, it is an absolutely devastating fact that a country as rich as ours has food insecurity. There is work going on right across government. We are bringing in human rights legislation, which I think will ensure that people have access to good quality food. There are food banks in every community, but when I spoke earlier about the impact of welfare reform, you can see the rise in food bank existence in the 11 years since the Conservative-Lib Dem coalition came in in 2010. There is lots and lots of evidence that food insecurity has increased since that time because of the impact on welfare reform. We are determined to tackle food insecurity. We have recognised that there are lots of communities providing food banks in different ways with more dignity at its heart. There are community larders and that type of thing rather than a food bank. Behind all of that is the devastating fact that there are more people with food insecurity than there ever were. We need to put in place policies that will prevent that from being the case. We will have to move on to palliative care, because we have a significant amount of members who want to discuss palliative care with us. On the Good Food Nation issue in the Food Standards Scotland and everything around it, we have a question from Sandesh Gohani. It is about children and ensuring that they are getting good quality foods in school. What standards are in place to ensure that the children get good quality food? There is not just an unhealthy option that is taken up all the time. What is being done to ensure that the areas around the schools maintain healthy eating areas? In terms of the quality of food in schools, I can certainly send you further information about the food standards in school. In terms of access to that, we have increased our offer of school meals for primary school children and made it all year round. I can certainly send you more information about the quality, about the offer of that and the quality of that. In terms of tackling the food environment, as a whole we need to tackle the food environment. We have an obesity-enic environment in Scotland where it is very easy to eat badly, it is very easy to exercise very little and that applies to children as much as it does to everyone else. In terms of controlling the environment around schools, I can see the logic for that and I am interested in looking at it, but children live everywhere. Children navigate life, not just around the school, they navigate life right throughout our communities and they are exposed to advertising, for example, at sports events that influence their behaviours. We need to be thinking broader than just the environment around the school, but you are right that that is one place that we will look at, but I think that it needs to be bigger and bolder than that. We move on to talk about palliative care. I have quite a number of my colleagues. Once I come in, Evelyn Tweed first of all. Sport, will the Scottish Government give... Broadcasting, can you bring up Evelyn's mic? There we go. Thanks, convener. What support will the Scottish Government give to hospices for adults to support the best end of life care for everyone? It is impossible to disentangle where we are just now from the experience that we have had over the last 20 months. What we saw over the last 20 months was more people dying at home than ever before. In some ways, you might consider that to be a positive thing. When you ask people where they want to die, they largely do want to die at home. We need to ensure that support systems are in place. We need to ensure that everyone who requires palliative care can access it. We need to ensure that that offer is available to people whatever condition they are suffering from. There are concerns that palliative care is more focused on conditions like cancer and less available for conditions like heart failure. We need to ensure that palliative care is accessible right across the board. We also need to ensure that palliative care is accessible right across our community. Palliative care, as with every kind of care, has a health inequality aspect to it. People from richer areas are more able to access palliative care. That will be a focus for all of us. We need to ingrain palliative care. We need to be having conversations about death and dying. We need to be looking at advanced directives and advanced planning. Those things need to be handled extremely sensitively. People need to be well informed and supported to make their own decisions. We need to have more conversations about that. We have a great deal of work going on across the board in palliative care. Sue Webber. We have heard earlier about the importance of the 20-minute neighbourhood, easy access and walking distance. You have also made the statement that centralising services far away is not helpful. You have also mentioned the importance of quality end-of-life palliative care close to the heart of communities. Will the Government therefore encourage health boards to do everything that they can to preserve and expand the services that are in the local communities? On a very specific local issue, Craig Hoy, one of my colleagues and I were both at a rally on Sunday at the hands around Eddington hospital. Right now, it is a very serious issue for the community in North Berwick, where we have already said that care should be within communities. Will you now go out and reach out to Lothian health board specifically and urgently reverse the closure of the inpatient palliative beds at Eddington hospital? I am more than happy to look into that issue for you. I would be pleased if you could write to me on that specific issue and I am happy to pick it up and look into it for you and see what I can do to help. Time and time again, we talk about people being able to access flexible, holistic, patient-centred care as close to home as possible. In fact, in my own part of the country, as you would expect, there has been real innovation over the past 20 months in terms of providing palliative care that might have in the past been provided in a building, in a centralised place, providing support to local people in order to provide that care at home. They are using technology in a way that they have never used it before and there are networks bringing up using technology between health professionals that have never been available before. I am obviously not going to pronounce on that particular situation that you raised with me now because I am not aware of all the details. What I would say is that what we want is for patients to experience high quality end-of-life care at home or as close to home as possible. I want to come in on palliative care, Gillian Mackay. Thank you, convener. It is a very brief supplementary to follow-up Emma Harper's questions. What work are you doing alongside the minister for mental wellbeing to make sure that families and carers who have been bereaved are being supported? We have had a year, 18 months of where grief has been very odd for many people, so I am just interested in what work is being done there. Absolutely. In my portfolio, the funeral sector is there. I had a meeting recently with representatives of the funeral sector. In all the work that they have done to ensure that people can still access these really important rituals, despite the fact that that has been one of the toughest aspects of the pandemic, asking people to stay apart at a time when usually a community comes together and supports people and reflects on somebody's life and celebrates it. There have been really, really tough times. We already have work going on. Certainly when I was Minister for Children and Young People, we had work going on recognising the significant impact that childhood bereavement has on children and an inspirational young woman, Denisha Kylo, I think her name was, was doing a lot of work gathering together and looking at what is available for children and trying to join up that patchwork. I am honest to make sure that it looks more cohesive. I think that we can learn from that type of work to ensure that bereavement care is front and foremost for families. More people have experienced bereavement in more difficult circumstances over the last 20 months than ever before. I just wanted to ask you quickly as well. Do not attempt to carry out pulmonary resuscitation or DNRs, as they are quite often quoted. It has been in the news quite a lot and it has created a good bit of fear. It has been felt at times that it has not been consensual. I know that I have not looked into that myself to a good degree as well. That kind of rubbing together of families just instinctively want to save their loved ones and have them have as long a life as possible. However, the DNRs as well can prevent actual real harm and distress occurring as well. I think that lots of people do not understand quite how distressing these kinds of procedures can be there. What I really wanted to ask you about was, are we looking at the public message there as well about making sure that our relatives have kind, compassionate and comfortable deaths rather than a focus on DNRs and fear factors? What are we doing to alleviate that and improve it? There is really good work going on in the palliative care community to raise the profile of those conversations. It is important. One of the challenges that we have is that there is still a taboo around death. There is still a discomfort in talking about it. We still use lots of euphemisms to talk about death. People are not exposed to death in the way that they might have been a generation ago. Most people die in hospital and there is a distance between us as a society and death. Death and taxes are the only sure thing in life, as they say. It is really important that we have those conversations. At the moment, there is a campaign going on. In a couple of weeks, I will tweet about it if I can find out more information. Talking about opening up those conversations should not be something that is reserved for the end of life. We need to be talking about death and about wishes. There is a great deal that goes on around the organ donation question. We have really tried hard to ensure that families talk about organ donation long before that in that situation. We heard the story of the most amazing woman whose husband had died suddenly in really difficult circumstances, but because she had that conversation, she knew that she wanted to ensure that his organs were donated. That act helped many families. That has helped her bereavement process in turn. It is really important that families talk about it. It is important that we have those conversations early and that we are more open and honest. It will take the fear factor out of death. It will ensure that people are able to access the services that will support them as they approach death. It makes life a lot easier for the family who are not left wondering whether they did the right thing. I am all for increasing those conversations and I will do whatever I can in my role to support that. Last question on this theme from Sandesh. Yesterday, when I was in GP, I had a DNA-CPR conversation and it is not one conversation. It is the start of a conversation and you need to go back to it on multiple occasions. I visited the Prince and Princess of Wales hospice and they are providing absolutely amazing care. They even have beds for young adults. This is where my question is. Because they are independent, if a patient wants respite and has money and says that it needs to go and is being controlled by the council, they are not able to access the Prince and Princess of Wales. They go to big chains only and they are unable to access the amazing care that hospice provides. Is that something that you would be able to look at and be able to stop that from happening and allow people, even if councils are controlling the respite money, to be able to choose where they go for their respite care? I think that the best thing that you can do is write to me about that particular problem and explain it to me. I am more than happy to find out what the situation is and come back to you. It is not an issue that I am aware of that people are not able to access hospice care when they need it. I want to know the details of that before I give you any advice on that. The top-level priorities. I am going to move it on to what members want to talk about clean air and the issues around clean air, starting with Gillian Mackay. Air pollution monitoring will clearly be key to identifying problem areas. Has the Scottish Government considered implementing a system of health alerts informed by air pollution monitoring to people with lung conditions so that they know which areas to avoid? I will look into that. There is certainly a national system of health alerts that we have seen over the course of my lifetime. The weather forecasters on television will now, at times of low air quality, pass a warning on low air quality, which people with lung conditions pay a great deal of attention to. There is a recognition that conditions like asthma, for example, were in an asthma epidemic many years ago in London, which prompted that change in practice so that the national weather forecast highlights when air quality is particularly low. The challenge would be communicating it to the people who need to know. You are right that we have systems in place. As I said, people are significantly more health literate now. People are looking after their own conditions in a way that they have not before. There may be an opportunity to communicate that risk in a different way rather than broadcasting it on television. I am interested in an update on the respiratory care action plan and how that will address air quality issues. I am asking because I am the co-convener of the long health cross-party group. I have already mentioned just how important it is for us to tackle climate change. Active transport is a solution to that. Getting cars off the road, reducing and making spaces more comfortable for people, but also reducing particulate pollution is absolutely a win-win. We are investing in active transport infrastructure. That is a really important priority for this Government. I spoke recently—I was at a World Health Organization panel where I presented with the Deputy Mayor of Paris. In Paris, they have done remarkable work in a very short period of time, partly because of the population density. There are so many people living in such a small space that it is really difficult for people to have enough space to navigate, but they also had a really significant pollution problem. The pandemic offered them an opportunity to put in place infrastructure that really transformed the way that people live. It has been hugely popular. You will know that spaces for people in Scotland during the course of the pandemic have been some controversies associated with that. Some of the infrastructure that was put in to make the environment more easy for active transport has been removed. We need to work with communities to find out what works for them. We absolutely need to increase the level of active transport. We need to increase the level of active transport because it will tackle climate change. We need to increase the level of active transport because it will make us healthier, because we will be more physically active. We need to increase the level of active transport because we need to reduce the level of particulate pollution that people are exposed to. All three of those are incontrovertible targets. I am assuming that you are good for another 10 minutes, because we are coming to the end of a session. Are we good for another 10 minutes of your time? We have a couple of Paul Cain on the clean air aspect of things. Thank you, convener, and thank you minister. I think just to follow on from that point, I think obviously we meet during COP, so these two things are really interlinked, the climate change approach in terms of clean air, but also the public health duty. I'm just keen to maybe get your brief sense of the clear the air report that came from Asma UK and the British Lung Foundation. They have highlighted the specific impact poor air quality has on low income communities. We need to get a sense of what we are doing within the strategy to target those particular low income communities in areas of multiple deprivation around things like active travel and active transport. Right across the board, in everything that we are doing, we are looking at things through an inequality lens. We are making sure that any policy that we introduce looks at things that way and that we particularly target those people who suffer most health inequalities. One of the simple things that we're doing, we had that manifesto pledge about ensuring that children all over Scotland had access to a bike. We have pilots, we've got 10 pilots now going on in different parts of Scotland. The barriers to bike ownership are different in different communities, but we are making sure that we are putting in place pilots that make bikes accessible for every part of our community. The challenges are not just simply being able to afford a bike. The challenges are having somewhere to store a bike, so if you live in a flat in the centre of the city, you may not have anywhere to put your bike. The challenges are lack of bike infrastructure, so most people would think twice about letting their children out on these busy city roads. There needs to be cycle lanes for them to cycle safely. There needs to be an awareness and an ability to repair bikes throughout the community. The challenges are multiple, but those pilots will help us to solve it. One of the threads right through the pilots, we thought about having a specific pilot for people who need accessible bikes, but we thought that the more important thing is to ensure that those are available everywhere. We also have that thread running through it. We're trying to ensure that those people for whom bike ownership is really challenging, perhaps because they have a disability and can't use a standard bike, and we're trying to ensure that that works. I think that those pilots will give us a great deal of information that will help us to transform the landscape over the course of this parliamentary term. The final question on the clean air aspect from Sandesh, and I'll come back to Paul. He's got some questions on indirect health harms from Covid-19, so I'll go to Sandesh first. I'm glad to hear that one of the aims is to get cars off the road, and I think that one of the big problems especially is commuting to work because of the traffic and you're all sitting there. As an example, we'll talk about the Queen Elizabeth, but it is an example of a greater issue around Scotland, where public transport wasn't good enough to get people from the city to the hospital, where there's no cycle lanes really to get people cycling in, and there's no showering facilities for people who do cycling. So how can we ensure going forward that other places around Scotland have the infrastructure that's required to stop people driving into work, and how can we help big hospitals like the Queen Elizabeth? You're absolutely right. One of the challenges is that these things have to be in at the design stage, so we have to be thinking about how we're going to encourage active transport at the time that we're planning the infrastructure. And there are more barriers than just simple bike ownership as I articulated there. One of the things that we are trying to do, I think you missed the conversation earlier because you arrived late, but we spoke about using our NHS facilities as anchor institutions. Part of that is about procurement and spending money in local communities, but part of that is also about ensuring that healthcare settings are as healthy as they can be, that people working there are able to access them via active transport rather than having to take their cars. And it's really important that we do that. One of the real challenges of my role, and I say this time and time again when I'm speaking to people who are interested in sport and physical activity, one of my challenges is that I'm regularly preaching to the converted, so I speak to other people who recognise the importance of sport and physical activity. What I need to do is speak to people who don't recognise that. I need to speak to the people who are making decisions on spending public money in councils, in the NHS. I need to speak to people who are planning infrastructure. I need to speak to people right across the board who are making those decisions so that we have that cohesive approach that we're thinking about 20-minute neighbourhoods and that we're thinking about our NHS staff being healthy. That's another example of public health reaching into all different areas of life. I was online this night, so I did it here. Excuse me, that's good. Can I just round things off? Pauline, you have some questions around the indirect health harms of Covid-19. Thanks to the minister for staying that little bit extra. Thank you, convener, and yes, thanks to the minister for her extended time. I will shine round this together because I think we've had a very meaningful discussion this morning around public health and around what needs to be done, and it's a huge amount of work. I think that that narrative of a public health Parliament perhaps has permitted many of our discussions so far, but obviously we have Covid-19 and the long-reaching impact of Covid-19, and we're about to enter next session here a bit about the pressures that are on NHS as we come into winter. I'm just keen to get a sense. How can we address the wider impacts in terms of public health and the challenges that continue to exist, have been exacerbated by the pandemic, and balance that, essentially, with the huge challenge that we have in terms of remobilisation and getting services back to a level in terms of acute delivery particularly? I suppose that the first thing that I would say in response to that question is that the pandemic is not over, and each and every one of us still has to take steps to reduce the transmission of those basic mitigations, wearing a mask, keeping your distance, not mixing indoors, where possible. All of those are really important. Another thing that's really important is getting your vaccination. We have a massive vaccination programme going on at the moment. It's remarkable the level of vaccination that we're managing to achieve in this country. I think that it's nine and a half million vaccines already in people's arms since the start of this programme last December. The requirement for vaccination during the autumn programme this year, the first tranche of vaccinations, was eight million vaccines, Covid two doses to the eligible population. Oh, we've got seven and a half million to be given in half the time because we're combining Covid boosters with flu vaccines. It's a phenomenal task, but taking that vaccine and getting people vaccinated is a really important step. You're absolutely right. The healthcare system is facing a challenge, the most challenging, as people have said. I've heard my cabinet secretary say several times that it's the most challenging period in the 73 years of the health service. At the moment, we're still facing a global pandemic. I think that there are around 800 people in hospital with Covid at the moment. Many ICU units still have a number of Covid patients, which makes it difficult, as you say, to restart the NHS, because many people who have, for example, routine operations will need a period in ICU afterwards. It's extremely challenging times. People are presenting with a level of acuity, there's a level of pent-up demand, because people haven't been accessing healthcare in the same way over the last couple of years, and there's a level of pent-up demand. All of those are exceptionally challenging. We have a great deal of work going in to improve the situation just last week. For example, an announcement around A&E using the multidisciplinary team to ensure that people get the right care at the right time and that only those people who need to be presented and treated in A&E are getting it. We have excellent work. I know just over the last few days I've been briefed about some excellent work that's going on in Greater Glasgow to improve the flow through the hospitals, and we're recognising just how significant that could be if we used it all over the country. We are very close to the issues and challenges that people are facing on the ground, and we are finding ways to improve the situation. It's a very dynamic situation, but we are finding ways to improve them as we go along. It is going to be a difficult period ahead. There is absolutely no doubt about it. The flow, we are anticipating, that there could be a significantly more severe burden of disease just because immunity has dropped, because we haven't experienced a flu season last year. There are massive challenges for us to rise and face, but we are absolutely across them and in a dynamic way taking steps to rise and face them over the next few months. Welcome back. Our third item today is an evidence session on seasonal planning and preparedness. It seems to be an echo in the room. I wonder if we can get that sorted out. It's not just in my head. I think that that's it sorted. Thank you very much. I would like to welcome Dr John Thomson, the vice president of the Royal College of Emergency Medicine, Dr Andrew Beust, the chair of the British Medical Association GP committee, Colin Pullman, the interim director of the Royal College of Nursing, Sharon Weiner Ogilvey, the Pediatry Service Lead for NHS Borders, representing the Allied Health Professions Federation Scotland, Annie Gunnar Logan, the chief executive of the Coalition of Care and Support Providers in Scotland, and John Mooney, the head of social care for unison. They are all joining us remotely and thank you very much for hanging on while we had that extended session with the minister earlier. One of the things that struck me and all the submissions that you made in talking about winter preparedness and that I suppose we're in winter now and it's all starting to kick off. We've seen all the concerns coming out about the ability of the NHS and social care to get us through winter. Probably one of the most challenging times, as we've heard, in the life of the country. All of you have pointed to one thing. There's one thing that is thread through every single one of your submissions and that is the staff vacancies and the issues around recruitment that you're all having to be able to have the full capacity of your services up and running to meet that demand or to try to meet that demand. Can I just go round each of you just to get a sense of what the difficulties are in filling those vacancies but also where you think action could be taken to assist filling those vacancies and if I maybe just come to you each in turn and come to John Thompson first of all. Thank you. Good morning, convener. Yes, there's certainly significant issues within emergency medicine throughout the country in terms of all vacancies, not just in medical vacancies but as I'm sure my colleague from the Royal College of Nursing will state as well in terms of our nursing colleagues. The training scheme for doctors within emergency medicine is quite prescriptive and the numbers are determined nationally and that is effectively based on the predictive numbers of consultants that will be required six years hence from when those individuals finish their training. That's essentially significantly out of date. The college undertook for the first time ever this year a workforce census and that was really quite revealing in terms of the information that it provided and we've submitted that in our written submission. The ideal consultant to patient ratio is one consultant for every 4,000 patients and currently in Scotland we have one consultant for every 6,450. Acknowledging that there's been a significant expansion of consultants in the last few years we're still significantly understaffed and the college estimates are at approximately 130 whole time equivalent consultants still in Scotland to allow us to safely staff our emergency departments with senior decision makers. Thank you and if I can come to Dr Andrew Beust next please. Thank you convener. Well, unlike emergency medicine general practice hasn't had an expansion of our numbers in recent years. The workforce survey published recently showed that our numbers have flat lined. They're no higher now than they were in 2013. We do have an agreed policy to expand the GP numbers by 800 in 2027 but I don't think we've made any progress towards that. We carried out a survey last month that showed that there are about 225 whole time equivalent GP vacancies just now across Scotland. The key thing is to recruit and retain more GPs. Right now I'm worried that we're losing GPs but the work intensity has risen enormously throughout Covid. That survey that we published on Friday showed that in one week in October last month we provided over 500,000 appointments in general practice in Scotland. That's one in every 10 people in Scotland was assessed by a clinician in general practice in one week. It is an enormous strain on the workforce just now. Many of my colleagues are extremely tired. Their morale is down. I'm worried that they are running out. It is those sort of circumstances that individuals decide that they're going to cut down what they do for their wellbeing or sometimes leave the profession. We really do have a serious situation with general practice, which is so fundamental. The foundation, as the previous cabinet secretary called it, of our NHS. We need to retain and recruit more GPs. Dr Pierce, I want to come back on something that you said about morale. One of the things that's been brought up to me in my constituency speaking to some GPs is how demoralised they feel about the perception of them in the media and that they are constantly fighting against this rhetoric that GPs need to, quote, get back to work. You've never stopped working throughout this pandemic. I'll be interested to know your thoughts on that because that seems to be a narrative that is making things an awful lot worse for the morale of GPs. Indeed, it has. Most of that rhetoric has come from England, I would say, but there has been some in Scotland and what newspapers print down as it does creep up here. The public see that and some of them believe it. In fact, general practice has been very much on the front line of the fight against Covid since March last year. Not just in their practices but working in the out-of-hours centres and indeed the Covid assessment centres, which have been so important in keeping people with Covid symptoms away from general practice so that we can see patients with all the other problems that they come to general practice to reduce the risk of infection transmission. It's what we've seen in the media and sadly what some politicians have said about what we've been doing is and has been demoralising. I'm going to move on to Colin Pullman from the perspective of the RCN, Colin. Thank you, convener, and thank you for the invite to address you. I mean, our members are telling us that they've never been under great pressure and the sustained levels of stress pressure over the past two years in the workforce. They've exhausted the war now and that brings me to what is the significant issue for us. That's about retention of the current workforce. We're hearing from nurses on a daily basis and when we're conducting surveys about people who are looking to leave the profession because of the sustained pressure they're under and the difficulties they have in delivering day-to-day services and the pressures that are put on them and their colleagues. What do we need to look at to resolve that? The difficulty is that we don't have thousands of people waiting to be employed. That's part of the issue, so we need to look at how we plan for the medium to long-term student nursing training and how we get a better supply. We just need to be upfront. The workforce planning measures that we've all had in place haven't been sufficient to meet what we now require. We need to build on our workforce planning and plan not for what we can afford but what we need, because that's where we've made mistakes in the past. We've planned for what we can afford and not what we need. My response to that is that there's never been more vacancies than the NHS currently for nurses, so we need to do as much as we possibly can to address the issue of retention as it equally is important to the recruitment. Everyone who leaves is logical. That's another person that we need to recruit. The pressures are extremely difficult. We need to work with all stakeholders and that includes the public. We need to be upfront with the public and Andrew just talked about that in relation to GPs. We sadly are also hearing stories, but the council of nurses is quite frankly being abused because of the messages that are being put out about what is possible and what's not possible. The media and ourselves need to do everything that we can to be open and honest with the public. Thank you for that. We're all nodding along to that, because that idea of patient frustration but expectation is something that a couple of my colleagues are going to come back on. Can I come to Sharon Weiner Ogilvie from the Allied Health Professions Federation? Hello. Thank you very much for inviting the Allied Health Professions Federation. We are representing 12 Allied Health professional bodies. It includes physiotherapists, occupational therapists, dieticians, speech and language therapists, podiatrists and radiographers. I won't name them all, but I will just give you some examples. Like your other speakers, we are also experiencing significant staffing issues within our workforce and real difficulties in filling vacancies. There are particularly acute pressures around radiographers at the moment and podiatrists, but we are noticing vacancies in all professions, occupational therapists and physiotherapists. That's really both affecting our ability to help people to stay safely at home and self-manage at home and prevent hospital admission but also prevent us from supporting the public health agenda, the preventative agenda. In relation to what is causing those acute exacerbations, I would break that down into two areas. One of them is that we currently do not have a sustainable educational model in Scotland to support workforce development within Allied Health professionals. We are very much at the mercy of the higher education institute to decide what the commission will march on. That is very much depending on market pressures, so what students want to study. We really need to move to a more sustainable model where perhaps Scottish Government would discuss commission places from higher education institutes across all professions. The second thing that exacerbates our ability to recruit and sustain staff within post is short-term funding and the lateness of funding to boards. I love the time when we receive funding around about autumn time and we expect to spend that money by March and deliver outcome. Existing challenges that we have around recruitment is very difficult to fill those fixed-term posts. We need to take a much more risk-assess approach to finance and recruitment because the money that we are getting from the Scottish Government is going to make it very difficult to have an impact on the winter pressure this winter. Annie-Gynard Logan Our social care organisations in our membership employ around 43,000 people and they have all been operating high volumes, delivering high-quality care right through the pandemic and by and large have been able to maintain services to the people that we support. Like other colleagues, this is not a sector that needs to be remobilised because we have never stopped. Staff recruitment and retention issues for social care providers are now acute. They are worsening. The staff, we have a brilliant, but they are exhausted, they are leaving and they are not coming back. It has always been an issue in social care recruitment but we have never referred to it as a crisis before now. We first raised major issues around this back in the summer of 2021 and we conducted a survey of our members and I think the outline findings of that are in the briefing that we gave to you in writing. What are we doing about it? We are not just sitting around, there is a lot of activity going on. Providers are continually advertising posts, many now taking advantage of the MyJobs Scotland portal, which we are now able to access free of charge, which is brilliant. Members are looking at ways to increase recruitment, including local community job fairs, events in local supermarkets, shopping centres, use of social media, local newspapers. All of that obviously requires a lot of resources, time planning, costs of advertising and so on. There is a national marketing campaign for social care that actually began yesterday, running until mid January. That is really welcome. Remains a lack of confidence amongst providers about how successful that is going to be because it is about awareness raising. There is a very competitive job market out there. On that note, retention remains a significant issue. Our members indicate that that is primarily due to burnout, stress, increased workloads because of staffing shortages, better pay and terms and conditions elsewhere. That is particularly true in remote areas where retail and hospitality offer much better pay. You asked what we would like to see. I have a list. The next phase of the campaign needs to focus on recruitment, i.e., there are jobs available now. Here they are rather than a general awareness raising around the importance of social care. National and sector collaboration is better needed to understand and address the specific needs of particularly remote and rural providers. We need increased consideration of retention with some national activity around that to understand why people come into social care, why they stay, what needs to change to get them to stay long term. Organisations like ours need to be much more included in some of the national and strategic discussions around that. I said in the briefing that we were part of a rapid action group convened in the summer to look at recruitment. That has been stood down. We do not know where the discussion has gone and wherever it has gone, we are not part of it. That is very serious. Fundamentally, what we need in social care is much faster progress towards fair work. There is a lot of activity going on. I am part of it. We are looking at pay, terms and conditions and so on. There is a lot of promise. You would have seen the proposals for the national care service and what it says about fair work. My worry is that that is still years away. We are talking about this winter. The national care service will not be here for a long time, so we need to do something much more immediate. We also need a complete overhaul of the way social care is commissioned. The Auditor General no less said in the Audit Scotland's submission to the national care service consultation that current funding and commissioning arrangements make it virtually impossible for employers to deliver work. The system persists with short-term, price-driven, competitive tendering and it is killing the sector and it is killing recruitment. Finally, we need a reappraisal of the value of social care. With the greatest of respect to my fellow witnesses here this morning, our system is very NHS centric and to the extent that social care is considered valuable, its value is often assessed according to how far it relieves or indeed contributes to pressure on the NHS. Social care is a public service in its own right. It has a value of its own, which is entirely distinct from the NHS and requires a distinct skill set and approach. We need to see that emphasised much more if we are going to attract people in. There are short-term, medium-term and long-term approaches to recruitment. That is very helpful. A springboard for quite a lot of my colleagues to come in and ask to pick up on supplementary questions around that. Can I come to John Moody from Unison? Yes, thank you, convener. I am delighted to be here today to speak on behalf of Unison members who arrange, support and provide social care across Scotland. As you can see from my written submission, Unison Scotland has finished a survey of thousands of members in social care with some newly alarming statistics around where we are headed this winter. In particular, I would like to draw attention to the fact that 35 per cent of respondents are already considering leaving the sector or actively trying to leave the sector, with a further 53 per cent speaking about the fact that they need an urgent break. I think that that should really draw your gaze to the issues that we are facing up front. The national care service, there are loads of proposals in there that are going to be very helpful to social care, but quite frankly, that is years away. What we need is urgent radical action. I would comment on freedom in the areas just now. First of all, what we need to do is we need to boost recruitment. To boost recruitment, we need to make working in social care an attractive proposition that takes the organisations involved to be able to fish in a different type of pond from people who are seeking jobs in other areas. To put quite bluntly, the proposals to increase the pay by 52 per cent does not remove the potential job seekers who are also looking in retail. We need something far more radical than that. We are currently looking at recruitment from providers that we deal with. We are looking at them sitting around 90 per cent to 94 per cent staffing, which is really concerning. We are hearing weekly reports of them holding interviews and the people who are supposed to be attending interviews, just not attending at all. Recruitment is a really urgent, high-priority issue for us. Following on from that, there is also the issue of staff sickness, which is also a major issue, because the 94 per cent recruitment drops to around 80 per cent to 84 per cent in terms of staffing when the staff are off sick. The reason for that is that two members across Scotland have stopped since the beginning of the pandemic, and the demands are just greater and greater and greater every day. It is constant shifts. There is no work-life balance in social care. People in other sectors will not even begin to consider that. They give up family time and are pressured into picking up these shifts, and that needs to change. That takes us on to the detention issue. We have just come through a Covid-19 pandemic. We are now facing a burnout pandemic. We already have investigations into why there are so many Covid deaths. I am really concerned that, at the end of this winter, we are going to be looking at investigating deaths as a result of staff shortages. I really cannot impress upon you enough. The message is coming from our members that they need help. They need more staff. They need more respect to work. They need to be valued. They need a level of fair pay and other measures to try to keep people within the system. You can see from our paper that we have a number of suggestions. To be honest, there is a number more that could be made. The Scottish Government has very helpfully brought in the social care staff support fund, which helps with payment of sick pay for Covid-related absences. However, the reality is that workers in social care are after-off sick with other issues. Many of them do not have sick pay, so it is very easy to see why people are choosing to move elsewhere to other areas where the stress is less and the pay is the same. I say to colleagues that we will come in and pick up on some of the issues and others around that. If colleagues can make a note as to who they would like to direct their questions to, because we will not be able to go around absolutely everyone. John Thomson, do you want to come back in briefly on something before I hand over to my colleague David Torrance? It was just to echo some of the comments from colleagues on the moralisation of workforce planning and unknown factors. Within emergency medicine, one in five colleagues have stated that they plan to take early retirement in the next five years, and one in two colleagues have stated that they plan to reduce their hours and work less than full-time. Or, if they are already less than full-time, reduce their hours even further. Those factors are not mitigated for in workforce planning, so we are going to move into an even greater crisis in terms of reduced workforce due to the pressures that colleagues are facing. I will come on to questions from David Torrance. Good morning to panel members. On the staff shortages in the NHS and the social care sector, what impact has Brexit had on you being able to recruit internationally? I guess that we want to pick up on a couple of different disciplines. If we go to emergency medicine first, then maybe come to the RCN and then GPs. If we come to Dr Thomson again, please. I am not aware of any significant effect in terms of Brexit. We tend to have full recruitment in terms of the start of training schemes within emergency medicine, but unfortunately we lose colleagues along the way for a variety of reasons. Those gaps that then become apparent further down in terms of several years after those colleagues' start training are very difficult to fill because people of similar experience who are not already working in the specialty just do not exist. We tend to find that we then have multiple rotas at many different levels with significant gaps, but we do not struggle to recruit to the specialty in the first instance. Colin Pullman on the issue that Brexit and immigration might have caused you? We have seen numbers reduced from individuals who have come from European countries on the national member council register. It is a difficult one to assess because we have been dealing with the pandemic. The issue is that we have not had huge numbers of people leaving thankfully that we have reported who have been recruited from the European Union. Within social care, some providers are reporting that it has caused difficulties in relation to individuals who have come to this country and to work within social care and help who have left and went back and have not seen the continued recruitment from individuals from the European Union. It has not had an impact. I could give you the assessment of the exact numbers, but it has contributed. There is no doubt about that, as all the other difficulties have. In relation to Brexit in particular, it depends where you are looking. In private sector care homes, there has been quite a high proportion of non-UK nationals working where there has been quite an on-going campaign to have people applied to the settlement scheme, for example, so that they can stay. One of the biggest issues for us is that the Migration Advisory Committee still regards social care as an unskilled area of work, which, apart from being a bit offensive to those of us who are involved in that, does not help here because we cannot actually recruit internationally. We have had some conversations with the minister about that and we are involved in some of the initiatives to try to tackle that. If you were looking for a social care perspective on that particularly, you would probably want to seek one from Scottish Care, which represents care homes very specifically. They would be able to give you a bit more chapter inverse on that. To round this off, I can come back to the BMA and Dr Buest on issues around Brexit immigration. Brexit has not significantly impacted on the majority. Most of our staff are from Scotland or the UK originally, so at least one thing has not impacted on us. There are clearly a range of factors that have contributed to the challenges that exist in relation to retention. Brexit is often cited as the key issue. What kind of mitigation work was done by the Scottish Government prior to Brexit around the issue for care providers? Was there a detailed piece of work done to tackle what was perceived to be the challenges around staffing as a result of Brexit? If we can just unmute. No, that's fine. Yes, there was some specific work around Brexit in social care. We were part of the working group and so were our colleagues in Scottish Care. As I say, it was a much bigger issue for them. We had a bit of a sweep of our third sector social care members around the proportions of EU nationals that were working in social care services in the third sector. It was actually quite low. It was 4-6 per cent. There are exceptions to that and I would cite very specifically Camp Hill Scotland because they have a very positive and strong approach to international recruitment. For them it was more like 40 per cent. However, it has to be said that they were a bit of an outlier. So there was a lot of work in preparation. It's still going on for our own membership. It's not kind of top of the list of concerns. But as I say, Scottish Care would be able to give you much more information because I think their own survey of them members was the proportion of EU nationals working in social care and care homes in particular was actually very much higher. I wonder if my pivot is just on to a point that Colin Pullman has raised. Everyone has spoken about the challenges in retention this morning. I think that that is evidently keeping people in the system and supporting people to remain in the system is a huge challenge. I'm keen perhaps to understand from Colin. Does he feel that the Scottish Government's seasonal planning, the winter plan, has done much in this area of supporting retention, particularly within nursing? I think that the additional investment in the psychological support and other types of support is fully welcome. It's not great that it's taken a pandemic before we've put for the investment in these areas to support staff, but it's there and that's really helpful. I think that the issue for retention for us is around about it does come back to numbers, it comes back to the pressure and stress, it comes back to the policies that we've put in place to support people. We have been disappointed by the Scottish Government in the last week or so where we're on one hand we're saying to our colleagues that you need to get your rest in recuperation and then on the other hand we're now offering to buy back and use Daniel Leith. I don't think that's a good message and I don't think any of my trade union colleagues think that. The problem is that the pressures are on us and the difficulties are on us. It's how we get people through that. I think that the investment on four million pounds in relation to areas of rest areas and also making access to basic things around food and hydration are welcome. We will be keeping a close eye to see that that makes a difference. What our colleagues are telling us is that they're looking for the basics to be able to take their breaks to get access to food and hydration, to get opportunities to have time off. The other important thing is that, as I said, the money is really well received in relation to the services that have been set up in the support services, but that other issue about getting people the opportunity to get access within their work time is not there either. We need to work as much as we can to make sure that the processes that we are putting in place, people can have access to them, because last week I was challenged quite rightly by a nurse who said, That's all great. You've got all these extra facilities that they're going to develop for us, but if I can't get off the work, it's no good to me, and it's more frustration to see it be done. We've got a lot of issues that we need to address and work through, and it's that whole issue about sustained pressure, because, as I said, it comes back to what I talked about for workforce. Everybody that leaves increases the vacancies and increases the pressure on their colleagues around them, and that's where the real difficulties are. Annie Gunnar-Logan wants to come in. Yes, just to come back on that, what Mr O'Cain was saying about retention, a lot of the key to retention is about looking after your staff and taking care of their wellbeing. I mean, we've already talked about the kind of exhaustion and the burnout that's going on. I just wanted to mention that there is absolutely excellent resources available through the wellbeing hub, and we've contributed to that. That's being hosted by Nest Scotland, and I say that not just because I've just joined their board, but I have just joined their board, so I should declare that for the purposes of propriety, but the wellbeing hub is a brilliant resource. The challenge that a lot of social care employers and staff have in relation to that is making the time available for staff to access and use those resources, because, as we've already heard from John and others, there are people being asked to do extra shifts and take on more responsibility, so actually carving out some time in that to access the really, really good wellbeing resources is quite challenging. I also wanted to mention the announcement in October of additional funding for the social care workforce, so it was £2 million, and it's being distributed through local areas. Now, as of this week, only a handful of our members have heard from local authorities or health and social care partnerships about how to access this fund. Now, the guidance around that fund was very, very clear that this was for the whole sector, it wasn't just for the public sector social care, and one provider, one of our members has already been told, no, no, this is just for local authorities, it's not for you. We really, really need to tackle that one straight away. We want to see streamlined and agreed processes to accessing those funds, because we find that it's not coming to us, and there needs to be some reporting back to the Scottish Government on how it's been used. Thank you for that. I think you've just reported back, Ms Logan, so that's all on the record. I've got a couple of you, my colleagues, on line, wanting to come back in. John Mooney first of all, and I'll come to John Thomson. Yes, thanks. Just to come back on the kind of spirit of that conversation, I think, listening to our members, the real answer here is recruitment. We need to boost recruitment to take the pressure off the people that are currently delivering the services. Because they're so close to burnout. Just to illustrate that, a couple of responses that we've had from members get us help soon, or too late if it's not sorted now, help us before we burn out. I'm on the edge and I feel that nobody cares. Absolutely, boosting recruitment is probably the best thing we can do to actually help with the tension. I think that your microphone should be live now. Sorry, did you call me in? I didn't actually hear what you said. You requested to speak in the chat box, so I'm just coming to you. Thank you, yes. Sorry, what you said was just to have cut off a bigger burn. Just to highlight from an emergency medicine perspective on staff wellbeing, the one thing that staff highlighted that would improve their wellbeing was actually improving patient flow within emergency departments. Improving the experience for our patients was the one factor that staff highlighted as being the most important factor in terms of their wellbeing, which I think is an interesting conclusion. Thank you. I'll come to Sharon Wiener-Augovay. Can you hear me? One untapped resource that we possibly have is people that have, within allied health professions, people that have dropped out of the healthcare professional council register because they had to take a career pose and perhaps care for young children or parents and perhaps return to work schemes. It might be very useful to attract some of those people back. We do know that a lot of health board do have very positive and flexible working and flexible policies for people. So really just trying to attract those people back into those landfill posts and having some support to the boards to have those returned to work training schemes might be helpful as well. Thank you. A few other members want to talk specifically on recruitment and pick up some issues that you've mentioned. Just a reminder to members to direct their questions to individuals if possible. Gillian Mackay. I think that this is probably a question for Dr Andrew Bewist. We've seen the commitment to recruit 800 GPs by 2027 from the Scottish Government. Does Dr Bewist believe that they should be 800 full-time equivalents rather than an 800 head count? I have a concern about recruiting eight. Obviously, we have a problem with the number of GPs reducing their hours or going part-time rather than being full-time. Does Dr Bewist believe that they should be 800 head count or should we be focusing on full-time equivalents? Thank you, convener. I think that when the announcement was made, it was never specified whether it was head count or full-time equivalent. The head count tends to deliver less, around maybe three quarters of a full-time equivalent. In terms of delivering what we need, 800 full-time equivalents would be better for Scotland. As I said earlier, I don't think that we've made any progress in this so far. Even an 800 head count would be a positive step forward. 800 full-time equivalents, yes, would be better, but we need to up our game in terms of delivering this additional workforce. We're four years into the process and we're largely where we were at the beginning of it. Sandesh Gohani. Thank you. With the recruitment, it's a difficult one to direct at one person in particular, but in view of how desperate we are in the nursing situation, what do you think is the realistic timeframe that we'd be able to recruit people from other countries, get them in and get them into the workforce? In international recruitment, it has its challenges. There are ethical considerations that we need to all think about. I think that the Scottish Government is talking about around 200 before April. We need to, if we are going to recruit internationally, we have concerns about that, but we need to recruit people from countries where there is a vision of nurses not to take away from health systems that are struggling. That is something that we need to consider. In realistic terms, to be fair to the board, I think that a number of the boards have already moved. One of the boards, indeed, are recruiting nurses from Hong Kong who have shown a willingness to come to the UK and Scotland specifically, which is excellent that there is more people coming. In respect of how long it takes, realistically, you are talking to me six months before somebody goes through all the processes and then you get people in. Of course, if it is people who are clearly able to come straight on to the nurse and midwifery council register, if there is an adaptation programme and period, that will obviously have had some months to be able to be fully active within the workforce. It takes a piece of time, but it is like all the things that we have talked about. Every small thing about the recruitment of individuals who have left the profession and coming back and looking at every single opportunity, we then add in the smaller numbers that make a significant difference. As I say, it would take months. This is directed to John Mooney Unison. I absolutely care about what is happening in the social care sector and in particular to the workers in that sector. If there was one thing that we could push the Scottish Government to do now, what would you suggest to us? At the top of my list at the moment is some kind of golden hello and loyalty payment, some kind of lump sum. The golden hello will hopefully attract people into the sector and the loyalty payment will help to detain people as well as making them feel valued for the work that they have done. We said from the start that it was great to get recognition when people were clapping for them, but claps do not pay bills and low pay without social care is still an issue. What we would ask the Scottish Government to look at is a situation where there are these golden hello-type payments being made to HDV drivers so that we can all of the latest iPhone, but we need to look at value in the care that our elderly relatives and disabled people, the most vulnerable people in our society, are receiving. I would urge people to consider that option as an absolute starter, to be honest. I have got so many things that we could mention, but as a starter that would be an instant impact. There are some organisations that are already trying to do that. The golden hello and the enhanced payment. If you have been doing it for a year then you get more than the real living wage of the basic. If there are only some organisations and not others that are able to do that then it just increases the churn between social care organisations. If it were a national approach that everybody is starting in social care but a golden hello and everybody got an enhancement after a certain amount of time then that would need to be funded right across the board and it would eliminate the competition between organisations that characterises social care. Paul Cain wants to pick up on that if you direct your question, Paul. Thank you very much, convener. I think both to John and perhaps if Annie is able to comment as well. I think that the points that you are essentially making is that we need to deal with pay more broadly in the care sector because I think that John alluded to the fact that you can go to a supermarket or often bar work and you can earn more money. What is the view in terms of, for example, other two unions, such as the GmbU and Unison and others, campaigning around £15 a never as a standard wage for care work? I think that our members are absolutely worth that. Our members are worth more than that, to be honest with you. It is clear that where pay is currently pitched, as I said, it just isn't lifting people out of that vision for the future. I think that we need to look at some of the plans for this winter, including putting another 1,000 staff into the NHS. The reality is that, because of the difference in pay in terms of conditions, that is likely to be social care staff. We need to look at social care in the round. I think that Annie made the point in her opening statement that the way that social care is judged is based on its impact on the NHS. I think that that is true. I think that we need to look at all the different roles in social care. We need to look at what is required to run social care and we need to make sure that, at the worst-case scenario, it is given a fighting chance to actually recruit the staff that it needs. We are going to start drilling down on some of your specific disciplines and, in terms of accident emergency, some members have questions specifically about that. I imagine that they are going to be directed to Dr John Thomson. I will probably buck the trend with that. This one is probably for Andrew from the BMA, but it relates to A&E. How does the BMA respond to claims by the Royal College of Emergency Medicine that demand in A&E is now partly attributable to the reduced access to GPs in primary care? It is interesting. We are part of one big joined-up system. As I mentioned earlier, when we looked at activity general practice last month, one week in Scotland, over 500,000 appointments were given out. In a typical week in an accident emergency, there are around 25,000 attendances. 20 times as many people each week in Scotland have a consultation in general. If 1 per cent of those GPs go instead to accident emergency, that 5,000 people represent a 20 per cent increase in A&E attendances. You can see how the gearing affects significantly. The announcement last week on redirection from A&E is something that I have supported. Indeed, in July last year, I said to Jean Flynn when we were discussing redesign of urgent care, a policy that I do not support. I suggest that, across A&E Scotland, they adopted the redirection policy that works in Tayside and has helped our attendants to stay above 90 per cent consistently. They did not want to do that at that time, but now the Government has decided to go ahead with that. As long as we explain to the public how the system works and where it is the right place to attend with different types of medical problems, and that there is capacity where they are redirected to to deal with them, that is something that we should support. However, as I said earlier, general practice is absolutely maxed out just now. We are providing over 500,000 appointments a week, and that is putting a considerable strain on general practice. Our numbers have gone up. Our capacity is down because infection control measures means that we are slightly less efficient. Consultations are up because there is a rise in mental health issues, which tend to be dealt with in general practice. There is significant back pressure from hospitals affecting general practice. When someone is referred for an operation and has to wait, say, over a year, they continue to have problems while awaiting the surgery. The only place that they can go to is general practice. Investigations that patients are waiting for in hospitals long waits for that. Again, the patients tend to come back to general practice. We are performing extremely well, but it is taking its toll on us. If some of those people overflow into A&E, it is somewhat inevitable, given the pressures on general practice, the numbers of patients that we are seeing. As I said earlier, one in 10 people in Scotland have contact with their general practice for a consultation every week. I do not know whether there is much more that we can do with that than that. That is why it is desperate that we start to build the GP workforce. It is important to say that the Royal College of Immersive Medicine Scotland has never said at any point that people are attending A&E because of lack of access to primary care. I agree entirely with Dr Bruce's comments on the pressures on primary care. That was a colleague in the college in England who said that. That is not the case. It is not something that we have ever said in relation to access to primary care. I think that it is important that that is made clear. Thank you, convener. It is clear that the traditional points of entry or access to healthcare are both emergency services or the GP. We can hear quite loudly today from both of you that those are the services that are suffering right now the most. There are quick supplementaries on Sue's question, such as Emma Harper and then Sandesh Gohanies. I am just thinking about out-of-hours service and, also like NHS 24 referrals, two out-of-hours, as far as winter planning and capacity. I am wondering if there is a role for how the Government, doctors and wider multidisciplinary team representative bodies can help make the public aware of what needs to be done. Is there a need to manage expectations of the public better, especially when we are looking at all the different ways of referral into services, whether it is GP out-of-hours or emergency services? That is something that I have been calling from Scottish Commons since September of last year. We absolutely need to bring the public along with us and explain to them what is going on. Right now, we do not have the normal level of capacity to meet all their needs. There has to be a degree of prioritisation and that means that sometimes their needs will not be met or not be met in the way that they would normally expect it to be. We need to explain that to the public so that they understand and help us get through what we expect is going to be a difficult winter. Do you think that the public is still at that stage, whether they are not using their pharmacist as much as they are not aware of the services that they can get at their pharmacist that might mean that they do not need a GP appointment? Is that still an issue? I think that it probably is. I know that there is another door drop that is planned in the next few weeks to explain to the public the options that they have available to them. I think that the community pharmacy option, the pharmacy first, is one that has probably been, you know, many people are still not fully aware of and is certainly a useful option for many conditions that might otherwise certainly go to general practice. Thank you. There are a couple of other panellists who want to come in on this. We have Sharon Rean at Ogovee. On that point, I think that care navigation is still very much needed and I think that health boards or GP practices in different areas have greater or lesser extent of that. What we are noticing certainly from the Allied Health Profession Federation perspective is that we are seeing more Allied Health professionals working as part of first contact. Practitioners within GP practices, from short-term evaluation projects that are being undertaken at the moment, we see quite positive response and positive impact of those first contact practitioners that are making at the moment. I think that it is just really around care navigation of patients and signposting them to who else can meet their needs other than the GPs. A supplementary question on this from Sandesh Gohani. Thank you, convener. This is really for Dr Thompson and Dr Beust. With 85 times percent of all patient contacts happening in primary care, it is quite clear with the demand happening in primary care, there is going to be patients who are desperate in going to A&E, but with patients being redirected from A&E back to GP, are we seeing a set of patients who are just being passed between primary care and A&E and what can we do to stop that from happening? I think that, Sandesh, that is clearly a risk. The redirection policy is that I support it, but it needs to be introduced sensitively with a degree of flexibility of the senior clinical decision maker at the front door. In an area, once it has been established for some time, the public get to know that turning up at A&E with a sore back you have had for two months is not going to get you seen. In areas such as Tayside where they have used this for a number of years, patients stop doing that and they will come to their GD instead as appropriately for a problem like that. I worry about a merry-go-round of people getting passed around and why I am very strongly against the policy that is being pursued just now on the redesign of urgent care, where patients who would previously have attended A&E are supposed to phone 111 NHS 24. Sometimes they have to wait up to 25-30 minutes to get that first call answered and then the idea is that they are maybe given an appointment time to go to A&E. That could be with a cut to their leg or maybe a broken wrist. I just think that it is a policy that is full of flaws and unintended consequences, one of which is the merry-go-round that you mentioned. It was good to hear from Dr Buest the mention of Tayside, where you have got the NHS working together with local authorities to roll out the enhanced community model there, especially around older people at home. My question, though, is really directed towards A&E and perhaps John Mooney as well. In the past, we have done quite a bit of work as far as integrated joint boards were concerned of looking at, you know, actually preventing admissions to hospital and making sure that we get discharged as quickly as possible, which kind of fits in with the Tayside model there. I am just wondering what your views are on how helpful that can be going forward, how much of that we need to incorporate going forward. Thanks for that question. It is an interesting one for our constituency of interest because most third sector providers are supporting people who have sometimes very complex social care needs but they are not in and out of hospital. That goes back to what I was saying at the top of the meeting about seeing social care through the prism of the extent to which it acts as a pressure valve for the NHS. That is where your question is going. Most of our members are supporting people who have learning disability, perhaps mental health issues, who are not in the position of being admitted and discharged from hospital. They use the NHS just like you and I would use. What you are referring to there probably is delayed discharges for older people. Certainly, there is an awful lot more that could be made, in my view, of the third sector there. I would recommend that you would speak to organisations like, for example, British Red Cross, who have got some fantastic home from hospital services. They are not registered care services in the same way that we conceptualise social care, but they do a huge amount also with volunteers. The whole staffing and recruitment issue is entirely different for them. The delayed discharge issue tends to focus around old people who are admitted, sometimes in emergencies, unplanned admissions and then are not able to be discharged because social care packages are not available for them. There are a number of ways to tackle that. For the purposes of our membership, that is not really where their main activity is located. On the A&E issue, we have found the question from Gillian Mackay. I am concerned particularly about regional variations in waiting times between health boards. For example, NHS Forth Valley in my region for the weekend in the 24th of October, only 51.8 per cent of people attending A&E were seen within four hours. It is a considerable improvement from 41 per cent on the weekend in the 10th of October, but it is still considerably lower than the national average. I know that Forth Valley will be subject to the same acute pressures elsewhere. Dr Thomson, in particular, had an insight as to why particular health boards seem to be struggling with that strain more than some of the others. I think that you have raised a very valid point. The demands on emergency departments are unrelenting and the four-hour standard performance for the month ending September is the lowest ever since records began. We have more patients waiting greater than eight hours and more patients waiting greater than 12 hours than we have ever had before. That equates to crowded and unsafe emergency departments. For the weekend ending the 31st of October, there was no major emergency department in Scotland that did not have patients waiting beyond eight hours. All bar one had a number of patients waiting greater than 12 hours. We know in some departments that some patients are waiting many days for a bed. What that reflects, quite simply, is inadequate capacity within the system for patients who need admitted to hospital. The emergency departments on average admit about 30 per cent of the patients that attend emergency departments. The vast majority are seen and discharged, but that 30 per cent are waiting far, far longer than is required for a bed within the system. We know quite simply that patients waiting that length of time come to harm. Do we have a sense of why certain health boards are maybe struggling with this more than others? Is it the number of consultants that there are in particular health boards? Is it particular health board geography in particular? The fourth valley was the example. I use it as a relatively urban health board comparatively with NHS Lanarkshire next door. Its A and E numbers are worse than NHS Lanarkshire, who are obviously on a higher crisis footing than fourth valley are. Do you have any particular insights as to why some health boards are struggling more than others? You mentioned variation across Scotland. Some emergency departments will deal only with emergency department patients and other emergency departments. That is the conduit for all admissions to the hospital to come through. Those patients who are referred from primary care in some hospitals will go directly to the ward and other boards will go to the emergency department and wait there for a bed. There is significant variation across the country. The main issue that is causing the very poor performance equates to a very poor patient experience in terms of the length of time patients are waiting within the emergency departments is a lack of bed capacity within the system. We estimate that we are approximately 1,000 acute beds short nationally. As we head into winter, the expectation is that, unfortunately, patients will be spending longer and longer within emergency departments and coming to more harm. That is a very useful insight. We have zeroing in on some of the specific areas, colleagues. If you can direct your questions to individuals, I will come to some questions following up on social care from Evelyn Tweed. My question is about the social care sector and capacity. I know that, in my constituency in Stirling, we have an acute shortage at present, but can you give us a flavour of the picture across Scotland in general? Can you also tell us something about how we can help the issues that are being experienced in remote areas in particular? I think that capacity is a big issue. I mentioned earlier in the meeting that we surveyed providers on their recruitment issues. There were some findings that addressed capacity. I shall just flip them up and let you know what they said. We had 30 providers responding to our survey, and they are all pretty large organisations. They are the ones that are operating in multiple authority areas. 63 per cent of them said that they had already had to reduce capacity for service delivery as a result of recruitment shortages. That is just shy of two thirds across the country, which surprised us. I have to say that it was as high as that. We also had 53 per cent of those providers saying that they either have or would have to refuse any new care packages, even if commissioners came to them and asked them to do it. Again, that is over half of providers saying that. Those are pretty significant numbers. We have not seen anything like that before this particular period, which is 18 months into a pandemic approaching the winter. Yes to serious, what we can do about it is very much hinged on how we get more people into the workforce. The social care workforce is very different to the NHS workforce. Typically, the NHS model is that you train, you qualify and then you start work. In social care, you start work and then you train and then you qualify. We do it the other way round. A lot of recruitment is more about values based. What kind of person are you? Are you the right person to do this kind of work? If so, let's have you in. Then we start training and qualifying you. The kinds of issues that colleagues were talking about in terms of how long it might take for nursing staff to come through the system or medical staff, that is not really the case with social care. If it was an attractive enough option for people, they could start tomorrow. We need to make it more attractive for people to start tomorrow. In rural areas, that means being able to compete with retail and hospitality purely on pay. Overall, it is back to fair work to make it something that people want to do, to understand what it is. I talked at the beginning of the meeting about the value that is placed on social care and what people think it is. It is not just a pressure belt for the NHS. It is not just time and task personal care. It is standing alongside people and supporting them to live their best lives. That is what social care is about. We do not hear a lot of that. Social care is mentioned in the list of public services that people like to speak about when they are on platforms, doctors, nurses, teachers, etc. Social care is nowhere. There is a whole awareness raising that needs to be done. In the immediate term, we could get people in the door tomorrow if it was attractive enough and particularly if it was attractive enough in pay terms. It is really as simple as that. Thank you, Annie. That was really helpful. Thank you, convener. Maybe just continuing with Annie for a moment. I have been hearing a lot about unpaid carers being in crisis because they feel that they cannot access the packages that they need or they have been told by their local authority that their package will have to be scaled back or cut back. Particularly around care at home and not only for older people but particularly for people who have learning disabilities. Again, from the work that you do with providers and your survey work, is that a sense that there is a crisis for unpaid carers as well? Yes, I think so. Some of that is also a kind of hangover from the pandemic. I said that we are not a sector that needs to be remobilising because we have been here all the time. There are exceptions to that and the exceptions to that are congregate care settings. We know about care homes but there has been very little focus on things such as daytime opportunities, which are buildings-based, and especially on short breaks for carers, what we used to call respite. A lot of those had to close at the beginning of the pandemic simply because of the restrictions on the numbers of people that were allowed to meet indoors and the social distancing. Those were buildings-based congregate settings that just couldn't admit people anymore. What that has meant for a lot of family carers is that they just haven't had a break at all for 18 months, none, no support whatsoever. One of the things that I was going to ask the committee to consider is that you have a lot of providers including me. That is who I am speaking on behalf of, but there are a number of user-led organisations that have a lot of information on that. Inclusion Scotland would be one of them, and they have been tracking carers coalition. They have been tracking what has been happening to people's support. It is not particularly happy picture. I would thoroughly recommend to the committee that at some point you have a session, not for me to tell you your business, but you would really get some very rich information from those organisations, which would come from the people who have lost out on receiving social care. I can talk about the staff, providers and the impact on the sector and all the rest, but the really important thing is what is happening to people who rely on social care. The capacity issues that we have in the sector have had quite an impact on them for sure. I would like to move on to questions around the general improving outcomes. It has been alluded to by many of you throughout everything that we have talked about so far. That is really the crux of the matter, how we improve health outcomes for people over winter. You have pointed to quite a few areas, but Emma Harper has some specific questions on that. As we are looking at planning for winter, which this session is about, how do we look at improving outcomes? I am the co-convener of a few health care cross-party groups, and health inequality is one. We know that we need to improve the outcomes for many people. We heard about the women's health plan earlier from Minister Marie Todd. I wonder if any members of the panel have specific proposals about improving outcomes, not just for winter but in the future as well. I think that our recipe for improving outcomes was contained in our submission to Derek Feeley's review of social care. There is a whole range of approaches for that. For us, fundamentally, it means that we just drop the whole idea of competitive tendering for social care. That takes us nowhere in relation to improving outcomes. It is about a skilled workforce that is discouraged by competitive tendering and current commissioning arrangements. It is about standing alongside people and letting them make their own decisions. Interestingly, the national care service consultation did not have enough to say about that and the importance of self-directed support. In social care, that has been legislated for eight years now. The whole point of self-directed support is that people identify their own outcomes and the role of social care is to support them to achieve it. That, for me, is the absolutely essential part of all that. We need to be really serious about self-directed support, we need to implement it properly and we need to put more resources behind it and get it moving. That is certainly what Derek Feeley said in his report. At the moment, there is a little bit of a mismatch between what Derek Feeley said and the proposals for the national care service as they stand. I think that the job that we have all got to do over the next few months is to make sure that they can realign on that because the best people to tell you what outcomes they want to achieve are the people that we support. Unison's long-time stance is really straightforward. A highly trained and valued workforce is the best thing that it can do to improve standards within social care. It is something that we have been pushing throughout the Feeley review and also into the national care service review. I think that that work has really got to be centred around the fair work principles. That is certainly the direction of travel in which we should be going in. When you are talking about an overnight fit for the staff shortage stuff and lots of the fair work principles, I am not going to deliver an overnight success. In the medium to long-term areas that we should be going down, I am probably not going to surprise you by saying that the conflict between private profit in-care and providing a top-notch service is clear for unison to see. I was disappointed in the national care service proposals that private profit is something that appears to be accepted going forward. We have got lots of members responding to our survey speaking about even though they are struggling to provide the services that they currently provide. There are still organisations out there that are tendering for new services. Speaking about the fact that, essentially, if they had the level of training that they need, things would be a lot better for service users on the ground. I think that we need to shift some of the resources or think more about how we can develop resources around prevention and early intervention. We have seen that prior to the pandemic. We have begun to see the shift, but because of the pandemic and the needs of the population have changed and the requirement for more therapeutic intervention and longer rehab, a lot of the allied health professions workforce has been diverted to address those acute issues, rather than focus on prevention and early intervention. For example, how might we support people with low or medium-level frailty in the community so that they do not develop or access any acute services? I think that we need to shift some resources to that preventative agenda. I know that I read in the submission from the Royal College of Emergency Medicine that the data showed that, for every 67 patients waiting 60 to 12 hours, one of them will come to an avoidable harm. That is an issue that we need to look at. How can that be avoided? For every harm that occurs, there is a data entry system that requires that to be tracked and dealt with. I think that it is a data system and I know it because I am a former nurse who used to enter adverse events into the data system. I am interested to know how we will make sure that we have a wider ability for our GP's or doctors to utilise a system or use that to learn so that harm can be avoided in the future. Dr John Thomson, first, please. On the issue that you have raised, there is clear evidence, adjusting for all other confounding factors such as age and deprivation, that a weight in an emergency department of 8 to 12 hours increases mortality on that admission for patients. For every 67 patients waiting between 8 to 12 hours for admission to hospital, there will be one avoidable death related purely to that excess weight in emergency departments. That is absolutely unconscionable and completely avoidable with the correct capacity in the system. What we do not know is what harm that does not result in death is happening to those patients who are waiting a significant length of time. Emergency department staff are not trained to look after patients for many hours after their initial assessment and immediate management. Therefore, those patients, despite best efforts of all our staff, are receiving poorer quality care than they would if they were in the correct bed under the correct in-patient specialty. However, there is no doubt that, as we head into winter, if we see a continuation in the long waits of patients waiting for beds within emergency departments, those patients are not waiting to be seen. Patients are being seen within an appropriate timescale. Those patients are waiting many hours to move to an appropriate in-patient bed. We have a couple more questions that we want to ask of you all before we go away. Sorry, staff welfare has been mentioned many times in this session. I am just looking at my colleagues. I have a number of colleagues that want to ask specific questions on staff welfare if you can make your questions direct and quick. I had a very long bit, but I will make this as succinct as possible. When it comes to nurses working in the acute sector, how feasible is it to really provide them with the opportunity to do for flexible working? I am just with the challenges and the restrictions in their wellbeing and retaining those members of staff. I guess we go to the RCN for that, Colin. I think that it is absolutely possible. I do not think that there should be restrictions. I think that we should look at all flexible working options for any individual who wants to look at that. If it is going to retain them in the service, that is a way to do it. If it is going to help them to maintain their health and wellbeing, that is a way to do it. I do not think that there are any barriers to not look at flexible working within the acute sector, as well as across the whole of the health and social care sector. We need to get much more in working with our workforce around what suits their work-life balance. That means looking at flexibility of opportunity and flexibility of employment. It is hugely important. Far rather, we had individuals who could work some of the time and even extend their career. I am going to use the word flog them until they feel they have to leave. I do not think that there are barriers. It is more around about choice and about making those choices available. That is great to hear. One of the things that the Government is looking to do is to attract people back who have maybe retired early. Do you think that flexible approach would attract people back who have maybe felt that they wanted to take early retirement? That is a huge point, convener, because we have not only got the people who have left who we want to attract back. There was some pension implications, but that was changed with the pandemic with emergency measures. Currently, we know that we have an aging workforce. We have some changes to the pension provisions going forward. We also know that there are a lot of people who are looking at retirement now, and we need to make sure that we keep that expertise in the workforce for mentoring and for support, as well as providing patient care. It is a part of both, but I do think that if we could get that right, we have seen a number of people come back during the pandemic. Not as many as we would all have wished or hoped, but we have seen a number. We have also got to ask those individuals what have we done that has made it work for you so that we can improve what the offer is and maintain people in the workforce. Those individuals who choose to retire take such an experience and we need them to support our new workforce that comes in and new qualified nurses and to help them to develop the best practitioners that they can be. It is something that we have talked about for a number of years, as many of you will know, but we are not on that right yet. Just to support that, obviously in social care but also in the NHS from colleagues, staff are looking for a degree of flexibility in their work. It is our understanding that many people are considering or have already moved on to things like the bank, and the only real reason for doing that is to give people more control over the shifts at the worker, how they work and what they do. Clearly, there needs to be a more modern approach, some way to meet in the middle where a service division can be maintained but also people can get the work-life balance that they want. I think that we really need to focus on going down that route in the future. The general question is about wellbeing and welfare of staff. As I have said before, fair work is top of the list and access to wellbeing resources. For our sector, it would help enormously with morale if staff and commission services were not treated as second-class citizens compared to the rest of the system. I put in our written submission that the uplift to £10.02 as a minimum wage for care workers is absolutely brilliant, fantastic announcement. It is now being entangled in a whole load of implementation problems that we think are going to, for some organisations at least, make it worse rather than better. We are simply not viewed as an equal part of the system compared with public sector employees. That is a hugely demoralising thing for staff in our sector. The same goes for organisations. Our submission talks briefly about some of the financial support that has been made available to our sector. Again, hugely important. We are very grateful for it but the way it is being administered is an absolute catastrophe. We all feel like we are slightly outside the loop as third sector organisations. Parity of esteem would help tremendously with staff wellbeing and for all of us working here in the third sector. We are trusted enough to provide very intensive personal support to arrange hundreds of thousands of people but somehow we are not trusted enough to deal with the money. The support in the same way that other organisations are. That really needs to stop now. We are coming to the end of our session but Paul Cain has some lessons learned from dealing with Covid last year. Over to you Paul to end the session. Thank you very much, convener. I appreciate that we are tight for time here at the end. My question would really be whether we are still living through the pandemic. We had a winter last year that was unprecedented. I suppose that I am keen to understand what are the feelings on lessons learned from last winter. Has the Government learned the lessons of what didn't work so well and perhaps what did work? Has that been factored into the winter preparedness plan? The winter demands that we see year on year are entirely predictable. In my experience we put short term measures in to mitigate over this period and we do not put longer term solutions in that allow us to deal with that fluctuation demand. For example, it is entirely normal over this period to reduce the amount of elective surgery to accommodate the increased bed base that is required for unscheduled care admissions and we do that every winter. As number of admissions decreased, we revert back to normal. I think that it will be the same again. It will be short term mitigation that is required and I do not see anything that has changed that has made things any different for this coming winter from any previous winter in terms of this element of cross your fingers and hope that we cope. I think that there is a sense there around every winter that we see these pressures and I take the point about what you said about elective surgeries but do we feel that because of the unusual circumstances of the pandemic having already cancelled more and more elective surgery that creates a problem for us at the other end of winter? I think that any remobilisation plan that has been discussed or published in regards to Covid recovery, particularly around waiting lists and surgery, has not taken into consideration unscheduled care and without doing that is likely to fail. There needs to be a single overview of the capacity that is required for unscheduled care. Although it is unscheduled, it is relatively predictable. We know at what points of the year that we are particularly busy and at what points of the year that we are not. I guess that this is the concern this year is that during autumn, which is a normally relatively quiet time heading into winter, we are at our worst ever performance, far worse than any previous winter and we are not yet in winter. I think that what will happen again is that medical patients will be admitted to surgical beds because that is where the capacity is within hospitals to allow these patients to get to bed. I have a long come to terms with the reality that, on behalf of our sector, I tend to say the same things that I said last year and indeed the year before that. That is also true this year. However, staying positive, the FELE recommendations and the national care service proposals would go a long way to supporting social care in the way that it needs supporting in the winter or indeed at any other time, but they are a very long way off. In terms of the Scottish Government learning lessons and understanding what needs to be done, I think that there is a very broad understanding of what needs to be done. We are not doing it yet. It comes back to what I was saying about the long-term prospects being quite positive, but in the short term we need some very rapid action around some of those things. Unfortunately, a lot of that will take money. There has already been quite a lot of money allocated. The £10.2 is brilliant. We are all very pleased about that. As I have said, some of the implementation methodology around that and some of the other financial support that we have is just not doing it. We need a bit of an injection of urgency and speed into some of the solutions that we already know will work. Unfortunately, we have really gone over our time. I want to thank everyone who has given us evidence this morning. Is there anything specific that you want to follow up on? The committee is always here to take any of your emails and letters to us about some of the specific issues that you might feel that you did not get time to express, but thank you very much. Everything that you have said has been extremely helpful to us. That next meeting in 16 November, the committee will take evidence from the Minister for Mental Well-being and Social Care on session 6 priorities. That concludes the public part of our meeting today.