Hepatitis C
The next item of business is a debate on motion S3M-1943, in the name of Shona Robison, on hepatitis C.
I am grateful to be here to open this debate on our plans to tackle hepatitis C over the next three years with the second phase of the hepatitis C action plan. No one here would argue with the first part of the motion: the fact that hepatitis C is a significant public health issue for Scotland. Health Protection Scotland recently estimated that almost 50,000 people in Scotland have been infected with the hepatitis C virus—around 1 per cent of the population. That is about twice the level of estimates in the other United Kingdom countries, suggesting that the disease is a particular problem for us in Scotland. Although that may seem a relatively small number of people, hepatitis C is a serious and long-lasting condition that can often go undiagnosed. It has been referred to as the silent epidemic because those who are infected can live for years without knowing that they are infected, even if they are showing symptoms.
Hepatitis C places a heavy burden on the national health service and is a significant blight on the lives of those who are affected. With the second phase of the action plan, we are not only acting to address the serious needs of those who are currently suffering from the infection, but putting in place a set of services and a strategic approach to prevention to limit and, we hope, halt the spread of the condition to others. In that way, our investment in the action plan is an investment for the future—one that, in the longer term, will deliver benefits to individuals throughout the country and significant savings to the NHS.
Hepatitis C is a disease that is commonly associated with injecting drug use and it is true that the vast majority of those who are infected are current or former injecting drug users. However, a significant proportion of individuals with the disease—particularly those who are beginning to seek treatment—have long since moved away from chaotic lifestyles and have reintegrated into society as productive members of the community. The disease can be a destabilising and debilitating presence and it is our duty to ensure that such individuals receive the support and treatment that they require to continue their recovery and maintain their role in society.
There are also a small number of people who have been infected with the virus through infected blood products or other medical interventions. It is our duty to ensure that those individuals receive the best possible care, treatment and support to enable them to clear or to manage their condition.
In 2006, the previous Administration published the phase I "Hepatitis C Action Plan for Scotland". In addition to seeking to improve practices and services throughout the country, much of the work of that action plan was to gather evidence to inform the development of the second, much more substantial phase of action. The product of that work—the phase II action plan—was launched on 19 May in Dundee and I was pleased to be there.
Most members will have had a chance to consider the plan and I hope that there is broad agreement around the chamber that it is a bold one. It is certainly not short of either vision or ambition. It sets out 34 challenging but achievable actions for NHS boards and others in an attempt to deliver what could perhaps best be described as an industrial-scale intervention to tackle hepatitis C. A plan of such vision and ambition needs our support, which is why the Scottish Government has made more than £43 million of funding available over three years. We are investing funds now to reduce the longer-term burden on the NHS and on the people of Scotland from hepatitis C.
A significant strand of the activity within the plan, which is supported by £28 million, is about improving the testing, treatment, care and support services for those who are infected with the disease. We are setting ourselves the target of quadrupling within three years the number of people treated annually for the disease. Instead of treating 500 people every year, we will treat 2,000 or more people every year. We estimate that, if we can maintain that level of service over the next two decades, 5,200 cases of hepatitis C-related cirrhosis, including 2,700 cases with liver failure, will be prevented over the next two decades. That will not only change the lives of the people who are affected and their families, but create a significant saving in NHS resources.
It is worth considering the costs to the NHS of some hepatitis C-related conditions. It costs approximately £10,000 a year to manage someone with hepatitis C-related liver failure; approximately £8,500 a year to manage someone with hepatitis C-related cancer; and approximately £40,000 to give a person who is infected with hepatitis C a liver transplant. If we can successfully diagnose and treat a greater number of hepatitis C-infected people, we can reduce those significant costs to the health service. That is why quadrupling the number of people in treatment is such an important element of the plan.
To treat effectively those who are infected, however, we need to be able to identify them, and we are not yet good enough at testing for or diagnosing hepatitis C. It is an insidious condition, the symptoms of which are common to a wide range of other conditions. It can be difficult to spot, by doctors as well as by those who are affected.
Health Protection Scotland estimated that 38,000 people are chronically infected with hepatitis C. Of those, only 38 per cent have been diagnosed, only 20 per cent have ever attended specialist clinical services for chronic hepatitis C and only 5 per cent have received the antiviral therapy that has the potential to cure them. That is why we need to invest in testing and diagnosis, in awareness raising for health professionals and the public, and in professional training for those who are most able to spot and diagnose the condition. The phase II action plan seeks to do all those things.
The plan also acknowledges the social care needs of those who are suffering from hepatitis C, through actions that are aimed at improving links between clinical, addiction and mental health services, and through improvements to the range of support services that are provided by voluntary and non-governmental organisations. I am sure that members will agree that social care and support are just as important as medical treatment. We all know that the success of any treatment—particularly in the case of a difficult treatment such as antiviral therapy for hepatitis C—depends on the motivation of the patient, the support available to them and their ability to deal with other underlying conditions such as addiction and mental health problems.
The action plan does not, however, seek simply to improve the way in which we identify and deal with those who are infected with the disease. It also recognises the importance of activity to prevent people, as far as possible, from becoming infected in the first place. We will develop guidelines on needle exchanges and seek to improve access to exchange services throughout Scotland to ensure that, as far as possible, drug misusers have access to clean and sterile injecting equipment.
With Learning and Teaching Scotland, we will produce educational materials on hepatitis C that can be used in schools and other educational establishments as part of broader educational activity around blood-borne viruses. We will also develop educational materials that are aimed specifically at injecting drug users, who are the group that is most likely to be exposed to blood-borne viruses. All that activity will be supported by £8 million of the money that is available for the hepatitis C action plan. That money will be provided to NHS boards and will be in addition to the existing blood-borne virus prevention funding of around £9 million a year.
Underpinning all the good work on testing, treatment, care and support, and prevention, the action plan will introduce more robust monitoring and surveillance systems to allow us to better understand the scale of the hepatitis C problem in Scotland, to monitor progress in tackling the disease and changes in epidemiology, and to measure our progress in taking the plan forward. That will give us good-quality data so that in three years' time we will have a clear idea of how the landscape has changed, what impact the action plan has had and where further action is required. As I said, this is an ambitious and testing agenda, but I believe that the NHS in Scotland, in its 60th anniversary year, is capable of delivering it. This is the NHS at its very best.
I will say a word about the way in which the plan has been developed. A wide range of people, led by Health Protection Scotland, have been involved in developing the proposals. There has been a stakeholder event at which everyone had a vote on the proposed actions and a group of stakeholders has been discussing the pros and cons of the different proposed actions.
In its ambition and scope, it is a plan to be proud of. In the way in which it was developed by the NHS and others, the plan is an example of best practice in public policy development. On that theme, I will take this opportunity to thank publicly the key people who have steered the process and worked so hard to get us here today.
I thank Professor David Goldberg from Health Protection Scotland, who deserves much of the credit for steering the process; Dr John Dillon from NHS Tayside, who deserves credit for leading the testing, treatment, care and support working group; Professor Avril Taylor, who led the prevention working group; George Howie of NHS Health Scotland who led the education, training and awareness raising working group; and Dr Syed Ahmed of NHS Greater Glasgow and Clyde, who led the executive leads working group.
I also thank Brian Adam, who is convener of the parliamentary working group on hepatitis C, and the various members of the working group over the years. The group played a key role in shining a light on the issue of hepatitis C some years ago and leading us to where we are today. The group has continued to take an interest in the progress that has been made and I hope that the action plan has its support.
I am happy to accept both amendments. They are constructive and they add to the Government's motion. The action plan is a watermark document in tackling hepatitis C in Scotland. With the plan, we are leading the way in the UK—if not in Europe—in tackling hepatitis C. I hope that all members support the plan and that, like me, they look forward to the great strides that we will make in treatment, testing, care and prevention in the next three years.
I move,
That the Parliament recognises the leading role that Scotland is taking in tackling hepatitis C as a significant public health issue; acknowledges the launch of the Scottish Government Hepatitis C Phase II Action Plan, backed by funding of £43 million, on 19 May 2008 as a significant step forward in seeking to prevent hepatitis C and in delivering testing, treatment, support and care services to those affected by the disease, and considers that this will enable NHS boards and others identified in the plan to deliver on the actions set out to improve hepatitis C services for patients and others in Scotland.
First, I draw members' attention to my declaration of interests. I still do some work in the drugs field, on single shared assessment.
Unusually, we lodged an amendment that changes the wording of the Government's motion from "acknowledges" to "commends". I do not know whether that is unique in the Parliament, but it is a measure of the fact that we welcome the phase II action plan, which undoubtedly takes forward the previous Executive's phase I plan in a way that should transform the management of hepatitis C and maintain our leading role in the area.
Following the Labour and Liberal Executive's statement of intent in 2004 and the consultation on the draft action plan in June 2005, the phase I report set out in detail the challenges that we face in tackling the problem. I pay tribute to Keith Raffan, who is no longer a member. He was forceful in drawing our attention to the matter in the first session of Parliament. He constantly railed against the Scottish centre for infection and environmental health's estimates, which the centre itself admitted grossly underestimated the problem. At the time, we were told that the number might be 30,000. Now, we know that it is probably nearer 50,000.
As the Minister for Public Health said, the main route of transmission by a huge margin—some 45,000 of 50,000—is current or previous intravenous drug users. It is worrying that hepatitis C is not diminishing. Indeed, the report is correct to estimate that 1,000 to 1,500 new intravenous drug users are infected annually.
In the phase I plan, we endeavoured to collect information and detail the existing services. The plan contained no fewer than 41 action points, including the delivery of a comprehensive national examination of the problem; work to build on the efforts of existing services; the examination of co-ordination, prevention, testing, treatment, care, support, education, training, awareness raising, surveillance, and monitoring; and the piloting of a number of concepts.
One of the most important things is that we now have two managed clinical networks and it is clear that, as a result of the action plan, the work will be rolled out. Traditionally, managed clinical networks are horizontally integrated but, as the minister said, they also need to be vertically integrated and to include voluntary organisations and NGOs as well as user groups. I have been unable to find out from the action plan how many user groups were involved in the stakeholder group and it would be helpful if the minister could put that on the record when she sums up.
I want to take us through a hepatitis C patient's journey. As the action plan shows, the problems that we face begin with diagnosis. Many substance misusers are treated in general practice. The involvement of primary care is vital to the delivery of an effective diagnostic service, yet the action plan states that approximately 95 per cent of GPs did not diagnose a single case of hep C in the previous year.
There are also problems with needle exchange services. They were set up in response to HIV and were successful in that regard, but they have been unable to test for hepatitis C because most are based in pharmacies and they do not have the necessary facilities. Such services need to be developed. Many of them are open from 9 to 5 on Mondays to Fridays, which is not satisfactory for the group. A further problem is that hepatitis C is significantly more infective than HIV, so the challenge that we face with the spread of infection by needles is even greater than it was with HIV. We must not let up on tackling that. I know that there has been a separate report on that, which is important.
Another point is that numerous drugs services are offered by voluntary organisations and social workers, neither of which groups is easily positioned to offer testing. It is also disappointing that prisons, which should be in the best position to test, are yet patchy in their response. Even when a patient is counselled and gets to the point of being shown to have the hepatitis C virus on the basis of the test, that test is not standardised throughout the country. Again, the report indicates that that needs to be tackled.
If someone tests positive and requires specialist assessment and treatment, they are usually managed as if they were a typical patient: stable, with a clear or at least some understanding of their illness, and possibly symptomatic. However, we know that the illness is asymptomatic. As the minister has said, it is silent. The patient often does not understand why they need to be treated as they do not really have any problems, apart perhaps from being a little tired.
The result is that between 20 and 70 per cent of patients fail to attend the specialist clinics. Even when they attend, the clinics may judge that they are not suitable for treatment on the basis of their continued drug use or their social circumstances. Again, such decisions are not based on a standardised, common assessment tool. It will depend on the clinic that someone goes to and the attitude of their clinician as much as the circumstances in which they find themselves.
Once someone gets to the clinic, they may still be somewhat chaotic and there may be many other things with which they are still dealing, such as benefits meetings or appointments with drug clinics or general practitioners. If they fail to attend the clinic for whatever reason, they may be subject to the new ways waiting times. As Dr McKee and I have said, the patients in question will find that difficult to follow. As the report advised, there needs to be a careful look at non-attendees. I suggest that the new waiting times will damage further the attendances at such clinics, so there needs to be a sensitive application. If patients attend and are treated, some will relapse and require further courses, some will fail to complete the course and a number will not be treated because their type of hepatitis does not respond. Some estimates suggest that 20 per cent of those untreated may require a liver transplant, and it is clear that the increased treatment programme must deal with that.
We need to improve that difficult journey; the managed care networks will do that.
Of the 41 action points in the first phase of the plan, 40 were found to have been completed. One, in relation to prisons, was not completed, and my colleague David Whitton will deal with that. It is an area that requires particular attention. I want to use my final few minutes to offer some constructive criticisms of the report, which, as I have said, we warmly welcome.
First, other routes of transmission appear to be rather neglected in the second phase. There is a brief reference to pregnancy but almost no reference to the acquisition of hepatitis C from abroad. We know that such acquisition of HIV is increasing and it will almost certainly be increasing with hepatitis C.
Secondly, I suggest that the deadline of 2010 for the standardisation guidelines to be produced by NHS Quality Improvement Scotland seems far away, given the urgency and the good targets of increasing treatment set by the minister.
Thirdly, the managed clinical networks are important but, unless they involve primary care and community services, there will be problems. However, there is only one reference to community health partnerships in the report.
There is no indication of whether the national enhanced service contract for those practices participating in substance misuse services will be examined to incorporate testing and dealing with hepatitis C. There is no indication of whether the quality points for either preventive or testing work for other GPs will be examined. There is little mention of pharmacists, who play an important role in connectivity to the group. Will the minister examine that?
We are talking about a difficult service for often difficult people who can be homeless, previous offenders, unemployed, living on benefits and struggling to manage even day-to-day living. Therefore, we have to be sensitive to their challenges.
I want to make one point on the question of records. Hepatitis C patients may have up to nine separate clinical records: GP, voluntary sector drug services, social work, the health service, the blood-borne virus clinic, the needle exchange, the specialist drug service, the mental health service and the hepatitis clinic itself. That is not satisfactory. We need a patient-focused service.
I do not have time to deal with training, but STRADA—Scottish training in alcohol and drug abuse—is not mentioned in the report as the prime provider of services to tackle substance misuse. I hope that, rather than there being a fight over which board will lead, STRADA might be involved in that delivery.
I conclude by saying that we warmly welcome the report. The funding is excellent and I hope that the Government will be able to deliver, along with the health services, which are undoubtedly committed to making Scotland a leading player in tackling hepatitis C.
I move amendment S3M-1943.1, to leave out "acknowledges" and insert:
"commends the hard work undertaken by those staff involved in delivering 40 out of 41 action points in Phase I of the Scottish Government's Hepatitis C Action Plan and welcomes".
I do not think that anyone in the chamber disagrees with the progress that has been made and which is embodied in phase II of the action plan. We continue to recognise, as the minister made clear, that hepatitis is potentially one of the most significant public health issues to confront Scotland. We must bear that in mind. After Parliament starts to address an issue, the danger is always that people elsewhere think that a box has been ticked and that something has been sorted. However, that is not the image that the Government presents and I hope that Parliament will not present it. The problem remains serious.
We welcome the 34 actions in the plan. We particularly like the proposal to tackle the variations in the approach to the management and social care of people with hep C. Only two NHS boards have managed care networks for hep C and I welcome the extension of that. I also welcome the focus on increasing the number of individuals, and particularly prisoners, who receive antiviral therapy. Mr Whitton might expand on that, as presaged by Dr Simpson. That is linked to the recommendation to create in-prison needle exchange programmes to reduce the transmission of hep C. The link between social care, addiction services and hep C treatment is vital, because many hep C individuals have drug and alcohol problems or social needs. All those thrusts are warmly welcomed.
Our amendment raises the issue of continuing education, training and awareness raising. I am well aware that that was given much attention in phase I, but having read the substantial phase II action plan and looked back at phase I, I think that we must renew and in some ways reconfigure the important aspect of education, training and awareness raising, which was very much part of the phase I process. However, in so far as that developed satisfactorily into information gathering that improved awareness, we have a body of knowledge, which is a consequence of achieving 40 of the 41 actions in phase I.
We have now to look again to use that raised awareness and increased understanding to enhance the substantial part of the action plan and make it easier to implement. Different professions and different people will move into different stages, so education and awareness raising will continue, which might be through educating, informing and raising awareness among existing health professionals, notwithstanding the work that was done as part of phase I. That must link into the different challenges that are presented to the criminal justice professions as a consequence of our new information.
Our knowledge and understanding of how to support people who live with hepatitis C have increased. If we genuinely want to support people who live with hepatitis C—and it is equally important to reach the large percentage of that substantial body, which is estimated to be as much as 50,000 people, who might be undiagnosed—we must pay more attention to the programme of training and awareness raising. Otherwise, we run the risk that we will not capture those people as part of the all-important phase II development. As I have said, we must consider the knowledge of professionals, the potential scale and implications of hep C and exactly what is available to us at all levels.
It is also interesting to observe some of the work that has been done. We assume that those who deal in specialist non-pharmacy needle exchange work will have a high level of knowledge, but we continue to get evidence that there is a lack of standardised training and education of needle exchange staff, in particular on safer injecting techniques. We cannot lose sight of that issue, although it was a major element of the phase I action plan.
We warmly support the recommendations in the phase II action plan. Our amendment asks the Government to look again at the substantive section contained in the phase I action plan and perhaps bring it up to date so that by continuing—in combination with all the measures contained in phase II—to increase education, training and awareness raising, the overall impact will be greatly to help us tackle the potential problem of a hepatitis C outbreak.
I move amendment S3M-1943.2, to insert after "prevent hepatitis C":
"and working to raise awareness among professionals, the public and those at risk of infection".
We, too, will support the motion and the amendments.
Concerns about hepatitis C have been raised in the Parliament since 1999, by Brian Adam and by many others. Although the previous Administration is to be commended for its commitment to the phase I action plan and the achievement of 40 out of 41 of the plan's action points, there is no doubt that much remains to be done, particularly in the light of the statistic that 50,000 persons in Scotland are estimated to be infected with the hep C virus and that 38,000 are chronic carriers.
When I read the hep C action plan, I noted in particular the evidence base, the actions to be taken and the outcomes as well as the reviews, audits and monitoring systems, which we agree are essential to ensure that there is a targeted and focused approach. The evidence base that underpins the action plan is shocking and it aptly illustrates the fact that co-ordinated action is needed for diagnosis, treatment and support.
Other members have raised some of the points that are made in the phase II action plan, which states:
"The training of the Hepatitis workforce is substandard."
It also states:
"There is a lack of integration among primary care, specialist, addiction, prison and social care services".
How often have we heard that?
As the minister said, the plan points out that
"Insufficient numbers of infected persons"
are given antiviral treatment. As Richard Simpson and others have said, the plan refers to variations
"among laboratories in the way they test for Hepatitis C and report results to clinicians".
In addition it states
"More than half of Scotland's main Hepatitis C treatment centres have no outward referral links with mental health and addiction services and only one-quarter have outward referral links with social care services."
Furthermore it notes that
"Approximately 95% of GPs in Scotland did not diagnose a single case of Hepatitis C during 2006."
I have mentioned but a few of the evidence-based issues. That is all against the background that approximately 50 per cent of newly diagnosed infected persons who are referred to a specialist clinic fail to attend their appointments.
We have no doubt that action is needed. How does today's hep C action plan fit in with the drugs strategy that will be announced next week by Fergus Ewing? In the Health and Sport Committee's short scrutiny of the budget, we raised many concerns about drug and alcohol detoxification and rehabilitation interventions and treatments. The picture that was painted is similar to much of the background information in the hep C evidence base. There is a lack of co-ordination; lack of knowledge about which interventions are most effective; lack of knowledge about investment in relation to outcomes; and a distinct lack of a joined-up service throughout Scotland, although there were undoubtedly areas of good practice.
In respect of integration, I am pleased to note that the action plan includes mental health services. I appreciate that there are many answers to the question why people take illegal drugs, but there is no doubt that for some people drug taking is a form of self-medication for issues that should ideally be addressed in a mental health setting in which they can be given the appropriate support and treatment. If we expect people to stop injecting and spreading the virus, we need to provide them with the appropriate mental health support, at the appropriate time, in the appropriate place.
My other concern relates to the NHS QIS standards for hep C testing and treatment, care and social support for persons with hep C infection. The standards are welcome, but I was surprised to learn that they are not due to be developed until 2010, one year before the end of the phase II action plan period. I am concerned that the integrated and co-ordinated approach for which all of us hope may not be achieved until the NHS QIS standards and guidelines are set out. I hope that the next two years will not see more of the muddled and ad hoc approach of the past and that actions will not be delayed until standards have been published.
Given the crucial need for an integrated approach between the NHS, social services, primary care, the voluntary sector, mental health services and secondary care, it is interesting to note that each local authority will identify a strategic and operational lead for hep C infection and that each health board will have a hep C prevention lead person. I accept that the monitoring that will be put in place will produce robust data, as the minister said, but I am not sure what will be the lead organisation or authority with responsibility for co-ordinating all services, to ensure that the user does not fall through the net, as happened in the past.
Scottish Conservatives welcome the publication of the action plan, but we have concerns about the inclusion and integration of all stakeholders, in order to put the patient first. It is fair to say that injecting drug users are not the most compliant patient group. For the action plan to be effective, it must, first and foremost, be tightly co-ordinated with the patient's needs.
It is a great pleasure for me to speak in support of the motion and amendments that are before us. A number of members have taken a keen interest in hepatitis and the various challenges that it has posed over the past nine years. Some of those have related to difficulties with blood-borne viruses that have arisen as a result of transfusions for haemophiliacs, but a much greater number of people have hepatitis C infections and the morbidity and mortality problems that are associated with hepatitis C as a result of other means of transmission. Although there may be some anxieties about the pace at which we are moving forward, there is no doubt that we are moving forward. It is sensible that we are doing so using an evidence-based approach.
Phase I was about identifying challenges and how to go about tackling them. It involved an awareness-raising programme that focused not on the natural target group—the 50,000 people who are infected—but on professionals, people working in NGOs and people offering support services. If we cannot prepare the professionals to make the change, it is unlikely that we will succeed immediately with the folk with whom they work, many of whom have fairly chaotic lifestyles. Even those who have put chaotic lifestyles behind them may wish to put all the potential harm that they are carrying around with them out of mind.
In a tight spending situation, a very significant amount of money has been devoted to the problem. Funding will increase stepwise, to the point at which £20 million a year will be delivered to treat 2,000-plus patients a year. If that many patients are to be treated—and the number could go up to 50,000—not everybody will be able to be treated immediately. There is also no guarantee that everybody will be cured. Some people have a natural mechanism to clear the virus from their system; they are able to get the harm to themselves—and potentially to others—out of their system. However, the proportion of people who are able to do that is modest.
We have moved on from the time when antiviral treatments had a success rate of only 10, 15 or 20 per cent. In the early days, we worked with interferon. I can remember when, as a young biochemist, I was really excited about this marvellous molecule that would be the saviour of mankind. It was a naturally occurring substance that would be terribly important. It is still important, but there is no silver bullet for some conditions.
Progress has been made with combinations of antiviral treatments. For example, HIV is no longer a death sentence, and the same goes for hepatitis C. The treatments will lead to much higher success rates, perhaps of 50 to 70 per cent. However, that will not eliminate hepatitis C from society; we will have to take other measures, too. Harm reduction methods and messages will be part of that. Uniformity of approach to training and services—which previous speakers have spoken about eloquently—will also be important. A coherent, step-by-step plan will eventually take us to a point at which hepatitis C is less important, in that the level of harm that is done to individuals and to society will at least have levelled out, if not been reduced.
I do not wish to take up any more of your time, Presiding Officer. It is a great privilege and pleasure to be associated with the group that has presented the action plan. I commend the Government ministers on their work.
l welcome yesterday's announcement that the Scottish Government will dedicate £43 million to combating the spread of hepatitis C, ushering in phase II of its action plan. As I understand it, the money will be distributed to health boards across Scotland and will be used in treatment, testing and care for those who are suffering with the disease.
The action plan has been announced against the background of world hepatitis day, which was held on 19 May. We have learned that, in order to oversee world hepatitis day, and to ensure that it is a patient-led initiative, the World Hepatitis Alliance was established in Geneva with a governing board of patient representatives—one from each of six world regions—and a president, representing the totality of hepatitis patients. During the summer of 2007, the alliance asked 12 worldwide communications agencies to pitch to run the world hepatitis day campaign. It chose Fleishman-Hillard. I wish the World Hepatitis Alliance every best wish for success in its mission.
I note from The Scotsman of 19 May that Charles Gore, the chief executive of the Hepatitis C Trust, was talking about the importance of preventing further infections. He said:
"These diseases are as widespread and as deadly as HIV/Aids, TB and malaria, but there is nowhere near the level of awareness nor the political will to tackle them. This must change because this huge death toll is largely preventable."
I hope that the World Hepatitis Alliance, whose study has estimated that 500 million people are infected with this dreadful disease, notes the introduction of this and the previous action plan and acknowledges the dedication and commitment shown by many of my MSP colleagues, who have done a massive amount of work on the issue in previous parliamentary sessions, as testament to the Parliament's political will.
I note the Hepatitis C Trust's statement that it—and 200 patient groups—pledges support for world hepatitis day, which is the first truly globally aware event for chronic viral hepatitis B and C. As I said, I hope that the alliance will judge that the action plans reflect strong political will in Scotland; however, as Mary Scanlon has said, much remains to be done.
Like other members, I congratulate the team that worked so hard to achieve all but one of the 41 action points in the first action plan, which was produced by the previous Labour-led Administration. The action plan that is now under consideration is a product of the first action plan, and I know that MSPs of every political party will wish all the very best to all those who are involved in taking forward this work. As members have acknowledged in previous debates, this is, first and foremost, a human issue, not a party-political matter. I feel for anyone who has been diagnosed with hepatitis C and worry for the others who do not know that they are suffering from what has been described as a sleeping giant of a killer.
The £43 million funding will be vital in progressing the action plan, which, as the minister and other members did, singles out for praise Professor Goldberg and his colleagues at Health Protection Scotland. I echo that praise, because their critical expertise will help us to tackle this dreadful disease. I am certainly pleased to learn that Scotland is at the forefront of this work in Europe, and all political parties should congratulate one another on their determination in tackling these issues. The many hundreds of others who have contributed to the action plan should also be thanked for their input.
Other members have covered the issues that I wanted to raise, so I will spare the chamber any repetition and move quickly to my other points. Suffice it to say that I agree with those who have mentioned substandard training, clinical management and the QIS standards.
I hope that the minister will reassure me that a thorough screening programme is being implemented. After all, if we do not introduce such a programme now, we will have to be prepared to put up our hands and accept our part of the blame when, in 15 to 20 years' time, the extent of the problem becomes apparent and can no longer be ignored. The US and France, for example, are already taking effective action. It is estimated that the costs of treating those who have been diagnosed might be as high as £200 million.
I note from the action plan that
"by 2011, actions will have led to considerable increases in the numbers of persons diagnosed with Hepatitis C and the numbers of infected persons having cleared their virus through antiviral therapy, and early signs"
that the prevalence of the disease might start to decline. However, I suspect that the Scottish Parliament will want to monitor that statement carefully with a view to having further deliberations, if necessary. After all, outcomes are not always what we expect them to be.
The action plan also says:
"A Project Management approach to co-ordinate the effective, efficient and timely delivery of the Action Plan, will be employed. This will involve establishing a Project Management Team … and appointing Project Managers at … Board level".
I hope and pray that they will ensure a consistent and integrated approach to action plan co-ordination.
On research, not much has been said about the interventions that are used in other countries to reduce the transmission of hepatitis C. I believe that that comment was made by respondents in the analysis of the 2004 action plan.
Like a number of members, I am conscious that significant progress has been made since 2006. As Richard Simpson said, phase I of the action plan has resulted in the transformation of services over the past two years.
Richard Simpson correctly pointed out that Keith Raffan played a significant role in highlighting hepatitis C issues during sessions 1 and 2. Brian Adam also played an important part, and I suspect that their dogged determination to ensure that hepatitis C was a recurring subject of debate in Parliament led to the development of phase I of the action plan. Their role in ensuring that the issue was addressed effectively must receive appropriate recognition. I congratulate them on the work that they have done over the past eight or nine years.
I agree strongly with Ross Finnie that hepatitis C remains one of the most significant public health problems that our nation faces. It is also a significant health problem internationally—it is estimated that some 500 million people worldwide are infected with hepatitis B or hepatitis C. The fact that that is 10 times the number of people who are infected with HIV/AIDS puts into context the extent of the problem across the world.
Brian Adam said that there might be concerns about the pace at which some aspects of the phase II action plan are being progressed. I do not necessarily share those concerns. From what I have heard, that is not a matter of great concern. However, given the significance of the problem that we face in Scotland alone, it is legitimate to ask why it took us so long to introduce an effective action plan for tackling hepatitis C. I do not know whether that was reflective of the difficulties of the patient group concerned, many of whom acquired the condition through drugs misuse, which leads to a chaotic lifestyle and many accompanying problems.
Another factor might have been the asymptomatic nature of hepatitis C, which has led to its being described as a silent killer. Perhaps that is why effective progress was not made sooner. It is worth considering why that was the case, given that hepatitis C was a significant public health problem long before 2006. In saying that, I do not seek to lay blame on the previous Executive; I think that the reason goes wider than that.
I welcome phase II of the action plan and the additional financial resources that will be provided to ensure that it is delivered effectively. Two of the main objectives must be to prevent further transmission of hepatitis C and to ensure that those people who are infected with it have access to the best quality of treatment services.
In my view, how hepatitis C can be contracted continues to be surrounded by a large body of ignorance. One of the most important aspects of the phase II action plan is the continuing education work to ensure greater understanding of contraction of the condition and higher rates of testing. We understand that a large number of people could have hepatitis C without being aware of it. The importance of education in phase II cannot be underestimated.
The Scottish hepatitis support network has highlighted a number of important issues. There are notable gaps in services for hepatitis C sufferers and their families. The link between mental health services and hepatitis C services is often poor. It is commonly acknowledged that depression and mood changes can be significant side effects of treatment for hepatitis C. As phase II develops, mental health issues will be given greater prominence, and it is important that provision for those who have hepatitis C and treatment for mental health problems are linked more effectively. Additionally, there is a need to consider providing more effective support for those who are not suitable for antiviral treatment, or for whom that treatment may have been unsuccessful.
Another important area is the wider support that must be provided to the families of those who suffer from hepatitis C. The requirement for that area to be addressed more effectively has been highlighted, but I am not convinced that phase II will address it as it should. The illness can affect the whole family unit, children and adults, so there is a need to ensure the provision of more effective support for the family unit, particularly for the primary carer whose direct role is to support the individual who has hepatitis C.
There is a clear need for greater linkage between alcohol services and services for those with hepatitis C. The role of alcohol in accelerating liver disease is an important factor that must be recognised. I hope that, during phase II, there will be more effective linkage between those two service areas.
I speak in support of the amendment in the name of my colleague Richard Simpson, which I am pleased that the minister has accepted. As Richard Simpson indicated, I will focus on what is happening in Scotland's prison estate with regard to hepatitis C.
In the introduction to the phase I action plan, Dr Harry Burns, the chief medical officer for Scotland, said:
"Prevention is as important and necessary as treatment and care … existing services may need to change the way they do things."
I will return to that point.
The phase I document went on to say, under its action points, that the Scottish Prison Service would pilot an in-prison needle exchange scheme at Craiginches jail in Aberdeen, and that a report on the pilot would be available in 2009. It was also reported that the Scottish Prison Service would provide access to training on hepatitis C to all prison staff as part of a larger training programme on harm reduction. The intention was that staff in Aberdeen would be given special training on safe injection techniques, as part of an intended pilot needle exchange in that prison. Why was it felt that that work was so important in Scotland's jails?
In April, as was reported, the prison population in Scotland reached an all-time high of around 7,700. There is widespread overcrowding; cells that are meant for one prisoner are sometimes used by not two but three inmates, and prisoners are locked up for longer. I do not think that anyone in the chamber believes that no drugs are available in our prisons; indeed, drugs have, in many cases, replaced tobacco as the currency of the prison. The reports before us make it clear that the vast majority of those with hepatitis C are, or have been, intravenous drug users. There are many drug users in our jails; in many cases, that is why they are in jail. Those who are locked up and taking drugs often share needles, and ultimately spread infection.
One of the most shocking statistics in the phase I report comes from a study of Shotts prison inmates a few years ago, which found that a quarter were infected with hepatitis C. I venture to suggest that a similar study that was done across Scotland's prison estate today might come up with the same figure or one that was even higher, which could be up to 2,000 prisoners. If that is the case, it is a cause for concern that the only one of the 41 recommendations in the phase I action plan not to have been implemented was the pilot of the needle and syringe exchange scheme at Aberdeen.
The Aberdeen scheme has been rescheduled as action 17 for phase II, but under "Outcome" the plan states:
"This action will demonstrate the acceptability, to users and prison officers … of an in-prison service providing injection equipment."
Will it? My understanding is that the main reason for the Aberdeen pilot not going ahead was resistance from the Scottish Prison Officers Association, which regarded the scheme as a health and safety matter for its members. Action 17 says that if the pilot gets the go ahead, it will be evaluated in 2011. I urge the cabinet secretary and her minister to consider that matter further. I hope that they would sit down with the Scottish Prison Service and the SPOA to ascertain whether the pilot can be introduced more quickly and whether the findings can be accelerated.
I remind the cabinet secretary that the phase I plan said that
"existing services may need to change the way they do things."
On page 19 of the phase II plan, it is made clear that intravenous drug users who continue to inject in prison
"do not have access to injection equipment in that setting."
It is estimated that as many as 300 prison inmates inject at least once a month, using home-made, unsterile equipment. Needle exchange schemes have been introduced in some European countries, including Spain, Germany and Switzerland, but that has yet to happen in the United Kingdom. Will the cabinet secretary consider making Scotland lead the way on the matter?
Under action 23, a
"survey of Hepatitis C prevalence and incidence among prisoners in Scotland"
will be undertaken and the results published in 2011. Given that we have a captive audience in Scotland's jails, it should not take three years to garner the information. If hepatitis C tests can be organised in the Parliament, as I think happened last week, it should not be difficult to organise tests in a prison.
In section 4.5 of the analysis of consultation responses to the proposed action plan, under the heading "Prevention issues", it is noted that respondents
"acknowledged that significant action was already underway in SPS in the area of harm reduction and immunisation for Hepatitis B."
However, section 4.5 continues:
"Respondents called for further efforts to:
Educate and raise awareness among prison staff about Hepatitis C.
Stabilise chaotic drug use through effective substitute prescribing …
Develop needle exchange programmes or make available vending machines for distributing sterile needles/syringes and other paraphernalia.
Discourage tattooing, and inform inmates of the risks involved in using make-shift and non-sterile equipment for this purpose."
There is much to be commended in the phase II action plan. The minister mentioned the foreword to the document, which says:
"the Hepatitis C Phase II Action Plan amounts to intervention on an industrial scale; an investment in the public health of Scotland that should, over the longer term, significantly reduce the problem of Hepatitis C in Scotland."
If around a quarter of our prison population is suffering from the disease, intervention on an industrial scale is needed in prisons now.
I congratulate the minister and everyone who was involved in the production of this hepatitis C action plan and the predecessor report. I also welcome the significant investment of £43 million to support the implementation of the plan during the next three years.
I have had first-hand experience of looking after people who have been infected with hepatitis C and I know how devastating the condition can be. My first such patient became infected as a result of a blood transfusion, but fortunately has not developed liver cirrhosis. However, her fear and anger, her irrational shame and the fact that she and her husband must use a condom when they have sex, to prevent him from becoming infected, have affected her in such a way that her life will never be the same as it was before she contracted the disease.
That woman did nothing to bring the disease on herself, and it is tempting to feel sympathy for such people while feeling no sympathy for the majority of people who have the disease, who became infected as a result of a drug habit. However, people turn to drugs for many and varied reasons and behind nearly every case is a victim who is equally deserving of our support. The difference between the two groups of patients is that people who have drug habits are exceedingly difficult to help. There are inevitably setbacks and moments when the professional and the patient or client wonder whether anything is being achieved. Patience and perseverance are needed.
If I have a criticism of the action plan, it is that some sections are almost too focused on hepatitis C. We must always remember that we are treating a person and not a condition. Hepatitis C is only one of a series of health risks that drug users face. I am sure that the minister is well aware that such people need to be screened for HIV and hepatitis B, for example, and that she is confident that that is happening, but I looked in vain for a mention of that in the document. I know that only a small proportion of hepatitis C cases are transmitted sexually, but given that the infection can be deadly, there would be merit in making a strong recommendation in management plans on regular use of condoms, especially if the drug user is also a prostitute.
On page 16, under the heading "Prevention", the plan says that the provision of injection equipment is, unlike methadone maintenance programmes, designed to prevent the transmission of blood-borne viruses among intravenous drug users. However, in Lothian, the methadone maintenance programme and its precursors were introduced specifically for that purpose and had some degree of success.
The sad fact is that the efficient use of any sterile injection equipment is beyond the ability of many drug users, involving as it does the regular collection of clean needles from a central source, returning or safely disposing of used needles, and never, ever sharing. As the plan says, although we distribute 3.5 million syringes and needles a year, no one knows how many are being safely disposed of after use—or how many are casually discarded, making them a risk to others.
No member has mentioned what goes into those syringes. Although I am not surprised that there is no plan to provide intravenous drugs of an acceptable standard, every year intravenous drug users inject all sorts of rubbish into their flesh and veins. They inject dangerous drugs of uncertain strength and provenance that are mixed with anything from talcum powder to rat poison. They risk abscesses, blood clots, loss of limbs, and even loss of life. If a person is truly to be helped, pathways into oral maintenance should form a major part of any strategy.
In exploring further the issue of compliance, the plan tells us that 50 per cent of newly diagnosed infected persons fail to keep their specialist appointments. I am surprised that the percentage is not higher, given the chaotic lives that many of those people lead. How does the Government suggest that compliance will be improved? We are told that plans will be developed and that "innovative" strategies will employed, but what plans, and what innovations? Until we know and can assess what is proposed, such statements are nothing more than benign sentiments.
I do not want members to think that those few criticisms mean that I believe that the plan is critically flawed. On the contrary, for the first time, we have a national plan that is evidence based and which demands high standards of knowledge and service delivery from all practitioners. That approach should be emulated for many other conditions. I repeat my plea that we should remember that we are treating people, not conditions, and that holistic care plans should always form the basis of treatment.
We move to the wind-up speeches. I call Jamie Stone.
I thought that Jackson Carlaw was to speak before me, Presiding Officer. Is that not the case?
You are correct, Mr Stone. [Interruption.] Please excuse me; I have the cold. I call Jackson Carlaw.
Once again, on a matter that enjoys support across the parties, the subject of debate has brought out the qualities of a concerned, informed and collective chamber by way of members' contributions.
The Government's announcement of £43 million of additional funding is welcome. It is to be widely congratulated on doing so in seeking to meet the challenge presented by the scale of the hepatitis C problem. Many members detailed that during the debate—Dr Simpson and Dr McKee did so with considerable expertise. The action plan follows the first phase of the strategy that the previous Administration implemented—which we also supported—which, in turn, followed Brian Adam's sustained focus over many years and the subsequent members' business debate in 2004, at which the Conservatives joined others in recognising hepatitis C as one of our most serious public health risks.
Perhaps we should measure the Government's announcement today in terms of our ability to say to Charles Gore of the Hepatitis C Trust that we have responded directly to the comment attributed to him, which was that the condition is
"as deadly as HIV/Aids, TB and malaria but there is nowhere near the level of awareness nor political will to tackle"
it. The quotation continues:
"This must change because this huge death toll is largely preventable".
Helen Eadie also quoted him in her speech.
The incidence of hepatitis C in Scotland is chilling. It is estimated that 1 per cent of the Scots population—twice the percentage of elsewhere in the United Kingdom—is infected by this blood-borne virus. We are told that too few are aware of their infection and that thus far we have treated far fewer of those who are infected than is the case in Germany, Italy or Spain. We are also told that, in France, people who are infected are five times more likely to have been treated than is the case in this country.
We welcome the fact that phase II has followed on from a phase I. We do so not only because that is the rather obvious and natural order of things, but because we can see that phase I has been implemented almost in its entirety—all but one of 41 actions have been implemented. During phase II, the Government will endeavour to tackle directly the enduring ignorance that, if corrected, could be so influential in the success of the preventive campaign.
We therefore applaud the Hepatitis C Trust's assessment of phase II that it is comprehensive and evidence based, that it involved wide stakeholder consultation, that it addresses health inequalities and that it takes account of Scotland's geography.
That said, perhaps we should be concerned at the sheer volume of public health information that we find ourselves having to, or planning to, communicate. We have vital messages on sexual health, such as those on the need for chlamydia screening among young girls and especially young men; the message on drugs generally; the effort to tackle obesity; the forthcoming strategy to address the ever-worsening scourge of alcohol abuse; and the statement on smoking prevention earlier this afternoon. The list goes on. To an extent, every new message and campaign competes for public awareness, often among the same demographic groups. We must be concerned about and alert to the possibility that that may begin to dilute the effectiveness of individual messages, however vital they are, and could lead to a need for even higher expenditure to break into the consciousness of any target group. We must therefore learn to be increasingly imaginative and versatile in our approach. Using the same medium every time may produce diminishing returns. At some point, we need to pause and dwell on the array of public health initiatives that are under way and planned. We do not want to stand accused in years to come of having been willing to spend money, but in a manner that became contradictory and confused.
The Government is to be applauded for being prepared to tackle the public health agenda head on and with fresh urgency, building—I say without hesitation—on what went before, which was also bold. However, the agenda is becoming wider and more ambitious in its reach every week. It is in all our interests that it succeeds, so I repeat that, at some point, we should find time to draw an understanding of the breadth of the competing and complementary strands. My colleague Mary Scanlon gave an immediate and worthwhile practical example of that when she referred to the forthcoming strategy on drugs. It is important that the immediate initiatives work effectively and concurrently. Richard Simpson identified a parallel issue about records.
As others have done today, we welcome the aims and objectives of phase II of the hepatitis C plan over the next three years and measures such as the direct support to health boards as they seek to meet the challenge. Taken together, the announcement of the inquiry and the phase II funding represent a significant and undeniable effort by the Administration to do justice to the historical hepatitis C issue, coupled with a striking commitment to mitigate future incidence. Surely none of us has any ambition to carp or complain. We must ensure that the money that is allocated is spent effectively and that the various strands of the strategy are monitored closely, as they all need to succeed so that, on hepatitis C, Scotland achieves a clear strike, even if it is in isolation. Lives will be saved if we do so.
I conclude by answering Charles Gore's challenge, which I mentioned earlier, by quoting from him today. He welcomed the Scottish Government's approach and concluded by saying that it will mean that
"thousands more patients are diagnosed and treated and this will save lives".
We must see that it does.
I apologise to Mr Carlaw for not calling him earlier.
The trouble with Jackson Carlaw's excellent speech is that he has taken away just about everything that I was going to say. The trouble with the winding-up speeches in a consensual debate is that members end up saying exactly the same things. However, in my usual manner, I shall try to digress into some interesting sidelines.
The minister put us right on the ball by setting out the exact nature of the problem. We have heard it said many times in the Parliament that 50,000 people in Scotland are infected and that the rate of infection here is twice that in other parts of the United Kingdom. We should dwell on that and consider why it is the case. Let us hope that, as phase II proceeds, we will come to conclusions on that. The funding is welcome. There is to be £43 million over three years, and £28 million for improved testing. The number of people to be treated each and every year will quadruple from 500 to 2,000.
Richard Simpson joked that we should commend and not just acknowledge the work that has been done, but that is true. There is a consensus that excellent work was done in phase I and that phase II will build on that. Dr Simpson flagged up an interesting point about the role of pharmacists and connectivity. Pharmacists have a wide knowledge that may be of great assistance in tackling the disease. We should remember that and build on it. Another important point that Dr Simpson made was that people who suffer from hepatitis C can have up to nine separate records. I had not realised that the situation was so bad. To use his words, that is not good enough. That could be an easy issue for the Scottish Government to tackle, and co-ordinating the records may assist the Government in its endeavours.
My colleague Ross Finnie moved my party's amendment, which is entirely about raising awareness among sufferers of the disease, the general public and health professionals. Mary Scanlon and other members asked why the rate of GP diagnosis is so low. That question must be answered. We are missing something and the answer may be to do with raising awareness, as mentioned in our amendment. Perhaps that applies to GPs as much as it applies to other people.
Ross Finnie suggested that because we have had the debate, it might seem easy simply to tick the box—to say that the matter is sorted and that we do not need to think about it any more. In that case, does not raising awareness apply just as much to us, as members of the parties in the Parliament, as it does to ministers? We need to remember that.
I have mentioned what Mary Scanlon said about GP diagnoses. She spoke about training, the lack of integration and variation in testing methods. She made an interesting point about drugs strategy. Fergus Ewing will shortly be introducing the drugs strategy, and the connectivity between the different areas involved is there to be seen. Ross Finnie and I have discussed in the past the lack of joined-upness—perhaps it exists as much in my party as it does in the governing party—between announcements by justice ministers on the licensing regime for drink, for example, with responsibility lying with Fergus Ewing's portfolio, and the medical aspects of the issue. Perhaps all parties should think more carefully about how to marry those two things. We shall be probing that matter in the future.
The speeches from back benchers were of a very high quality. Brian Adam knows the subject inside out, and he has pursued it doggedly—both with and after Keith Raffan. I can only salute him on his first-class speech. Michael Matheson brought an international context to the debate. Shame on anyone who did not listen to what David Whitton said about what has been happening in prisons—although I am sure that everyone listened. His was a very thought-provoking speech indeed, and all of us found it instructive in relation to what might be at the heart of the problem in prisons. [Interruption.] I will give way. I am sorry—I heard a sedentary remark behind me, and I thought that someone wanted to intervene. I am saddened.
Dr Ian McKee talked powerfully about the idea of treating the person, not just the disease. There is huge mileage in that.
In getting the message out, we might mention the hepatitis C support network, medical professionals and the role of the general public, but there is a difference, to my mind, between such organisations as the hepatitis C support network and drug users themselves. Whether drug users are in prison or out on the street, a lot of them know one another and they know where to get the drugs from. There is a network there. When we try to do work in the area of prostitution, for example, although it is a wickedness and a terrible thing in society, we find that the people involved talk to one another. If we can plug into those networks, in a non-threatening, non-I'm-gonna-tell-the-cops way, we can perhaps get the message out. Perhaps the hepatitis C support network and other organisations are indeed doing that, but perhaps not. Word of mouth, as the drugs are bought and sold on the street, could be one way forward. I would be interested to hear the minister's thoughts on that—if not today, then in the future. There might be something that we could do on that front to take a new approach.
Anyone who is suffering from hepatitis C should take comfort from what has been said today. We speak with one voice. We have heard about what the antiviral medicines can do, and Brian Adam has given us great cause for hope. We have a strong message, and it is unique when this Parliament, on one of its better days, speaks with one voice. I am happy to support the amendment in the name of my boss, Ross Finnie, the Labour amendment and the motion.
This has been a consensual debate, which reflects the continuing desire of the Parliament to tackle the problem effectively. Brian Adam, to whom people have paid tribute for the work that he has done, referred to the fact that phase I of the action plan gathered the evidence and assessed what things are like. He made the important point that we are going to proceed on the basis of that evidence.
Many members have commended the phase II action plan. It is a model of clarity in setting out the objectives and how they might be achieved. I will not go over all the figures regarding our situation, but members referred to them and to the fact that the situation is worse here than in some other parts of the UK. However, as Helen Eadie, Michael Matheson and others said—referring to both the outcomes and the numbers involved—it pales into insignificance in world terms.
The most striking thing in the action plan is the target figure and the funding for treatment that is associated with it. Members also referred to that. Increasing the number of treatments from 450 in 2006 to 2,000 annually after 2011 is quite a tough target. I commend the Government for setting it, and I wish it and the health service well in delivering it. If we treat 2,000 people in 2011, we will treat as many as we have treated in total so far. That indicates the scale of the target that we have set.
Mary Scanlon said that integration is crucial, and it is. Her view is supported by speakers such as Ian McKee and Michael Matheson, who referred to the family and the patient, who must be the focus.
I have concerns about some of the systems that we are setting up, in particular the substantial bureaucracy that is being created. Mary Scanlon alluded to that by asking who is in charge. According to the action plan, there will be 14 health board leads, a Scottish Prison Service lead, 32 local authority leads, a lead for each managed clinical network, a co-ordinator for each network—which might mean up to another 14 people—and leads for prevention, national information, education, training and awareness. That is a lot of people, and the action plan lays out how many times they will meet and discuss issues. I suggest that that aspect needs to be examined closely to ensure that we do not end up with an overly top-heavy bureaucracy. We need to ensure that the focus is at the level of the individual.
Ian McKee said that the fact that there are so many non-attendees is important. Both he and I know from experience that we are dealing with a highly damaged group who, in relation to attending clinics, are not as responsive or as responsible as others are.
We are dealing with what many speakers have referred to as a silent killer—an asymptomatic disease—facing individuals who have many other problems to face. The disease may not be a priority for them, and that makes it difficult to deal with. I reiterate the point that it must be dealt with sensitively. Ian McKee rightly indicated that it would be dealt with sensitively under new plans and that there would be innovative ways of tackling it. However, we need to understand what they might be. I used text messaging for many such patients when I worked with drug addicts before I re-entered the Parliament, and they responded well to that.
Jackson Carlaw and others referred to primary care and the fact that 90 per cent of GPs did not identify a single case of hepatitis C last year. It is perhaps worse that 80 per cent of GPs do not ask about risk factors. GPs are on the front line of prevention and early identification, so we need to ensure that primary care is engaged. CHPs get only a brief mention in the action plan, but they are central to integrated delivery across local authorities and the voluntary sector. I would like the managed clinical networks to consider closely how the CHPs will deliver on those issues.
David Whitton was the main speaker on prisons and addressed the fact that the only one of the 41 actions in the first plan that was not fulfilled was the needle exchange pilot that was to be carried out in Aberdeen prison. That is regrettable but perhaps understandable. The issue is difficult for prisons to tackle—the culture in this country is different from that in Switzerland, Spain and Germany. Nevertheless, I reiterate and reinforce his call for the Government to seek early discussions to identify what the barriers were, tell us what they were and try to introduce the pilot as rapidly as possible.
Prisons have addressed a number of issues. For example, they are giving back needles that were confiscated on admission if they were supplied in police custody. That practice has been rolled out across the Prison Service, which is also training staff in hepatitis C, so the picture is not totally negative. There are 25,000 admissions annually to Scottish prisons but only around 7,000 residents at any given time, as David Whitton indicated, and a quarter of them might be infected. Many of the 25,000 will have a drug problem, and up to 40 per cent of those will have been intravenous drug users. That is a captive population that could be educated, tested and offered treatment.
It is startling to note from the action plan that, out of 450 patients who were treated, only 30 were prisoners. Given that the prison population has an overabundance of people who are infected with hepatitis C, that figure of 30—only 12 were treated inside prison—does not reflect the real proportions. I hope that, as we increase the number of treatments, the number of people who are treated in prison will increase.
I know, because I have asked, that the Government will reach a decision shortly about restoring the provision of medical services in prisons to the NHS. That is fundamental to the delivery of the plan. It is another reason for ensuring that the discussions between the NHS and the Prison Service address the relatively small disparity in funding, in order to deliver an English-style system in which the NHS is responsible for medical services in prisons.
Several members have highlighted the importance of pharmacists. They deliver much of the needle exchange programme and therefore have a huge educational role to play.
My colleague Margaret Curran, who was going to sum up the debate, intended to raise the issue of the hepatitis C inquiry budget line, which we are not totally clear about. It has been suggested that we need to make a freedom of information inquiry about that. It would be good if we could get a little clarity around that budget line, so that we can understand the overall budgets.
The debate has been highly consensual, with little criticism. The calls for speedy action from many of us are perhaps a good thing, as they keep the pressure on the Government. It is not easy to deliver on expansive plans such as this action plan, and I wish the ministers well. We will certainly keep them up to speed on the targets that they have set for themselves.
I am grateful to members of all parties for their engagement with this important area. I sense that there is consensus around the chamber that what we are doing is a positive step forward. I will respond to a number of issues that have been raised.
In his opening speech, Richard Simpson asked how many users were involved in the development of the plan. I can tell him that around 20 users were actively involved in the stakeholder group that fed into the plan's development.
Richard Simpson and Mary Scanlon asked about the timescale for the Scottish intercollegiate guidelines network guideline. The SIGN guideline is already in place; it is the standards that are to be developed by 2010. That is the earliest point by which that can be done, as QIS has a heavy workload. Nevertheless, the standards are one of QIS's priorities and it is factoring that work in as quickly as it can. We will keep that under scrutiny.
Richard Simpson also talked about the roles of the MCNs, which will include representatives from primary care, pharmacy and social care. He was keen to hear how the co-ordination will happen. He also mentioned the role of STRADA, which I confirm will be involved in the education and training elements of the plan.
Richard Simpson asked about transmission of hepatitis C from overseas. I am sure that he has noted that one of the actions is to determine the prevalence of hep C among people in the Pakistani community in Scotland, who will have acquired their infection, in the main, in Pakistan. Pakistan is one of the countries with the highest prevalence of hepatitis C in the world. There are various reasons for that, one of which involves the previous childhood immunisation procedures, which, unfortunately, led to the spread of the condition. People have not found out that they have the disease until later in life—if at all—so it is important that we target the Pakistani community with testing, treatment and support.
Mary Scanlon asked how the action plan relates to the drugs strategy. As she will know, the strategy has not yet been published, but I assure her that the approach that is taken in the strategy will be fully dovetailed with, and complementary to, the action plan. When the strategy is published, she will see that the action plan is fully referenced in it.
David Whitton asked whether we can speed up the work in prisons. Given that that was one of the actions that were not achieved under the first phase, I understand his concern. I recognise the seriousness of the situation in prisons. His point was well made and we will certainly consider the scope for injecting more urgency into those actions as we take them forward with the Scottish Prison Service.
Ian McKee talked about methadone treatment. We acknowledge the importance of methadone in reducing injecting and therefore in potentially reducing hepatitis C transmission.
Our ambition is that, with the action plan, things will be better in the future. People with hepatitis C will be diagnosed quickly through a trained and knowledgeable NHS that is supported by effective and efficient diagnostic services. Those who have the disease will be quickly referred to specialist services that will be able to provide all the information that is required and to assess suitability for treatment. Where treatment is recommended, it will commence quickly and be supported throughout, and the service will link into other services such as addictions, mental health and local authority services.
There will be care and support services throughout the country to provide non-medical support to those with the condition. All that will be supported by a national awareness-raising campaign for both the public and professionals to ensure that people know what hepatitis C is, what the risks are, what the symptoms are and where to go for help. In short, the hepatitis C phase II action plan will fundamentally improve the services in Scotland for those with the disease.
As the Minister for Public Health, I made it clear at the outset that this is an important public health issue for Scotland. I sense that there is broad support from members around the chamber for what is proposed in the phase II action plan, and I am sure that those who are suffering from the disease or working in the field will be grateful for that. A number of issues on which we will be able to keep members informed about our progress have been raised during the debate. I am happy to undertake to ensure that members are kept informed of progress. I look forward to sharing that progress with them over the coming months and years.