 Good morning, and welcome to the eighth meeting of the Covid-19 recovery committee in 2022. This morning, we will continue our inquiry into excess deaths in Scotland since the start of the pandemic, and I would like to welcome to the meeting Rob Gowans, policy and public affairs manager of the Health and Social Care Alliance Scotland, Lawrence Cowan, director of communications for Chest, Heart and Stroke Scotland, Peter Hastie, policymaker for Macmillan Cancer Support, Dr Linda Fenton, consultant in Public Health Medicine, Public Health Scotland, and Dr Francesco Perez-Rechet, Institute of Complex Systems and Mathematical Biology School of Natural and Computing Science, University of Aberdeen. Thank you for giving us your time this morning and for all your written submissions. This session will be the second of two evidence sessions with stakeholders on the inquiry before we hear from the cabinet secretary for health and social care on 17 March. Each member will have approximately nine to ten minutes each to speak to the panel and to ask their questions. If you would like to respond to a particular issue being discussed, please type R in the chat box and we will do our best to try and bring you in. I am keen to ensure that everyone gets an opportunity to speak. I apologise in advance, therefore if time runs on too much, I may have to interrupt members or witnesses in the interests of brevity. As all our witnesses are remote today, can I please just ask you to briefly introduce yourself and can I start with Rob Gowans, please? Good morning, I'm Rob Gowans, I'm the policy and public affairs manager at the health and social care reliance. Thank you and Lawrence Cowan. Hi there, I'm Lawrence Cowan, I'm director of communications at Chest Heart and Stroke Scotland. Thank you, Lawrence and Peter Hastie. Hello, I'm Peter Hastie, I'm the policy and public affairs manager for Macmillan Cancer Support. Thank you and Dr Linda Fenton. Good morning, Linda Fenton, I'm a consultant in public health medicine in Public Health Scotland. Thank you very much and Dr Francesco Perez-Rechet. I hope that I pronounced that correctly. Hello, this is Francesco Perez-Rechet, so your pronunciation is great. I'm a senior lecturer at the University of Aberdeen. Thank you very much. If I now turn to questions and if I may begin by asking the first question. Although during this inquiry so far some previous witnesses have said that at this stage it's still very difficult to draw any conclusions on excess deaths and we may have to wait some considerable time to do so. Although from the written submission from the Chest Heart and Stroke it has said approximately in the past year there's been 1,389 more deaths at home from heart disease and stroke and 679 fewer deaths in hospital. This could be a reluctance to visit the GP and latest data in the submission says that 25% of people saying they would avoid contacting their GP still. These statistics are very worrying and I was wondering Lawrence if you'd like to comment further on this. Thank you very much for that. I think you're absolutely right. I think the figures are in self-concerning as I agree with previous witnesses at the committee saying that actually the full magnitude of this will become known over a longer period of time. I also think that what we're talking about in terms of excess deaths but also in terms of further complexity of cases and people having a greater impact on their everyday lives because of seeking medical help. Potentially later we'll actually have a long-term impact on our health service beyond just a few years. This is something that's going to be with us for a long time. The worry for us is that this has created a bit of a dangerous domino effect. There's a number of reasons behind this, I think, the figures that we see. Firstly, it's that healthcare hesitancy that you talked about with the number of deaths of people being at home and also emergency admissions and presentations are still lower than average, so there's a real concern there for us that people, whether that is Covid-related and fear of coming into contact with Covid or playing into that view that the NHS is actually overrun and I'll be okay, I'll see if things get better later. That's really worrying for us, so we really need to be addressing that. There's also the wider impact that we need to take into account of the things that we had to do because of the virus. Lockdown has had a big impact to increase isolation and loneliness, for instance. 48 per cent of people, according to Scottish Government figures, say that they've been isolated and lonely. There's the wider impact of policy priorities pre-pandemic, which I think are worrying for us as well. It's about making sure that the whole system is properly integrated and that includes charity services like ours. We support people who leave hospital to stay well and happy at home, which then has a wider impact on their health and wellbeing, which then has a positive impact on services and pressures in the system. For us, there's a mix of things that are concerning here. They're all interlinked, but, as you say, I think that those initial figures are quite concerning for us and do point to some big issues that need addressing. Thank you very much, Laurence. I do agree with you, and I think that it's trying to get people's confidence back to visit the GP and not to ignore warning signs is extremely important. If I could bring my next question to Public Health Scotland and Dr Perez-Rache, can you give the committee your interpretation of the excess deaths data? I think that the excess death measure is very helpful and has been a robust measure of the overall mortality impact of the pandemic period, both through Covid-19 and other causes. I think that we can see three phases across the pandemic of excess mortality with slightly different causes across them in the very early phase in March and April 2020. There appears to have been a short period of a few weeks when there were deaths that are likely to have been due to Covid-19 but that weren't certified as such because of testing or diagnostic difficulties, but I think that that was a fairly short-lived issue. The period over the winter 2021 excess mortality was largely driven by Covid deaths, but perhaps the most concerning period is in 2021, from around about May to December 2021, when we saw a consistent period of excess mortality around about half of which was non-Covid mortality, which occurred across a range of causes of death, so from substantial contributions from circulatory causes and also the other group, which I can go to a little bit more detail, but is likely to be external causes like drug-related deaths and liver disease. We see that excess mortality occurring across a range of age groups, so it's not concentrated in one particular cause or age group. From January, actually, there has been some improvement and we've not seen an increase in excess deaths over the last two months of reported data from NRS, so my interpretation is that this is a substantial issue, there's a range of causes and deaths and age groups affected. I think we need to recognise that in view of that breadth there's likely to be both health service factors and factors that are related to the determinants of health, so we know that as Lawrence mentioned, a lot of things have changed through lockdown in terms of people's material circumstances, in terms of their social isolation as well as their access to services, so we need to look at what is driving health and ill health in the first place. Just to reflect on your first question a little, it is possible to draw some conclusions at this point. I don't think our understanding will grow over time and the full extent will grow over time, but we can take what we know of determinants of health, what we know about health in the pre-pandemic period and what we know about what has changed across the pandemic to draw some initial conclusions. Thank you, Linda. Can I bring in Dr Perez-Rechet, please? My conclusions are a lot in line with what Linda Fenton just posed. I looked into the variability of the excess death in addition to the, say, the suspected value or the mean value, say, because, and then, yeah, so I agree that the main concern is that the non-COVID excess deaths, that there was a consistent excess death in the late, well, I mean the second half of 2021, which before that, there were excess deaths, a period of excess death and periods of deficit as well of known COVID. I'm talking about known COVID, yeah. This period of deficit is also important to have them in mind, yeah. Probably it might be because some people unfortunately died of COVID before the time they would have died of other disease, yeah. This is something that seems to come out from the data, but certainly there is this period in 2021 from July or so that there is a clear, you know, consistent excess death of known COVID and this is statistically robust. It's not that, because sometimes it depends how you compare things, you might find some result or another, but in this one, I think this is statistically clear that there is an excess, I mean, an consistent excess of known COVID deaths. Well, perhaps an interpretation could be that some people perhaps go to a point in which their disease was a known COVID related disease was already at a critical state and then it took two years perhaps or one year and a half for this to appear, yeah. And this is worrying, this is worrying because it means that something has been built up in there until there were these excess deaths. Then in January 2022, the data is not that clear whether there is an excess or not, but it's not statistically significant that there is a deficit or an excess, yeah. So it looks like at the moment we are back into kind of normal times, but for known COVID deaths. Then my impression is that this will probably fluctuate because you have this balance between people that have died before time and then there is a deficit of deaths and then it might be that this time in the second half of 2021 was one of these times in which there were more deaths than expected and then now we will go perhaps through a time in which there might even be a deficit, but certainly given the backlog, I think there will be more periods of excess deaths in the future, yeah. So this is more or less my interpretation, yeah. Great, thank you very much for your valuable input. I think we'll probably have to wait to see the data from this year, maybe a bit further down the track. Can I bring in my defraser please? Thank you, convener, and good morning to the panel. I just like to follow up the questions that the convener asked, both of which I think are important. First of all, just to pick up that question of data, I was taken by the submissions both from Chest Hark and Stroke Scotland and from Macmillan Cancer, who are both making the point that there's anecdotal evidence of people suffering from heart disease and stroke in one case and then from cancer in the other case, presenting later at hospital, but so far it's only anecdotal and not enough data. Maybe I could ask Peter Hastie from Macmillan Cancer to elaborate on that and when you would expect the data to appear, and then perhaps I can go to Dr Francisco Perez-Rickey whose paper suggests that there is a bit more concrete information available rather than just anecdotal, but Peter Hastie first, please. Thank you very much, Mr Fraser. Yeah, I think the figures are starting to come through. We know that there was excess cancer deaths in 2020 and 2021, but we don't yet know how significant those figures are, because naturally people who died of cancer may have gone on to get cancer, and so the figures can be fluctuating, as Dr Perez says. But there is no debate whatsoever that cancer patients are presenting later. We know that that means more advanced treatments, poorer prognosis and more likelihood of death. The cancer system was not good before the pandemic, and all the problems that we knew existed have been exacerbated. The data that we know is that the most recent staging data showed a reduction in stage 1. Obviously, if you are going to get cancer, you want it to be diagnosed as early as possible, so in 2020 there was a reduction in stage 1 diagnosis. We expect to see the same, but we won't get the staging data until later this year. In April, we have cancer incidents and cancer survival stats coming. That might help us later in the year. We will have more cancer mortality and cancer staging data, which might help us. However, let me just talk about one piece of evidence that is crystal cruel or numbers. When the Scottish Government suspended the cancer screening programmes, it said that per quarter, when they were cancelled in March 2020, that would mean 248,000 fewer bile kits getting sent out, 46,000 fewer breast screening examinations, 101,000 fewer cervical screenings. It then lasted six months, so that's 500,000 fewer kits sent out, 100,000 breast, 200,000 cervical. We know from the Scottish Government's own figures that around 850 people would have been detected with cancer at each of those quarters, so that's 1,700 people simply not diagnosed during the first six of Covid. It's simply plain what will be happening over that cohort. One of the real concerns is that the bile screening programme is still in a six-month delay. When you're 52, you don't get your kit at 52, you now get it at 52 and six, seven months, the same at 54, at 56, at 58. That backlog in delay has continued. Eventually, that will write itself. Once everybody has had it, you'll be back in a two-year pattern. However, clearly the long-term issues on cancer diagnosis been late and poorer prognosis will last for years. Some of the statistics that you've given us are really stark. Being a gentleman of a certain age, I'm in that category of missing my bowel cancer screening. I recognise what a problem it is. Maybe I could go to Dr Peris Ritchie, because in your paper you're a bit more definitive than just anecdotal evidence, aren't you? You're quite clear there is evidence of patients presenting in a more acute condition. Can you tell us a little bit more about what you found? This is a tricky question given the data I had. I tried to make the most of the data I had access to, and then what I realised is that if you compare the delay of deaths with respect to admissions, hospital admissions, then you see that at the beginning of the pandemic, the delay was between two and 15 days, perhaps. Then if you look at this data, which again is limited, but then you look at later periods. In particular, to this period where there were more excess deaths of known COVID. I'm talking about known COVID all the time. Then it looks like the data supports the idea that the delay between admissions and death is shorter. This might be due to many factors, including factor could be that the registration of deaths was not made at the same pace or something like that in these periods. This could be something that has nothing to do with actually more acute disease or anything like that. There is at least this evidence that it looks like people that died in the late stages of the pandemic, like in the second half of 2021, died in a shorter time. Of course, one would need more data to really see if this is the case, because my evidence is supported by very limited evidence. I mean, the evidence is not so strong, I would say. I would ask for more data in this respect. Actual data of how long does it take for someone to get admitted to hospital or get diagnosed and die. This is, I think, a measure that would be great to have. I couldn't find this anywhere. The other measure was the proportion of deaths by admission. What is the proportion of people that are admitted to hospital and died? Again, this is based on limited data, but it shows that we have been above the normal trend. This is, I think, in my figure three in my report. Actually, in this period where there was this excess of known COVID deaths in 2021, we see that it looks like the proportion of people that died had been admitted to hospital is higher. I thought that this could also indicate perhaps a kind of more acute, a signature of more acute disease. Again, it would be great to have more detailed data to be more solid on that. Okay, thank you very much. I would like to ask if there is time, convener, just one other question again following up the convener's first line of questioning on access to GPs. Maybe I could ask this to Rob Gowins from the Health and Social Care Alliance initially. When we speak to the BMA about the issues of access to GPs, the assured us that GPs are working harder than ever. They are still seeing patients. There has never been a problem getting to see the GP, and yet the evidence that we hear from people like yourself, in your written submission, is that there is a lot of concern from the public that they haven't been able to get GP appointments or that they have been reluctant to approach a GP. My question is how much of this is a supply issue? In other words, it has been difficult to get appointments with GPs because of Covid restrictions, or how much is it a societal and cultural issue whereby people just haven't been coming forward seeking GP appointments, either because they are perhaps concerned about leaving the house and catching Covid, or because there has been so much emphasis on Covid that they don't want to take away from that, and they don't want to distract GPs from dealing with Covid patients to deal with what they might view as a more trivial matter. Do you have any insight on that? I think that there is a range of issues in some of which you have covered. During the pandemic, there has been a question that has been created for many people that you shouldn't go to the GP unless you have got Covid and that that was the priority. As we have moved the artists, people have found it difficult to get appointments at those stages if they didn't have Covid. We have recently done a survey of people's experiences of accessing GPs during the pandemic, and the initial findings show that about a third of people felt that their expectations weren't met when they called the GP surgery. That can be things like people who felt uncomfortable discussing issues with receptionists in the pre-age function and would prefer to subspeed to the GP. We found that there were phone appointments that worked well for some people for others. They were concerned about how effective they were, and similarly with digital services, such as near me. Again, while they are suitable for some people for others, who haven't got access to a device or a good connection that could be difficult, or that people don't feel comfortable with that way. There is a mix of issues, partly around the supply, particularly at the earlier parts of the pandemic, but also around being able to cope with the demand and demand in some cases, because people have put off going to a GP and now they are presenting in a worse condition. I note that the health alliance highlights that the health inequalities have widened during this period, and that Heart and Stroke Scotland and their submission talk about poor diet, lack of exercise and isolation all increased during this period. The question is, what actions does Government need to do? One is the data there to demonstrate clearly that people with lower social economic backgrounds are in poorer health and that the impact has been greater, and what action needs to take place. Specifically, on the submission for chest, heart and stroke, there are a wide range of public services out there, so there would be health services. Is there any kind of planning taking place? Should there be specific planning taking place around inequalities and deprivation in order to recover from that? I will start with Lawrence. You are right that the impact of the pandemic has been more marked in areas of deprivation, whether that is economic impact or societal impact. There was a recent report on non-communicable diseases that was produced by BHF, which showed that there were significant increases in unhealthy behaviours that were eating unhealthily, increasing isolation and loneliness and increasing smoking levels. That will impact the risk of stroke, heart disease and COPD, which are some of the biggest conditions that we deal with in Scotland. Are things joined up, as well as they should be? I think that the clear answer is no. That is because it loosed to one of the points that I was making beforehand. Some of the problems that we are seeing now have been exacerbated by the pandemic, but they have also existed pre-pandemic. That is because we have seen health very much as a medical model. The services that we provide, when we say that we keep people happy and healthy at home, are about helping them to adjust to life after a life-changing event, such as a heart attack or a stroke or a diagnosis of COPD. However, it is also about improving their exercise. It is simple interventions such as that that can have a massive impact on improving their diet and their wellbeing. That is work that we do right across the country, including in areas of deprivation. That can have a significant impact on someone's health, which then has a knock-on positive impact on the health service. We have not joined that up properly. For us, we need to integrate that a lot more readily. What do I mean by that? That is making a very clear diagnosis pathway and referral pathway into services such as ours. It works in some health boards in other areas that do not exist. That needs to be a lot easier. At the moment, we are doing a lot of partnership working with health boards, which is really positive, but it is actually us doing the running on it. It needs to be an automatic system where the patient in the hospital, when they are discharged, they are discharged automatically to a wealth of services. It happens in some areas and it does not happen in others. That is one of the things that we think needs to be addressed. It needs to be addressed before the pandemic, but it needs to be addressed now. Partly, it is about providing a release valve for pressure for the health service, but it also improves people's health and the areas of deprivation that are markedly. That, for me, is a real big priority as we go forward. That is helpful. Rob, can I ask you, maybe, similarly on that question of the widening inequality gaps that is taking place? What needs to happen to bring services together and what together? There are a number of things that need to happen, that we know that, particularly the excess deaths are twice as high in the most deprived areas compared to the least deprived areas. One of the things that we need is data in particularly disaggregated data, known by age, sex, race and different areas, to understand the impacts fully. It is also to take an equalities and human rights-based approach to make sure that people's human rights at the heart of policy in practice and that health inequalities can be tackled. Helistic care and support is really important in terms of the House of Care model, which I particularly recommend. I think that, as Lauren suggested, the involvement of the third sector has a key role to play in supporting health care and should be an equal partner. It is to address funder funding and undervaluing of the third sector to allow it to be a meaningful and valued partner in the design and delivery of care and support forward. That would mean adequate funding for the sector. I think that Dr Fenton had something to say on that as well. Thank you very much for the opportunity to come in there. Just while we are on the topic of health inequalities, I was just keen to highlight that, yes, we very much do know that there are substantial socioeconomic health inequalities that precede the pandemic in Scotland and have been worsening not only through the pandemic period but in the immediate period running up to that. We know that, unfortunately, from around about 2012, overall life expectancy stopped improving in Scotland, as with a number of other health high-income countries, and that stalled improvement in mortality was much more acute in populations in our more deprived areas to the extent that mortality rates were actually increasing in the most deprived areas in the run-up to the pandemic, which has then been overlaid by the situation we know in which COVID mortality was 2.5 times higher in the more deprived populations. I think that this just begins to speak to some of the underlying factors that are common across both COVID and non-COVID health that influence people's wellbeing and their ability to cope with challenges. In terms of actions, we would very much be looking to the income support that people are able to access in the welfare, and I think we welcome the support that have been there through the pandemic period in terms of furlough and universal credit uplift, but recognise the challenges that are likely to be there now, and the fact that people's income has been hit hard and the cost of living is going up is going to limit the choices and opportunities that people have and further straighten their material circumstances and also the consequent psychosocial impacts of that are likely to play out across this period and ahead. We would also focus on our other universal services outside health, like education and early years support, as well as housing and improving the places and spaces for people, which really brings us to think about health in all policies approach, and I think that we would strongly advocate for that in the COVID recovery period that we think about how we can address wellbeing and inequalities across a range of policy areas. Okay, thank you. I'm going to bring in Peter Hastie on that question as well, but before I do, I can also ask Peter, in terms of the—you gave the good example of Bialtest and how there's now a delay in that—is Covid still having the major impact in the hospitals, or can we see a shift to non-Covid conditions in terms of those being seen as a public emergency? What actions—so, for example, the Bialtest seems quite clear—what other actions do you believe that we need to be looking at in Scotland around the NHS, specifically to cancer? Peter? Thank you very much, Mr Milley. I think that health inequalities remains at the heart of everything that Macmillan Cancer Support wants to do. If you live in a deprived area in Scotland, you're more likely to get cancer, you're more likely to be diagnosed later, and you're more likely to die. I can't see how it's possible that the pandemic will have improved that situation, so I think it would be great if the committee, given its looking into excess deaths, starts to look into palliative and end-of-life care. We know that there's been such a dramatic shift, but what does that mean? For some families, they may well have a household that can cope with that situation, but for many others, particularly in the poorest areas, they will not be able to cope. We still don't have a palliative and end-of-life care strategy in Scotland. The last one ended 14 months ago, and I think it's key that we understand the excess deaths and what has happened to patients during this, and Macmillan would obviously input with that from a cancer level. The pandemic is clearly not over yesterday. The weekly figures from Public Health Scotland showed more than 4,000 NHS staff off because of Covid, rising hospital cases again, so we are really concerned that we're going into yet another wave, and we've only just come out of the Omicron wave, so it's really hard to see how we're going to continually catch up with cancer backlogs as they build up each time. Again, for Macmillan, we desperately need modelling of the cancer workforce to see how we deal, particularly with patients coming through a later stage, because as you come through a later stage, you need far more treatment and more end-of-life treatment. There's workforce issues here, and we look forward to the delayed Scottish Government's workforce strategy that has been published, but it has to talk about modelling of the cancer workforce. It wasn't good before the pandemic, and we are deeply, deeply concerned about the long-term trends. In terms of workforce, what can we do to retain staff? We know that staff are burned out. Can we do more learning and development for staff to learn about cancer and to move up their grades? We have a wonderful cancer workforce, but it needs to be supported in terms of learning and development and time off for training to keep people motivated and keep them in their posts. There are huge issues, but health inequalities, as I suggest, remains at the centre of what Macmillan tries to tackle in Scotland. Thanks very much. We've covered a bit of ground so far. The balance between Covid and other conditions. I suppose that a general question to start with is whether we, as a society, have put too much emphasis on Covid and taken our eye off all of those other issues. Maybe I can start with Dr Fenton on that one. Given that we faced a novel organism with high transmissibility and high virulence, it was appropriate that we approached that on an emergency footing. It was a priority not only for Public Health Scotland but across a range of public agencies. It has dominated our response over the initial period. Throughout public health, we recognised that there would be a balance between harms and benefits of how we approached that. That is part of our role to balance that evidence and try to provide information to inform that decision making. As I have alluded to before, there are substantial pre-existing health issues with our population. That is some of what we are seeing now in excess mortality as those continuing to play out and be exacerbated. I would very much support a focus on addressing the underlying determinants of those. It is difficult to view it as a direct competition between Covid and non-Covid causes, because there are many commonalities in the factors that will influence health and outcomes across both sets of conditions. The fact that we see such substantial inequalities in Covid mortality shows us that if we can do something about people's free existing health and their ability to control their lives and their employment, then perhaps there would be much lower Covid mortality, as well as improving health in general. There are big inequalities between those who are better off and less well off and so on and so forth. However, in a particular group, whether they are better off or less well off, did we put too much emphasis on Covid should we have been looking at cancer for richer people, cancer for poorer people? Is your question specifically about allocation of resources within the NHS? Yes, effectively it is. So, I mean, I guess our role in public health Scotland is very much focused on prevention and early intervention and less on the allocation of resources within the health service, so I don't have detailed information about the clinical decisions that were taken in front-line services. I think that Mr Cowan would like to come in, perhaps. Thanks very much. I totally agree with what Dr Fenton was saying, but it will be cut. It is a debate that will need to happen in health services for a long time now. It is how do you ensure that resources are out? My microphone has been muted. I am going back in a lost you there, sorry. I totally agree with what Dr Fenton was saying. I think that this is going to become a bit more, this is going to be a more consistent challenge for health service planning as well, because I think that the virus itself will still be with us and we will have to manage its impact as well as improve how we deal with existing serious conditions, such as chest-hunt stroke conditions. Just to answer your question about the focus, I think that quite rightly the focus was on a virus that was ready to overwhelm society and the NHS. Over time, what we now have is the space to think about what do we need to ramp up to make sure that we do not create more deaths from things like stroke or people who will experience more disability in the community because they present late. That is why we are saying that we need to have a reinvigoration of the fast campaign and those awareness campaigns to remind people that bulk is something that you need to get urgent treatment with quickly. We now have that space and we need to make those calls because we need to remind people that they need to seek urgent treatment for stroke and remind them what the main symptoms are. I think that I will have to move on to someone else. I think that Mr Gerrins would like to come in. Briefly, in terms of the balance between Covid and non-Covid, the pandemic certainly is not over in terms of the impacts that the people are feeling and the needs for healthcare, and I think that particularly people who were or are in some cases continuing to shield and concerned about that. Equally, some mentioned earlier, people have faced significant access barriers to healthcare during the pandemic, and I think that that is not fully relieved. I suppose that it is not necessarily that it was wrong to take a focus on Covid, but equally that people's health has worsened as a result of reduced access and in some cases it has, unfortunately, reduced people's faith in the NHS. Going forward, it is important that there are efforts that have increased in both areas. The other point that I wanted to make was to come back to Dr Fenton. There were a couple of points in your paper that I was quite interested in. I just wondered whether you could expand on them. One was the concept that cancer is one of the few conditions where staging is routinely carried out and recorded, and it is therefore presented as a proxy that may help us in understanding. I just did not quite follow that why we are using cancer as a proxy. The second point was that you talked about YLL, which I think is number of years of life lost. That was not particularly a phrase that I was familiar with. I assume that it is commonly used in some circles. I just wondered whether that is something that we should be focusing on more rather than the number of deaths or some of the more simplistic measures, Dr Fenton. On the cancer point, when we are seeking to understand the point in a disease at which people seek care and the impact that earlier or later presentation has on their outcome, cancer is clearly important in its own right as one of our most important causes of mortality and morbidity. However, it is also useful as we have quite rich data and also a clinical staging system. At the time of diagnosis, patients are given a stage between one and four, which describes the spread of the cancer. That information is gathered. For other conditions, for example, coronary heart disease and angina, there is not such a consistent way of describing at what point in their condition somebody is at the point that they present. In cancer, we have this. It is also very closely linked to what your anticipated survival would be and treatment response. It will provide a way of us tracking into the future whether those things are deviating from what we would have hoped for pre-pandemic in this post-pandemic period. I think that cancer's condition will have a function as a tracker, almost, of this delayed presentation issue. I would agree that we could broaden our use of measures. Years of life lost is a measure that describes healthy life expectancy. We have life expectancy, which is a summary measure of deaths across the population, which is helpful for comparisons in time and place and remains important as an overall measure. Healthy life expectancy sits alongside that, but provides an assessment of the years of life spent in good health and sums those up into the summary measure. Healthy life expectancy is there in the national performance framework indicators, and I think that it will be helpful to continue to measure. Unfortunately, it was also falling in the pre-pandemic period and will continue to do so. There are some other measures that we could consider as ways of monitoring. The NRS recently published the avoidable mortality measure, so there are specific conditions that are thought to be amenable to healthcare. There is a range of other options. That is lovely. Thank you very much. Good morning to the panel. I would like to start by following on from my colleague John Mason, who is around data. My time in the Health and Sport Committee in the last term before Covid, one of the recurring themes was that we seemed to be behind the curve, not just on collection of data, but on how we analyse that data. That has been exacerbated greatly by the pandemic. Looking ahead, do you think that that gives us an opportunity to reset how we collect data to the benefit of the healthcare system and use that data to drive Government policy on healthcare? I start with Dr Perez-Rez, please. I think that it would be a good opportunity to try and make relevant data available on a more regular basis. Now, after all, perhaps there is an awareness of how important it is to have good data and up-to-date data. I think that something that might help in this respect is if there are clear consultations with people that work, data scientists like me or professionals on this, just to see what kind of data would be needed. Sometimes this connection perhaps is not that clear. Perhaps someone might come up with an idea of, well, it would be good to have this data. Then it might motivate. What I mean is that this kind of reformulation of how data is shared or how data is collected and so on, it would be good to reformulate it in consultation with people that will ultimately analyse it. I guess that this would help. Maybe it's been done like this in the past and I was not aware. Thank you. That's very helpful. I think that it was a recurring theme last term around the way in which we collect data and analyse that data could be improved. If I take that a stage further, I was really interested to hear what Lawrence Cowan said earlier around the inequalities and the access, if you like, to the work that they do that was restricted because of Covid at around group physical activity, which I have mentioned before. That is more likely to happen in the lower SIMD. In that respect, I wonder whether that kind of data, collecting that kind of data on physical activity throughout the pandemic and what impact that has had on excess death. I wonder whether using that as well as or cross-referencing that with the health data that we are talking about just now, again, would help us to probably integrate third sector offering into NHS offerings. I wonder if Lawrence has got an opinion on that. Yeah, absolutely. Thanks very much for that. I think that we do need to see a lot more of that data. We do know that we have a lot of data about the impact of physical activity levels on people's general health and the lack of physical activity opportunities in areas of deprivation, but it is wider about making sure that the services that are available are meeting those needs. There is also a really key point for me. Data presentation is one thing and data collection is one thing. Data sharing in terms of patient data is at the centre of integration, and that is not happening. To put it politely, it is very difficult to do for a third sector organisation to work with the NHS on data sharing agreements. That needs to change, because that is what is standing in the way of those interventions being more smoothly and widely available and essentially reducing pressure in our NHS and helping staff to do the work that they are great doing. There is another element to data for me, which is about making sure that data sharing is a lot smoother and more easily accessible to everyone who is helping people's wider health and wellbeing. You raised a question that has been exercised by the Health and Sport Committee for a while. It is around who owns the data and how you can use the data. We will not get into that in this committee. I know that Linda Fenton would like to come in on that. I recognise the need for on-going development around the collection of healthcare data, but it may be helpful to recognise the opportunity that the pandemic gave us to develop some of our data presentations. We have made big strides in making more timely data available, not least the Covid daily dashboards, but our wider impacts dashboards, which provide monthly data on the impact on health services of the pandemic. One thing that I would highlight in terms of restart and recovery will be the importance of bringing back to comparable pre-pandemic status of our health surveys, particularly the Scottish Health Survey, which is one of our main sources of information about people's health and wellbeing that does not rely on healthcare statistics, which will be really valuable. Of course, being able to have our census this year will be invaluable in beginning to know our population accurately and where they live and an understanding needs from that point of view, so those survey approaches will be very helpful. I will finish off my line of questioning here. I want to tie up what you said, Dr Fenton, with what Lawrence Curran said about the need to share data. It is a difficult question to ask to Dr Fenton. Do we have the IT system underpinning our ability to collect and analyse the data? I think that there is a range of IT systems across our health service, so some of those support that more easily than others. I would not say that we have a single system that easily supports that, and certainly there are areas that would benefit from development. I am just going to go back very briefly to a question that my colleague Murdo Fraser asked earlier on to Dr Perez about the patients not being able to get access to a doctor or choosing not to go to a doctor because of belief that the NHS could not allow you to see your doctor. It was just your understanding of that that you seem to be saying that the data supports that the diagnosis to death—and I hate to be so blunt about that, but unfortunately that is what we are talking about—the diagnosis to death is shorter, but it is not definitive, as a result of people not seeing their doctors. There would be no way of telling in the data that you have got that death could have been avoidable. Had that been shorter, is that correct? Well, actually my measure was from admission to death. I am from admission, so no diagnosis because maybe there is data I didn't look into this. Perhaps there would be ways to try and see if really there was a problem—I mean that it could have been avoidable. One thing that might be that—there could be ways, but this would require some modelling, you know, mathematical modelling that—and it would require someone to do it, of course, not just the idea. Perhaps I think the best way would be to really have data on how long did it take from admission to death in several periods. I think the data, rather than the modelling, would be more definitive. That is basically the thing. Okay, thank you. I am going to go to Dr Fenton. Again, you may not have the answer to this, but just that question sparked a train of thought for me. How has people not being able to get access to treatment post diagnosis contributed to excess death, or has that been a contributor? This is one of the areas where we will still be gathering information. I think that we don't have clearly—so, from the example of cancer, I think that the main issue there was people not presenting with symptoms or not being identified through screening. I think that the evidence from the cancer data is that, certainly in 2020, once people presented their time then to being diagnosed and beginning treatment was the same. I think that we can hypothesise from what we understand. For conditions like coronary heart disease, which might present with chest pain to your GP that occurs on exercise, if people have decided not to take that problem to their GP, then they would not be started on the medications that help to prevent that condition progressing, and therefore it may become more severe and lead to a heart attack in a sooner time than if they had gone when it was milder and they had been able to start on the medications that would have presented disease progression. We can use our knowledge of the impact of secondary prevention through healthcare services to understand how the delays in seeking care may have impacted. To conclude, there was no delay in getting the treatment after diagnosis. From the 2020 data for cancer, which is what we have, is that once patients had been diagnosed, their progression to treatment was as before. Certainly the majority issue was in patients initially being diagnosed, though either presenting services or being found through screening. Okay, would either Peter or, sorry, chest, heart and stroke, my apologies. Peter, would you like to come in on that first? Yes, thank you. Obviously earlier I talked about the screening issues and the on-going issue around bowel, so we have that on-going issue. As Dr Fenton said, once you are in the health service, once you have been treated for cancer, we have superb services once you are in the system, but it was getting people into the system that has been the problem. That is a mixture of the screening programmes not existing and the various ways of people not going to their GP. Also, sadly, a lot of people are diagnosed with cancer at A&E, and again we saw a reluctance of people throughout the start of the pandemic to come forward. We also saw a couple of weeks ago record diagnostic waiting times, not just cancer, but if you are trying to get an endoscopy to record waiting times. The problem is at the beginning of the cancer journey at the moment. Once the decision to treat has been taken, we normally always hit the 31-day target in Scotland, but that is about coming into the system with a red flag. There is a problem, flagged up via a GP, flagged up via screening, flagged up via another condition at A&E. Can you get the diagnostics done, and then the decision to treat in the treatment beginning? However, during the early times of the pandemic, there were a lot of decisions taken about people not coming in for chemotherapy and not coming in for radiotherapy, and we understand that, but it was a very difficult decision. Okay, thank you. Loris, do you want to add anything to that? Absolutely. Part of it, as I previously said, is that healthcare hesitancy has had an impact, and we discussed that quite a lot this morning. In terms of stroke in particular, it is essential that the timing of treatment is quick. The performance of the health service, the professionals on the ground have been moving heaven and earth to make that happen during the pandemic. There is no doubt of that. However, in terms of the data, if we look at the stroke care bundle, that is a bundle of targets that has been specifically set out to make sure that people get quick treatment when they arrive at hospital with a suspected stroke or a TIA, which is also known as a mini-stroke. Those have been missed pre-pandemic, and they were missed again with data that shows early pandemic data. We have really got an eye on that to make sure to almost answer your question there, I suppose, of the wider impact of the pandemic on deaths from stroke and more disability from stroke. That will be coming through from the stroke care audit soon, but it has been identified as something to flag in the last stroke care audit that there is something that they are worried about. I will follow up on that process with Dr Fenton. The Alliance states that access to doctors was an issue and some of their evidence. We have had doctors to this committee talking about the enormous strain that they are under, and yet there seems to be this perception in the public that you cannot get to see your GP. Clearly, the processes have changed as a necessity to try to deal with the pandemic. Are people just going to have to accept the fact that access to a GP going forward is going to have to be done differently? I think that primary care is fundamental to delivering effective and efficient healthcare. I would very much advocate for investment in our primary care services. Determining how those best meet the health needs of the population is almost a conversation that needs to be had with the population. We need to understand those healthcare needs and meet them appropriately. The pandemic has had major shifts in how we provide healthcare. Some of those will be beneficial learning from, some of those will have adverse effects. I think that there is an opportunity to review how we provide services and how their best meeting needs. One thing that I would highlight, though, is that in the pre-pandemic period in primary care, there was a substantial operation of the inverse care law. The people in the most deprived areas had the worst provision of primary care, as it were, in terms of putting ahead of population than those in the least deprived areas. That is a fundamental importance to appropriately match our primary care offer to the health needs of the population. Having listened to all the evidence that we have heard today, we clearly still have a major problem in the disparity between the richer areas and the poorer areas, so the health inequalities are very clearly there. The service, once you got into it, was actually as good as it was prior to the pandemic. We may have, to change the way primary healthcare is delivered and that our screening levels have to get back up to at least, if not better than they were before, in order to allow us to get out of where we currently are. Is that a fair assumption or an assessment of what you have told us today? I think that those points are reasonable. I would add to them the need to act on the drivers of ill health. We needed to do this before the pandemic and we still need to do it now, and that is to act on the fundamental determinants of health in terms of people's opportunities and chances to build a healthy life. Lawrence, would you like to come on in on that as well? I just want to point out a point about the GPs. It is fair to say that they are doing things differently, absolutely, that patients have benefited from some of the things that have been done differently. At the moment, they are doing things differently to manage pressure rather than being focused on improving things. There is a real different emphasis there, so it is really about making sure that we can take pressure off GPs with some of the services that we offer. For example, long Covid is a big condition that is causing a lot of pressure on general practice. We see similar problems in matching up data and sharing data among primary care, which is exacerbating those pressures. From a policy level, it is about making sure that we do things differently to improve service rather than to manage pressure. On the point about service delivery, in terms of stroke, a particular time after time targets have been missed. Yes, when you get to hospital, you get exemplary care, there are real warning signs of pressure in the system that we are incredibly concerned about. The last point that you make is that we are not quite out of the pandemic yet, either, so... Absolutely. Thank you, Mr Fairlie. I thank the witnesses for your evidence and for giving us your time this morning. If witnesses would like to raise any further evidence with the committee, they can do so in writing, and the clerks will be happy to liaise with you about how to do this. I will now briefly suspend the meeting to allow a changeover of witnesses. Good morning. We shall now move to agenda item 2. The committee will continue to take evidence at the stage 1 of the coronavirus recovery and reform Scotland bill. The focus of this evidence session will be on the name person nomination contained in part 3 of the bill. I would like to welcome to the meeting Dr Aran Chopra, medical director of Mental Welfare Commission Scotland, and Dr Roger Smyth, chair of the Legislative Oversight Forum of the Royal College of Psychiatrics. Psychiatra, sorry, in Scotland. Thank you for giving us your time this morning and for your prior and submissions. I will give members the opportunity to speak to the panel and ask their questions. If you would like to respond to an issue being discussed, please just type R in the chat box, and we'll try to bring you in. As our witnesses are remote today, can I just briefly ask you just to introduce yourselves? Would you like to come in, Dr Aran Chopra? Thanks. Good morning, convener and members. I'm Aran Chopra. I'm the medical director of the Mental Welfare Commission Scotland. Thank you very much. Dr Roger Smyth, I hope I'm pronouncing your surname correctly. My name is Roger Smith. I'm a consultant psychiatrist, and I am the chair of the Legislative Oversight Forum for the Royal College of Psychiatrists in Scotland. Thank you very much. If I may begin with the first question. What do you believe are the potential benefits and risks associated with the proposal to remove the requirement for a nominee as a named person to have their signature witnessed by a prescribed person? Can I bring in Dr Chopra, please? Thank you. I think that there are many benefits towards this proposal that we remove the requirement that the named person's signature is to be witnessed. If I could lead with some data around this, I think that that might be quite helpful to the committee. There are various provisions within the act, which are there to ensure that when a person is detained under the Mental Health Act that their rights are protected and that their voice is heard, especially at times when they're quite vulnerable. One of those safeguards is the ability for a person to nominate a named person. One of the processes involved in that is that the named person's signature requires to be witnessed. We know from data that we hold at the Mental Welfare Commission that we have a duty to monitor the act and how it's working. From some of that data we've found that the uptake of that is around 25 per cent. Around 25 per cent of people who are detained under the act have a named person. What we found from looking at three years' worth of data, including last year's data, is that despite the effects of the pandemic and the need for social distancing, removing that requirement that the named person's signature is witnessed meant that there wasn't a further reduction in the number of people who had that safeguard. So there's a real benefit in reducing bureaucracy and allowing people to exercise their rights through having a named person. Thank you, Dr Chopra. Can I bring in Dr Smith, please? Do you have any further comments? I would agree with Dr Chopra. I would just say that the benefits of this proposal relate back to the benefits that the framers of the 2003 act saw in having a named person at all. The Mental Health Care and Treatment Act 2003 introduced the idea of a named person that instead of simply going to next of kin, an individual who was or in future might be subjected to the provision of the mental health act could identify a named person to look after their interests, to represent them, to help them to exercise their rights, and to be kept informed by procedures under the act. Given the benefits of that that were seen by the framers of the act and that we as psychiatrists would like to obtain for our patients, we want to expand as far as possible the ability of people to have a named person when they are treated under the mental health act. This proposal, although comparatively minor, we believe will enable that to happen. Thank you, Dr Smith. If I could just stay with you for the time being. What are some of the issues encountered when organising witnesses, witnessing of a named person nomination, and do any of these issues predate the pandemic? The procedure for identifying a named person was changed somewhat with the amendments introduced by the Mental Health Act 2015. Prior to that point, there had been a default named person. If no named person was identified, a default named person was identified and that was removed except for individuals under the age of 16. Alongside it was the proposal that there would be a signature by the nominated person and that signature would be witnessed by an individual from a set list of professional individuals. The reason why the proposal was enacted when many of the other easements in the coronavirus act were not enacted was because it was easy to foresee that at a time when you could not bring together multiple professional groups and there were fewer professional groups available on site in the sort of places where patients might be looking for them, that this would provide an additional hurdle. However, that hurdle was always there. In general, the greater complexity of any procedure the less likely it will be carried out accurately and completely. The amendments in the 2015 act were there to try to reset the balance. There is a balance to be struck here. The rights of individuals to have a named person of their choice and for as many people who want a named person to be able to identify and appropriately notarise a named person is one part of the balance and the other is to ensure that people are not placed in the position of becoming a named person unwillingly or unknowingly or without proper scrutiny by them of the roles that they would be expected to undertake. What the 2015 act did was it moved the balance a little bit more towards protecting the rights of those who might be unwillingly nominated. That is a small tweak to the procedure to make it slightly more simple, slightly more straightforward and move it back to making it fractionally more easy for an individual to obtain a named person, a correctly nominated named person. Having had the experience of its use through the pandemic, we had seen real but small benefits to that but had not identified any attendant risks. Thank you, convener. I would agree with that and just to add that I think what the pandemic did is brought in difficulties around social distancing or the requirement for us to have physical distancing. That made it difficult for the named persons to perhaps visit people in hospital where they could meet someone who might be able to witness their document or indeed for the person to go out and witness the named person signing the document. There was that physical distance aspect that the pandemic has brought. However, as I mentioned with the data, I think that one of the things that is quite clear is that, even before the pandemic, there was a difficulty in the uptake or our data shows that there hasn't been the level of uptake that one might expect for a safeguard that has that importance. I think that relates to knowledge of the safeguard and the need for us to really ensure that people are aware that the safeguard exists and to reduce any sort of barriers that there might be, both those that were brought by the pandemic but beforehand in the uptake of individuals having a named person. I think that it's fair to say that we have had some concerns raised with us as a committee about the proposed change. The Scottish Association of Social Work has told us that witnessing the signature of a named person provides an opportunity to verify the named person, inform them of the role, allow them to ask any questions, ensure that they understand the responsibilities and confirm that they are competent and able to perform the functions correctly. The Scottish Association of Social Work says that this is particularly important since there is little guidance around the role and responsibilities of a named person. Can I ask you to respond to that, whether you have any concerns that removing this requirement means that people taking on the responsibility of being a named person won't be fully advised of what the role involves? Perhaps Dr Chopra first? Thank you. I understand the concerns that are being raised about whether the witnessing actually provides a mechanism for people to discuss with the named person. Have you understood that role? That is a crucial and important point that the Scottish Association of Social Work is making, but I am not sure that we need the additional bureaucratic hurdle of the actual witnessing taking place. We can separate those two things and make sure that named persons are fully informed of their rights, duties and responsibilities. That takes place in many health boards and local authorities, where the multidisciplinary team, as well as the MHO and others, will discuss that with a named person and say, look if you understood. That can still take place. There is guidance that I can speak to in a second. There is no legislative requirement currently that the witness is certifying that the named person understands the roles and duties. They are actually just witnessing from that prescribed class. I fully understand the benefits that, as we are discussing, but I do not think that we need to add an additional bureaucratic hurdle to that. I think that we need to ensure that that happens anyway. With regard to guidance, there is a, from my perspective, good guidance, which is Scottish Government guidance, which the Mental Welfare Commission assisted with in the production of, which is a guide to named person. I know from speaking to colleagues that, in some areas, that guidance is sent out to all named persons. It is up to date with all changes up to October 2018, so depending on outcomes or proceedings, there will need to be some tweaks to that. That guidance is good and explains the process well. Thank you, Dr Chopper. Just before I bring in Dr Smith, maybe I could ask a brief follow-up to that. Do you think that a nominee to be a named person should be required to declare that they understand the role, rights and responsibilities? I think that that is a helpful suggestion. If you look at the current form, the current form talks about the person's desire to become a named person. Adding something to that to say, I understand my role or this has been explained to me. It might be a really helpful addition, which brings in some of the points that Scottish Association for Social Work were making, at an additional check for that named person to say, could I have a bit more information or have I read the guidance? That is a good idea. Okay, thank you. Same questions, please, to Dr Smith. Yes, thank you. I agree particularly with the last point that Dr Chopper made. I could have quite well understand the points that Scottish Association for Social Work were making. The particular concerns that they had were things that certainly should be addressed in the process of identifying and correctly nominating a named person. The issue was whether the procedure of witnessing by a member of a certain prescribed class actually did that, because it is certainly not a legislative requirement that they do so. While we certainly cannot speak to every instance of witnessing, our experience was that that was not the case. It was simply witnessing that the correct person had signed, rather than identifying any particular understanding. I think that the idea that the form should include a declaration, as well as information, is a very good one. The other thing that I would say is that the involvement of a named person is a process rather than an event and that there are opportunities to engage with multiple people along the way, particularly at the outset with the mental health professional and with the mental health officer, especially through a social worker who will be involved with the instigation of pretty much every period of detention under the act. They will provide a lot of information, not just about the abstract role but about the actual duties that fall upon the named person and the opportunities that they have to speak when the person that they are, the named person for, is under any particular section. That has got to be a process rather than an event. If the act works as it should, you would nominate the named person when you were well and when the prospect of future illness and future periods of treatment on the mental health act were at least theoretical in the future. It is only whenever those events happen that the reality would be brought to bear and that it would be inappropriate to consider the information that the person received as a named person, as to their role and responsibilities and particularly their rights, as to be contained within a period of time of meeting, a witness meeting that had occurred maybe a year or more in the past. That would have to be a process of on-going information to the patient about their rights and the named person about their rights and responsibilities. We saw it as being an on-going process that was provided for by multiple other points of contact with the health and social care system rather than being contained within a one-off meeting, a witness meeting and signature. There is a suggestion that someone could accept or be a named person without properly understanding the roles and responsibilities that go with it. Is that a concern that is genuinely there as there have been problems in the past? Or do you think that we are just cutting out some bureaucracy and there are no real threats? Can I start with Rodger Smith? There is what we had seen it as, in order to agree with the point that you opened with, that it is a small bureaucratic step that did not contain, as we had experienced or could foresee, any real threats to patients being unwittingly or unwillingly nominated. Again, that is a balance between ensuring that as many patients as possible have a named person of their choice against procedures to ensure that people do not end up as named persons against their will. However, we saw the benefits of expanding the number of people with an appropriate named person because of the reduction of unnecessary bureaucracy, as significantly outweighing that theoretical risk that we had not seen as clinicians in the practice of the act since 2017 when the new procedures came into place. That is not the only opportunity—an individual has an opportunity to make a declaration that they are no longer a named person. That does not tie anyone in to anything, and that would apply throughout their role as a named person if they decided that, as their own personal life moved on or as their duties became more onerous or as they simply, as someone else would become more appropriate, they could quite easily make a declaration that they no longer wished to be an in-person, so they were now, in no sense, trapped. Essentially, we saw it as obtaining a benefit at only theoretical cost and no practical cost. Thank you. I recognise the point that you are making. I suppose that I would start by saying that it is a really important role being an in-person. You have the right to be consulted on any compulsory measures that are being taken towards the person you are the named person for. You have the right to make an appeal on their behalf. You get everything that goes to the tribunal, to the patient, will also go to their named person. It is an important role and an important safeguard, and you want people to undertake that role, understanding it very well. There are processes within the law that have not changed and which are just to say which ensure that, when someone is nominating someone as a named person, they fully understand who they are nominating, why, and that they are not doing it under duress. If I take your question and move slightly upstream from the process of the named person, there is a process to make sure that the person who is nominating a named person is not doing that under any duress and is fully understanding of all the information that is going to go to their named person. The second point is just around data again. I already mentioned that over the course of three years only about 25 per cent of people who have been detained have a named person. When you break that down by year, so 2018, 2019, 2020, you are not seeing huge differences. Even when these measures were commenced in 2020, we did not see a massive rise in the number of people who became named persons, nor did we see it fall. It is important to note that there has not been a huge change just because this measure was brought in. The third point to make is that there are safeguards available if there is someone who has become a named person and is deemed to not be appropriate to be in that role. Dr Smith has already mentioned mechanisms available to the person or the patient at that point to say that, you know what, I do not want this person to be my named person, but there are also mechanisms available to the mental health officer or the person or for professionals who are working with them or indeed anyone who has a role in the welfare of that person to say to the tribunal that this person is not appropriate to be a named person. So there are safeguards, both upstream and downstream, of the aspect that you were asking about. Thank you very much, thank you, convener. Thank you. Can I bring in Jim Fairlie, please? Thanks very much, convener. Doctor, you may have just answered my question, but first of all, can you define for me who the people are as somebody who would require a named person? Shall I go first? Yes, please. Yes, so in fact the act actually points towards this because it says any person can nominate someone to be a named person, but the value of having a named person really finds its expression when someone is subject to compulsory powers under the mental health act. So when someone is well and if they have a mental health condition, which they recognise may cause them to require compulsory treatment in hospital under detention, they can nominate someone to be their named person. They can even do it at the point of detention if they understand and have capacity to understand what it means to have a named person. They can appoint someone as their named person. That person then, and I did start to talk about this in response to the previous member's question, they then have all the same rights as the patient to have all the information provided to them about what's being said about them or the tribunal paperwork goes to them. If a doctor or a social worker is planning to take any compulsory measures under the mental health act, they have to advise the named person of what they're doing and they have to consult with them. So they're the sort of powers and they're the sort of people for whom having a named person is really important. So we are talking about some of the most vulnerable people who are subject to mental health law, who get the most benefit from having a named person. Okay, so I'm going to just clarify. This is not the same as somebody being given power of attorney. Is this a separate thing? This is a completely separate thing under the Mental Health Act, Care and Treatment Act, Scotland 2003, that provides a safeguard for anyone who's been detained under the act to have someone who is important to them. Dr Smith was emphasising the point about choice. This is someone who a person has chosen to say, do you know what, if I'm detained under the act, I want this person to know everything that's going to happen to me and receive all the paperwork about me. I want the doctors to consult with my named person about measures that they're taking. I want them to be advised of anything that you're doing to me. So that's what the named person is. It's different from that power of attorney. Excellent, that's of great importance, thank you very much. In terms of when that person, are they entitled to change the, I think you just asked us, but they are entitled to change a named person at any given time, but if they are in, for instance, an episode in the hospital, that named person would stay until an episode passed, is that correct? Yes, unless they felt that they had capacity to say, I no longer want this person to be my named person and then they can make a revocation and they'd be assessed that they have capacity to make a decision that they don't want that person to be their named person, but generally speaking, people will make their nomination around having a named person either when they're well and they've experienced an episode of detention and then before they're ever detained again should that event ever happen and hopefully it doesn't, but they're able to say, if this happens, I would like this person to be my named person and then what happens at the point of an assessment around whether someone needs to be detained is that the mental health officer, so an especially trained social worker who's got extra experience in mental health, will do their absolute utmost to ascertain whether this person has got a named person and involved them in any discussion. Okay, thank you. There is also the process around, so there's two types, I won't go into too much detail, but I think this is really helpful to understand the pathway and again it fits with what Dr Smith was saying that let's not view this as an event, but as a process, so when people are first, usually first detained under the mental health act under what's called a short-term detention certificate for about 28 days, we've found that only 11% of people have a named person. When you start looking at compulsory treatment orders, it reaches around a quarter, around 25%. You can see that even during the process of being detained, people are able to obtain safeguard, I mean the levels are really low, and I'm conscious of that as I'm saying that, but you can see that even during an episode of detention that safeguard becomes available to people. Okay, so just to clarify, what we're actually, this bill is doing, what's happening here is that the requirement for the witness to be, sorry, the signature to be witnessed is what we're doing, but would it make more sense for the legislation to ensure or to require anyone who is going to be a named person to have given sight initially of what it means to be the named person and for them to then acknowledge that, which is, I think, what Murdo Fraser was saying. I totally agree with that point. I think it's really helpful for them to have had guidance and for them to be able to say, yes, you know what, I've been made aware of what powers I have, what duties I have, what responsibilities I have, and that's much more helpful than a bureaucratic step that requires them to find someone who can witness their signature Okay, thank you. Thank you very much. Can I move on to John Mason, please? Thanks very much, convener. I think probably just one question, which would be, I mean, you've kind of touched on those other issues here apart from just the witness, and I think there may be reforms to mental health legislation at some stage, so I'm just wondering if it would be better to leave this, this is just one small change, would it be better to leave this and look at the wider issue of mental health legislation, because, I mean, specifically, I'm very concerned that only 25 per cent of people have a named person, and, you know, there's something bigger here than just the witness, is there not? I don't mind. Dr Chopra? I agree. I think this is one of the points that was made when they were last looked at the mental health act with the 2015 amendments and there was discussion then that we really do need to promote this as a safeguard. It was in response to this committee that we actually started to explore the data set that we had to understand the level of uptake, so I think this has been helpful to provide a sort of benchmark for Scotland as to where we're currently at, so I think that was really, it's helpful that we're looking at this, so I think we do need to do more. And my colleagues who I spoke to about this again in preparation said, we can't just leave it at the, and I know I've done this today talking about mental health officers and their specific duties, but it is the duty of the whole multi-disciplinary team. It is a process rather than an event, so we all need to do better at making sure our people who are likely to be detained or who are patients have a named person. Should we leave it for mental health legislation? I think that this is something which we've highlighted now, that pandemic has put a spotlight on it. We've made a change which is actually being good, and I would say that we press ahead and enshrine this so that we can build on where we are. I think we are some years away from the provisions of a new mental health act or new mental health legislation, however that looks, and I would be keen, and the commission is there to protect folks' rights, and I would be keen that it takes place as soon as it is possible for people. That's great. Helpful. Thanks, Dr Smith. Anything else? No, I agree with Dr Chopra. The John Scott review to the Scottish Mental Health Law, as you certainly know, is due to produce its draft consultation in a couple of weeks, but that is a change. Some years away, it's very unlikely that, had there not been a pandemic, that we would be asking the Scottish Government to produce primary legislation for this particular point. However, what we're doing is looking at how the act with this amendment operated during the pandemic and feeling that it offered patient benefit that should be sustained through the several years until any new legislation is in the statute books. Okay, thanks. Thanks, very much, and that concludes part of our evidence session. I'd like to thank Dr Chopra and Dr Smith for their evidence and giving us their time this morning. If witnesses would like to raise any further evidence with the committee, they can do so in writing, and the clerks are happy to liaise with you on how to do that. The committee's next meeting will be on 17 March, when we will take evidence from the Cabinet Secretary for Health and Social Care on the inquiry into excess deaths in Scotland since the start of the pandemic. We will also take evidence from the Deputy First Minister and Cabinet Secretary for Covid Recovery on the latest ministerial statement on Covid-19 and subordinate legislation. That concludes the public part of our meeting this morning. I suspend the meeting to allow the witnesses to leave and for the meeting to move into the private session. Thank you.