 Good morning. Welcome to the fifth meeting of the Citizen, Participation and Public Petitions Committee. Our first item this morning, in fact, is to welcome a new member to the committee who is replacing Tess White. First of all, I would like to thank Tess White, although she was not with us for very long, for the contribution that she brought to the committee. I know her on-going interest in a number of the petitions with which she was involved. However, we are joined now by Alexander Stewart. In the first instance, I would like to ask Alexander if there is any interest that he would wish to declare before assuming his position. Thank you, convener. I am delighted to join the committee. I have no declarations of relative interests that are appropriate to this committee. We will be taking evidence from ministers at around about half past 11, we think. Prior to that, our second item today is the consideration of new petitions. Again, just for those who might be tuning in to see the progress of their petition or others who are watching this morning, we do in advance of our consideration of petitions, seek submissions from the Scottish Government and receive submissions from others so that we have a certain amount of informed information at our disposal before we proceed. The first of our new petitions this morning is number 1876 to accurately record the sex of people charged or convicted of rape or attempted rape. That has been lodged by Lucy Hunter Blackburn, Lisa McKenzie and Cath Murray. The petition is calling in the Scottish Parliament to urge the Scottish Government to require Police Scotland, the Crown Office and the Scottish Court Service to accurately record the sex of people charged or convicted of rape or attempted rape. In its submission to us, the Scottish Government states that the crime statistics that it publishes are derived from data held in the criminal history system. The criminal history system is an operational database that is used and maintained by Police Scotland for the primary purpose of recording of information on people accused of convicted of perpetrating a criminal act. The submission argues that it would therefore be for Police Scotland to determine how the sex of people charged or convicted of rape or attempted rape is recorded on the CHS. Since the publication of our meeting papers, the committee has received several written submissions, including from Fair Play for Women, Dr Shona Dillon, from Women's Scotland, from Sharon Dowie MSP and from the petitioners. In its submission, the petitioners highlight that crime recording practices in Scotland are overseen by the Scottish Crime Recording Board, the role of the board, which is chaired by the Scottish Government, is to support the production of accurate and objective statistics on crime in Scotland. The petitioners therefore reiterate that the action that they are calling for is for the Scottish Government to require Police Scotland, the Crown Office and the Scottish Court Service, to accurately record the sex of people charged or convicted of rape or attempted rape. In their submission, the petitioners also highlight that the Scottish Government published guidance on collecting data on sex, gender and entity and trans status last month. That guidance cites that the investigation of serious sexual offences as an example where data on biological sex is required. The petitioners argue that the fact that the chief statistician chose to single out sexual offending in that guidance lends weight to the argument that the nature and gravity of such cases justifies accurate recording. Thereby, by introduction, I am now happy to ask whether members have any comments that they would like to make and if you can give me an indication if you would like to do so. I see that David Torrance in the first instance. David Torrance. Thank you, convener. I would like to investigate this petition more, keep it open and there's a lot of stakeholders here, so I'd like to write to them to get their views. Police Scotland, Crown Office and Prosecutorate Fiscal, the Colleagues on Human Rights Commission and the Scottish Courts and Tribunial Service, to see what they say about the petitioning. Bill Kidd, thank you very much. I think that the suggestion by Mr Torrance is perfectly logical and sensible. This is a petition or a group petition that really does state something that isn't in the public domain to a greater degree. I think that it is incumbent on us to investigate it and then bring it back once we've got the responses to be able to respond successfully to it. I would concur with my two fellow committee members. I think that the petition raises important questions about trust in statistics and data. It gives us an opportunity to seek some more views and opinions from some of the stakeholders so that we can take that forward and then have a more measured approach as to how it is. It is a very sensitive and delicate situation that we find ourselves in, but it is important that we engage with that and try to gain as much information as we can so that we can have a more balanced approach on the process. I agree that an evidence-led approach is critical and I concur with colleagues that the routes of research that are identified and proposed are appropriate and I support those actions. I am going to be a bit blunt here because I was struck by one paragraph in the Scottish Government's submission. The crime of rape is committed by someone with a penis, including a surgically constructed penis. As the petition mentions, a person male or female can also be convicted of rape when their involvement was art and part assisted in the perpetration of the crime. I note that the petitioners wonder whether, although that is technically stated, it has actually been the subject of any subsequent prosecution or not. I do not think that that is entirely clear. I think that there are a number of people that we can write to if I can have some suggestions on who they might be. David Torrance, do you have any particular bodies that you would like to specifically contact? I think that we should write back to the Scottish Government and see if there are any figures recording this and what they have stated in their statement. David, you have already suggested just to police Scotland to the Crown Office and the Frot Curator Fiscal, the Qualities and Human Rights Commission and the Scottish Courts and Tribunals Service, so we are agreed in doing that. On the back of my own comment, your suggestion, if the committee is agreeable that we would also write to the Scottish Government asking for some validation of the actual prosecutions that have taken place in those circumstances. Presumably, where the Scottish Government talks about prosthetics and other things, that could be a crime committed by a male or a female. The analysis of that is something that I would like to understand the reality of rather than just the theoretical and technical aspect of it. Bill Kidd? Thank you. I think that that is perfectly logical, although I do see in the Scottish Government response that they state that they publish each year a statistical bulletin on the criminal proceedings in Scotland. It presents statistics and criminal proceedings, including a breakdown by sex of convicted persons of crime type. I think that the Scottish Government has given us something already that I think we could respond better to by first contacting those other organisations, as suggested by David Torrance, and then coming back to the Scottish Government with those results. I am quite happy to do that, to the way that I am content. Any other comments? We are going to keep this petition open. It touches on issues that require to be clarified, and we will consider the petition again when we have received responses from the various parties to whom we are now writing. Our second new position this morning is to provide an accessible and professionally developed learning and teaching resource on Israel and Palestine, petition number 1879. It is important prior to proceeding that I declare my own interest as the convener in the last Parliament of the building bridges with Israel cross-party group, which has yet to be reconvened in this Parliament, but which I hope and expect will do so later this month. The second petition for consideration today has been lodged by Hugh Humphries on behalf of the Scottish Friends of Palestine. The petition is calling on the Scottish Parliament to urge the Scottish Government to acknowledge the right of Scotland's pupils to a bias-free education on the topic of Israel, Palestine, by ensuring that Education Scotland hosts an accessible and professionally developed learning and teaching resource on its national internet service and re-establishes a strategic review group to oversee any revision of the original resource developed in 2016. In its submission, the Scottish Government states that in 2015 a working group was established to scope out appropriate materials to support practitioners to develop learning on the conflict and issues around Israel and Palestine. An initial set of resources was made available on Glow, the Education Scotland's national learning platform, in 2017 on a pilot basis. The Scottish Government states that by February 2018, following engagement with interested stakeholders, it was apparent that the consensus on the resources sought by Education Scotland could not be achieved. It states that an offer by Education Scotland to further develop the resource was not agreeable to the Educational Institute of Scotland, the EIS, as a joint owner of the resource. The EIS did, however, offer to publish the resources on its own website where it is still available. The Scottish Government states that, given the lack of consensus across stakeholders and the EIS publishing the resource on a publicly available platform, the Scottish Government and Education Scotland concluded that the matter was closed. The committee has received several submissions, including three from the petitioner. In his response to the Scottish Government's submission, the petitioner states his view that it was clear from early 2017 that there would be no consensus between stakeholder groups and the resource. The petitioner believes that the Scottish Government has been lobbied into first amending the resource and then removing it from Glow. He also highlights that Glow is promoted as a destination hub for staff looking for additional learning and teaching resources. He argues that in placing a teaching resource on another platform, it is effectively being consigned to obscurity. Since the publication of our papers, the committee has received a late submission from the Scottish Friends of Israel and a further submission from the petitioner, which provides opposing views on the development of the education resource. Those have been circulated to members and are published on the Scottish Parliament's website. I would be grateful to members if they would like to make any comment on the petition. David Torrance I am concerned that the Scottish Government and Education Scotland consider a matter closed, and that the curriculum excellence is down to local authorities and individual schools to create. I would like to close the petition under rule 15.7 of standing orders, because I do not think that the committee could take us any further. Bill Kidd I think that that is a reasonable approach on the basis that the petitions committee has probably taken this as far as it possibly can. As the Scottish Parliament has cross-party groups on both issues on Friends of Israel and on the situation in Palestine, I think that those two cross-party groups existing within the Parliament show that the Scottish Parliament is not ignoring or just throwing away this important issue. I do not think that it is for us to chase it, but I would like to hear that the cross-party group MSPs on both cross-party groups would at least come together at some point and speak to each other in a rational manner, which might help to develop a better approach here in Scotland. I think that that would be something, but I do not know that we could influence that at all. Thank you. I have two things to suggest. One is that we close the petition and one is that we maybe draw the petition to the attention of the respective cross-party groups. Is that within our competence? Cross-party groups are not being officially recognised by the Parliament, but yes, I think that we could do that. I think that it would be useful at some stage for members, certainly the elected members of both the cross-party groups, to initiate a discussion. So, we close the petition on that basis. Thank you. Our third new petition this morning is petition number 1885 to make offering community-shared ownership mandatory for all wind farm development planning proposals. The final new petition has been lodged by Karen Murphy, and the petition calls on the Scottish Parliament to urge the Scottish Government to make community-shared ownership a mandatory requirement to be offered as part of all planning proposals for wind farm development. In its response to the petition, the Scottish Government states that electricity generation is a reserved matter under the Scotland Act 1998. As such, the Scottish Parliament does not have the actual legal competence to change the law for a purpose relating to the regulation of the control and electricity generation, as the petition would request. In the absence of powers to change the law, the Scottish Government has developed best practice documents to encourage community-shared ownership for on-shore renewable energy developments. The petitioner's submission argues that, without a mandate to offer community-shared ownership, the Scottish Government will not meet its new target of 2 gigawatt of community and locally-owned renewable energy by 2030. The petitioner suggests using existing land and buildings transaction tax, the LBTT, to raise a form of tax that requires all developers who do not own land to offer 15 per cent community-shared ownership to locally-impacted communities. Do members have any comments or suggestions for action on this one? I found the petition interesting. I think that it strikes an interesting interface. Although the prima facie case from the Scottish Government was that the matter is reserved, we know that there have been cases in the past, for example, development of atomic power stations in Scotland where planning powers are used effectively to direct or influence policy decisions. There is an angle—there is an element of leverage that can be deployed here—where we can look at opportunities to increase or create greater incentives for community ownership. I think that it is worth further exploration and further evidence-garring. I think that there is potentially the Scottish Land Fund, for example, and other stakeholders who operate in this field who might have some interesting innovative suggestions about how policy could be developed, particularly with a view to potential changes to planning legislation in Scotland, which is devolved and which could introduce incentives that are indirect but nonetheless effective. I think that it is worth further exploration. I am saying that that is a perfectly reasonable way to go forward on an issue. Obviously, with COP26 coming up this year in Glasgow, I think that Scotland should be to the forefront of thinking about how to make developments go forward into the future, so I am perfectly happy with that. We will keep this petition open and we will make further inquiries along the lines suggested by Paul Swinney and supported by Bill Kidd. Are we agreeable to that? We are, thank you. That brings us to the end of our second agenda item, and we will suspend shortly to allow witnesses to join us. Welcome back. This morning represents our first evidence gathering session, and I am absolutely delighted that we have the Minister for Public Health and Women's Health, Mary Todd, with us. Online, we have David Bishop, the mesh team leader, and trying to join us, but not yet having managed to establish a link, Terry O'Kelly, a senior medical adviser for the Scottish Government. This is a continued petition, number 1865, calling for the suspend all surgical mesh and fixation devices, lodged by Roseanna Clarkin, Lorna MacDougall and Graham Robertson. The petition calls on the Scottish Parliament to urge the Scottish Government to suspend the use of all surgical mesh and fixation devices, while a review of all surgical procedures that use polyester polypropylene or titanium is carried out and guidelines for the surgical use of mesh are established. At our last consideration of the petition on 8 September, we agreed to invite the Cabinet Secretary for Health and Social Care to give evidence at a future meeting. The Scottish Government has advised that the issues raised in the petition are within the portfolio of the Minister for Public Health, Women's Health and Sport. My first job is to invite the minister, having welcomed her to the meeting, if she would like to make a brief opening statement before we open up the floor for questions. I am grateful to the committee for having me here today and I want at the outset to acknowledge the efforts of those who have brought this petition forward. I commend them for doing so. As those here know, we have taken decisive action on transvaginal mesh. That action is well documented elsewhere and so I think that it is important today to focus on the use of mesh in other situations. We are acutely aware that there is concern about the use of mesh in other sites, not least from those who are experiencing complications. I am very sorry to read of the impact that those have had on individuals and their families and I was also sorry to read in the submissions to the petition that people felt their symptoms were dismissed when they presented for help. Some people did not feel that they were informed of the risks of the procedure they went under and that it is only natural in those circumstances to feel let down. I will, for a moment, focus on the use of mesh in hernia repair, which is a really common procedure in NHS Scotland. The Scottish Government asked the Scottish Health Technologies Group to review available evidence for the use of mesh in hernia repair, first in adult inguinal hernia and secondly in abdominal wall hernia, more generally. The Scottish Health Technologies Group published their report on adult inguinal hernia in January 2020, which concluded that, compared to non-mesh procedures, using mesh resulted in lower rates of recurrence, fewer serious adverse events and similar or lower risk of chronic pain. Publication of the second piece of work, considering the more general use of mesh in hernia repair, is awaited and is expected imminently. Of course, there are other gynaecology procedures for which mesh is not halted. In those circumstances, there is a high vigilance protocol in place across the whole of NHS Scotland. It is important to remember that some of those procedures are complex and long established with few, if any, viable alternatives, so to suspend their use would leave a cohort of people with limited or no treatment options. I know that this is a very difficult and emotive subject, and I welcome being questioned on it. I want to reassure the committee and anyone watching that the Government is absolutely committed to ensuring that everyone with mesh complications gets the care and treatment that they deserve. Thank you very much minister. I start first of all by acknowledging and applauding the Government's forthcoming bill on transvaginal mesh. This really is a complete and comprehensive response to an earlier petition, which, in light of the bill itself, we were able to close at an earlier meeting that had been brought by one of my constituents, Elaine Holmes and Olive McElroy. I know that, having spoken to them, they are really pleased. I know that they have also had meetings with the Cabinet Secretary for Health and I have been reassured by the approach that the Government is taking. Finally, in relation to transvaginal mesh, at a recent meeting of the cross-party group on chronic pain in the Parliament that I attended, there was a really enthusiastic recognition of the bill, a concern from one or two women that, at the earlier stage in the process, some of the problems that had been experienced some years ago of clinicians suggesting that some of the problems were illusory, resurfacing again and that they were being encouraged down a mesh option to request. There was concern about that. I point that out to the minister. I think that it would be helpful just to at all times ensure that we are not losing sight of the future concerns of women who might be in a position to be considered for such an option, given the various actions and prohibitions that the Government has been put in place, as well as I know the redress and recovery and restitution that will be at the heart of the forthcoming bill. One of the things that came up when we first considered transvaginal mesh was the claim that there was a lack of evidence to support the concerns of the original petitioners and the assertion that there was an appropriate level of informed consent. I am struck in the submissions that we have received that those two phrases reappear that there is a lack of evidence of concern about the use of mesh more widely, particularly in males. I think that we also potentially know that men can be less forthcoming generally about their health concerns and that I know that many men watched with interest the way that women were able to come together and represent effectively the issues relating from transvaginal mesh. I notice that the cabinet secretary refers again to the lack of evidence, and I notice that you were quoting yourself from the Scottish health technology group letter, which then goes on to say, after the quote that you gave, that the advice for NHS Scotland was therefore that surgical mesh should be used for elective repair in Gweinol hernia in adult males following a process of shared decision making and informed consent. So, I guess my opening question to you would be what effort or what process is in place to encourage or identify examples of difficulties that have arisen, because there wasn't one for women in relation to transvaginal mesh, and what is the actual informed consent process in the case of mesh in women? That became something that was published very publicly, was available in GP surgeries and was very much to the fore of any conversation that would subsequently take place with patients. I'm interested to know in respect of the issues that we're considering today how those two issues are properly covered and reflected. So, it's really important in a situation like this that we work with the evidence that's available, and I know that sometimes that is limited, the full picture isn't clear, but currently the available evidence, as we have said, points to the benefits outweighing the risks in most cases. But as you say, we do have to, as well as working with evidence, work with the principles of realistic medicine, and you'll know that that's been an important principle for us in Scotland for a number of years now, one that we are, it was almost considered revolutionary at the time that Catherine Calderwood wrote the first report on realistic medicine, and we've come some way since then. I say that we've come some way, but we're not fully, I would be confident that we're not fully at the point where we can be absolutely 100 per cent sure that every patient in every case, every time is engaging in a shared decision making process and there is work on going to ensure that surgeons are confident about raising the issues and raise them in a manner that enables people to ask questions. There's a power imbalance in medicine, which makes it more difficult for patients to ask questions of surgeons, so we need to ensure that patients are empowered and true to shared decision making does take place. It's interesting that you mentioned about women being more able to get together and form strength in numbers, which I think is an interesting observation. One of the reasons for the women's health plan is that there is evidence that women face inequalities in access to healthcare and in health, and one of the reasons for those inequalities is the general power imbalance for women and the fact that women are, as with many other groups of people who suffer health inequalities, easy to ignore. We are working on many of those issues in many different ways. In terms of the gynaecological procedures that have not been halted, there is a high vigilance protocol in place that will systematically gather evidence going forward on those issues. It's unfortunate that Terry O'Killie is not here, but should you want more information, I know that there is also a system of unique device identification being worked up, which will mean that there is a barcode entered onto an electronic patient's records, which will give information about the actual device that was used, the surgeon that did the operation, the details around the surgery and that will enable, as in NHS Scotland, to follow those cases through for a number of years. We will have high quality data and good quality data available to us. In terms of the general thrust towards informed decision making, because in fact, Terry O'Killie has now joined us on audio, so given that you have just addressed that point, I wonder if he might want to elaborate specifically on the point that you've just been addressing. I'm told you. I apologise profusely for IT issues. I'm sitting here in my office in Aberdeenwall infirmary and I can confirm that the NHS Grampian firewall is as robust as you might wish it to be, so I'm very sorry to join you by phone rather than by video conferencing. I think that there were two parts to that. First of all, what evidence do we have and how is that shared? We're waiting for the Scottish Health Technologies Group to publish their assessment, not only looking again at inguinal hernia but also use of mesh in other abdominal hernias. I think that the original report has found that the majority of the evidence that we have refers to use of mesh in men. Clearly, what we're looking for is not only use of mesh in other sites in the abdominal wall but also use in women with hernias. My understanding of the evidence is that use of mesh does have benefits but there are risks. I started my training in the pre-mesh era, so we're going back to the 1980s, and introduction of use of mesh for hernia repair I thought was transformational and made hernia repair much less haphazard and particularly with reference to outcomes. Recurrence is one of the major fears that people have if they have a hernia and having surgery and mesh has made a significant difference to that. For every patient, it is important that they understand what the procedure involves and also if they are going to have mesh implanted. It will be for them, with the information that they have, to balance the risks of use of mesh against the benefits. It is important that they are empowered when meeting with their surgeon or clinical team, thus those risks, to look at alternatives and also to consider what if I have no treatment. With regard to going forward and ensuring that informed consent occurs, there are two parties, two experts involved in any of the decisions. The surgeon, who is informing and advising, and the patient, who is the expert about themselves and knowing about what they want. I think that it's making as sure as best we can that the culture present in our clinical spaces is to allow those meaningful discussions to take place. As far as we can to flatten hierarchies to adjust attitudes, those decisions and those conversations take place in as equal fashion as possible. We also, I think, need going forward to collect data that has been spurred by the vibrational mesh. There is a unique device identifier project coupled with that, which will allow the information about the individual devices, such as the barcode associated with the product, to be captured at the time of insertion. It will be associated with the patient electronic record, so that, going forward, we will know the patient, the surgeon, the place, the time, the product, and so that both static performance and also product performance can be followed every time. Two very brief supplementary questions, and then back to the minister and then to other colleagues. What is the timing for the introduction of that pathway to record the information, Mr O'Kelley? The other question that I have is that you referred to the transformational advance that you felt the introduction of mesh made. Do the skills still generally exist for a non-mesh surgical option? If I could take the last point first, when I talk about transformation, I think that anyone who trained in the pre-mesh era would recognise, I think that they would recognise, as I did now that others have, that use of mesh and mesh in these circumstances is non-tension mesh, so this is providing a synthetic framework for ingrate connect tissue to create a robust scar and hernia repair. Before use of mesh, either native tissue was used, as it still can be now in certain circumstances, but native tissue was used, which we know in a number of circumstances that is not normal tissue and therefore generates disordered connected tissue formation and weak repair. Alternatively, that was augmented by use of a lattice or framework of sutures, and those were non-absorbable sutures, polypropylene, which would hopefully strengthen the initial process of repair, but also stimulate ingrate tissue. Creation of those lattices was not uniform, and the resulting outcome was not predictable. I think that with use of mesh, recurrence was reduced substantially. As I said for many patients, that is transformational and an important outcome. With regard to the non-mesh skills, I think that it will be necessary to look at that in individual boards. We have anticipated with publication of the Scottish Health Technologies Group report that we will write out to medical directors and potentially to chief executives, governance leads and emergency medicine leads as well to ask what provision is made in boards for this. If this is a recommendation of what provision is made in boards for non-mesh surgery, what is there a skill gap and how might that skill gap be addressed? I don't think that every patient will want to have hernia repair without mesh, but for those who do not want mesh to be used, I think that we need to make sure that there is some provision of service for them, and we will need to look at that. With regard to the UDI project, the unique device identification project, that work is ongoing. There is a project programme board with papers being submitted to Government for funding. As we appreciate, none of this will come free of charge. We are looking at funding for a number of millions of pounds to do that. I will return to the minister and begin by asking if the funding will be available for the recording of that information and put her on the spot while then inviting you to carry on with the evidence that you are going to deliver. I cannot make a decision on the funding until I see the full proposal, but rest assured that Government is willing to look very closely at any information that comes forward. We are well aware of the need for a solid evidence base in that area. I interrupted you earlier to go to Mr O'Kelly, and I wonder if there was more that you wanted to say before. To be fair, I cannot recall quite where I was at. I am happy to pick up on the second report that is coming. I am more than happy to put the offer right now that I will come back to the committee to discuss that, should you require that. We will certainly inform the committee when that information is available when it is published. I am conscious. Mr Bishop, I have not invited you to come in as yet as the mesh team leader. Is there anything that has been said so far in which you would like to comment before I bring in colleagues? No, I completely agree with everything that has been said, so that is all good for me. David Torrance Good morning, minister, and to other witnesses. My question is about hernia and a domino mesh, and I will put on record that I am one of the ones who has had very successful and one of the lucky ones. You were talking about data there. Do we have information on the number of procedures that has been carried out and the number of complications that has been recorded in this area? I think that we do. My understanding and perhaps Terrio Kelly can confirm this. There are over 5,000 procedures carried out a year in NHS Scotland. I think that the rate of complications is somewhere between 0 and 5 per cent, but I will ask my clinical colleague to confirm that and make sure that it is the correct information that the committee gets. Is it something that the Scottish Health and Technology Group has looked at until, obviously, it will be concluded in their report. My own understanding of the information is that there are between 5,000 and 6,000 mesh hernia repairs performed each year. We know that the number of mesh removals per year is about 20 to 30. Not many meshes are needed to be removed, and it is a small proportion of the total number. It is very significant for those patients. With regard to other complications such as chronic pain, etc., I cannot give you a precise number of those per year, because we have not got that recorded. What we do know from the evidence that is available is that, certainly, as far as things like chronic pain are concerned, but any individual has that. It is devastating. Overall, the evidence suggests that chronic pain is either less likely to occur with use of mesh or that it is no more likely to occur from the evidence that is available. You mentioned earlier about mesh removal. How easy it is for somebody who has complications in the hernia and adorno area to get that procedure to remove the mesh? I think that I may pass over to Terry O'Killey for that level of detail. Certainly, we are aware that when women came forward with concerns around transvaginal mesh, there was a long story, which was a long process of firstly not feeling like they were being listened to, feeling like their concerns were dismissed and then difficulty. Again, that partly reflects the power imbalance that operates throughout healthcare. There was a feeling that it was difficult for people to raise concerns. I am sure that every MSP around here will have male constituents who talk about feeling worried about raising concerns about their medical treatment, who are concerned that, if they do so, they will somehow suffer detriment in their passage through healthcare. I expect that some of those experiences, which we saw earlier, with the women who had transvaginal mesh implanted, would also be common to the situation. I would like to think that, since 2018, we have put procedures in place and communicated well with healthcare professionals to ensure that that is not the case. As I said, the general thrust in NHS Scotland has been, for a number of years, towards realistic medicine, holistic care and patient-centred care. I would like to think that that would be less problematic going forward than it might have been in the past. However, I will ask Mr O'Kelly to talk you through the process of presenting with complications and how you would then access surgery in order to remove mesh. Mr O'Kelly? So, mesh complications, when they occur, they are either caused by mesh or is there a complication, and mesh is caught up in that process of condition. With regard to removing mesh, it depends when the mesh was put in, how soon after surgery. If it has been in for a while, then there will be associated connective tissue fibrosis associated with it. That is why it is there. With regard to the removal and what impact that will have on the patient, it is determined by what the problem is and what other structures are adjacent to it. There is, unfortunately, because the hernia is caused by protrusion of the intestine through the abdominal wall, the possibility that bowel can be in close contact with the mesh, I think that what one would do in these circumstances is to remove the mesh from tissues rather than tissues from the mesh, and the intention will be to preserve other structures intact, if at all possible. Once the mesh is removed, then clearly the patient is left potentially with a defect that needs to be dealt with and what happens with the circumstances that pertain at the time. Locally in my own centre, and in a number of others, colleagues who have developed specifically interested in mesh surgery following the acquisition of training certification have got together to form multidisciplinary teams or clinical networks so that those patients would be discussed and the strategy prior to surgery would be devised what they are going to do and how best to achieve an outcome that will be to remove meshes that are necessary, but also to manage any residual defect that is left behind. If the bowel is involved, it is often a major problem. It is not common that this occurs, given the total number of meshes that we have used, but clearly for every patient that is going to be very challenging and that will need to be discussed in the way that we have presented already around the intention of the procedure, what is required, what are the risks, what are the benefits and the patient, sadly, will be in a position of looking at that in a very difficult circumstance. When an individual presents, it will be a GP who goes to first how aware are the GPs of this and how much information is given to the Scottish Government given to GPs. I think that most GPs will have worked in the era of use of mesh in her new repair. If they have issues, they will refer on or make contact with clinical colleagues. Going back to the question, is it a mesh problem or is there a problem with the surgery and mesh is incorporated into that? If somebody has a wound infection associated with a hernia repair, is the mesh the cause of the infection or has the patient now got a wound infection but mesh is involved? GPs are pretty quick to refer patients back. In these circumstances, when patients do have problems, it is incumbent upon my colleagues in every patient, every time, to make sure that they are welcomed with sympathy and empathy and they are dealt with in the holistic terms that have been discussed. Minister, do you want to add to that? Just one follow-up question and then I have an indication of colleagues who would like to comment on that. One of the scandals that arose in the transvaginal mesh was the quality of the mesh itself. It turned out that the regime in place to ensure the highest standard of mesh material was really not robust and in some women, to our shock and dismay, some of the mesh that had been fitted was no different to the mesh that you find wrapping round packages that come to you through the post. In relation to the mesh procedures that we are talking about just now, is there a strong regime in place to ensure the quality of the product that is actually being fitted in any operation? As I understand it, it is the MHRA who grant licences for those products on a UK-wide basis. David Bishop may want to come in. The transvaginal mesh situation prompted a review of all those processes. I think that there is still some on-going work being done on that. Our feeling in Scottish Government is that the MHRA should be absolutely robust in its procedures and that there were lessons to be learned from that situation. We are keen to ensure that they are learned. David, if you would like to come in and give some more information on that front. I can certainly say to you that, Mr Bishop, if we were relying on the MHRA at the time, they were woefully inadequate, both on the explanation of the procedures and in the subsequent regulation to ensure that only the proper materials were being used, because some of the products clearly bypassed that. I am interested to know whether that is upon which patients can proceed with greater confidence. I might ask Terry O'Kelly if he wants to comment further on that, because I think that you will probably know perhaps more about this than me. At the time of the transvaginal mesh issue, it was taken up with the MHRA. Both our ministers at the time and the then chief medical officer wrote to the MHRA about that issue to query it. We did raise concerns, as the minister says. My understanding is that the MHRA is reviewing procedures now and, obviously, they are taking forward new medical device regulations at the moment, which obviously come about as a result of Brexit. I think that at the end of the time, we will leave that question there and I will go to Bill Kidd. Thank you very much, convener. Is there any plan or idea of looking to ensure that everyone who has had a mesh procedure over a period of time to be decided is contacted to ask them about their experience since they have had the treatment? I happen to know that there are people who have been uncertain about who they complain to and whether they are wasting people's time, but they are in discomfort and are affecting their lives with the material inside them. I think that that would be a challenging undertaking retrospectively, but certainly with regard to the use of mesh in other sites for gynaecological procedures, which was not subject to the halt, that high vigilance protocol has a number of procedures in place that would ensure that that was perfectly possible. There is documentation of all the procedures on an agree database, documentation of all the complications on that database and the reporting of complications. There is also documentation, crucially, given to every single patient treated with mesh detailing their procedure, the mesh in that other product used in the name of the patient. For gynaecological procedures in which mesh is used, I think that going forward that precise situation that you outline would be less likely to arise. I was speaking recently to a man who had had an abdominal repair a hernia, and he has suffered great pain and almost disability. It is not something that has been covered widely in the media, but there are men who do not really know what to do next in terms of whether they should, who they complain to, do they just go back to their GP, do they go somewhere else. It is basically because there are people who have problems, but they do not know what to do about it. I was just wondering if they could be contacted, if they have had. Everyone who had this procedure had been contacted, then issues might be raised, which are being ignored at the moment. I am not sure how that would happen, given the scale of the procedures occurring, five to six hours per year since the 1980s. Certainly, as Mr O' Kelly outlined, patients should first of all present at their GP. They must be listened to, and I think that this is the key point that has come out through all of these testimonies, is that people do not feel listened to. We must learn from the transvaginal mesh incident, and their concerns have to be taken seriously and acted on appropriately. In many areas, there will be a multidisciplinary team in place, as Mr O' Kelly outlined. There is a complexity to dealing with mesh complications. The multidisciplinary team will look together at each individual case, but it must be straightforward for patients to access that level of expertise when they find themselves in the situation that they describe. Minister, in your opening statement, you acknowledged that individuals have been let down, that individuals have been dismissed, and that there are risks associated with this very complicated situation that many people and individuals find themselves in. You talked about lessons being learned, and I think that that is vitally important that we do learn. From what you said this morning, I am helping myself to think that that is happening along the process. I specifically ask about where we are with the research for longer term when it comes to hernia. We have learned issues from the transvaginal mesh issues, and we have gone through that. Is there research being done for a longer term when it comes to hernia? If there is no research, how are you managing to take forward some of the issues that have been addressed or raised by individuals who have suffered? There will be research on going all the time and what the Scottish Government has done is asked for a review of the evidence. The Scottish health technology group has already published a report of a review of evidence into the primary in going on hernia repair in men. Following on from that report, we asked them to look more broadly to examine hernia, to include men and women, to review the outcome of mesh versus non-mesh surgery in a whole variety of abdominal wall hernias. We have asked them to look at the published evidence of that and come back to us. That is the report that we are waiting for publication. We were expecting it at the end of summer this year. That is quite a broad term, but we are hopeful that it will be published very soon. We are hopeful that that will give some good quality evidence. Without high-quality evidence and well-reviewed evidence, it is not possible for patients to make an informed decision. Obviously, the pandemic has had huge implications for the NHS about individuals not having the opportunity to have some of their operations. Can I ask what the Government is doing to ensure that people do not have to seek private treatment for some of this? In the whole mesh situation that we had in the past, individuals had to seek private help after, because they were not able to, through the waiting times or the lists, ensure that they had that opportunity. They felt that they had no option other than to go private to ensure that they received the care that they required. You are absolutely right. The pandemic has placed immense pressure on the NHS. We talk about that almost in every committee in this Parliament and regularly in the chamber. There is undoubtedly, after 18 months, an impact on capacity in the NHS and an impact on how we work. There is undoubtedly a pent-up demand for surgery. We have seen that over a number of different clinical areas such as orthopedic surgery. Cancer surgery has been prioritised throughout, but there is an NHS recovery plan in place. There is work in place to ensure that we can, first of all, tackle the pandemic and keep the numbers at a level through which the NHS can function. There are also plans in place to recover the NHS. There are national treatment centres being developed where surgery can occur. It is not going to be instant or overnight, but there is a plan in place to recover the NHS that will benefit absolutely everyone who is awaiting treatment, not just those people. I note that the petitioner highlighted the work of surgeons at the shoulders hospital, a pioneering alternative treatment and natural tissue repair. There were some interesting outcomes from that technique and the study of that technique. What is your view of the natural tissue repair technique compared to mesh implants? What are we doing to train surgeons in Scotland in this technique? Are we developing a critical mass of knowledge in Scotland that is an alternative means? I am conscious that there is significant inertia in the medical profession about the use of mesh. There is already a significant normalisation of that technique, which is long established in Scotland, so trying to move away from it in any way is going to be bound to meet some resistance. Looking at the pioneering frontier alternative treatments, are there ways of better embedding it in building it up in Scotland? That is probably a clinical decision, which I will defer to Mr Kelly on comparing the two techniques that are way beyond my level of expertise. I would ask Mr Kelly to give you some information about whether there is an evidence-gathering process going on about new and pioneering techniques and comparing them with existing techniques. Medicine is slow to change practice. When I first started out, you will know that in my past life I was a clinical pharmacist. When I first started out in my practice, there was about a 15-year gap between evidence and practice. The ability to review evidence and obtain evidence from all over the world and the internet has speeded up that process. We are faster at gathering evidence. You have seen, over the course of the pandemic, a brand new virus that nobody knew anything about. You have seen, all over the world, the collaboration of scientists and clinicians turning together to find a way forward in the emergency that we found ourselves. I am very hopeful that some of that collaborative effort will survive into future practice and mean that we solve some of those big questions. There is less concern about often commercial concerns at the heart of it and more altruistic concerns to try and solve some of those medical problems, but that is a bit of a philosophical answer. I will let Mr Kelly give you the actual clinical answer. Mr Kelly, do you want to add anything? Just to say that shoulder ice repair, popularised by the shoulder ice clinic, is a non-mesh tissue repair for inguinal hernia. It will be one of the areas that one would look to if patients did not want use of mesh. There are other non-mesh techniques. It is not something that every surgeon undertaking hernia repair in Scotland is familiar with, but there will be those who are skilled in this. Again, it is one of their skilled assessment that we would need to do and addressing skills gap if they exist. Having said that, the technique will not be applicable to non-inguinal hernias and also for patients with larger defects that it may not be appropriate for and with very degenerative tissues that it would not necessarily be appropriate for in Scotland. It is certainly something that we know would be a technique that we would look at. It was interesting that the owner seemed to be on the patient to demand that some alternative. Again, that goes back to the issue of a power imbalance, perhaps, about knowledge that, unless somebody is quite robust and challenging this, I wonder whether there is a potential concern. It is absolutely clear that the process of informed decision making would be about the patient and the clinician sitting down together and talking over the options, understanding the condition that the patient is presenting with and what the options are and using, I do not know if I have mentioned already, the acronym that is gaining popularity in realistic medicine circles as brands, so considering the benefits, the risks, the alternatives, what if I do nothing. Alternatives are absolutely part of that process. That is becoming ingrained in medical practice in Scotland. That action and brand appears on the weight in the virtual waiting room in the NHS near me. You will see advertising campaigns about that to normalise that process. The clinician should be sitting and discussing alternatives. Here is what you have. Here is my understanding of factors that are significant for you as an individual. What do you need me to understand about you as an individual? What are the alternatives on the table? Let us see if we can make a decision together. That is how it should be. It should not require the onus to be on the patient to ask questions that we are intending for an atmosphere to be created where it is normal and for patients to ask questions. It is their body and it is altogether a more satisfactory process if patients are empowered to make a decision in this situation. Okay, thank you very much minister. Thank you very much Mr O'Kelly for your audio participation and to David Bishop, thank you all very much. I would like to suggest to colleagues, I certainly would like to reflect on some of what we have heard, to do that and just to look again at the official report of everything that we have heard this morning and to return to this petition at a subsequent meeting of the committee. Does that meet with everybody's approval? We will suspend very briefly to allow our subsequent witnesses to come. Thank you again minister and welcome back. We are here now to discuss petition 1837 to provide clear direction and investment for autism support. Continued petition lodged by Stephen Layton and the petition calls on the Scottish Parliament to urge the Scottish Government to clarify how autistic people who do not have a learning disability and or mental disorder can access support and to allocate investment for autism support teams in every local authority or health and social care partnership in Scotland. At our last consideration of the petition we agreed to invite the cabinet secretary for health and social care to give evidence to future meeting and the Scottish Government has advised that the issues raised in this petition are within the portfolio of the minister for mental wellbeing and social care. I am absolutely delighted Minister Kevin Stewart to welcome you here to our petition's committee meeting. Accompanied as you are by Hugh Macklin, deputy director for mental health complex care and Jacqueline Campbell, unit head learning disability, autism and neuro diversity. In the first instance, minister, I very much welcome any opening statement that you might like to make, which will help inform our discussion. Thank you very much, convener and committee. It's a little bit strange being back in a committee room, not that I've not had any committee appearances over the past while, but this in person stuff is going to take so I'm getting used to it again. I do thank you very much, convener, for inviting me here today. And I'm grateful to be given the opportunity to give evidence to the committee on how the Scottish Government is supporting autistic people. The Scottish Government published the learning disability and autism towards transformation plan in March. The plan looks at the actions needed to shape supports, services and attitudes to ensure that the human rights of autistic people and people with learning and intellectual disabilities are respected and protected. Moving forward, we are taking action, taking forward exciting new leadership and engagement plans with central roles for autistic people and people with a learning disability and putting them in the driving seat. The Scottish Government has just published the evaluation of the Scottish strategy for autism. It concludes that the strategy delivered valuable resources and services, but that more work needs to be done to meet its ambition of allowing autistic people to be supported to live productive lives and to see change at a local level. In response, I was delighted to recently announce £650,000 this financial year for tests of change on adult neurodevelopmental pathways for diagnosis and support. Additionally, I announced new funding of £425,000 to trial the Scottish Government's new learning disability and autism leadership and engagement work. I also announced £400,000 for the understanding autism project charity funding for a second year. The Scottish Government also established the national autism implementation team, which supports health and social care partnerships to consider best practice and improve service in the redesigning of autism diagnostic services. On Wednesday 8 September, the Scottish Government published the national neurodevelopmental specification for children and young people principles and standards of care. On 14 September, I announced £5.25 million for NHS boards to build professional capacity to support children and young people with neurodevelopmental support needs. Additionally, we have listened to the calls for a commissioner and have committed to creating a learning disability, autism and neurodiversity bill and commissioner to uphold and protect the rights of autistic people and other people with neurodevelopmental difference. We are committed to this and will be commencing scoping work on a bill shortly. Let me be clear though, convener, that whilst money is always important, this is not just about money. It is about how we treat people with neurodevelopmental difference in our communities, our workplaces and our schools. It is about innovation, focus and working together across national and local divides to provide solutions that work for the people that we are here to serve. That is why our new engagement will support all of that. I am very much committed, as members will be aware, to ensure that the voices of lived experience are at the very heart of all that we do. I look forward to hearing the views of the committee and look forward or maybe not to your questions. I acknowledge the work of former colleagues, Mark MacDonald and others, in the previous session, who did so much to ensure that those issues were at the forefront of concern and whose work in those areas has helped to inform and lead to the actions that the Government is now taking. I invite colleagues to lead the questioning on that occasion and, first of all, David Torrance. The independent review of a 10-year autism strategy for the Scottish Government and COSLA was published this month. What recommendations will the Scottish Government take from that? I think that we have to look very closely at all of the recommendations and find a way forward to ensure that we provide better support and create greater opportunity for people with autism. I know and I am sure that you will pick up on that and I will go into further detail if required that, in some areas, the services that are provided to people with autism and learning disabilities are very good. In other parts of the country, I could not claim that that is the case. What we need to do is to ensure that we do our level best in all parts of the country so that we are providing the services and the help that is required to all folk who have a neurodevelopmental condition. That will take quite a bit of work. In all that, as well as the recommendations, we all have a duty to continue to listen to the voices of those folks with lived experience about what works for them and what does not. The minister answered a bit about 32 different local authorities and the type of services that you have there for people who are diagnosed with autism. Minister, can you have figures for how many are diagnosed every year in Scotland? Yes, I do. I have a figure of how many autistic people there are in Scotland. I do not have a figure about diagnosis each year, but I can see if we can provide that for the committee. There are approximately 44,133 autistic people in Scotland with a national Scottish autism prevalence rate of 1.035 per cent. That is according to the Scottish Government-funded micro-segmentation of the Autism Spectrum research project, which was published on 26 March 2018. Around 32.7 per cent of autistic people also have a learning disability. In terms of the diagnosis numbers per annum, I do not have that to hand, but we will see what we can do in terms of providing the committee with that information if that is required. Can I just say to Hugh McLoone and Jacqueline Campbell, if they feel that they would like to commit at any point to try to catch my eye through this perspex screen, which is between us? I could just about see you despite the reflections. Have you included? Paul Sweeney. Thank you, minister, for his outline on the intent of the Government. I think that that was really helpful. One thing that I noted in the petition and some of the background reading on that was the independent review that was reported to ministers in December 2019. A key finding in that review was that the current legislation is indirectly discriminatory towards autistic people. It was welcome that new legislation is in the pipeline, but in the meantime, it is important to consider what actions the minister might consider to protect human rights of autistic people until that legislation is able to kick in, which is obviously going to be quite some time. I am not a person who likes to stand still. I think that there always has to be continuous improvement. Although the legislation is very important and there is no doubt about that, that does not mean to say that we should not be taking actions in the here and now where that is possible outwith the legislative framework. I have to say that the Government officials are working to consider all the recommendations from the review. I have already been provided with some advice and we have already taken some actions as I have outlined in my opening statement. We will co-ordinate a full Scottish Government response to the report. Obviously, coronavirus has delayed some aspects of the work, but we are now getting back on track in that front. Work has been carried out, convener, against a number of the specific recommendations. For example, we have already published new mental health standards. We have commissioned the Scottish Learning Disabilities Observatory to carry out a study into the use of psychotropic medication, as well as committing to scope out and introduce that bill that I mentioned in my opening statement. We will continue, as we move forward, to do all that we can outwith the legislative framework to ensure that there are improvements. Alexander Stewart Thank you, convener. You spoke about the health and social care partnerships and their role in the process, but I would also like to tease out from you about the local authorities that come part of that social and health partnership. Have you identified any councils specifically that are requiring more support to provide services that have a key area of concern within some of those local authorities? convener, it would be fair to say that, when you take on a new ministerial role, you have to do a wee bit of a stock take in terms of what is going on out there. I have been talking to lots and lots of folk about the various issues that I am responsible for and what the committee can be assured of, that that general stock take applies right across the board. I know that there are a number of health and social care partnerships and local authorities that are doing very well in that area, as I said previously. I know that a number of others who are not doing as well as they should be to meet the needs of their people. I will continue the very detailed conversations that need to be had to do that stock take to ascertain what is going on out there right and what is not going on out there quite so well. Mr Stewart knows me from numerous other committee appearances, because we seem to cross one another's paths on a regular basis. I will probably bore him now, because he has heard me saying this so many times before, but we have had some success in other areas around this. I am one of those folks who gets very frustrated when we do not export best practice across the board. Although we are a small country, sometimes people are afraid to blow their own trumpets and say what they are doing well, and others do not have the opportunity to pick up that good practice. I assure Mr Stewart and the rest of the committee that my ethos, when it comes to the exporting of best practice, remains in place, and that is what we will aspire to do. Are there any recommendations or proposals for the autism service to go into the national care service itself? If that was the case, where would the scrutiny and the accountability lie for that? I am not going to pre-empt the national care service consultation, convener. We have posed a number of questions within the consultation document about what should be in, and we will look at the views that come back. I know that, in some cases, some folk think that some of the questions and some of the things posed are a little bit controversial. No matter what, as we move forward, national care service is going to be extremely important because it will set high-quality standards across the board. That is what people want for services, whether they be in or out of the national care service. That high-quality standard is what we require across the board, including in autism and neurodevelopmental services. I have to say, convener, that service users out there, not just from the autism community but from others, are often very frustrated about accountability. We have to ensure, as we move forward, that we ensure that they know who is accountable for the delivery of services. What we cannot afford is a continuation of the postcode lottery that exists in the country where you can live in one place and get a very high-quality service in a specific area. The next-door authority, your entitlement, is much, much less. High-quality standards, no matter what, whether they are in or out of national care service. It was an interesting point that the minister had. I am pleased about that ethos of continuous improvement. One of the themes that we have seen recurring through the evidence sessions this morning is the power imbalance that often people or service users experience. Perhaps there could be a reporting mechanism where people have experienced good practice or activity that they thought was exceptional. That could be fed in a way that could then be learned from and tried to be introduced across the board. Service users are helping to inform where this is important. Perhaps that already does take place, but I thought that in light of what was discussed there, allowing the service users to illustrate where good things are happening as a pointer to setting standards of excellence would be helpful. It might be a method that could be considered ahead of legislation. I will start off being a bit controversial. I agree with most of what Mr Sweeney has said. However, we also have to recognise the fact that, in the minds of some folk, some services that would be deemed by some to be good would be deemed by others not to be that great. I will take the committee back to my previous role as Minister for Local Government Housing and Planning. In terms of the vast changes that we made and with some of it still on-going, in terms of homelessness, policy, regulation and legislation, the voices of folk who have lived experience of homelessness were at the very heart of all that we have done. I am not saying that what we have done is absolutely perfect because it never is. However, I think that the place that we have got to, the journey that we are on, is a good one because we have listened to people and their experiences. That is fully what I intend to do in this role, whether that be for autism services, whether that be social care, whether that be mental health services. I will continue to listen to the voices of lived experience. In some of the conversations that I have had, thus far, in coming into this role, some of the assumptions that we all make rightly or wrongly around what we think needs improving first and where our priority should be is not necessarily the priority of those folks with lived experience. In talking to folk about mental health services in general, one of the things that cropped up again and again and again was the top priority, I would say, and some folk are inevitably going to disagree with me now. Out of the groups of folk, one of the top priorities is about a complaint system that does not work for them. That is something that we need to look at very closely in this area and others as we move forward. Beyond that, in those areas of business where there is very good practice, normally what you find is that service users have helped to shape that service. Again, that is something that we need to push further, because we know again that in some places authorities, local authorities, health and social care partnerships are very good at listening to the voices of lived experience and shaping services. Others are not quite so much, so that, again, is a journey that we need to continue on and to make sure that everybody is doing that. Of course, in the national care service consultation, the proposals are that community health and social care boards have the voices of lived experience at the table, which I think is essential. Minister, you have been addressing some of the issues that I am just about to raise again, but it might not do any harm just to take them from a slightly different angle. In submissions that we have received, the issue has been linked to a misunderstanding at service level where individuals should be directed for appropriate autism support. Does the Scottish Government have plans to review the legislation in respect of autistic people so that it is no longer assumed that they have either a mental disorder or a learning disability? Is there any timescale for such a review? The programme for government itself, published in September, committed the Government to carry out scoping work on the remit and powers of learning disability, autism and neurodiversity in this parliamentary term. We are going to have to take time to scope all that to get that right. We need to continue some of the conversations that we have been having. There are some polarised views out there about the proposals for a commissioner, for example. We need to listen to all sides in order to get that right, but that scoping will happen and we will move on within this parliamentary term. Work that is going on concurrently is the Scottish mental health law review, which is due to report in September of next year. As the committee will likely be aware, the review will make recommendations that give effect to the rights, will and preferences of the individual by ensuring that mental health and incapacity and adult support and protection legislation reflects the people's social, economic and cultural rights, including the requirements of the United Nations Convention on the Rights of Persons with Disabilities and the European Court of Human Rights legislation. Although today's ruling has put some difficulties in our way in terms of some of the UN convention rights and embedding that into legislation, that is probably a discussion for another day, so I am not going to go into a rant about that, convener. You are probably glad to hear, but it would be fair to say that I, like many others, are quite irate about that. I think that the Scottish mental health review is extremely important in all of this as well, but we need to ensure that we listen to people and we need to ensure that we embed rights into any legislative change, whether that be in terms of the learning disability autism and neurodiversity bill or anything that comes from the Scottish mental law review itself. Thank you, convener. Without ranting, I think that even my follow-up question was taken away there, so that's fine. Thank you very much for that. I would only observe that only angels Russian were only fools Russian were angels feared to tread, minister, so I'm grateful for your forbearance in holding back. It's not like you either, normally, but there we go. Well, I think that the questions that Bill could raise there were important, because they actually were at the heart of Stephen Layton's actual petition, and I'm glad that we've touched upon them. Professor Jean McClellan and her submission, a former director of the Autism Network Scotland, highlighted the creation of one-stop shops across Scotland. She thought that the pilot had been highly valued, the space lessons, social isolation, anxiety and depression, it was informative, the advice and support that people gained was useful, but she said that following the pilot finances were withdrawn and therefore the only some of the spaces that it had led to had survived. Do you have a view on the success of the pilot in relation to that and where future accessibility will stand? Let me talk in general about the provision of one-stop shops, which I think is important. Provision varies from local authority to local authority, and I think that that's probably what was being driven at. Local authorities are responsible for commissioning and delivering local services. We have examples of really positive provision in some local authorities, such as South Lanarkshire, which operates the Autism Resources Coordination Hub there, Edinburgh City, with the Lothian one-stop shop. Similarly, there is a one-stop shop that is supported by Perth and Kinross. However, there is still work to do to ensure that there is the right provision in other parts of the country. It would be fair to say that some parts of the country have very few services to meet the needs of autistic people. Nationally, the Government works with national and local autism charities, which operate a number of services and had some discussion about that just the other day—yesterday, in fact. Scottish Autism and the National Autistic Society have national coverage, but we also have close links with inspiring Scotland with effective and valued local organisations such as the Arredine one-stop shop and Autism Rights Group Highland. As I have said, we have to be honest about that. In some places, the provision is excellent. In some cases, the provision is not. We need to encourage Cajol and maybe even take further action in relation to regulation to ensure that provision across the board, over the short term, gets better. Beyond that, as I said earlier, we have the opportunity with the changes that we are making with national care service and the other actions around about that to make sure that we put a framework in place of high-quality standards that can be expected by all. It leads on to just me wondering where autism services are being provided to an individual who does not actually have a learning disability or a mental disorder. How do you ensure that for that group of autistic individuals that there is a properly and sustainably funded resource available to them? I will come back in, convener, if you do not mind. Some of the work that we are doing, particularly the work that the minister announced around development of a single adult neurodevelopmental pathway for diagnosis but also for support, I think is quite critical in the sense that it looks to support people in a much more holistic way in the same way that it has been done for children. Rather than at the moment people having to be put down a certain path, which is dependent on somebody making a decision about which aspect of the issues that they have is most important, people can be treated as a whole, so it should in that sense, we would like to develop that work so that you may have a combination of things going on, not just LDN autism or other things too. That should not matter, you should still get the support that you want through that. So, as the minister announced, we are just embarking with three or four HSCPs on some work to test out those approaches in the next year. Convener, if I can just add to that, because I think that it is very important in terms of all that we are doing at this moment to highlight the fact that the work that we are going to carry out, the legislative change that there is going to be in terms of care here in Scotland, puts the person at the very heart of it. We need to take more person-centred approaches on many, many occasions. Again, I would say that in many, many cases that happens, but where it does not happen, that causes great difficulty for the individual, for their family and often for their communities. We have to start looking much, much more at those person-centred approaches and doing that at a very early stage, rather than waiting for a crisis point in somebody's life to provide the services that are required. We must move to much more preventative measures, taking people's views into a kink in order that we get that right as we move forward. Can I ask a question to help me to understand the broader issue as someone who comes to this as a consequence of the petition? Having followed some of the work that has gone on in the Parliament before, how many people are diagnosed in Scotland? Do we know as being autistic? Is there any regional variation in that? You have talked about the disparity of approach between some local authorities. Does that, in any way, influence our understanding of the number of people diagnosed with autism, or is that not a by-product of that variable approach? Do we have a fairly clear idea? I gave you some numbers earlier, convener, and I will repeat them. I think that some of the questions that Mr Torrance asked about diagnosis each year I don't have at my fingertips, and neither do I have any regional variation statistics at my fingertips, either. I may bring in Ms Campbell, who may well have them, because she is the font of all knowledge, and if she doesn't have them, she will find them without a doubt. As I said earlier, there are approximately, and I say approximately, but I gave a specific number, 44,133 autistic people in Scotland. Regional variation, can I pass over to you, Ms Campbell? We don't formally collect statistics that will show us how many people are being diagnosed each year. I think that, around autism in particular, there are clearly issues that we are very aware of around children and young people who might be coming forward for diagnosis, but also adults, and that is a growing population. We can certainly look into whether there is something that we can do to give you a better idea of what that looks like across the country. Because we support the national autism implementation team, that is essentially, in a less formal way, the collection of stats is the work that they are doing and working with leads across the country to look at their diagnostic pathways and how that works. The only other thing that I would like to say is that diagnosis can be really critical for some autistic people, but not for everyone, and it is very much a personal choice. Diagnosis will give you one aspect of it, but there will also be a wider range of people who are supported but do not have a formal diagnosis. That is one of the things, convener, that we also need to take cognisance of in terms of shaping services. Waiting for a diagnosis does not mean to say that you should be waiting for that help and support. That help and support should come naturally, no matter whether there is a diagnosis there or not. Again, that is a scenario in which, in some places, we have that service provision that helps right in other places, not so much. I apologise to David Torrance for not having properly understood the response to the earlier question. Do any other colleagues wish to place any further questions? No. That has been incredibly helpful. I am very grateful to the minister, to Hugh McLoone, to Jacqueline Campbell for your participation here this morning. Again, colleagues, I think that I would like to reflect on the evidence that we have had, have a chance to just look at the written record again and for us to consider how we might take forward some of these issues at a subsequent petition. Thank you very much, minister, for your attendance and participation here today. That brings us almost to the end of the meeting, but I just would like, for the benefit of everybody, those who are watching and also for colleagues to place on record the committee's thanks to Gemma Cic, who is going to be leaving us as our clerk. She is going, our loss is education's gain, but I am very sorry that she is leaving. She has been with the committee for the last two years, provided I know already a high quality of understanding and support to the committee, so we very much wish you all the very best in your next appointment. With that, I close this morning's meeting of the committee. Thank you.