Health, Social Care and Sport Committee

Meeting date: Tuesday, November 9, 2021

Official Report 712KB pdf

---

Session 6 Priorities

Our second item is an evidence session with the Minister for Public Health, Women’s Health and Sport on her priorities for session 6. I welcome Maree Todd. This is the first time that the minister has been in front of the committee—I know that we have all got the “welcome to your new role” greetings out of the way, but welcome to your almost-new role. I also welcome the Scottish Government officials who are supporting the minister. Michael Kellet is the director for population health, and Marion Bain is a senior public health adviser, and they are joining us remotely.

I believe that the minister wishes to make a brief opening statement.

Thank you, convener—indeed, I do. Over the past 18 months, the Covid-19 pandemic has put unparalleled pressure on all our lives and particularly on our health and social care system. I thank all our front-line health and care staff for their hard work and commitment in response to the pandemic.

Our response to the pandemic has shone a spotlight on new ways of working and has shown what is possible in the face of overwhelming need. To date, more than 10 million polymerase chain reaction tests have been undertaken, and we currently have 55 walk-through testing centres and eight drive-through testing centres. More than 1,000 pharmacies across Scotland are able to distribute lateral flow testing kits, and 3,500 staff are involved in testing across Scotland.

We have delivered more than 9.9 million vaccines since the vaccination programme began, and more than 2 million of those vaccines have been delivered as part of the autumn and winter programme. I am sure that the committee will agree that the work on vaccinations and testing has been outstanding.

The pandemic has been testing for us all, but the impacts have not been experienced equally. We are all in the same storm, but we are not all in the same boat. Covid exposed and exacerbated deep-rooted pre-existing health inequalities. People from minority ethnic groups, women, disabled people and those living in our most deprived communities have been disproportionately impacted by the pandemic.

In his previous report, the chief medical officer said:

“A healthier population could be one of our nation’s most important assets and must be our ambition.”

That provides a strong rationale for the need to invest in improving population health and in tackling health inequalities. It also sets the context for our plans for the parliamentary term ahead. Our long-term goal is to create a Scotland where everyone can flourish. Improving health and reducing health inequalities is vital if we are to achieve that.

As we remobilise and redesign our health and social care system, we need to ensure that we understand and address barriers that prevent people from engaging with and accessing health services. We are taking a range of actions.

Health screening is one of the most important prevention tools. It is vital that we ensure that everyone who is eligible to participate has an equal opportunity to do so. That is why we are making concerted efforts to tackle inequalities in uptake of screening.

We have exempted all young people under 26 years old from national health service dental charges, which is a first step in removing one of the barriers to accessing high-quality NHS dental care.

We are the first country in the United Kingdom to have a women’s health plan, which outlines ambitious improvement and change across women’s health. When women and girls are supported to lead healthy lives and fulfil their potential, the whole of society benefits.

We have committed to improving access to and delivery of NHS gender identity services. We will publish a national improvement plan by the end of this year, and we have committed to centrally fund service improvements.

Non-communicable diseases such as cancer, health disease, stroke, diabetes and lung disease contribute to more than two thirds of all deaths in Scotland every year. Sadly, most of those deaths are wholly preventable. We need bold population-wide approaches to reducing the significant harms of tobacco, alcohol and unhealthy food and drink. I intend to take a range of actions to drive forward that work.

We will introduce a public health bill that will include provisions in relation to restricting food and drink promotions, marketing and dissuasive cigarettes. We are developing an updated, high-impact tobacco action plan to ensure that fewer people take up smoking in the first place and to meet our 2034 commitment. We are also driving forward our alcohol framework and will consult on a range of proposals to restrict alcohol marketing, and to improve health information and product labels.

We will continue to invest in our alcohol and drug partnerships, which provide a vital support mechanism for people who are facing problems that are caused by alcohol and drug use.

Our recently published out of home action plan will support families to make healthier choices when eating out or ordering in, and we will provide more support to parents and practitioners on healthier food, healthy weight and healthy eating patterns to support children to eat well.

We continue to support boards to innovate and improve their weight management services by enhancing their digital solutions. The links between physical activity and health are well known, and our vision is for a country where people are more active, more often. That is why we are doubling investment in sport and active living to £100 million a year by the end of the current parliamentary session.

Through our Scottish women and girls in sport campaign, we continue to shine a light on the vast amount of great work that is being done across the sector to support women and girls in sport at all levels. I was delighted to see that the fifth campaign, which was held recently, was such a success, with wide collaboration. That highlighted some of the examples of how sport and physical activity supports the health of women and girls from across the country.

We need to create the conditions that nurture health and wellbeing, and that responsibility needs to be shared widely across many different organisations, sectors, communities, and individuals. The potential impact of that combined talent, expertise and commitment is huge. I am under no illusions about the enormous size of this task, but by continuing to work together, learning from our recent experiences and building on our successes, I am confident that we can make lasting change that will improve the health and wellbeing of everyone in Scotland.

When society is faced with something like a pandemic, it reacts to it. Minister, you have been talking about a proactive and preventative agenda and the danger of that disappearing. You have outlined a range of measures that you want to take forward under your portfolio. How will the proactive and preventative agenda manifest itself in local areas? What can we expect to see in the next year or so that will make a difference and mean that people get that early intervention and proactive approach to their health?

We will see a number of significant differences, but the first thing to do with that question is to reflect on what the past 18 months has given us. It has been an exceptionally challenging time and it is hard for us all to think of any positives. However, some positives might have come from the campaign over the past 18 months. A light was shone on pre-existing health inequalities, and I feel strongly that Scotland is unwilling to tolerate those any longer. As a Government and as parliamentarians, we have a mandate, and we will be able to build consensus and take bold steps in tackling some of those inequalities.

If we think about how difficult it was when this new virus hit us and we had no infrastructure in place, and we talk about how much testing and vaccination we have done now, it is almost hard to remember that, at the beginning of the pandemic, what we did time and again was the impossible. As a Government, we have a taste for that. We achieved the impossible because we worked together and turned to face a common enemy. That is powerful. We have found ways of working together and collaborating that will stand us in good stead.

We have seen significant behavioural changes, although not right across the board. There are still inequalities in the behavioural changes that have impacted people in the past 18 months, but we have seen people making such changes as socialising through exercise, for example, or working from home and making sure that they take time to go for a walk at lunch time. We need to hang on to those behavioural changes. Members will certainly see work going on to try to encourage people to be physically active during their working day. We already have the daily mile, which is fully integrated into schools. Many schools are signed up to that, and we want to be a daily mile nation. We want everybody to have the opportunity to exercise every day.

My sense is that there has been an increase in health literacy. People know where to go for high-quality information. NHS Inform was already quite a trusted source of information, and it has now become the first point of contact with the health service for many people. That will stand us in good stead. People are looking at local data for the pandemic and infection rates, and are making risk assessments. There have been significant behavioural changes over the past 18 months that will stand us in good stead as we move forward.

On prevention, we will have to take bold steps on big issues such as non-communicable diseases and, on diet and obesity, we will have to take bold steps to tackle the obesogenic environment. That means that all of us will have to come together collectively to take steps to make it easy for the population to do the right thing. We will see consultations and work on all those things—on alcohol, tobacco and diet—over the next few months.

As I said, a public health bill is coming. That may not be in the first year, but members will see work in advance of that bill over the next year.

My colleagues have questions about your public health priorities.

We know that there is a lot of publicity around the drugs crisis that Scotland faces. The alcohol aspect of that is in your remit. People with alcohol dependence also need support and treatment. You have spoken a lot about what you are doing in relation to advertising and, obviously, there is minimum unit pricing. What is the Scottish Government going to do to help people with that dependence to access treatment and support? How might that link into the plans for the national care service?

I hope that that question was not too complicated.

No, that is fine.

Drug and alcohol services are often combined on the ground, so much of the work that is led by my colleague Angela Constance in respect of investing in drug and alcohol services will benefit people with alcohol dependence, as well.

You are absolutely right to highlight alcohol as a priority. We saw a rise in alcohol deaths over the course of the pandemic last year. That bucked the trend over a number of years. We have done a lot of work on that front, and we were starting to reap the benefits of that. Last year, we saw a 17 per cent increase in such deaths, which was devastating and tragic for those affected. We saw an increase in such deaths throughout the United Kingdom; in fact, the increase in Scotland was slightly smaller. There was a 20 per cent increase in the rest of the UK and a 17 per cent increase in Scotland. That is probably testament to some of the policies that we have in place.

In the work around alcohol prevention and treatment, we are driving forward our alcohol framework, which has 20 actions to reduce alcohol-related harm and which enables the World Health Organization’s focus on tackling the affordability, availability and attractiveness of alcohol. The key aspect of that work is minimum unit pricing. Like everyone here, I imagine, I think that that is a wonderful, well-targeted and effective policy. We committed to reviewing it within two years of its introduction but, unfortunately, the pandemic prevented us from holding that review. We have begun to gather information in order to review the minimum unit pricing of alcohol.

We are undertaking a range of work to improve alcohol treatment services throughout Scotland, including on a public health surveillance system and implementation of the UK-wide clinical guidelines for alcohol treatment.

Is there anything specific in terms of that access to the rehabilitation services that you have at this stage, or is that still very much being scoped out?

What do you mean?

If someone needed support right now, there are gaps. How would they get access to treatment? As you have said, there has been a rise in the number of alcohol-related deaths. That leads me to believe that there are perhaps more people out there with an issue with alcohol who are seeking support and help right now. That is a more specific issue.

09:15  

All over the UK, we found that people who drank heavily drank more during the pandemic, which I think largely explains the alcohol deaths. Twenty-three people a week die as a direct result of alcohol. As part of the national mission to tackle drug deaths, there has been increased investment, which is used by alcohol and drug partnerships all over the country. Those services are not separate on the ground—the alcohol and drug partnerships are the structure that is in place.

The investment to tackle the national drug crisis also supports people with alcohol addiction problems, and additional investment of £100 million to increase the availability of residential rehabilitation will benefit people with problematic alcohol use.

We recognise that more can be done to reduce the harms and increase help with treatment and recovery, but since 2008 we have invested more than £1 billion in tackling problem alcohol and drug use. This year, we are spending £140.7 million on the issue of alcohol and drug use.

I have a further brief question. I should declare that I am a member of the Edinburgh Drug and Alcohol Partnership; we had a meeting last week.

The point is that, yes, the money is coming, but it is all being spent on the drug-related aspect. I am worried that the alcohol element, although part of ADPs, is getting left behind.

I assure you that alcohol is equally a priority. Angela Constance and I work closely together, and we are determined not to introduce further silos in that work, which is profoundly unhelpful for the people who are accessing help. The money is intended to improve alcohol and drug partnerships and shore up the services on the ground, which will benefit people with alcohol problems.

Thank you, minister.

You spoke about shining a light on pre-existing health inequalities and their drivers. The Christie commission report has been around for quite a long time now—it has a big anniversary this year. What progress has there been with regard to the findings of Christie?

You are absolutely right—it is an unwelcome reality that, across our society, communities experience health, quality of life and even life expectancy differently. That is not acceptable, and improving health and reducing health inequalities across Scotland are a clear ambition for the Government.

The pandemic has both exacerbated health inequalities and heightened awareness of the people we need to protect. The first thing that we all need to be clear about is that the solution to health inequalities will not lie entirely in my portfolio. Health inequalities relate to inequalities in wealth and power. The solutions to health inequalities lie in, for example, tackling poverty, which is a high priority and a mission for the Government.

We absolutely have to tackle the socioeconomic inequalities. I will bring in Michael Kellet to tell you a bit more about how we recognise that our health and social care institutions can be anchor organisations in tackling socioeconomic inequality, by offering good employment opportunities and leading the way in good work practices. We have a fair amount of work going on in that regard.

On preventative policies, Christie’s work was incredible, and it is always important that we reflect on whether we have made the impact that he hoped we would. I do not think that we have, but we have done some pretty impressive work. If you think about the issue of alcohol, you will see that much of the effort that we put into tackling the problem relationship that we in Scotland have with alcohol is preventative. Much of that work is bearing fruit, but the issues are difficult to tackle and it will take longer for us to feel the benefits of that.

In the past year, there was an increase in the number of alcohol-related deaths all over the UK. No death from alcohol is acceptable and it is devastating that there was an increase last year. However, the slightly lower increase in Scotland shows that preventative policies are bearing fruit here. Although we had an increase, it was not as high as elsewhere in the UK. That can largely be attributed to our preventative policies, such as minimum unit pricing of alcohol, which is a policy that every one of us should be proud of.

I accept that we have been doing things on that. When taking evidence, the committee has often heard about how health professionals’ focus tends to be on the targets that they are measured on. How do we ensure that prevention and inequality are suitably prioritised? The health professionals said that those matters end up being pushed to the side because they have other numbers that they need to hit. We all know about what is measured.

Health services throughout the world are often criticised for being reactive rather than preventative. There is a lot more that we can do to ensure that people live long, healthy lives and that we prevent illness before it happens. We can support people to stop smoking, prevent people from drinking too much alcohol and make the food environment easier to navigate so that is easier to eat healthily than it is to eat unhealthily. We can do all those things, but they do not necessarily sit on the health professionals’ shoulders.

There are also actual health issues involved, too. For example, picking up and treating hypertension is an important preventative strategy. Much of that work lies in primary care.

I will bring in Michael Kellet. I mentioned the work that we are doing with the Convention of Scottish Local Authorities, the NHS and universities—a lot of public services—on using anchor institutions to change the health of the communities that they serve. That is exciting work. It is an exciting approach because it takes the burden off the healthcare professionals who are at the coalface but uses our NHS to improve the nation’s health. It is quite a clever way of doing it.

The work on anchor institutions is a really interesting agenda. Part of my role is to work across the Government with colleagues who work in the communities, education and economy portfolios on that agenda, which is gaining momentum. It is about thinking about the powers of the NHS and social care services as institutions.

The NHS employs more than 150,000 people in Scotland and there are many more in social care, too. The agenda is about thinking about how those institutions employ people, which people they employ and how they use their power as contractors for local services as an instrument of social good and to tackle inequalities.

We are working with NHS boards and health and social care providers on that agenda. We also work in local partnership as well. It is important that NHS institutions work with councils and colleges locally to think about how they employ people and tackle some of the agenda.

NHS National Services Scotland and NHS Education for Scotland are pioneering work on the youth academy. They are thinking about how to bring into training and work in health and social care young people who would normally be disadvantaged and excluded from those programmes. A lot of work is going on with that.

I echo the point about the need for further progress on the Christie agenda. We recognise that. The Covid recovery strategy that was recently published by the Deputy First Minister and the work on child poverty both recognise that we must work across the Government on the social determinants of population health. We are doing that. I agree with the minister that the pandemic has increased intolerance for health inequalities and has made that work even more important.

There have been recent announcements about priorities relating to place and wellbeing and about preventative and proactive care being based in communities. That might involve 20-minute neighbourhoods, where people have different services to hand.

The 20-minute neighbourhood is a win-win for public health. If people only have to go 20 minutes away and are easily able to access public services, active travel becomes more possible. If we design public services to be within walking distance of where people live, we are likely to have a more active nation than we would if we designed public services so that folk had to hop in a car and go to a centralised point.

That active nation agenda is vitally important. It ticks every box. The Government’s priorities right now are to tackle inequality and climate change and to improve health. The active nation agenda improves every one of those. If people are more active, we reduce the number of cars on the road and the level of pollution. We will tackle climate change and will have healthier people.

The 20-minute neighbourhood is an important part of what we are trying to achieve. As ever in Scotland, that may be trickier to achieve in my part of the country.

I am a rural MSP. For that to happen in rural areas, the infrastructure must be there.

As a rural MSP, I am focusing on that. We must make sure that people in rural areas benefit as much as others. We should not default to centralising public services far away from them.

I want to pick up on the minister’s point that the situation with inequality has not improved in 14 years, and may have got worse. It is important to acknowledge the root causes of inequality and to focus on those. We have opportunities to tackle those causes in this session of Parliament. We could use carers allowance or increase the wages of low-paid workers. We could have had a right to food bill. Those things have not happened. Does the Government acknowledge that the root causes of inequality must be tackled if we want to change health inequality? How will the Government work across portfolios to change things?

We are working across portfolios. The Tory-Lib Dem coalition came in in 2010 and brought in welfare reform, and there is powerful and well-documented evidence that that worsened inequality across the UK. Some of those welfare reforms affected disabled people most severely, and some of the most vulnerable people in society suffered. In the past 14 years, while the Scottish National Party has been in Government here, the UK Government has systematically dismantled the welfare system and has made health inequalities significantly worse.

Despite that, the Scottish Government has done a great deal. Those who look at the UK as a whole would say that the Scottish Government prioritises health inequalities and poverty. Work to ensure adequate housing protects people in Scotland from health inequalities.

An awful lot of money is spent on, for example, mitigating the bedroom tax in Scotland. That tax, which was introduced by the Tory-Liberal Democrat coalition, punishes disabled people in particular, and people in Scotland do not have to pay it. If we are looking at what has happened over the past 14 years, we really have to look at the welfare system, too.

09:30  

As for finding opportunities for mitigation, I again highlight the bedroom tax as a perfect example. If the Scottish Government has to spend money on issues that are reserved, that means less money for devolved matters, and there is a limit to how much of that sort of thing we can do. Every year, we spend millions on mitigating the bedroom tax, and that is particularly beneficial for disabled people in Scotland. As I have said, though, there are limits to how much we can do and how much we can spend. I am very proud that the Scottish Government has introduced the Scottish child payment and that, during this parliamentary session, we will increase that payment and extend it to all children. However, there are budgetary limits to what the Scottish Parliament and Government can do in the face of the systematic damage to the welfare system that is coming from our other Government.

Clearly there is a major problem with the UK Government’s treatment of welfare and other benefits. Do you commit to feeding back to the committee just how far the Scottish Government is prepared to go with mitigation and in ensuring that we in the Scottish Parliament do everything that we can in this respect? As we have heard from other experts in these evidence-taking sessions, the key thing that we in Scotland can do is to change inequalities, and that in itself will help us develop Scotland further and use our budget in the best way.

Absolutely. I am more than happy to write to the committee in more detail not only on the steps that we are taking but on what we are up against.

Good morning, minister. This issue that I want to ask about does not specifically fall within your portfolio, but it follows on from Carol Mochan’s questions. At our public health stakeholder evidence-taking session, I asked the panel members whether they felt that a universal basic income could help to tackle some of the economic inequalities that lead to poor health, and Professor Sir Harry Burns, among others, agreed that such an approach would help. I know that the Government is undertaking work on a minimum income guarantee, so what role do you see that playing in improving public health? Are you working with the minimum income guarantee steering group on this matter?

I will bring in Michael Kellet to give you a bit more information about the cross-Government work that is going on. However, one of the things that we in the Scottish Government have always recognised but which has become even clearer with the pandemic is that siloed working will not serve the citizens of Scotland. As a result, a great deal more cross-Government work is going on than there ever was before, and the Deputy First Minister, in his Covid recovery role, has a cross-portfolio role to ensure that policies join up across Government. There is work going on across Government on such issues.

On the universal basic income, health inequalities are, as I have said, related to wealth inequalities, so the solution to health inequalities lies in ensuring that people have an adequate income. We need to tackle individual disempowerment, and there are undoubtedly people and groups in our communities who are easy to ignore. It is not just a simple matter of tackling poverty, although that would go a long way towards tackling health inequalities.

My party is very sympathetic to the idea of a universal basic income, but we are not convinced that we can introduce it without the full powers of independence. As a result, we are exploring ways of assuring people in Scotland that they can have a dignified level of income, although I realise that that falls short of a universal basic income.

I think that you can see our commitment to such an approach in, for example, our handling of school lunch provision during the pandemic. It was quickly recognised that we should get money into the pockets of parents so that they could feed their children adequately. That was brought in all over Scotland quite quickly, because that is the best thing that can be done to support families and the most effective way of ensuring that children are well fed.

Michael Kellet will say a little more about the cross-Government work that he is involved in.

I hope that members can hear me okay. I echo the minister’s comment about the absolute recognition that addressing poverty and tackling inequalities in power, income and wealth are understood to be a central tenet of our approach to tackling health inequalities.

I reassure Ms Mackay that we are working with colleagues across Government on the agenda of tackling poverty in general, tackling child poverty in particular and exploring a minimum income guarantee, to which Ms Mackay referred. We will continue that work as a priority.

Child poverty has lifelong impacts, so tackling it is absolutely the place to start and to focus on for prevention.

It is interesting that you say that, because the committee is going to prioritise an inquiry into that very thing—children’s life chances and the drivers of inequalities in children’s health.

We will move on to the women’s health plan. Gillian Mackay wants to ask questions about that, so we will stay with her to kick that off.

I am really pleased to see work on endometriosis in the women’s health plan. Like endometriosis, polycystic ovarian syndrome is a condition that women often struggle to be diagnosed with. PCOS is mentioned only briefly in the plan. On average, how long do women in Scotland wait for a diagnosis of PCOS? What work is being undertaken to improve the diagnosis and treatment of it?

Dr Marion Bain, who is a deputy chief medical officer and was involved in developing the women’s health plan, can give you a little more information about PCOS.

It has been suggested to me that a number of conditions should have been included in the plan. I recognise that it is not all-encompassing. The plan and its priorities were developed with input from women, and we agreed with women who have lived experience the areas that we should target first.

The plan is momentous and I love the fact that Scotland is leading the way with it. I am determined for the plan to deliver tangible change for women, but it is just a start. There is more to come to tackle the health inequalities that women experience as a whole.

Your microphone is live, Marion.

Can you hear me?

We can hear you fine.

That is great. Thank you for inviting me to speak. I had the great privilege of chairing the group that put together the women’s health plan. The group was passionate about changing things for women’s health.

As the minister said, the plan concentrates on a range of specific items, but underlying all that is ensuring that the issues that matter to women—including conditions that are specific to them—are better addressed in the health service. That is about all the conditions that are specific to women and particularly those for which waiting times are longer.

First, our services must be accessible to women, so that they can get there when they have concerns about their health. Secondly, we must have specialists who can advise on and treat the conditions. The third aspect is research. All those points are woven through the plan.

As it is taken forward, the plan should have an impact far beyond the specifics and should certainly have an impact by ensuring that women can access and are encouraged to access services earlier, when they can benefit from them.

Another of the key themes in the women’s health plan is around ensuring that women have the information that they need to understand which symptoms they should be concerned about, and then also ensuring that our general practitioners and specialists have the information that they need to refer women on.

Similar groups will be involved as we move to the implementation. Concentrating on the treatment area that we are talking about, that will include GPs, hospital clinicians and specialists in different areas of women’s health. It is about ensuring, first of all, that women understand when they need to go and see a clinician. It is then about ensuring that they are appropriately referred on, and that we have the treatments available.

I will make a last point about the research area. The women’s health plan also identified that we need to ensure that we do the right research. A number of conditions are underresearched for women, and we therefore do not have enough information to really make strides forward. That is therefore also part of what is in the plan. I hope that that is helpful.

I will pick up on the role of research. Anybody who has read Caroline Criado Perez’s book “Invisible Women” will know that, for years and years, there has been a lack of research considering women in relation to common health conditions, for men and women. That has had implications for women.

How much of a priority is it for Government to undo some of that injustice in relation to historical research and—going right back to basics—through the training of our health professionals? That seems like a substantial piece of work that needs to be done—this is only a start.

It is a substantial piece of work. One of the things that I always say is that we have to understand the health inequalities that women have faced; if we think about the reasons behind the women’s health plan, it is about inequalities in wealth, power and income. Added to that, there have been millennia of mythology and fear about women’s bodies, which will not be undone quickly or easily. However, I think that this is a perfect moment in time to make tangible progress, and I am convinced that we can do that.

The convener spoke about research. One thing that is very clear is that evidence shows that women’s heart attacks are underrecognised and that, even when they are recognised, they are undertreated. That is one of the reasons why women’s heart health is a priority. Women are less likely to be put on to the battery of preventative drugs that are routine for men who have heart attacks.

Women’s heart attacks are often referred to as having an atypical presentation. However, the reality is that, for women, it is not an atypical presentation, but a perfectly normal way for women to present with a heart attack. It simply does not look quite like the way that men present. That is absolutely an insight into the situation that we face. It really is a man’s world—the world is built around the way that men present and the treatment that men need.

To be fair, there are some reasons why that might be. I am a pharmacist by profession and so I know that there are questions of ethics around women, particularly child-bearing women, participating in clinical trials of new drugs. However, most health professionals say that, as they went through medical school, the default setting was men’s bodies, men’s presentations and men’s illnesses. Marion Bain might like to reflect on her own experience of that.

That is absolutely right. It is very much a culture thing. What was considered normal when I trained is, when we think about it, completely not normal, because 50 per cent of the population are women. We need change to ensure that we think about all the population and that there is a focus on how women present and respond as well as on the wider aspects of what makes it easy or difficult for women to access both information and services.

I completely agree that we need change, and some of that is already happening. Of course, more than half the medical workforce that are coming through are women, which helps to ensure that we focus appropriately on women’s health and change what was regarded as normal but is not. It also helps us to focus on the things that we want to change as we move forward, especially with the women’s health plan.

09:45  

Emma Harper will ask a short supplementary question, after which I will come back to Stephanie Callaghan.

Research is under way on cervical cancer screening by self-sampling. I know that in NHS Dumfries and Galloway, 25 per cent of the 6,000 women who previously defaulted on screening appointments have taken that up. That means that 1,500 women are now self-screening. Can you give a short response on where we are with that research?

You are right that self-screening is being trialled in Dumfries and Galloway. It is initially being targeted at women who are not presenting for screening—that is, those who are not taking up the offer of cervical screening. Uptake is increasing through the use of self-screening.

You highlight one of the big challenges that women have in accessing healthcare. Women might have caring responsibilities that mean that it is impossible for them to go to an appointment, but that is not the whole story on cervical screening. One of the real problems is that the test is invasive. As we know, many people have experienced sexual violence and going for a test of that nature is a barrier that they cannot overcome.

I can see that some women would find self-screening at home helpful. The challenge is that we have not yet had a test validated or recommended by the national body to say that it is appropriate. As soon as that happens, we will have procedures in place to use it, but we are not quite certain of the technology yet. Dumfries and Galloway is just one of the areas in the UK where work is taking place to ensure that the quality of the test is sufficient to use nationally.

Before I pass over to Stephanie, I remind members that we have much to cover. The thing about public health is that there are so many plans—[Interruption.]

Tell me about it! [Laughter.]

I will pick up the pace, because members want to ask about other plans. Stephanie will ask the final question on the women’s health plan, and then we will move on to the best start plan.

Thank you, minister; and thank you to Marion, too. There is not much at all in what you said that I could disagree with.

We know that the women’s health plan is not all encompassing. I am thinking of conditions such as menopause, hyperthyroidism and even endometriosis, which I have suffered from. The number 1 point that we must address is that women are dismissed and disbelieved, as we have seen with the mesh situation.

When I was suffering from endometriosis, it took more than 10 years to get a diagnosis, as has also been the case for so many others. The disease was really severe and I have had several operations. I have a daughter and, like every parent, the last thing that I want is for her to go through the same thing. She is getting to the age at which she might be affected.

Great training is provided in medical school, but how do we propose to change the deeply embedded attitudes to women who present with health issues? A lot of the time, the attitude comes from the top. It is not just male doctors or consultants who are the issue; females can be just as bad. In my experience, the same dismissal of and disbelief in what we say has been apparent in relation to not only women’s health issues, but to our children’s health issues. How will we tackle that?

You are talking about broad cultural issues. As I said at the beginning, people suffer health inequalities because of inequalities in wealth, power and income. The power aspect is really important. If we move beyond the women’s health plan, you will see that, across the NHS, we are trying to provide a patient-centred service. Realistic medicine, for example, is very much about sharing power between patient and health professional, and coming to decisions together. A great deal of work is being done in that area, but there is a great deal more to do and women are more disempowered than most; you are absolutely correct about that. One of the ways of correcting that is through information. I say time and again that information is power. We have put a lot of effort into ensuring that NHS Inform, for example, has good high-quality information.

One of our challenges is, however, the level of understanding of what is normal and what is abnormal and might require help. That is not great in our population. Since I became the minister for women’s health, I have talked about the mythical status of women’s bodies and the fear that people have of them. I am 48—nearly 50—and when I started my periods, people were still talking about “getting the curse”. The language that was used was so incredibly stigmatising. How could anyone possibly imagine that that was anything other than a bad thing? How would you know to go and get help if you were anticipating a curse?

We are tackling many issues, right across the board, through education in schools at every opportunity. Throughout her life, there are multiple opportunities to offer a woman information about her health, and culturally we are trying to shift the dial.

Some of this work sits outside my portfolio, such as the work to tackle income inequality for women and close the gender gap. That will be important for empowering women so that they can navigate the healthcare system without being dismissed and disempowered in the way that you describe. It will not happen overnight, however, and much of it reflects our general culture. That is the reality of the world we live in. Even in 2021, it is still a man’s world.

I afraid that we will have to move on. As with all these subjects, we could spend 90 minutes just talking about each one.

Emma Harper wants to ask about the best start plan.

You have outlined a lot of what is being presented by the Scottish Government such as the child support payments and so on. I am interested in how the best start plan is working in rural and remote areas. As the convener said, she represents a rural area, as do you and I. How are we supporting the people who live in rural and remote areas?

Do you mean through the maternity services?

Yes. I am interested in the best start plan and I know that we have problems with maternity services on my patch.

I might bring in Michael Kellet to speak to this. One of the big challenges that we have in Scotland is that one size never fits all. In my constituency, delivering public services in the far north-west of Sutherland is significantly harder, given its geography, topography, and population sparsity, compared with a city. Inner cities, however, have their own challenges, such as poverty and access to transport and all sorts of things. There is in Scotland a recognition that one size does not fit all. That is important, especially from a patient’s perspective so, as I said, one of the things that we are trying to do with realistic medicine is to offer people person-centred care and flexible services that work for them.

Much of the work on implementing improvements in maternity services had to be paused as we turned to face the pandemic, but we are starting to pick that work up again. What you will see, I hope, is a family-centred service that recognises how important the family unit is to a child’s health. That is one of the reasons for the payments to support families when they are visiting children in hospital. There is plenty of evidence that shows the impact that such payments can have.

The day that I launched that service, I met an amazing woman whose child was in hospital with a long-term condition. She had had to change her job to a much lower-income job to be able to continue to visit her child in hospital. She said that when she arrived at hospital the costs racked up on her credit card almost immediately, so those payments will make a significant difference. We recognise that family are not just visitors; particularly in relation to neonatal care, families are an essential part of a child’s care. That illustrates our most significant strides towards that family-centred approach.

Michael, do you want to add anything?

I do not have much to add. I recognise that the work on implementing the best start plan has been impacted by Covid, as the minister said, but colleagues are progressing that. That is not in my portfolio in the Scottish Government; there is another director in health who looks after that agenda, but I know that the priorities around continuity of care, person-centred care and multiprofessional working are real. It will be challenging to implement those in rural as opposed to urban areas, but the principles persist and need to be implemented.

Minister, I could endeavour to write to the committee with more detail on Ms Harper’s question if that would be helpful.

We will come back to the issue. The minister will be aware that we are doing a perinatal mental health and new mother care inquiry.

I am conscious that we have a lot to get through, so I will move on to the active Scotland delivery plan.

I was interested to hear your comments about the pandemic and the fact that for some people it was a good opportunity to get physically active, get out and about, go for a walk and get the benefits of working from home. How can the Scottish Government hold on to the progress that was made and what can it do to make sure that access to physical activity and exercise is not too costly?

That is a great question and one that we mull over all the time, because we are trying to harness those benefits and ensure that they reach those parts of the population that were not able to change their behaviour during the pandemic. Physical activity and sport are central to Scotland’s recovery. I recognise that obesity is a risk factor for severe illness and death relating to Covid, so it is more important than ever that we tackle it.

The link between physical activity and sport and mental wellbeing was already strongly established, but many people have recognised that on a personal level over the course of the pandemic. I cannot be the only one here who found that the opportunity to get outside in the fresh air, connect with nature and say hello to my neighbours, albeit from a 2m distance, was the most precious thing that got me through the pandemic on a daily basis.

Sports clubs have done an astounding job and we recognise how important they are to their communities. Many sports clubs across the length and breadth of Scotland have stepped up during the pandemic by meeting the needs of vulnerable people in the population. Sport has a reach that we as parliamentarians or Government do not have; it reaches people whom we cannot.

We are reflecting on all that. Over the course of the past 18 to 20 months, as you would expect, relationships between the Government and the sporting sector have been strengthened significantly. That is not to say that it has always been easy, but, boy, we have had to work really closely together to rise to the challenges that the pandemic has thrown at us in order to bring back sport, which is something that we love. Those strong relationships will see us through the remaining tough times of the pandemic. They will also help us work together to tackle the broader health of the nation.

10:00  

As I said, we are pretty keen to do that, and it ties in with action on climate change. I have already had a bilateral meeting with Patrick Harvie, the Minister for Zero Carbon Buildings, Active Travel and Tenants’ Rights. Increasing activity in relation to transport is part of tackling inequalities, because anyone can walk and you do not need special equipment to do it. Ensuring that we have 20-minute neighbourhoods that are nice to walk in and in which you can access public services and tackling the provision of that infrastructure are important parts of delivering our aims. That will require us to work together and to keep things in focus, but I am absolutely determined that there are opportunities there.

Finally, on the active Scotland delivery plan, we do pretty well in that we buck the international trend and increase our activity levels, which most people would be surprised to hear. Much of that is about active transport, so that is something for us to focus on.

Sue, if your question is a quick one, I will allow you to come in.

Yes, it is. Thank you, convener. My colleague mentioned the fact that sport is perceived as costly, but, often, that cost is related to access to facilities, which is associated with charges payable to local authorities. What can you do to ensure that the costs to the clubs and participants are reduced and that local authorities keep rents as low as possible?

We are doing a couple of things on that. We are doubling investment in that portfolio area over the course of this parliamentary session. That investment will be focused on tackling inequalities and ensuring that everybody can access sport and physical activity. Over the coming year, we will work with sportscotland on next steps to ensure that, as a first step, the active schools programme is free for all children and young people by the end of this parliamentary session. That will provide more opportunities for children and young people to take part in sport.

You are absolutely right, however, that many local authorities have divested themselves of estate and we are keen to address that. We are setting up a fan bank to ensure that communities can take control of those facilities in an empowered way and run them for the benefit of the community. There is lots of work going on on that, and I am happy to provide more information on it.

That is great. David Torrance also has questions on the active Scotland delivery plan.

Physical activity and access to exercise are really important in tackling obesity, poor mental health, loneliness and medical conditions. There are many key stakeholders. How is the Scottish Government engaging with sporting bodies, whose experience could help you to deliver the plan?

We already work closely with sports governing bodies and a whole load of stakeholders. Sportscotland is the organisation that does much of the work on the ground. I am a huge rugby fan. We were unable to go to rugby matches because of the pandemic—in fact, Sunday was the first time since the pandemic started that there has been a full-capacity crowd at Murrayfield. There have been challenges in delivering sport, from huge elite-level events down to making grass-roots sport Covid safe. We have had to consider what rules and regulations need to be in place to ensure that Covid transmission does not occur while people are playing sport. We have worked incredibly closely with sports bodies over the past 20 months and I am absolutely sure that that will help us.

You are quite right that sport has the power to reach people and to motivate and inspire them in a way that me telling them stuff does not. We are pretty keen to use that power to tackle all the big problems. For example, over the course of the 26th United Nations climate change conference of the parties—COP26—I will have a couple of interesting meetings and collaborations about how we can use sport to tackle climate change.

I have heard numerous reports that, although good school facilities are available, it is difficult for communities to access them. Have you or do you intend to look at how communities can access the excellent facilities that are already there?

We have work going on in relation to that issue and, again, I can write to you with more details. I know that there are a couple of pilot schemes in Dundee around ensuring that children have access to the school estate out of school hours for not only sport, but creative and cultural activities. We recognise how important that is and that schools are a public space.

It is interesting that you should ask about sports facilities in schools. I recently took part in a four-nations sports cabinet meeting and found out that the United Kingdom sports minister is working on the issue. At the end of that meeting, I asked for more details from my officials about the situation in Scotland and I will be more than happy to share that with you when I get it.

We will move to questions on the proposed Good Food Nation (Scotland) Bill and Food Standards Scotland.

The bill was laid on 7 October and will be scrutinised by the Rural Affairs, Islands and Natural Environment Committee. However, given that nutritious diet and access to healthy food are integral to our public health agenda, this committee is interested in it, too. How will the Government work to ensure that public health priorities are integral to the bill?

As I have said repeatedly today, the solutions to some of the challenges that we face in terms of, for example, health inequalities do not all lie within my portfolio and, in order to solve them, we will have to rise to the challenge of breaking down silos to work together across portfolios. We need to ensure that there is a cohesiveness across the piece so that we can deliver our priorities. I will be working hard to ensure that public health priorities are reflected in the bill. One of the basic issues is tackling food insecurity. It is devastating that, in the sixth-richest country in the world, we have people who are food insecure, so we will be focusing on that, as well as on the broader issues of nutrition.

I know that the bill is a framework bill and is, therefore, not as prescriptive as other types of legislation. How will the Government work with local authorities and other stakeholders to ensure that the bill has the ability to guide everyone to take the good food nation plan forward?

Michael Kellet might want to come in here, because it is not my bill, so my level of detailed understanding of the bill is perhaps not what it would be if it were.

I understand that there are duties on local authorities and that there will be, for example, a requirement to procure locally as well as other measures that will deliver health benefits to the population.

Michael, can you help me out here?

I will do my best, minister. Again, it might be useful for us to write to the committee with more information. I can say that colleagues in my directorate who have responsibility for leading on challenges around obesity and diet work closely with colleagues who are working on the bill and colleagues in Food Standards Scotland. We see the bill as an important vehicle to deliver the agenda around better diet and health inequalities.

I have a quick final supplementary question. Our notes have a question about food banks. I read the statistic that we have more than 91 independent food banks in Scotland, and we know that food-bank use has increased due to Covid. It is worrying that the issue persists. Will the bill have a strategy to end the need for food banks?

Absolutely. As I said, it is a devastating fact that there is food insecurity in a country that is as rich as ours. Work is going on across the Government. For example, we are introducing human rights legislation, which I think will ensure that people have access to good-quality food.

There are food banks in every community. Earlier, I spoke about the impact of welfare reform. In the 11 years since the Conservative-Liberal Democrat coalition came in at Westminster in 2010, we have seen a rise in the number of food banks, and there is lots of evidence that food insecurity has increased since that time due to the impact on welfare reform.

We are determined to tackle food insecurity. We recognise that lots of communities are providing food in different ways, with dignity at their heart, such as by having community larders rather than a food bank. However, essentially, behind it all is the devastating fact that there are more people with food insecurity than there ever were, and we need to put in place policies that will prevent that from being the case.

We will have one more question on the matter, and then we have to move on to discuss palliative care, because a significant number of members want to discuss it with the minister.

We have a question from Sandesh Gulhane on the good food nation and Food Standards Scotland.

Good morning, minister.

My question is in two parts, and is about ensuring that children get good-quality food in school. What standards are in place to ensure that children get good-quality food and that there is not an unhealthy option that is always taken up? What is being done to ensure that the areas around schools maintain healthy eating areas?

On the quality of food in schools, I can send you further information about the food standards in schools and the fact that we have increased our offer of access to school meals for primary school children and made it all year round.

On tackling the food environment, we need to tackle the issue as a whole. In Scotland, we have an obesogenic environment, in which it is very easy to eat badly and exercise little. That applies to children as much as it does to everyone else. I can see the logic of controlling the environment around schools, and I am interested in looking into that, but children live everywhere. Children navigate life not only around school but throughout our communities. They are also exposed to advertising—for example, at sports events—which influences their behaviours. Therefore, we need to think more broadly than just the environment around the school. You are right, and it is one aspect that we will look at, but consideration of the issue needs to be bigger and bolder than that.

We will move on to talk about palliative care, which a number of my colleagues want to come in on.

What support will the Scottish Government give to hospices for adults to support the best end-of life care for everyone?

Again, it is impossible to disentangle where we are now from the experience that we have had over the past 20 months. Over the past 20 months, more people than ever before have been dying at home. In some ways, you might consider that to be a positive thing, because if you ask people where they want to die, they largely want to die at home. However, we need to ensure that support systems are in place and that everyone who requires palliative care can access it.

We need to ensure that the offer of palliative care is available to people, whatever condition they are suffering from. There are concerns that palliative care is more focused on conditions such as cancer and is less available for conditions such as heart failure. We need to ensure that palliative care is accessible across the board.

10:15  

We also need to ensure that palliative care is accessible across our communities. As with every kind of care, there is a health inequality aspect. People from richer areas are more able to access palliative care. That will be a focus for us all.

We need to ingrain palliative care. We need to be having conversations about death and dying, and to be looking at advance directives and advance planning. Those things need to be handled extremely sensitively, and people need to be well informed and supported to make their own decisions. We need to have more conversations about that. A great deal of work is going on, across the board, on palliative care.

You spoke to us about the importance of the 20-minute neighbourhood, which involves easy access to things within walking distance. You made the statement that centralising services far away is not helpful. You have also mentioned, and are aware of, the importance of good-quality end-of-life palliative care close to the heart of communities. Will the Government therefore encourage health boards to do everything that they can to preserve and expand the services that are in local communities?

On a specific local issue, my colleague Craig Hoy and I were at the “Hands around the Edington” rally on Sunday. Right now, that issue is a very serious one for the community in North Berwick. We have already said that care should be within communities. Will you now reach out to NHS Lothian and urgently reverse the closure of the in-patient palliative beds at the Edington hospital?

I am more than happy to look into that for you. I would be pleased if you would write to me on that specific issue, and I will be happy to pick it up, look into it and see what I can do to help.

Time and again, we talk about people being able to access flexible and holistic patient-centred care as close to home as possible. In my part of the country, as you would expect, there has been innovation over the past 20 months in providing palliative care that might in the past have been provided in a building in a centralised place. In providing support to local people in order to provide that care at home, technology is being used as never before. Networks that have never before been available are springing up between health professionals, through the use of technology.

Obviously, I am not going to pronounce on the particular situation that you have raised, because I am not aware of all the details. However, what we want is for patients to experience high-quality end-of-life care at home or as close to home as possible.

Other members want to come in on palliative care.

I have a very brief supplementary question to follow up on Emma Harper’s questions. What work are you doing alongside the Minister for Mental Wellbeing and Social Care to make sure that families and carers who have been bereaved are supported? In the past 18 months, grief has been very odd for many people. I am interested in what work has been done on that.

Absolutely. My portfolio includes the funeral sector. I recently had a meeting with representatives of that sector, and I am in awe of the work that they have done to ensure that people can still access what are very important rituals. One of the toughest aspects of the pandemic has been in asking people to stay apart at a time when, usually, a community comes together, supports people, and reflects on and celebrates somebody’s life. There have been really tough times.

Work is already going on. Certainly, when I was the Minister for Children and Young People, there was work going on to recognise the significant impact of childhood bereavement. An inspirational young woman called Denisha Killoh did a lot of work looking at what is available for children and trying to join up what is—to be honest—a patchwork so that it becomes more cohesive. We can learn from that kind of work to ensure that bereavement care for families is at the fore. More people have experienced bereavement in more difficult circumstances in the past 20 months than ever before.

Orders not to attempt cardiopulmonary resuscitation—often called DNRs, or do not resuscitate orders—have been in the news. That has created fear, because there is a feeling that some use has not been consensual. I have looked into this, I know that families instinctively want to save their loved ones and want them to have as long a life as possible, but DNRs can also prevent harm and distress. A lot of people do not understand how distressing resuscitation procedures can be. Are we looking at the public message about people having kind, compassionate and comfortable deaths, rather focusing on the use of DNRs, which involves a fear factor? What are we doing to improve that?

There is good work in the palliative care community to raise the profile of those conversations. There is still a taboo around death. One of the challenges is that there is still discomfort and we still use lots of euphemisms to talk about death. People are not exposed to death as they might have been a generation ago. Most people die in hospital. Our society is distanced from death, although death and taxes are the only sure things in life.

It is important to have those conversations. There is a campaign happening in the next couple of weeks—I will tweet about it if I can find more information—that will talk about opening up those conversations, which should not be reserved for the end of life. We should be talking about death and about our wishes.

A lot of that happens when we discuss organ donation. We have tried hard to ensure that families talk about organ donation long before they are in that situation. As part of organ donation week this week, we heard the story of an amazing woman whose husband died suddenly in difficult circumstances. Because they had had that conversation, she knew, even in the moment of crisis, that she wanted his organs to be donated. That act helped many families, which has in turn helped her bereavement process.

It is important to have the conversations early and to be open and honest. It will take the fear factor out of death and will ensure that people are able to access the services that will support them as they approach death. It also makes life easier for the family, who will not be left wondering whether they did the right thing. I am all for increasing such conversations and I will do whatever I can in my role to support them.

When I was doing my GP shift yesterday, I had a conversation about DNACPR, whci stands for “do not attempt cardiopulmonary resuscitation”. That is not one conversation; it is the start of a conversation that has to be gone back to on multiple occasions.

I visited the Prince and Princess of Wales Hospice, which is providing amazing care. It even has beds for young adults. Because that is an independent hospice, a patient who wants respite but whose funding is being controlled by the council is not able to access care at that hospice. They can only go to a hospice that is part of a big chain and they cannot access the amazing care that that hospice provides.

Would you be able to look at that, to stop that from happening and to allow even people whose councils control their respite funding to be able to choose where they go for respite care?

The best thing that you can do is to write to me and explain that particular problem. I am more than happy to find out what the situation is and come back to you. I am not aware of people being unable to access hospice care when they need it, so I want to know the details of that before I give you advice on it.

This is a session on top-level priorities, so we will move on. Members have questions on the issues around clean air.

Air pollution monitoring will be key to identifying problem areas. Has the Scottish Government considered implementing a system of health alerts, which are informed by air pollution monitoring, to people with lung conditions, so that they know which areas to avoid?

Again, I will look into that. There is a national system of health alerts. Over the course of my lifetime, television weather forecasters have started to give warnings at times of low air quality, which people with lung conditions pay a great deal of attention to. There is a recognition that that is important for conditions such as asthma—an asthma epidemic in London many years ago prompted that change in practice. The challenge is communicating the information to the people who need to know, but you are right that we have systems in place. People are now significantly more health literate and look after their conditions in a way that they have not done before, so there might be an opportunity to communicate that risk in a different way, rather than broadcasting it on television.

I will be quick, because I am conscious of time. I am interested in an update on the respiratory care action plan and how that will address air quality issues. I ask because I am the co-convener of the cross-party group on lung health.

Again, I have already mentioned how important it is for us to tackle that. For example, active transport is a solution to tackling climate change. Getting cars off the road will make spaces more comfortable for people and also reduce particulate pollution, so it is a win-win situation. Investing in active transport infrastructure is a really important priority for this Government.

Recently, I was at a World Health Organization panel event, and I presented with the deputy mayor of Paris, where the authorities have done remarkable work in a very short period. The population density of Paris means that many people live in a small space, so it is difficult for people to have enough space to navigate, and the city also had a significant pollution problem. The pandemic offered the authorities an opportunity to put in place infrastructure that transformed the way that people live, and that approach has been hugely popular.

During the course of the pandemic, there have been some controversies associated with the spaces for people programme in Scotland, and some of the infrastructure—which was put in to make the environment easier for active transport—has been removed. We need to work with communities to find out what works for them, but we absolutely need to increase the level of active transport, because it will tackle climate change and make us healthier—because we will be more physically active—and because we need to reduce the level of particulate pollution that people are exposed to. All three of those targets are incontrovertible.

Minister, we are coming towards the end of the allotted time for our session, so can we have another 10 minutes of your time? Paul O’Kane has a question on the clean air aspect.

That is fine.

Thank you, minister. I will follow on from that point. We are meeting during COP26, and the climate change aspect of clean air is linked to the public health duty. The “Clear the air” report from Asthma UK and the British Lung Foundation highlighted the specific impact that poor air quality has on low income communities. I am keen to get a sense of what we are doing within the strategy to target those low income communities and areas of multiple deprivation, with regard to issues such as active travel and active transport.

10:30  

Right across the board, in everything that we do, we look at things through an inequality lens. With any policy that we introduce, we make sure that we look at things in that way and that we specifically target those people who suffer the greatest health inequalities.

We are doing a number of simple things. For example, we had a manifesto pledge to ensure that children all over Scotland had access to a bike, and we now have 10 pilots going on in different parts of Scotland. The barriers to bike ownership are different in different communities. We are putting in place pilots that make bikes accessible to people in every part of our community. The challenge is not just with being able to afford a bike; it is also necessary to have somewhere to store a bike. Someone who lives in a city-centre flat might not have anywhere to put their bike. There is also the challenge of a lack of bike infrastructure. Most people would think twice about letting their children out on busy city roads. Cycle lanes need to be provided so that they can cycle safely. The ability to repair bikes is also required in communities. The challenges are multiple, but the pilots will help us to solve the problems.

We thought about having a specific pilot for people who need accessible bikes, but we decided that it was more important to ensure that accessible bikes are available everywhere. A thread that runs through our work is ensuring that there is provision for those people for whom bike ownership is really challenging, perhaps because they have a disability and cannot use a standard bike. I think that the pilots will give us a great deal of information that will help us to transform the landscape over the course of the parliamentary session.

I will go to Sandesh Gulhane for a final question on cleaner air, after which I will come back to Paul O’Kane, who has some questions on the theme of indirect health harms from Covid-19.

I am glad to hear that one of the aims is to get cars off the road. One of the big problems is with commuting to work, because the traffic means that everyone just sits there.

I will use the Queen Elizabeth university hospital as an example of a greater issue that exists around Scotland. Public transport to get people to the hospital is not good enough. There are no cycle lanes for people to use to get to the hospital, and there are no shower facilities for people who cycle in.

How can we ensure that other places around Scotland have the infrastructure that is required to stop people driving into work? How can we help big hospitals such as the Queen Elizabeth university hospital?

You are absolutely right. One of the challenges is that such considerations have to be taken account of at the design stage. We must think about how we will encourage the use of active transport when we plan the infrastructure. As I said, there are more barriers than the barrier to bike ownership.

You arrived late, so I think that you missed the part of the discussion about using our NHS facilities as anchor institutions. That is partly about procurement and spending money in local communities, but it is also partly about ensuring that healthcare settings are as healthy as they can be and that people who work there can use active transport to access them, instead of having to take their cars. It is really important that we ensure that that is the case.

Time and time again, when I speak to people who are interested in sport and physical activity, I explain that one of the significant challenges of my role is that I am regularly preaching to the converted. I speak to people who already recognise the importance of sport and physical activity; what I need to do is speak to people who do not recognise that. I need to speak to the people in councils and the NHS who make decisions on the spending of public money, as well as the people who make decisions about planning infrastructure. I need to speak to people across the board who are involved in making such decisions so that we ensure that we have a cohesive approach, that we think about 20-minute neighbourhoods and that we consider the need for our NHS staff to be healthy in going to and from work.

That is another example of how public health reaches into all areas of life.

Convener, I should just place on the record that, earlier, I was listening to the meeting online, so I was able to hear the minister.

That is good.

To round things off, Paul O’Kane has questions on the indirect health harms of Covid-19. Minister, thank you for staying on for a little longer.

Yes, thank you for giving us more time, minister. We have had a meaningful discussion about public health and the huge amount that needs to be done. The narrative of a public health Parliament has permeated the discussion.

We are dealing with Covid-19 and its far-reaching impact. In the next part of the meeting, we will hear about the pressures on our NHS as we approach the winter. How can we address the wider public health challenges, which have been exacerbated by the pandemic, while dealing with the huge challenge of remobilisation and getting the delivery of acute services, in particular, back to the right level?

The first thing to say is that the pandemic is not over. Each and every one of us must continue to take steps to reduce transmission. I am talking about the basic mitigations: wearing a mask, keeping your distance and not mixing indoors where possible, all of which are important. It is also really important to get your vaccination. A massive vaccination programme is going on, and the level of vaccination that we are managing to achieve in this country is remarkable. As I think that I said, about 9.5 million doses have gone into people’s arms since the start of the programme in December. The requirement for vaccination during the autumn programme this year—the first tranche—was 8 million doses, to cover two doses for the eligible population; now we have to give 7.5 million doses in half the time, because we are combining flu vaccination with Covid boosters. It is a phenomenal task, and getting people vaccinated is a really important step.

You are absolutely right to say that the healthcare system faces the most challenging period in its 73 years, as I have heard the cabinet secretary and others say. We still face a global pandemic. There are about 800 people in hospital with Covid at the moment and many intensive care units have a number of Covid patients. That makes it difficult to restart the NHS, because many people need a period in an intensive care unit after a routine operation. We are in extremely challenging times, with pent-up demand and patients presenting with a level of acuity, because people have not accessed healthcare in the usual way over the past couple of years. All that makes for an exceptionally challenging situation.

A great deal of work is going on to improve the situation. Just last week, you will have seen the announcement about A and E and the use of a multidisciplinary team to ensure that people get the right care at the right time and that A and E sees only the people who need to present and be treated there. Over the past few days, I was briefed about some excellent work that is going on in NHS Greater Glasgow and Clyde to improve flow through hospitals. We recognise how significant that approach could be if it were taken throughout the country. We are very close to the issues and challenges that people on the ground are facing. The situation is very dynamic, but we are finding ways to improve it as we go along.

The period ahead will be difficult—there is absolutely no doubt about that. We anticipate a significantly more severe burden of disease when it comes to flu, given that immunity has dropped because we did not experience a flu season last year. There are massive challenges, to which we must rise, and we are across those challenges in a dynamic way and taking steps to face them over the next few months.

We must end there. I thank my colleagues for being succinct and I thank you, minister, for giving us some extra time. In the next part of the meeting we will talk about winter planning and preparedness.

10:39 Meeting suspended.  

10:46 On resuming—