 Have a good morning. I am willing to welcome everyone to the 10th meeting of theAudience Government for discussion and public time on. I hope to see some of the witnessesruce experts very quickly, aware of their hatelleaments, and to tell everyone that the committee has gathered a challenge in the committee where it is, and many times nother, to share what has been done and how it comes down the path that it is leading with. ac mae'r bydd gynnig erbyn gyd yw 5 mwy o'r dynnu. Rwan and MacDougal ar attackedrad yn gyfnwyd ac yn cael ei parlyfa yn ystafell i'r Gwyl Llyfrgell gyngor gwarnodd hwnnw, a oedd mae'r gwrthod o rhan o gyfnodau, dwi ar lain o gyfnodau o rhan o oedd cymryd, ac yn cael ei gydag o gyfnodau rhan o'r of measure established. Now, interestingly, we've previously met with the minister. Welcome to you again. Thank you very much for being with us, Mary Todd. And we're delighted to have with us this morning the chief medical officer, Sir Gregor Smith. Good morning to you. And back with us, but online, is Terry O'Kelly. Good morning to you, Mr O'Kelly as well. And in our last consideration of this petition was online with Shoulders Hospital in Canada, where we were able to take evidence from Dr Fernando Spencer Neto. So there'll be a number of questions arising from all the evidence that we've heard. I mean, I think as we've gone along, I think that we've heard a lot of evidence that, you know, there are very many people who have benefited positively from mesh in relation to her near, but I wonder if I could just start with a couple of back questions. Minister, just if you don't mind, since this might be the last time we really cover mesh in quite such wide detail. In relation to the act that we passed for transvaginal mesh, there have been some reports that we're still at a stage of trying to negotiate. Excuse me, I actually have an open statement. I'd like to hear it. I very much wouldn't, yes, thank you. No problem, and that might set the context. Excellent, thank you very much. Answer some of the questions you're keen to put to me. So thanks very much for inviting me along and giving me the opportunity to return to this really important topic again. I'm pleased to say that we have made significant progress in our action on transvaginal mesh. We've established a national service for the management of mesh complications, and women have options with regard to their treatment, which can be undertaken in Scotland, elsewhere in the UK, and also with an independent provider if desired. Most recently, the Transvaginal Mesh Removal, Costry and Burstment Scotland Act 2022 was introduced, and the associated scheme opened on 6 June, just this Monday. The contract with Spire Healthcare has been concluded, and arrangements are being made for the first patients to attend surgery, and, meanwhile, discussions with Dr Veronica are progressing. I am, of course, very mindful of the concerns raised by campaigners over the year about the use of mesh in other sites, such as in hernia repair, and that is what I'd like to focus on today. I'm very sorry to hear of instances of any complications and the adverse effect that those have had on both them as individuals and on their wider families. As you know, the Scottish Health and Technologies Group has looked into the use of mesh in hernia repair and has published two reports on that subject, one shortly after my last committee appearance. Those reports, based on current published evidence, support the continued use of mesh in a variety of abdominal wall and groin hernia. Of course, it is subject to all the tenets of realistic medicine, ensuring shared decision making and informed consent with knowledge of benefits, risks, alternative measures and the possibility of doing nothing. We've discussed the findings of those reports with professional bodies, including the Royal Colleges and the British Hernia Society, and we'll continue to work with them on this important issue. There's also work on going with regard to establishing MDIS, which will provide important surveillance and outcome information. Since the last appeared before committee, the chief medical officer wrote to the board chief executives and medical directors in December 2021 to draw their attention to the SHTG report. In the letter, the CMO asked health boards to consider the availability of non-mesh surgery and how best to address skill gaps if they exist in the development of broader clinical networks for the management of complex cases. The actions resulting from this will be discussed at a meeting of the Scottish Association of Medical Directors in August. I know that the committee has received a report from the shoulders hospital in Canada, and although the results reported are absolutely indeed notable, it's important to remember that the shoulders hospital is a specialist centre dedicated to a natural tissue repair and that it operates in a very different healthcare system to the NHS in Scotland. For that reason, the report shouldn't be considered in isolation, but it needs to be considered in the context of the wider evidence available. As I've said before in front of this committee, there are, of course, still some gynaecology procedures for which the use of mesh has not been halted. In those circumstances, there's a high vigilance protocol in place across the whole of NHS Scotland, and it's important to remember that some of those procedures are complex and long-established with few, if any, viable alternatives, so to suspend the use of mesh would leave a cohort of people with limited or no treatment options. I want to reassure the committee members, as well as the campaigners who brought this petition forward, that the Government is absolutely committed to ensuring that everyone with mesh complications gets the care and treatment that they need, and I look forward to answering any questions that you might have on the matter. That was very helpful. As we've heard the evidence in relation to this second area of mesh concern, the evidence very much supports the view that there are nuances here, which mean that the way in which the future might be progressed is quite different to the prognosis that there was in relation to the transvaginal mesh campaign. You alluded there to the on-going conversations with Dr Veronica's, and that, of course, has been negotiations continue, has really been the situation for us for as long as I can recall. In fact, I might even have been a list MSP when we first heard that said. I recognise that there is a commercial interest in the Missouri facility that Dr Veronica's operates, and I know that the conversations at times have been strained. However, inherent in the act that was passed was a belief that that would be one of the options that would be identified and around which something would be concluded. Naturally, enough expectations are therefore raised that something will be forthcoming that can assist women in the near future. Some will have thought even sooner, potentially, than we are at now. Is it difficult to say where we are in those negotiations and how they are proceeding? I have to commend the NHS organisation that is pursuing the conclusion of that contract. It is very close to finalising it. I know that it is frustrating, but when we stop and reflect about the differences in the medical systems and in the legal systems in the two countries, it is understandable that there has been a deal of to-ing and fro-ing, but I am confident that everything is being done to conclude that contract. I hope to be able to update Parliament on that soon. We have been discussing the nuances in relation to hernia mesh. It has been at times about the proper explanation to patients of options, and that was partly one of the things that Professor Alison Britton was looking at in relation to the casework review and the way that women progressing through the trans-vaginal hernia mesh issue had been treated. Her inquiry has now been on-going for some time, and I did ask an oral question a month or so ago in Parliament. I just wonder if you are able to offer any update as to where that might be, because some of what she might report might also be of interest in relation to the way in which patients have to be properly notified and made aware of the options that are available to them. Absolutely. The review is now under way and it has been established following the serious concerns that were raised by some of the women on whether their case records accurately reflected the treatment that they have received. It is well under way and it is expected to conclude later this year, but I have to say that we have a system in Scotland, and I am sure that Dr Gregor Smith or Gregor Smith will want to come in on this around realistic medicine, where we want all patients at all times to be well informed and part of the decision-making process. We use the action in Bran to remind everybody involved to consider the benefits, risks and alternatives. The intervention is needed now. What happens if I do nothing? Those sorts of conversations are absolutely vitally important when considering surgery. There is no risk-free option when you have a hernia, and it is really important that people are well able to question and understand the treatment and not just the generality of it, not just what the general risks are but how those risks apply to them in order to make a full informed decision about how they want to proceed. I will let Gregor Smith say some more. Thank you. Is shared decision making really at the heart of the relationship between people who receive care and people who provide care? It is realistic medicine when we began to have a conversation with the profession late 2015. We saw the need to promote a better approach to shared decision making and personalised care. It has been right at the heart of realistic medicine to try to create a much more equal relationship between patients and providers of care. Since that point in time, shared decision making has been, I would say, absolutely wholeheartedly embraced by the profession in terms of the approach that has been supported very much through work that we have participated in with the general medical council on refreshing the ethical obligations and legal obligations around consent. It has also been greatly supported by our education establishments, whether that has been undergraduate education or postgraduate education through NHS education for Scotland, with several modules, really promoting what is the essence of shared decision making. Those four questions that the minister has outlined known by the abbreviation brand, what are the benefits, what are the risks, what are the alternatives and what would happen if I did nothing are really at the heart of consultations. We have them as part of the near me platform, the electronic platform that has been used extensively over the last two years, has now increased its presence across the country. We are also encouraging patients to engage with the clinical teams to use those questions to make sure that they are exploring those concepts. When they arrive at a decision, it is a decision that is well informed that can be said to be informed consent under pinza, and we know that in a situation like that it is associated with much less treatment regret afterwards if that conversation has happened fully. I think that the evolution of this exchange and shared decision making has materially progressed from the fact that such a process was meant to be the one that was there historically, but we discovered during the transvaginal mesh issue that it was not really there. If that has happened, I think that is a great and a very positive development. I should say that I have got a very good video feed of you, so at any time you feel you would like to say something, if you just raise a hand, I will know immediately that you are trying to come in, so do not feel you have got to do anything more, I can see you well. Minister, the last time we met, in relation to the extent to which there is a valid underpinning of the concerns that the petitioners have had, you thought that it would be very difficult to quantify this because there was no basis of evidence gathering that would allow a material judgment to be made about the extent to which anything is real. Has any thought been given to some sort of limited sampling or anything just to get some understanding of how many people may be experiencing genuine post-hernia mesh complications? I am not sure that I entirely understand what you mean by sampling of records or sampling of data. Certainly, there is a recognition that we need to, particularly where medical devices are used, they need to be more traceable and it needs to be clearer which devices were used where and there needs to be a system of retrieval in place. We are working very closely with the UK on that, so that in future, and I guess that answers your question, is that we found ourselves in a situation where it was quite hard to tell what had happened precisely, but in future that data should be gathered much more routinely and certainly where there are issues with a product, it should be perfectly straightforward to find where that product has been used, there should be a strong audit trail present in a patient's notes. Alexander Stewart Minister, you talked about the risks and also the benefits, but within all of this, the word complication seems to be the problem. We have had many individuals who have given us their testimony that they took on good faith and went through that process, but maybe three, four or five years on, the situation became so difficult for them that it ended up being a real problem for some individuals who found themselves in that situation. You have talked about consent and you have talked about that process, but it is about communication. I believe that anyone who goes in and gets medical support and advice will take on board that, but maybe they did not realise what complications could occur maybe three, four or five years later on and the damage that has then been done. That is where we have seen also in the hernia situation where people in good faith thought that the mesh was the right thing to do because that was what they were advised at the time, but it ended up not being and has put them in a really difficult and dangerous situation. It would be good to get a clarity as to how you communicate that to ensure that individuals do make the right choices and they are not steamrolled or advised. The doctor or the clinician is saying, we believe that this is the best treatment for you and they take that on good faith, but as I say years later, they find that that maybe was not. What should have been happening? I will start now. I see Mr O'Kelly raising his hand. I am sure that he is very keen to contribute here as a practising surgeon who has to go through these issues time and time again day and day out with patients. I think that you are absolutely on the button. It is really important that these decisions are shared and that is what we are talking about with realistic medicine. Moving away from in the past, we had a very paternalistic style of medicine where the doctor was all-powerful and told the patient what to do and their advice was almost always taken as law. What we are recognising now is that health is much better delivered in a shared way. It is much more likely to attain good health if you share that decision-making. Individuals have to be a party to that decision. There has to be a discussion with their clinicians about it. As I said, it is not just about the generality, it is about how those risks apply to them as individuals. It is a very individual discussion. A patient should feel, rather than accessing the internet and finding the data and assessing that themselves, they should feel that they are able to talk to their own health professional and have those risks explained as they apply to them, as they make the decision. Often, patients are in a very difficult situation where there is not a risk-free option. So, if you have a hernia, continuing with that hernia is not a comfortable situation to be in, and the options for treating it are never going to be risk-free. It is about that discussion, as you say, of an honest and transparent and well-documented discussion about those risks is a very important part of the process. The second thing that you were probably raising with me is the sense that sometimes, and I certainly as a politician, and we as politicians, probably hear more of this than it actually happens. We hear a certain select few stories, or select many stories, but we hear often from people who feel like they were not listened to. They go to their health professional and feel like their concerns were dismissed or their health problems were minimised. Again, we are working hard to improve that situation so that people, when they present to their health professional, who often, five years on, will not be the surgeon, so we are trying to make sure that their response that they receive is more empathetic, more understanding and they are suitably directed to people who might be able to help them disentangle whether what they are experiencing is related to the surgery that they had or not. Mr O'Kelly, I am sure that you would like to come in and ask me to do that. I think that you are just going to contribute as well. Good morning, Mr O'Kelly, and over to you. Good morning, Mr O'Kelly and the committee. I may well have raised my hands too early. I think that that was a pretty good explanation by the minister. I think that the issue about complication is, I think, difficult. I think that it is explaining complications that do not flood them with data and cause anguish about that it is inevitable that something dreadful is going to happen because look at all the things that can happen, but I think in that is a trying to lay fears that the risks are relatively small in that the risk might be less than 5 per cent or less than 2 per cent, but if you are the person that that complication affects then it is not a negative concept of a less than 1 per cent risk, it is 100 per cent that has happened to me. I think that there is a notion of an importance of trying to ensure that patients understand what the nature of the risk that they are exposing themselves to. I think that we know from realistic medicine and the work that has gone on that health literacy in Scotland is by no means ideal, and so there is a need for clinicians to spend time with patients to ensure that, not only have they told them or given them information, but that information has been assimilated and truly understood. I think that in that respect it is always a good idea to check, and it is always a good idea to ask patients to attend with a supporter or an advocate if required, particularly when one is engaging in a more invasive and perhaps more risky procedure. I think that that is very important. I think that that probably is the crucial thing. The other thing also is that, when it comes down to comments that you remember that Donald Rumsfeld made, and that was that there are the known knowns, and we know the complications through the looks of those, there are the unknown unknowns. We cannot tell you about what is going to happen in 10 years because products have not been available for that period of time and we do not know what the outcome is going to be over time, so there is a risk there. However, as he said at the time, there are the unknown unknowns, and they are the ones that will always catch us out. I am not suggesting at all that my colleagues in the past have always addressed themselves in glory, but I think that it is that recognition of being absolutely honest with patients and saying, we do not know what is going to happen in 10 years' time because this particular device, this particular product, this particular drug has not been available for that time, so it is impossible for us to know. What we do recognise is that at this moment, and given the time frames that we have experienced of, this will be of benefit for you, and this is the reason, this is the risk that we know of, this is the alternatives, and this is what might happen if we did nothing. There is quite a lot there, but for the patient sitting in a doctor's surgery, that is quite a lot to actually take on board. As Gregor was saying, it is not only the questions that are flattening the hierarchy, but also having the right attitudes, giving the patient the right environment where they feel that they are able to speak up in hospital. Do we have some understanding about mesh itself? Different types of mesh may well have different processes within the case, so how have we been investigating and taking steps to analyse some of the mesh products as to what kind of defects they may have? Has the Government and clinicians themselves had a look at any of that history to try to find out if there are defects that happen specifically in some types of mesh products that are more susceptible or more problematic for individuals? I think that that would once again give some reassurance if we are aware that certain products may be more susceptible than other products and that may reassure people in the future that they believe that the mesh that is being put in will be better because it is not one that has a track record that has caused some issues in the past. I think that I will let Mr O'Kelly answer the bulk of the question and he can certainly give you the picture of what clinicians are doing to understand you. As with medicines, it is possible to do randomised controlled trials with these medical devices and learn more and more about them. Also, as with the unit in Canada, it is possible to collect anecdotal evidence and observational evidence, and that happens on an on-going basis in this area of medicine, as in any other area of medicine. If I go back to your concern about finding out about the types of mesh that may have defects or not, the Cumberlidge report was very focused on the regulation of medical devices and found the UK environment wanting. We, as a Government, are absolutely committed to the recommendations that are made by the Baroness and her team. We have made significant progress on them since the report was published last year. Mr O'Kelly, you want to maybe answer some of that too? With regard to the base material, polypropylene, that has been used in surgery for 80 years. I think that it was introduced at the time, May 2 World War, perhaps just afterwards. That has been found to be very safe, very effective and well tolerated by a patient. Certainly, in vascular surgery, it is product of choice. As a suture material, we know that, over time, there have been no major safety issues raised. With regard to mesh itself, that has evolved over time. With regard to hernia mesh, the MHRA has looked at it, as you know. I know that there are issues with MHRAs sitting in front of this committee, but it has been scrutinised very carefully. You will appreciate that, both in this country and similar organisations in the state of the FDA. What it recognises is that it is an implanted product. It is important that patients understand, but it does not seem to be an intrinsic issue with the product itself. Rare reports of the press in the published ministry of patients are having some reactions, but they are very rare. Given that the numbers of meshes that are used each year and the time that they have been used for, going back to the late 1980s, we see very few patients, or rather, a very low percentage of patients coming back. Because those are common procedures, even rates of less than 1 per cent mean that there are a number of patients here that have troubles with problems related to their surgery. Although, yes, they have got a foreign body in the mesh, it is not necessarily the mesh itself that has been the problem. Modern mesh construction is probably as good as we are going to get it at the moment with this base material. There is a lousyng growth of fibrous material, a scar tissue, which causes a fibrous scar and strengthens repair. Problems can occur over time with shrinkage and contraction of that fibrous scar, which can lead to problems. It is important that the mesh is in certain attention free fashion, so that the possibility of causing injury is less. If it is used in a position where the bowel might come into contact with it, the steps are taken to avoid that as much as is possible. We have heard that, in some situations, individuals had one mesh for a hernia to put in, and that had to be removed and had a second one. On the second attempt, things have been better. They have not had the same complications once they have had the first mesh removed and the second one implanted. Is there evidence from yourself and others of that procedure when one is removed and a new one is replaced? Is that common, or is that just an ad hoc situation for certain individuals? I suspect that that is an ad hoc situation. I do not know the individual circumstances that relate to the case that you quoted. If a mesh was put in and it was tight—it can happen, these are technical exercises and sometimes they might be too tight—remove that mesh and put it in attention free mesh, that might be the answer. It is also possible if the mesh is inserted and held in place by sutures, that a suture entraps a nerve. You might not be able to see that at the time, and that is very likely. Physically removing that foreign body from the vicinity of the nerve might have alleviated patient symptoms, but it might be necessary to remove the mesh to do that. It may be that the second mesh, when inserted, was self-adhering or inserted and held in place with the tissue glue. There are reasons why, in a car, does something not work and you get a change and it works now. It is difficult to know precisely what the issue was in the ME service. Minister, in relation to the Cumbullage report, the committee was alert to the shortcomings in the regime regimen surrounding the MHRA. I think that all parties here in the Parliament endorsed the recommendations in the Cumbullage report. Did I understand you to say that you do believe that the discussions that are taking place in relation to that are constructive and are progressing to a positive outcome? We are working with that report and taking positive steps in the Scottish Government. There is still work to do to ensure that patients' voices are heard and listened to, and that is why we have proposed our patient safety commissioner in our programme for government and it was also a manifesto commitment. We consulted on that recently. The consultation has now closed and we recently published a report that provided an analysis of the results of that and we are certainly going to take that into account as we continue to work forward with patients and experts and develop that commissioner role, but we are keen to do that in Scotland and we are keen to deliver what patients are asking for on that front. In terms of discussions UK-wide with the MEHRA, I think that we have, as has often been the case over the last couple of years, some slow progress, understandably given the situation that we are in, but we are keen to pick that up as a priority and make sure that we make progress UK-wide. I think that all parties here recognise that the MEHRA regulation is reserved, but I think that there was a strong feeling that wherever support could be given to efforts that were being made by the Scottish Government in relation to progressing issues around the regulation of those devices, that would be forthcoming. I am sure that all parties would still be willing and able to offer whatever support the Government felt it might need if it was struggling to make the progress that we would all want to see. We will bear that in mind and take up your offer, if needed. Thank you for your contribution so far. It is very interesting. I have some questions around mesh removal procedures and protocols. We have had a number of written submissions from members of the public who have experienced adverse outcomes in the complications. Martin O'Neill commented that his life is now improving, that he has had mesh removed as statement reaches his followers. I am still mesh-afflicted due to the device being left so long in my body that the pain and damage is permanent, but I have some hope that it is now out. There is at least a possibility of me doing something with life rather than taking pills that do not allow basic functioning, coupled with pain that still does not stop sleepless nights and an overwhelming sense of wanting to die than to live in that horror of the pain that the mesh is causing. In other cases, individuals were told by surgeons that the mesh was too enmeshed in their body to be removed without causing serious consequences such as a loss of their rectum or testicles, and some individuals have resorted to private surgery to get their mesh removed, and some have even travelled abroad to do so. In another written submission, Carol Coot has described difficulties in getting her mesh removed on the NHS in Scotland, and our submission reads as follows. My GP discussed my case with other GPs. She said that none of them knew much about mesh. She tried referring me to the Scottish complex mesh surgical service, which is a service for women considering special surgical mesh removal, and she also emailed them as a patient. She refused my referral as they only accept gynaecological referrals. In 2018, your predecessor, Sir Gregor, as chief medical officer, wrote to the health board medical directors in Scotland about the use of mesh in sites other than the vagina. In the letter that the CMO wrote, it reads as follows, the management of patients with mesh-related complications must follow agreed pathways, which should involve a multidisciplinary team of clinicians with appropriate skills and experience. In light of that, what specifically can you talk us through those agreement pathways for non-gynaecological mesh-related complications referred to by your predecessor in 2018, and do you believe that those pathways are operating in a way that they should? First of all, when you recount the stories such as you've just done, the terrible symptoms that some people are suffering as a consequence of some types of surgery, it's always very difficult and you can't help but be moved by their experience at all. Terry will be able to say a little bit about the detail of some of the pathways, but you're absolutely right in that we have created an expectation in boards that they should be developing pathways that both offer alternatives to mesh surgery for patients who would prefer to explore other options, but there are also complications that may be a necessity for their revision surgery or to explore that in a place that has a specialist nature for that when that's required as well. Within each health board there are what's called exceptional referral protocols, and so what happens just now, and that's happened for many years, is that when particularly specialist services for a high degree of competency is required, we're perhaps in a local board area, but perhaps that service isn't available in a local board area. There's the ability for local staff to be able to refer outside that board to these places using that exceptional referral protocol, and sometimes that's to another area within Scotland, sometimes that's even beyond Scottish borders where there's a service that's provided from elsewhere, and that traditionally has been one of the ways of trying to deal with this. There's many surgeons with a high level of competency in Scotland in addressing some of the issues that you've described particularly in terms of the more complex end of mesh removal, but I would like to see what the reasons that my predecessor and then again myself have written to health boards about is to see a greater consistency across Scotland in terms of developing more localised services for those for that type of care. As I say, Mr O'Kelly might be able to say a little bit more about progress with that. We've heard that later on this year there'll be some more detailed discussions with the Scottish Association of Medical Directors as to what progress has been made following that letter, which was sent to them. I think it was just towards the end of 2021 perhaps, December 2021, but Mr O'Kelly might be able to say a little bit more just now. It's not only that clinicians recognise that there may be a need for a second opinion, but it's also the patient's right that if they are not receiving information or opinions that they are satisfied with, that they are able to ask themselves, or could I see somebody else for a second opinion? I think that there's a great deal of security in asking somebody else to review a case, and it not only helps me but also helps the patient. I think that that's something that we need to support. With regard to pathways, I think that those are going to be germane to each circumstance, not because the hernias and the meshes and all the procedures and the complications that have occurred will, because they're not that common, be bespoke. It's important that care is individualised, so it's very much centred on that particular patient. I think that it's important that clinicians form networks, and in my own health board that certainly is the case. I think that the networks need some support, particularly administrative support, and it's essential that any discussions that occur are recorded and discussed with the patients and the outcome of all the deliberations entered into the electronic patient record to go forward in perpetuity. There's a bit of work, I think, still to be done to ensure that that type of process is embedded into every board in Scotland. With regard to private healthcare, I think that it's a real shame, but it's still the perception that if I pay for something, I'm going to get it better. I think that often the same people, I think that what we need to be able to do is to provide for all our patients exemplary with care within our national health service, and certainly I think that we're all committed to doing that. Mr Sweeney, I think that we might have asked a slightly anticipated question, but... Thanks for that contribution. I think that the point about such a small number of cases and the national scale of things requires some degree of reflection on how best to address it, and I think that those pathways perhaps need some consideration about how do you get those learning curves established so that defects can be addressed by a network of people who are robustly capable of doing it rather than being a lottery. I just wanted to ask, is there a specific protocol? Could the NHS consider a particular protocol of investigating these particular cases where, for example, someone went for a private surgical solution, understanding why they did that and what was the outcome? What could have happened differently? Is there a way of addressing some of the submissions that we've had from patients and doing a deeper analysis of what's gone wrong through their journey to identify whether there are opportunities for improvement? Audit is an incredibly important part of learning within medicine or surgery, and the ability to be able to reflect on practice and to get good data and evidence of how practice has affected people, what kind of outcomes they've experienced, whether those are positive, whether those are on these occasions negative outcomes, and it relies upon the availability of good data. Some of the things that we've heard about today, such as the scan for safety approaches, where we're able to have much greater information about the type of devices or materials that are used in different types of surgery, help us to better understand over time through that data what kind of outcomes people are experiencing. Where care transcends between NHS and private facilities, it becomes sometimes a little bit more difficult to obtain that data and to be able to use it in a way that allows that proper understanding. However, the point that you make is still critical, and we rely on the use of that data to be able to understand outcomes that are associated with it. The new processes, protocols, as you described, that will come into play will allow us to do that a lot better in the future. I just wanted to follow up on a particular incident that was mentioned earlier on in one of the submissions by a patient. The Scottish complex medical, sorry, the Scottish complex mesh surgical service only accepts gynaecological referrals. I just wanted to ask why patients wish to have other types of surgical mesh and we couldn't utilise that service and why it's restricted in that way. Mr O'Kaley might want to add more to that, but that service has clearly been set up with surgeons whose focus of training just now has been on the urogynaecological use of mesh. Because that is so highly specialised and specific, perhaps it wouldn't be appropriate for them to be looking at the use of that in other sites as well. It's very site-specific, but Mr O'Kaley might want to add more. The centre was set up specifically for the purpose of the mesh complex, complications from urogynaecological mesh. There is a multispluit team that consists of urogynaecologists, urologists and co-rector surgeons. Over time, the group, if not yet, will take on the burden of rectopexy mesh, which is very specialised and crosses the boundary between urogynaecology and co-rector surgery, the interface between the last part of the large bowel and the gynaecological structures. In England, that is certainly the way that the management will proceed. With regard to other meshes, the distenser is not being constructed for that. For sure, I think that the conditions are available to be consulted, but it is not really taking referrals, as such, from or non-pelic, the planet of urogynaecological mesh, as described. I think that that is appropriate for that particular centre, as it is. The final area, just to touch on what you alluded to in your opening statement, Minister, is the evidence that we received in the subsequent oral testimony that we had with Dr Spencer Neto from Sholders hospital in Canada. David Torrance will lead some questions here. In evidence from Dr Spencer Neto from Sholders hospital in Canada, he highlighted how successful they were with natural tissue repairs and the low recurrence in herniers. How does pre-operative preparation and post-operative care for hernia repair surgery in Scotland differ from those undertaken in Sholders hospital? It is probably worth going to Mr Kelly on that question, but, as I understand it, that is a very specialised unit, and patients are somewhat pre-selected. It is not a population that would be reflective of the general population seeking surgery in Scotland. That aside, the results are very impressive and we are very interested in the work that they are doing over in Canada. However, as I understand it, if you were to compare the population that used that unit in Canada with the population seeking hernia repair in Scotland, there might be significant differences, for example, in terms of obesity or ambulation or things like that. However, I will hand over to Dr Kelly and he will be able to give you a better explanation. The Sholders results and their outcomes are very impressive, but they make the point that the relative contraindications and relative risks with regards to excessive surgery are smoking, obesity, diabetes and some other pre-existing conditions, the quality of the underlying structures and the size of the defect. Some of those aspects are going to the question that Mr Torrance asked, but we do not have a great deal of control over. However, in the build-up for surgery, I think that pre-habilitation that you might be alluding to could play a very significant role in getting patients fitter or surgery, trying to get them to stop smoking, increase in their exercise levels if they can, losing some weight, reducing alcohol, etc. That is all things that are going to be beneficial to patients, which we are looking to promote. If then surgery is conducted in a get-it-right first-time manner, patients in good shape will be able to not only benefit from that surgery but benefit from that surgery at an earlier stage with post-operative mobilisation in terms of normal activities. There are lessons to be learned from Sholders and things that we can apply to try to improve the loss of patients that are having surgery in this country. Kelly, there are very strict criteria at Sholders hospital, especially around weight loss. In fact, they quoted Dr Spencer Nettle that up to some of their patients could lose between £50 and £100 before they will even see them and go ahead with that natural repair. Could that criteria be brought into play here, or would it be acceptable to put a criteria on a repair here? It is very difficult, because are we going to deny patients access to surgery if we believe they are overweight? That would be the subject for, I suspect, parliamentary debate. The other issue is what is the problem that the hernia is causing. Is it that we have strangulated hernia? Do we need to engage in life-saving surgery? Is this preventing them from working? We also know that trying to get patients, when they are of a certain size, losing weight becomes almost impossible without some other medical intervention, and that would be the case if they are diabetic. However, I think that there are ethical issues that are profound and worthy of consideration, but perhaps you have an opinion on that, which might be better than my own. David Charnes, I think that you have raised a really interesting ethical dilemma there, haven't you? I know that it is one that many clinicians would feel uncomfortable with. I feel uncomfortable with even talking about it just now, but the restriction of access to treatment because of personal criteria is something that many clinicians, as I say, feel deeply uncomfortable with, particularly when there is a health need that lies at the bottom of it. However, if you turn around this concept a little bit and look at the education that we can work with patients in relation to the concept of risk, you then begin to explore an area where there is mutual benefit. It is about trying to be able to encapsulate the risk of certain personal characteristics for people before they enter all sorts of treatment where risk is increased because of the personal characteristics that they experience. Then, using education, working with patients for prehabilitation that is becoming more familiar to us so that they are able to prepare themselves for surgery in a way that helps to reduce that risk. That is part of the conversation that we spoke about earlier when we spoke about the benefits, the risks, the alternatives, what happens if I do nothing. We know that there are many approaches that we can take with patients to discuss that. The two most obvious ones are simply about weight loss before surgery. It is a good thing if you are overweight. It does not matter what type of surgery you are undergoing. If you are more obese, there are greater risks that are associated with surgery in general, and it is easier as a consequence of that. We know that, specifically with abdominal surgeries such as hernia repairs, being more obese is associated with slightly poorer outcomes there, and smoking, similarly. Knowing those characteristics, you can then describe risk in different terms to those individuals. You can begin to calibrate risk for them so that they will have their own tolerance to risk and are then able to judge, if I go forward and have the treatment that I really want to have and need to have, then those are the things that I can do with my personal responsibility to contribute to better outcomes. I think that many people would feel very uncomfortable about restrictive methods to access surgery when people are particularly experiencing a lot of discomfort. Are there skills in natural tissue and hernia repair techniques being lost in Scotland in favour of teaching surgeons mesh repairs? Could more surgeons in Scotland be receiving training in natural tissue methods? Mr O'Kelly will want to come in on that, but, as I understand it, there is real interest in improving the expertise within Scotland in natural tissue repair. They are looking at centres that use those techniques in Europe just because of the ease and practicalities of links with Europe versus links with North America. Mr O'Kelly will tell you a little bit more about that. There is a passage in the or section in the showdust report that you obtained from described mesh surgical training, and it was easier to do, and that is the reason why it was practised. That aspect of training was a germane to surgical training in Scotland. I think that that is a bit disingenuous. I think that there has been an emphasis on mesh training and mesh surgery, because of its efficacy, as proven and as revealed in the Scottish health technologies group report. Having said that, it needs to offer patients choice, that is really important, and there will be some for whom mesh is not appropriate. It is critical that, with each health board, patients have access to mesh surgery. When it is appropriate, and it may be within the health board, it may be somewhere else in Scotland. I cannot tell you how many surgeons we would need to train, but I think that it is going to be more than one. I think that one of the discussions that we will have with the associated medical directors when we meet them is about provision of training and access training for colleagues who wish to do this. In my own health board, one of my colleagues is keen to take this forward, and he has started to make contacts. He will probably travel with one of the surgeons from NHS Lothian. I think that one person in my board is not going to be sufficient. We need at least two people, so it is getting to depend a bit on demand. It is also important that the individual surgeons are not practising one procedure per year, because they have to have a volume, and it may be effective and efficient. Colleagues will need to buddy up, certainly at the start, to make sure that the numbers are correct and that they are refreshing their skills through practice. One of the successes of shoulder ice is that the surgeons are performing six to seven hundred procedures per year, so that is if 15 to 20 procedures per week are taken into account and leave one thing or another. They are doing the same thing every day and you become very proficient, I am sure, and that is something that we also need to do. The shoulder's example demonstrates the success of a specialised hernia repair unit. Is it possible to have a centre like that in Scotland taking into account the criteria that is needed to have that success rate? I can understand why you would ask that. If I think back to some of the debates in my own constituency, there is a real tension between accessing healthcare as close to home as possible, but being able to access national expertise when required. I get many more concerns from constituents who are having to travel even within the constituency in order to access care than I hear appeals to be able to travel for specialist expertise. The way in which we tend to work in NHS Scotland is that, for routine care, you should be able to access it as close to home as possible. I think that there are lots of good reasons for that. If you think about the medical model of health but think about the biopsychosocial, it is important that people are close to home and have the support around them and are able to recover well within their families, within their communities for that type of procedure. If you think about the particular challenging or complex procedures, we need to build on expertise and we are going to have to work in a networked way across Scotland to deliver that. We have said that there are challenges with volume. If people are going to train in natural tissue repair, they are going to have to be seeing enough people to maintain that training. We will certainly consider what is the best model for Scotland, but I am not right at this moment minded to reconstruct the unit in Canada here in Scotland. I will hand over to Mr O'Kelly, who is keen to come up. It is a couple of questions to come. With the creation of the national network of treatment diagnostic centres, there will be some migration of patients in their locale to the facilities. That will give the opportunities to concentrate colleagues who have particular expertise and interest in the field. It may be that, as careers develop, they will choose to have a more scheduled workload rather than the unscheduled care. If they do more herni lists, they will increase the numbers and move much more towards a shoulderised time model. I am not sure for most of our colleagues that that is a very attractive way for their professional life to do just one thing all the time. Okay, thank you. We are very short, so I am very grateful for the time that you have given us. Perhaps in just any final remarks that you might want to make, I will just invite Alexander Stewart and Paul Sweeney, both at supplementaries, if they would just like to ask them and then you could maybe round up just in any final comment, a response to either of them. Alexander Stewart? Thank you, convener. You touched on the necessity to try and create facilities that will support individuals. Canada gave us a very good example of what was being achieved, and I appreciate that you want to try and ensure that medical support is given to individuals at the closest point. However, there still may require to be some need for specialisation, because by doing that it then creates a unit or an expertise within the field for individuals and clinicians themselves to do that. I do think that that is something that should be considered in the way that we are going forward, minister, because that may help to iron out some of the difficulties that we have seen, and it would be good to get your views on that. I think that it was just to build on the point about the Scottish complex mesh surgical service being the opportunity to evolve this into a model where, given such a small volume of defects in the national population base, combined with Scotland's relatively small geography and population base, the idea of concentration to deal with complex defects and rectification of defects is a way of potentially building a service that could build on some of the examples that Dr Neto appealed for is the key takeaway of building that national centre. Wealth is not saying it. Everybody has to go and get a surgical repair of a hernia done in a national centre in Glasgow or somewhere if you are living in Lerwick, but if there are complex cases or high-risk cases then maybe that is the most appropriate solution. Would you agree that that is maybe where we need to look at it? Certainly, I think that there are two separate things. The shoulder centre is dealing with more routine operations, with quite high volume, and it is in terms of giving people options of highly skilled and highly trained surgeons who are using those techniques. That is probably something that we need to explore on a national basis, but we can build up local expertise. I agree that there needs to be perhaps a national multidisciplinary team that looks at those particularly complex cases and that clinicians need to be able to access that expertise all over the country. It is difficult to understand how challenging it can be to communicate cross boundaries within the NHS and it is a theme that comes up time and time again. We are very keen to bust those boundaries to make sure that clinicians can access the expertise that they require for their patients wherever they live in the country. We are very mindful about how to develop systems that mean that patients wherever they live in the country can access the right level of expertise. We know that people in Lerwick are probably more comfortable with travelling than people on the mainland travel all the time. Patient choice needs to be part of that as well. I will go back to that again. Those need to be shared decisions that are made with patients about what is the best option for them. I want to emphasise that, even if you look at the extant clinical strategy for the country, one of the concepts that was explored in that clinical strategy is the tension that exists between competency for any given procedure or approach to care and the volume of patients likely to be seen. The recognition that sometimes we need to look at ways where nationally we can provide a way of providing care for those low-volume type procedures. I think that that is something that all clinicians would certainly sign up to. There are different ways of achieving that. Mr O'Kelly has spoken about the informal and formal networks that develop around about care that can provide a highly specialised approach when it is required. That is something that we see under pins, much of our clinical strategy. Occasionally, there is a need to develop that further to centres of excellence, where we have a much more formalised structure and team that is approached there. It is gauging which is going to be the best method of providing the support to those people when they need it. I think that it would be something that I think Gregor would discuss and take forward to the medical directors how we can ensure that the best opinions, the best skills are applied when they are required on all occasions. That does not be an engagement through the board networks. It is how do we improve liaison and allow that sort of cross-fertilisation of ideas. Thank all three of you very much. Just in conclusion, I do not know if you saw any of our evidence with Shoulders Hospital, but Dr Spencer Neto, I understand the geographies involved in it all. In principle, he was very happy to facilitate any access to the expertise that they have developed with their clinicians to the benefit of the Scotland's NHS where that thought to be useful. They would be very happy to explore that further if the opportunity or the offer was one that the Scottish Government felt it wanted to pursue. However, I thank all of you very much for your evidence this morning and temporarily suspend this part of the meeting. Members, can I just confirm that we are content to consider the evidence that we heard in relation to the previous petition at a future meeting? We are. We are now bringing together four petitions that we have been considering into one evidence session. Those four petitions are a petition number 1845, an agency to advocate for the healthcare needs of rural Scotland lodged by Gordon Baird, 1890, which is to find solutions to recruitment and training challenges for rural healthcare in Scotland, with Maria Akin on behalf of the Caithness health action team. Petition 1915, to reinstate Caithness community council and Caithness NHS board lodged by Billy Sinclair. Finally, petition number 1924, to complete an emergency in-depth review of women's health services in Caithness and Sutherland with Rebecca Weimer. Maria Akin and Rebecca Weimer, good morning to you, are joining us as we consider this petition. We have Gordon Baird, I believe, and Billy Sinclair with us. I'm just my eyesight. Those things are very helpful if you've got good eyesight. They're not so helpful from a distance, but good to understand who you both are. Welcome to you all. We also have a number of interested colleagues from the Scottish Parliament who are with us in relation to this. We welcome Rhoda Grant, which I do at every meeting. It's nice to have you with us again, Rhoda. Emma Harper, MSP and Colin Smyth, MSP, both with rural healthcare interests in their constituencies. We'll return to our parliamentary colleagues when we've heard from our petitioners, as I know you are keen to speak in favour of the petitions. Members will have a number of questions that they would like to explore this morning. If the panel is happy, I think that we're going to move to the first of those. I should explain to our petitioners joining us virtually that if you would like to come in at any point, I can see you both on the screen in front of me, so you can either put an R on the chat box or if you put up your hand, I think that we're probably going to see that as well. I'd be very happy to bring you in at that point. For our petitioners in the room, if you again can catch my eye or one of the clerks, they'll make sure that I know that you're keen to intervene on one of the questions. I should also say that there's absolutely no obligation for you to feel that you've got to jump in and ask questions. You may just be content to hear the evidence that is coming in to understand how we proceed. We're now going to move to questions, and I'm going to invite Fergus Ewing to lead the questioning off in relation to this petition. Mr Ewing. Fergus Ewing, thank you, convener, and good morning to all our witnesses. Could I just begin by saying that I'm very grateful that, collectively, you've brought the issues of health in rural Scotland to Parliament. I think that they're very important ones. Could I start off by posing questions to Mr Baird in respect of your petition, which urges the Scottish Government to create an agency to ensure that health boards offer fair and reasonable management of rural and remote healthcare issues? I'm sure that you're familiar with the broad arrangements in Scotland whereby there are 14 regional NHS boards. There are, and there have been, since around 2014, 31 integration authorities. More recently, in 220, the remote and rural general practice working group published its report called Shaping the Future Together, and the Scottish Government accepted all the recommendations in this report, including—and I think that this is perhaps one of the most relevant ones—a commitment to develop a national centre for remote and rural healthcare for Scotland. I'm mentioning that because I think that it's important sort of backdrop. Just following on that, Mr Baird, I wonder if I could ask two questions to you and I'll just put them both. Firstly, how could the Scottish Government reform the way in which the NHS and social care is currently organised better to address the needs of remote and rural constituents populations? Secondly, will the development of this national centre for remote and rural healthcare for Scotland help address some of the issues raised in your petition? The first thing is that the current structures are very effective in delivering healthcare to many aspects of clinical care. The problem is the inequities that are occurring because of access. In the past, that's been dealt with by an advocacy process primarily through general practice. In the 1980s, Richard Smith, editor of the BMJ, wrote that Dupreason Galloway, where the NHS works well, and he wrote that most of the doctors in the region know the senior administrators and can find their ear without difficulty so much so that one doctor suggested that the advisory committees were redundant. In short, the ability to represent local issues was embedded in the system through a system of mutual respect and a process of advocacy. In 1989, he followed this up in the BMJ, he's editor of the BMJ and wrote specific articles about this. It was to flourish or fade, and at that point, 10 years later, he described an institutional view of Whittonshire as the Wild West. By 1999, the Dupreason Galloway health board was straining but optimistic, so this is a long-standing issue. The current structures alone fail rural patients. As Paul Sweeney said to the committee, the elephant in the room is the role of NHS health boards who are meant to be the democratic voice for stakeholders in the regions and who are clearly not performing that role effectively. There needs to be consideration of how effective those health boards are at representing the interests of those areas. I think that what we need is to alter the capacity of rural clinicians to influence management thinking far less further creating change, and instead of mutual respect, there's antagonism and ranker that we have to deal with. Best evidence is gaslighted and stonewalled, so all of that is currently within the system, and the boards are not particularly accountable. That's true throughout Scotland, and I think that Keith Ness will find the same. Our view is that an independent advocacy such as the commissioner's health in Australia and children and young people in Scotland have proven invaluable, and they've got to be separate of provider structures. That needs to be completely independent. There are other names for similar agencies, but, broadly speaking, we need an agency advocacy role embedded in healthcare management and externally imposed. In terms of the national centre—I cannot argue against the national centre for rural health—it's a good thing, but it strikes me that it's likely to have a significant provider role, and that provider role is a barrier to it being an advocacy process. Secondly, it's only central, generally speaking, in Inverness and Aberdeen if you're near Inverness and Aberdeen. Every time I hear centre as a GP of 40 years experience, I rather cringe and think, here we go again. That needs to be about local engagement and advocacy from the bottom up rather than a centre, which is yet another style, as described in the historic report. I think that the national centre will be very useful, and I cannot argue against it, but I don't think that it provides the advocacy that we are proposing, and furthermore, the advocacy that we propose will help the national centre to deal with the issues that it faces. I'm sorry that I've taken so long. Thank you for your answer. You covered a lot of territory, and I wonder if I might just pursue some of the points. I mean, your position calls for an agency, and that presumably means one agency, if I've understood it. I mean, how is one agency going to deliver the kind of advocacy that would be required on bottom up? Given that what you're suggesting, as I understand it, is not an agency to deliver or procure service provision, but to advocate that it be provided to people living in remote and rural areas more effectively, and that inequities of access are therefore addressed and not ignored stone walled or gaslighted. If that is the case, and I'm just putting this to you as a sort of devil's advocate, I suppose, would it not be more efficacious for achieving what you wish to achieve, that there be an advocate for the rural voice on each board? Would that not be a different way, perhaps, rather than the establishment of one centrally-based agency, presumably, or wherever it's based, it would have to be based somewhere, with an alternative model not to change the way health boards operate so that they would include and advocate amongst their number with a specific remit to make sure that remote and rural issues are not overlooked and are addressed? I'm just putting that to you as, indeed, other petitioners, because you're all covering interlocking aspects of this. Would that not be a better model, perhaps, than one agency, which inevitably would operate on a high level? Mr Baird, if any of our other petitioners might want to comment on this, then be sure to let me know, Mr Baird. Thank you. Yes, I've considered that possibility, but the thing is that various rural areas have got the same issues. For example, we've got in Dumfries and Galloway a lot of deprivation, the worst 1 per cent in Scotland, the worst 1 per cent for cancer access in Scotland, and probably at present the worst community maternity care provision in the UK. There are other areas such as Caithness that have it and throughout Scotland. The problem is that, if you fragment it, the problem has always been with rural and remote, and I was chair of the Royal College of GPs rural and remote practice subgroup. The problem with rural and remote is that it's disparate, and it's rarely seen as an holistic thing. The interesting thing is that NHS England Professor Chris Whitty, not having much to pass the time with in 2021, chose to look at NHS England's priority as health in coastal communities. So it's a big health issue, and if you join up, the strength is, first of all, strength in numbers, that it becomes a big problem that Government and boards can't ignore. Secondly, you can develop shared solutions and you can create a better understanding of where the solutions lie. So it's about sharing of information and sharing of solutions and gathering information and data. For the last 30 years I've been providing data to try and persuade our health board as an advocacy role, both when I was working and when I retired, that we don't belong on the east of Scotland, we're 40 miles west of Glasgow. I've been profoundly unsuccessful. So a specific advocacy, taking a national view, would help in that regard. In terms of being on a board, I was concerned about some local issues and tried to contact the whistleblowing champion on our board, and the response is, it isn't appropriate for me to meet with your group at this stage. Now, between our group we have 100 years of experience in the NHS and public service, and that is not the fault of the board member, particularly it's the fault of the system, but the whistleblowing champion was set up in response to the stirrup report, and what I would like to see is that there is some national oversight of this going and that's much more easily achieved by a national committee. To follow that, I mean I didn't quite understand why you didn't find acceptable the suggestion which you say you'd already considered anyway, that each board should have a member whose role would be thus. Why do you not want that? I would have thought that that may not be all the solution, but it might be a part of the solution. I think that summed up. The Government decided there should be a whistleblowing champion on each board following the stirrup report, and we're trying to provide advocacy for our patients, and the whistleblowing champion said, it isn't appropriate for me to meet with your group, so it doesn't work. You said that you welcomed the national centre for remote and rural healthcare, but perhaps you did, but you said that it was a step in the right direction. Could I ask you, would this new body when it's set up, could it be set up in such a way that its remit, and we can raise this with the Scottish Government following this meeting perhaps, if this is something that you and your colleagues think would be a good idea, we could perhaps seek views from the Scottish Government as to whether the national centre for remote and rural healthcare should have the specific remit of taking up the issues that Dr Baird, you have raised today. Would that be something that would be a step forward? I think that it would be a step forward, and I think that a national centre for rural healthcare is a good thing, whether it would solve these issues that I have concerns about. For example, I did quite a lot of work with Ness before I retired, and it was commonplace during visits or telephone conferences to be asked what was the weather like in Dumfries. Those are people who were embedded in rural healthcare with Ness, and they didn't even know that not only is Dumfries far away, it's not even in the next county. I have concerns about a lack of focus in such a wide-ranging view. We are talking specifically about clinical access issues. I am putting to you that this new body could be tasked specifically in law with the remit of addressing the access issues that you have raised, and whether that should be the case, it may not operate perfectly in practice, but if all one can do in setting up new bodies is to clearly define the remit and the duties of the new bodies and the tasks that they perform, surely if they are tasked to perform what you want them to perform, namely addressing inequities of access for people who live in remote and rural Scotland, that would at least give the opportunity for things to improve. We've already got those bodies that are called health boards. The problem is that they're not listening to the rural and remote issues. I'm keen to ask a supplementary relation to this, which maybe some of our other witnesses might feel they could comment on too. What do you think are the current issues impacting on recruitment of the health and social care staff in rural areas to all the— We raised the petition following a meeting with our local midwifery team, who discussed the worries about not being able to recruit midwives within the case-ness area, and their disappointment and the impact of the shortened midwifery course that was being delivered at the time from the University of the Highlands and Islands. That was then centralised to Edinburgh and the Scottish Government, which drew the funding for this course. My petition has about two aspects. The first is the need for rural communities to be able to access local training for professional healthcare qualifications and to gain the skills locally whenever possible. The second aspect is the need for an agency or an overseer to ensure that rural communities are not disadvantaged and are given equity in training for qualifications. One lesson that we learned from the Covid pandemic is that distance should not now be a barrier to access training and that technology can be effectively used to ensure inclusion and accessibility for remote and rural communities. Our students should not have to travel hundreds of miles from their homes to access the training and they should not have to take on large student loans to pay for accommodation to access a university. They should have a choice to suit their life circumstances and it is really important for inclusion and also for the sustainability of our communities, as the research suggests that where a student trains is often where they continue to stay. Higher education providers should provide inclusive distance learning methods to support rural education and recruitment using technology to enable remote learning and they should provide the clinical skills whenever possible locally. That is the main issue and I would bring up that we have worked with health boards for a number of years after our maternity model was downgraded. We have found that health boards are not accessible to the public for one thing and we have found them. Basically, we have experienced a lot of what has been raised in the historic report from the health boards. If someone was to be on the health board to represent our needs and to be our voice for rural and remote communities, it would need to be an independent person because they would need to be very strong to have that voice to support our areas, our remote and rural communities, which would be quite difficult to do in a very big health board. I am afraid that what we know at the moment with NHS Highland is that it does not work for the rural areas. It does not work at all. We know what works because we had it before and Orkney has it now as well. We would love Caithness to be put back into what we would call the Orkney model or what Caithness had before the NHS Highland took over. At the moment, we prepared things here. Can I go through this? Prior to 1995, Caithness was in control of his own council and national health service. There was a shared consultancy-led maternity services in the town of Wickham Thurso and a first-class general surgeon in the Wick hospital. Other than for highly specialised treatment, there was very little requirement for patients to travel out of the county to access national health service. Caithness had his own council, so it controlled over the budget and could make sure that the money was spent where it was needed. Over a period of six years, Caithness lost all control over its council and health services when the Highland Council and NHS Highland came into being, both based at Inverness. From that point on, at a local level, there has been a deterioration in the services provided in Caithness by both those agencies. The Boolean culture that exists in NHS Highland is well documented in the Starwick report, and, unfortunately, Caithness has been at the sharp end of this culture for years. Prior to removing our consultancy-led maternity service, though the public meeting which NHS Highland attended, unfortunately, it did not listen and the concerns that Express were ignored and it went ahead and removed the service anyway. NHS Highland stated that there was no clinical objection to the downgrading. That is untrue but typical of NHS Highland's culture at this time. NHS Highland did not even listen to their own staff—one who said, and I quote, the geographical distance and transfer times between Caithness and Regmore is greater than that accepted for a primary birthing unit and that Regmore is absolutely not suited to the additional workload generated by those proposed changes. The consequence of those changes to a midwife-led unit had an enormous impact on Caithness's mothers and babies and eventually resulted in baby's deaths. After the baby's deaths, a report was commissioned entitled, Caithness Maternity and Neonatal Services, a public health review published in 2016. One of the findings was that the babies died due to suboptimal care. Now, not being as smart as cookie in the jar, I had to look up what suboptimal care meant and it means care, not up to standard. It was also stated that Caithness as an area is socio-economically deprived. So this is what NHS Highland left us with when, as they say, they redesigned the service. What a damning indictment on NHS Highland, and then as a side, no one was held accountable. One of the recommendations made in the report was that first time expecting mothers should travel the 120 miles to give birth at Regmore hospital in Burness, the report completely ignored the risk to mothers and babies travelling this distance. It also stipulated that no Caithness operations should be carried out at Caithness general. So if someone requires an emergency area, what happens? The people of Caithness are desperate for this situation to be changed before we have another fatality. We are closing in there because in response to all our questions, your solution is going to be the reinstatement of that entity, which is maybe not developing our discussion just quite in the way that might be helpful as well. Rebecca Weimer, I know that you were keen to come in in response to the question, David Torrance-Pood. Hi, good morning. I do agree with quite a lot of the previous petitioner, but just going back to the recruitment issues, for those of you on Twitter and I, I am new to Twitter right now, it is not the most political damning evidence. How is the use of it actually posted yesterday that the NHS staffing levels are now at a record high in Scotland? The argument that I had back with him a few months ago saying that recruitment was almost impossible for the area has either done an enormous U-turn or that lots and lots of staffing is happening very, very centrally and not in a rural capacity. From what I have heard from people over the past year of campaigning and talking to people is that when the maternity unit was downgraded, we also saw the loss of the gynaecology department because often gynaecologists are so linked. Our gynaecological services have ticked away centrally and centrally and now we have hardly anything. We do not have an emergency gynaecologist, which means that we have an emergency women's healthcare. It is pot luck if you get a junior doctor who has done a rotational gynaecology. That is about as good as it gets at the moment. I have had lots of people who have said to me that they have been put off moving up for professional positions. Despite the fact that they have been very well qualified 10 years in a surgical position, they will not move up here because themselves or their families cannot access women's healthcare or maternity to the standards that they are used to and that they should expect. If they used to live in Scotland and they still live in Scotland, they should have the same quality of care no matter the postcode. I do think that Hamza Yousaf's post on Twitter is either poorly timed or lightly out of touch. I am looking forward to meeting him in person when he comes up in the summer to discuss it further. We have seen people either move away from professional positions to seek better healthcare or not move up because they cannot access the healthcare that they should have to. That might shed a tiny bit of light as to why those positions are not being filled. That goes for lots of sectors. Hospitality is struggling, the new care industry sometimes loses very good members of staff because they simply will not risk a pregnancy or somebody has a condition to make sure that it is a PCOS like myself and we cannot access the emergency care that we need. Emma Harper, I know that you have been listening to this and I am quite keen to come in specifically on some of the just themes that have been developing. I am very happy to involve you at this point. Rather than make any statements, I think that I will ask Dr Gordon Baird a question that might help to look at how an agency to advocate for patients might be something that we should consider. If we had board members that were part of each health board that were focused on a rural, that might be something that would see them then become embedded in the culture of that health board and not actually have a voice to advocate. An independent agency is something that I would support. I am interested to pursue what you said, Gordon, about the ranker or the confrontational issues. When I try and represent constituents in Dumfries and Galloway on health issues, it seems to be perceived as confrontational. That is the last thing that we need when we are trying to pursue best healthcare support as we are emerging out of the pandemic. I would be interested to hear from you, Gordon, about how an agency that can advocate would help to reduce the perceived confrontation that MSPs have, or anybody who is not engaging with a whistleblower, or how an agency would help to support that? The Sturrock report was excellent, and it gave a clue to the way forward. It talks continually about mediation, and I think that local people inevitably have focused local issues, and that is not always the best way to deal with things. What I have tried to do over the last decades is to use science to support the argument and reason rational and clinical arguments. That is not always popular, but the solution that I would offer to Caithness if I were king might not be acceptable, but I hope that it would be based on best evidence and shared good practice and be equitable throughout the area. That is not happening. In terms of being independent, as opposed to part of a national centre, that needs to be thought through very carefully. A national centre will almost certainly be a provider unit. It will be providing education, it will be providing services, and you really would not get off-chem run by SSE. It is not going to happen. The provider and the purchaser must be separate. In the 1980s, before the purchaser provider split, going back to recruitment, I advertised for a job as a partner in my practice, I got 80 applicants. One in the Lake District got 220 applicants. As Richard Smith said in the BMG, we were able to advocate for our patients. We knew that when we went to somebody on the health board and he mentioned that connection between the health board and doctors, both the executive and non-executive rural doctors, that worked really well. Now we will be very lucky in a rural and remote area if you get an applicant at all. A commissioner would take over that advocacy role, but he or she would have to be independent and not part of one of the embedded structures within the political and managerial system. That is my view, but it is based on my experience and my research in the literature and my time as chair of the college committee. One of the challenges that I have had—I know that my colleagues have had Finlay Carson and Colin Smith—is that the south-east cancer network is where Dumfries and Galloway is part of. When nowhere in Dumfries and Galloway is in the east of Scotland, the challenges are trying to look at that and engage. The health board said that it is up to the Government and the Government said that it is up to the health board. We do not want to dictate how cancer care is done, but we need people to have a choice of whether their radiotherapy is given in Edinburgh, which might be better, or Glasgow. That is only one of the examples that the 260-mile round-trip journey for folk feasts in Rhar are not given a choice about, or we are told that they are given a choice, but we do not have the evidence and the feedback about it. However, it is chosen to be run whether it is a commissioner or an agency, it is something that I am interested in pursuing so that we can look at the real challenges in rural healthcare. Our health committee is doing a health inequalities inquiry right now, and many of those issues are coming to light. I am hearing from the other petitioners as well that there are challenges for remote and rural, whether it is Caithness, Galloway or the Borders. It would be great to have some ability to join up all the work that is being done and see how it can be taken forward to specifically address the needs that we are seeing of our people. I will stop there, thank you. I think that we have two other parliamentary colleagues with us as well, and they have been listening to the petitioners who have all now spoken. I wonder whether either of you would like to just contribute at this point, Rhoda Grant. Yes, I think that the petitioners have made very clear what the issues are. There is a huge distance to travel to access healthcare, and they are not being heard. Now, as an example with regard to maternity services and Caithness, I have been asking the health board for a risk assessment of the journey between Caithness and Inverness when people go into labour early, for example. I know that people are more likely to be induced or have elective caesarians, but it does occur that people go into labour and need to drive down that road. That road is horrendous in the winter, and it can often be blocked. To have somebody—we are discussing this before—to have somebody drive their partner down that road when their partner is in labour. Given that it is an offence to use your phone in a car while driving, can you imagine what it is like to have someone in active labour beside you while you are trying to concentrate on a really difficult, dangerous road? Nobody will risk assess. That is the same for Murray. I have asked the same questions. Nobody will risk assess the journey and what happens there. I hope that the committee would at least request that in emergency situations where there is not local healthcare, where is the risk of transporting people? Certainly at the start, when this happened in Caithness, there was not enough ambulance cover. If there was someone being transported by an ambulance, quite often the county was left without an ambulance at all. That has been resolved to an extent, but it is still not ideal. Just to add my support to the petitioners that it is really not equitable the healthcare that they receive. My interest is primarily in the petition from Dr Baird, as you can see. What Dr Baird is proposing is an issue that is pertinent to all the petitioners that we are discussing today, particularly the common theme of inadequate health provision in rural areas. The very fact that no one appears to be advocating on behalf of those communities is not being listened to. Emma Harper highlighted the example of cancer care in Dumfries and Galloway, where we are constitutions of ours. Strun Rar has to travel to Edinburgh for cancer care treatment when there is a hospital in Glasgow able to provide that, and nobody is tackling that particular problem, the health board or the Scottish Government. A number of ideas have been suggested in the discussion on how we can tackle that, particularly from Mr Ewing. The suggestion was that we should have somebody on the health board with a particular rural interest. I would hope that, when people are appointed to a health board like Dumfries and Galloway, they have a knowledge of rural healthcare. So reinforcing that would not do any harm, but it fails to recognise that what we have is a Scotland-wide problem when it comes to rural healthcare, that there will be commonality between the challenges in careness and the challenges in Dumfries and Galloway, and there will be solutions to that that need to be Scotland-wide. The problem is often the health board, but it is not exclusively the health board when it comes to finding that particular solution. It was also suggested that the National Centre for Remote and Rural Healthcare could have an advocacy role. My understanding is that that is primarily a delivery mechanism, and crucially it is part of the NHS. It is not independent. It was interesting that yesterday the Government announced that it now supported an independent food commission and rejected the idea that Food Standards Scotland could take on that role. It did that, presumably because it is independent of Government. That is a key point in the discussion. There is nobody independent with national authority advocating on behalf of rural communities when it comes to healthcare. We have a model in Australia where we have a rural health commissioner. That is a model that we should be looking at here in Scotland. I see no harm in a piece of work being carried out on how we strengthen advocacy for rural healthcare in Scotland with that as a commissioner, or another model, because what is absolutely clear is that the current setup is simply not working. I thank our parliamentary colleagues just for those interventions at this stage. I am keen to bring the petitioners back in. Rebecca Whammer, you are keen to contribute again. Hi, just a quick one. I want to thank Rhoda for her input about a travel client in the distance and the quality of the roads. I asked Mr Yousaf about that in correspondence before and during the petition. Not only do I have business on the NHS500 route, but I can tell you exactly how busy it is in winter and summer. The road is appalling in the winter and my dad is in the east for 11 or 20 years. The amount of people that he pulled out of the roads smashed cars, and that was before it became one of the busiest. It is the top 10 busiest roads and traffic journeys and routes in the world now. It is incredibly popular. One of the worrying things that we are seeing more and more of is that young groups of under-25s hire and sports cars in groups of eight, nine and twelve racing each other around the track. The overtakes that they take, if they hit oncoming ambulance, if there was somebody behind those vehicles trying to concentrate on the road, it is almost impossible to get from Inverness to WIC without some sort of near miss accident. I know that most of you have probably already been to the area or have a similar problem where you are, but for those of you who have not, the one-way journey from WIC to Inverness, which is the most straightforward route. If you live in Sutherland, if you live in Betty Hill, it is slightly longer. It is the same as from where you are sitting, to Newcastle upon time, and if you add it as a combined return journey, the mileage equates from where you are sitting to the city of York on far worse quality roads. It would not be acceptable for the vast majority of women in Edinburgh to travel on far better roads, for routine scams, appointments, clinics and labour. All miscarriages—even active miscarriages—in the past 12 weeks are expected to travel on those roads for upwards of four to five hours in the summer, and three to four hours on awful conditions in the winter. I spoke to Ms Eugasif about this, and rather than taking into account the near misses and small accidents that can still cause harm to patients in an emergency stop situation, he decided to focus on road closures. He spoke to Traffic Scotland and came back with a bunch of statistics saying that the road was only ever closed for less than 4 per cent of the time over the last four years. The last four years include two years where nobody could travel, so I do not think that those statistics are necessarily accurate. If it was rerun now, there would be a much more clear and accurate response. How often is it either closed on one side of the road, closed on both sides of the road, or there is a diversion that takes you on a very, very rural track where you cannot get to the hospital any one year as fast? I will leave it there. I have more to say on the travel situation, but I just wanted to back-brode it up on the fact that it simply is not safe. I do think that an assessment of that journey has been skirted around for quite some time, and it does need to be looked into. Your point on distances was well made, and characterising it in terms of a distance travelled from here, which is possibly more familiar to people than the one about which you are talking, was very well understood. Mr Sinclair. I just want to follow up on what Rhoda Grant said again about the distance and the hazards associated with travelling that distance. Just last year, a wicked lady started the journey in Labour and to stop at Galsby, one hour away from Inverness, and she gave birth to the first of her twins. She was then loaded back into the ambulance, put off to Regmore, where she had her second baby. It was a miracle that both mums and babies were well. There is another case of a lady giving birth in a lebi, also near Galsby. This could happen again in present circumstances. What trauma these ladies suffered, and what is supposed to be one of the happiest times of their lives, is this really the best outcome for case-ness mums? What would members of the committee think if this was their wife, partner or daughter going through this? As a walsins, Maria Aikins had an opportunity to contribute. Is there anything you would like to say at this point before I bring in Paul Sweeney? No, we lost the link there. I think that there has been a very compelling testimony about the democratic deficit around decision making on health boards. The tension that exists between the tendency for the medical profession to want to centralise into national centres and to build a capacity versus the rights of rural patients to access services has been borne out in the discussions that we have had in a number of different petitions. I want to ask the petitioners about defining the rights of patients, regardless of where they are. Perhaps the vehicle, the advocacy body that has been proposed is the best way of delivering that. To define the right of a patient, whether it is in a gynaecological context or any other context, to access services within a safe standard in a safe way. The example that you described in Cathness, for example, could be identified through data and study and inquiry as unsafe provision. Therefore, the health board has an obligation to address that. It could be placed on the health board as an obligation by this body to deal with it. Although, in instances where it is appropriate, for example, for neurosurgery to travel to Glasgow for an operation, the patient has the right to have their travel costs covered and has the right to accommodation for a companion through the duration of that period of surgery and recovery. Perhaps those are methods or mechanisms by which those things could be defined and therefore advocated for clearly. Maybe that is the mechanism by which that could be delivered. By setting up such a national body where stakeholders from different parts of different geographies can come together and define the standards that all patients and citizens should be entitled to in different contexts and can take evidence from clinicians and patients. Perhaps that is what we are all driving towards, but the petitioners agree that that is perhaps where this needs to arrive at. Well, just before we hear from Mr Beard, I went to Marie Akin and unfortunately we lost the link, but we are back with you now. Marie Akin? Thank you. At the time, in 2016, when our maternity service was downgraded rapidly and without any consultation at all, we went to just about everyone to try and get help and to have our voices heard. No one listened to us. We went to the health council, MSPs who did listen, but actions are not taken from what we are saying. Basically, we are feeling that we are being forgotten and we are feeling that we are being ignored. We are disempowered in decisions that are made about our communities because what tends to happen is that those decisions are made in central areas of Scotland and with people that maybe have not lived in a rural area and do not know the challenges and the barriers that we have. For example, most of our medical clinics and things are in Rigmore, which is a 200-mile journey. If we need to claim fuel costs just now, it has gone up recently to 15 pence a mile. When we were looking at the rates of subsidies that the Scottish Government gave for attending those courses, it was 20 pence a mile to take your bike to the Scottish Parliament. We are giving 15 pence a mile to try and access our healthcare. A lot of people cannot afford it. Straight away, your disadvantage and your deciding, am I going to have heat or food or am I going to be able to access help with my healthcare? We need people who know about living in rural and remote areas to make sure that we are being heard and to make sure that the decisions are made are based on what is best for our communities. Leaving on a positive note for recruitment, a really good example of obtaining a professional qualification is within the teaching profession in Scotland. You can study up to masters degree level distance learning using technology. You do not have to leave your home. You do not have to leave your families or your communities. You can then progress for a year or two years part-time distance training for PGDE and then have a paid years teaching experience within your local area. The Scottish Government has also set up, if you tick the go anywhere box, you can get £6,000 to teach in other areas or £8,000 for secondary teaching posts. I have spoken to a lot of teachers that live up here now who have done that. They have come to the rural areas, love living here and they are bringing up their families here. It is a way to keep our communities sustainable and to encourage professionals to come up here and live. It is things like that that need to be looked at. When courses are set up to get professional qualifications, that independent person can say that that could be done remotely. The person does not have to attend a central university to get that professional qualification. It removes people from poverty if they can get that professional qualification. I did it. I would not have been able to get my teaching qualification because I had a family and I live up here. I could not leave them to go and get a qualification in the next event. I was able to access this training and my life changed and my family's life changed because of it. That is where fairness and equity come in. It has a huge impact on communities in rural and remote areas of Scotland. Mr Baird, I want to come back to Paul Sweeney, who posed the question. The symptoms are perfectly clear of what has happened. They are dreadful and disabling symptoms that we all heard from rural and remote agencies that are suffering from a sick system. The system is wrong because of new public management, which has had enormous benefits in technical things such as joint replacements, cardiology, minimally invasive cardiology, survival of neonatal benefits. The reason for that has been the power of the providers. I suspect that the new national centre for rural and remote health will be very focused on the provider issues. That is good because public organisations such as telephones, power and water all have independent agencies that look after those who otherwise lack advocacy. All that we are asking for is for the NHS, which had a good advocacy system in the past, is to do what other new public management systems do, which is to provide a good advocacy system, to provide what you are talking about absolutely minimal standards. It is not acceptable for somebody to travel. By the way, in neurosurgery, at least when I was at work, I went to Edinburgh as did neurology, which is a pathway that does not suit people with motor and neurone disease. However, there has been no advocacy for those people, and the providers are quite happy because they look at the figures and say that this is okay, that they get good results. What we are asking for is quite common practice in other public management systems. Mr Sweeney, do you want to come back? This is where we began, Mr Ewing. I do not know whether having heard all that we have heard there is anything that you want to ask as a final point. I think that it has been really worthwhile in the sense that it is focused on what the effects need to be. It is effectively a check and balance on health boards and the providers to ensure that there is a correction where necessary through inquiry, through the experiences of people who are affected by it being given proper formal voice and able to apply obligations on the providers. In that sense, the petitioners' requests are significant and require further advocacy by the committee. Mr Ewing, you put a lot of these questions back at the start. I wonder whether anything occurs to you to ask any of our petitioners now having reflected on the evidence that is unfolding. Listen with interest to what the petitioners have said, and there are two issues. One is that Mr Sinclair and two witnesses online are calling for reinstatement or provision of services locally, whereas Dr Baird is calling for a slightly different additional model of advocacy. Both arguments have a rationale behind them, so I understand that. Part of our job is to play the devil's advocate to some extent. Let me put this to Dr Baird just to see what your response is. The MSPs here represent, myself, Rhoda Grant, Emma Harper and Colin Smyth represent constituencies that are either largely or partly rural. We are performing an advocacy service of a sort in the case work that we do, and that is a job that I suspect that we all take very, very seriously. It is a big job and we each represent tens of thousands of people. How on earth can one centralised body hope to advocate the interests of people throughout the country who are living in the plethora of remote, differing remote communities, each with their own particular needs, problems, interests and challenges? I guess my question is how could one centralised body perform such an enormous role effectively? How would they be accessible to people? Is there not a risk that it would just be another faceless organisation adding to a number that exists already? I am sorry, I am putting it a wee bit provocatively, Dr Baird, but I am just trying to make the point that, as someone who takes very seriously advocacy for remote rural areas in my constituency, it would take me a day to go over properly a case with an individual if I do justice, because you need to really listen to be able then to represent properly that individual's concerns and articulate them. You cannot do it quickly and you cannot cut corners. Inevitably, it is very time consuming, rightly so. How on earth could a national agency actually be efficacious in one issue? We no longer have a day to discuss them, so Mr Baird, if you would like to just maybe make a final comment, and then I would just like each of the other petitioners, if there is any point, they would just find a light to contribute to our thinking as well. If you could be quite concise, that would be appreciated at this point. I will do my best. It is not my forte. The first thing is that I did not envisage this is taking on individual cases. There are plenty of ways in which that can be done, and that is what the role of all of us are, either as community groups or as politicians. The question is whether there is a systemic failure here. We clearly identified that. Science has not, over the last 30 years, which is the way that I have tried to influence things. If you want to google me on Google scholars, you will see the publications that I have got before. Those are not working. What we are looking at is the systemic failures. Cateness is a problem. We have that problem. We become a more accountable issue for boards and politicians if we get together and we benefit from shared solutions. I was not envisaging it as taking on individual cases. Having said that, for new public management, it is pretty common—indeed, almost invariable—that there is a formal agency that is provided to make sure that minimal standards are applied. That would be of minimal standards and not about excellence. Is there a final comment that you would like to contribute, Rebecca? Yes. I was waiting for my microphone to be put on. The question raised about how there would be one advocate to answer all of the questions. There already are advocates. There already are community groups. There already are people shouting about these problems and advocating. I have a dossier of 42 women's stories who gave me six months ago to go to the Parliament. I have been blocked at every single stage to try to get those stories to the people who need to see them. An independent advocacy system that then listens to the community groups who filter down to the members of the public. It works at the branches of a tree, and they exist already. It is just that the trunk is not listening. I think that if I could just come to Maria next. Just a brief final comment, if you would. Just waiting for my microphone. You are with us? You hear me now. Yes, just echoing what Rebecca has just said and Gordon has just said, and the centralisation of professional training and qualifications needs to be governed by someone. Someone needs to make sure that examples such as the fast track to midwifery course that was funded for the UHI in Inverness, a really good university that had that funding withdrawn, that needs to be monitored and assessed for fairness and the equality impact on rural communities. Things like that should not happen. Mr Sinclair, any final thought? We, most of the talk to now has been about maternity, but we have also had 14,000 people travelling to Inverness every year as outpatients, a colossal number of people. We are trying to go green, aren't we, these days? There are 14,000 journeys going down there. The time it takes, these people are ill. If they are travelling by train or bus, you are talking about eight hours of travel to get down there and back again. It is a situation that must be changed, and that is what we are calling for. We are really calling for something that has to change, because what we have got at the moment certainly does not work. A couple of sentences perhaps each from our parliamentary colleagues who are here with us. Emma Harper. Thanks, convener, again. My thoughts would be just to add another example of in Dumfries and Galloway patients are means tested for trial reimbursement, whereas in other parts it is a given that people are supported that way. I think that the means testing is an example of how an agency could advocate to change that model. I thank the witnesses here and Dr Bordenbeard for coming to Edinburgh today, because it is really good to hear everybody's input. I am now keen to see progress with this petition, so thanks. I think that we should be offering them an operation while they are here, having made the journey. Mr Smith, I think that I might not go down too well in Strumraer. Many people are trying not to travel to Edinburgh. They are trying to get that service that will be closer in Glasgow, but I think that a very powerful case has been made for the need for a bit of further work to look at how we advocate, or frankly, we do not advocate for healthcare in rural areas. It is not about individual cases, although collectively it will probably reveal policy failures. It is actually about trying to assist as well. The commissioner model in Australia, for example, is about providing policy advice to Government on how they tackle some of those big rural challenges. I think that looking at that model and looking at whether we need an advocacy service to support rural healthcare in Scotland, is a really important piece of work. I hope that that is something that the committee will certainly support going forward. It is certainly something that I very much support. I wonder if the committee had any discussions with the Health Committee about whether it would look at that. I know that, in the previous Parliament, the committee looked at rural healthcare and some of the issues there. In a way, that stems right from the very start, from training of clinicians to how we support them in different areas. They are all trained to work in huge teams now. When you are in a rural general hospital, you are not working in a big team. The standards of care are written for urban areas, they are not transferable to rural areas. One of the lessons that I have learned in my time in Parliament is that policies are written for rural areas, work in urban areas but not the other way round. We should be turning that on its head so that we make sure that people have access to the services that they need. I wonder about the health committee. I think that it needs a light shawn on it and it needs some detailed work to make sure that we get the changes that we need. We certainly need people advocating for our rural areas, because that is just not happening. We do, in the Highlands and Islands, get travel assistance and accommodation. I would have to say that it is absolutely inadequate when you get £40 a night to be in Inverness and you cannot find a room for less than £400 a night is impossible. It is actually creating a barrier to healthcare. I can say that among the options that the committee has considered ahead of the evidence session today is the possibility of such a referral. That is something when we consider the evidence afresh that will be one of the options that is open to us to explore further. We have gone 20 minutes over the time that we thought we would, so I am very grateful to you all because those are all very important petitions. They are thematically linked but then individual in their own characteristics. I very much appreciate the way that the witnesses both online and in the room have advocated on behalf of their petitions. Historically, we used to hear from all petitioners but the volume of petitions such now is that we do not. We all do very much value the opportunity to meet and to talk with the actual petitioners themselves and to hear you advocate on behalf of the petition that you have lodged. It is still quite a big thing to come before the Scottish Parliament and present your evidence in that way. I am probably thinking that you are up against a team of inquisitors. I hope that that has not proved too intimidating and we have encouraged you to contribute as much as possible during the course of this session. Again, I thank our parliamentary colleagues who have joined us for this morning's session and to suspend the meeting at this point. We are back again to consider other petitions following the evidence. I just agree with colleagues that we will consider the evidence that we have just heard from our petitioners and parliamentary colleagues at our next meeting as well and review our actions at that point. We are now just going to consider other petitions. The first is a petition on which we have taken evidence on a couple of occasions, which is petition 1804, to halt the Highlands and Islands Airport Limited's air traffic management strategy. We heard last on 6 May when we took evidence from Peter Henderson and then we heard from David Amery from Prospect and Ingalls Lyon, the managing director of Highell. Rhoda Grant is still with us. Rhoda, is there anything that you would like to say just before we consider how we might proceed now? Yes, and just to echo some of the things that the petitioner said in his response to you about Sombra radar, I share his concerns, because he has highlighted some areas that we need to look at. When the whole 80MS project came to light, everybody agreed that something had to change and safety improvements had to be made. It was just that Highell was going in the wrong direction, so radar is really important. My understanding is that there are concerns with the training that is being delivered to the new operators of radar that would be transferred across. The petitioner says that training has been ceased, so all the work that has gone on beforehand has now stopped. The training manual is being rewritten and then needs to get CAA approval, so that is going to build in quite a time lapse. It would also be good to find out how many people they need to receive this training and how many people they actually have who were in training and who would continue to the new programme if it was once it gets signed off. I also understand that the whole thing might not have been signed off by Transport Scotland as well. I would say that we need to find out whether that is the case from Transport Scotland. It might be well worth speaking to Nats about what they understand. They run the Sumbra radar at the moment, so they must have a date in mind because they are under contract. They must understand what is happening there to get their understanding of when they will be handing over the radar to Haya also. There are quite a few concerns being raised with me about that. I also wondered if the committee had given any further thought to the suggestion about Audit Scotland looking at all of that. If they had, maybe they would look at the transfer of radar as well. David Torrance, I think that over two Parliament sessions this has been well investigated by the committee. We have taken evidence from everybody and I think that the last session that we had, we got assurances that it would not go ahead for five years. I do not think that we as a Parliament could take that any further because how many of us will be here after five years? I believe that the conditions in the petition that I originally called for have been met, so I am happy to close the petition under rule 15.7 of standards on the basis that issues raised by a petitioner now appear to be resolved. Having listened to Rhoda Grant, I think that there are issues afresh, but I am not sure that those might not be best as the subject of a fresh petition because I do think that looking at the actual terms of the petition that we have met, the objective of the petition itself. Any other colleagues of a view? Paul Sweeney? So, standardly, the issues were addressed by the petition and the actions resulting from it. I think that if there are subsequent areas of inquiry then there is no impediment to the new petition that is focused on those issues being addressed by the committee in due course. So, if people feel that it would be a tidy or exercise to do that then, I am not particularly strong feeling out of the way. Alexander Stewart? I would agree with David Torrance, convener, that I think that for this petition it requires to come to its end because I think that we have gone through that journey. But I do think that as you have indicated that there may be subsequently something that may be afresh up with a specific issue. As Rhoda Grant has indicated, there may be aspects that may require a fresh petition to come forward looking at specifics, because, as we have already heard, over the next three to five years things will improve, we hope, but if there is still issues that Rhoda Grant and the community want to bring up, I think that that could be done in a new petition. I think that this has been a substantive position. It is not a question of thinking it, it absolutely has. I think that the mood of the committee is to close it, but can we write the petition as thanking them, but also identifying the concerns that we understand they have articulated, which Rhoda Grant has articulated again today, and just pointing out that it may well be that, if they feel that there is a justification to do so, that that would be better as the subject of a focused petition in relation to that directly. Are we agreed to that, colleagues? Can I just take the opportunity of thanking the committee? They have done a huge amount of work on this, taking evidence and I think that I am in some way responsible for where we are now at, which is a much better position than we were when the petition was first put in. Thank you to both you and Leah MacArthur for your considered and forensic additional cross-examination of witnesses as we have progressed through this petition. I hope that some of us will be here in five years to ensure that we don't find that there's been any grit, well maybe not in this particular, well David you've been here forever anyway, but to find if there's been any progress or any reversal of the commitments given. Thank you very much. Petition number 1875, a public inquiry into the Scottish Qualifications Authority, lodged by Jordan Anderson. Do the colleagues have any comments to make? David Torrance. I think what the petitioner has called for as well has been achieved because I would like to close the petition under rule 15.7 of standard and orders on the basis that terms of a reference of Covid-19 inquiry have now been published and will include consideration of provision of education and certification during the pandemic, but in closing the petition the committee will also wish to draw education, children and young people's committees to the tensions of the issue raised within the petition. Thank you, so I think that the petitioner in some measure has had the objectives of the petition reached out. Are colleagues content to close the petition on the basis as advocated by Mr Torrance? We are, thank you. Petition number 1897, to reform certain of the procedures for the collection of council tax, lodged by Richard Anderson. The minister for public finance, planning and wealth, community wealth reiterated that council tax is a local tax, set and collected by each local authority in every council financially and administratively accountable to their electorate and states that the Scottish Government has no plans at this stage to review the processes set out for council tax regulations, and we've also heard from COSLA that they have nothing further to add to their previous submissions. Do members have any suggestions as to how we proceed now, Mr Torrance? I think that considering the evidence from COSLA that they have no further procedures to go and the Scottish Government have no plans to review this and change it, I think that we have no option but to close the petition on the rule 15.7 of standard orders. Colleagues, are we minded so to do? We are, thank you. That concludes this morning's meeting. We will next meet a week today on the 15th of June, when we'll be hearing from the Minister for Parliamentary Business and the Minister for Public Finance, Planning and Community Wealth. I now formally close this meeting of the committee. Thank you.