Chamber and committees

We made a commitment in our manifesto to publish the long-term conditions framework next year, and it will be published early next year. I am grateful for all the work that has been done by people with lived experience and other stakeholders. There has been lots of third sector involvement and I think we will come up with a really good framework that everyone will be satisfied with and will be able to work to.

On the issue of ME, as you said, we have put £4.5 million into health boards and they have now received that money. My experience of asking my local health board—NHS Highland—what it had done with the money was slightly different from yours, convener, because I found out that it is setting up and building a service.

As is sometimes the case, its communication with individuals who had been involved in developing the service was not great, so the feedback loop to people with lived experience who had helped to shape the service was not great, but I am hoping that that will improve. I am very happy to go back and see what is happening to that money nationally, then come back to the committee in future with details on what the service is shaping up to look like around the country.

First, yes, you can expect to see population-level measures in the alcohol harm prevention plan. We have made great progress in recent years, but we have not gone far enough. In fact, the most recent statistics showed that approximately 1,200 people died of directly alcohol-attributable causes last year. That is only the tip of the iceberg—those are, largely, the people who are dying of liver disease. The number is higher than the number of those who are dying of drug-related causes, and the issue affects every community in Scotland.

We are not very good at identifying alcohol-related deaths in which alcohol is only one factor. About one in 10 breast cancer cases include alcohol as an attributable factor. Alcohol contributes to several cancers, cardiovascular disease and a range of ill health issues that we do not accurately measure. What we do accurately measure are directly alcohol-attributable deaths.

When it comes to lumping alcohol and drugs together, there is a lot of commonality across the broad spectrum of substance use. You are talking to a pharmacist—I think of all those individual drugs, and I think of alcohol as a drug. The substantial difference with alcohol is that it is legal and culturally condoned. It is not only a legal drug; it has a particular status in Scotland, which means that you need to take a different approach to tackling alcohol harm. There is a level of alcohol consumption that can be considered safe, but the medical evidence suggests that alcohol is a health-harming substance.

It is not wrong to consider alcohol and drugs together, but there is no doubt that there are times when different approaches need to be taken, simply because alcohol is a legal drug and drugs are largely illegal and drug use is largely illicit.

Thank you very much for that question. I expect the alcohol harm prevention plan to be published pretty soon; I cannot give you a specific date, but we are working hard on it at the moment and I expect it to appear in the next couple of months.

Inequality is at the heart of all that work. There is a clear inequality in mortality and morbidity for individuals experiencing harm from alcohol, and a similar but wider inequality exists for drugs. It is really important that all our work on substance use disorders takes those inequalities into account. We spoke earlier about work that is going on in prevention, and the cabinet secretary has mentioned a couple of times that 80 per cent of people’s health is influenced by factors other than healthcare, which we see very starkly with alcohol and substance use. You are absolutely correct, including on gender inequality: it is men who are dying, and men from more socioeconomically deprived backgrounds.

Population health measures work very well for those men. Minimum unit pricing for alcohol is the most significant policy that we have introduced to tackle alcohol harm over the past decade or so, and the modelling suggests that it has saved hundreds of lives. It has prevented hundreds of deaths and averted hundreds of alcohol-attributable hospital admissions, and its impact has been greatest in the areas of highest deprivation, with the largest impact for those living in the 40 per cent most deprived communities. Sometimes, instead of thinking that we have to target individuals, we find that population-level measures work best in the areas where the harm is worst.

That highlights the tension and the real area of challenge for politics, politicians and people who are involved in the public debate about those issues. Should we provide people with information that might help them to make choices that reduce harm, and should we support them to take drugs in a less harmful way, or to choose less harmful drugs, which is the question that you put to me, or does that simply encourage drug taking? That is the real tension at the heart of this.

As a public health minister, and as a health professional, I am very focused on approaching the issue from a public health perspective and reducing the harm that I see happening across Scotland right now.

You are absolutely correct to point to the harm resulting from ketamine use. It is one of several drugs that have burst on to our scene. One of the challenges that we face in tackling drug harm is that it involves an ever-changing scene and an ever-changing market. As a pharmacist, I was astonished to hear that people are using ketamine recreationally, but it is being used widely, and its chronic use can undoubtedly cause irreversible bladder harm. As you pointed to, in the north-east, a whole new service has had to be built to respond to that level of harm.

Some public health initiatives to inform people are happening. One of the challenges is that we need to be agile. I talked about the ever-changing market. Over the past few years, we have invested in a system that has brought strong benefits to Scotland: the rapid action drug alerts and response—RADAR—system, which picks up on changes in drug use and the drug market. It very quickly highlights to people on the front line—those who are working in substance use services and those who are using drugs—the associated harms. We do not see that information because we are not on that scene, so you and I will miss out on that very rapid response that comes out to the population, but the people who need to see it are aware of it.

Young people are just amazing. I have met individuals who have experienced irreversible harm from ketamine use but, through TikTok and other means that young people use to communicate, they are explaining to the population what happened to them. They are bravely saying, “Here is my experience, and here is why you need to avoid this happening to you.” That peer-to-peer education is one of our most powerful means of raising awareness and reducing harm.

We have been working on that for a period of time, and it is a major ambition in Scotland. Again, there are great pockets of work—in Badenoch and Strathspey, which, of course, has the natural asset of the amazing environment, they are really good at including options for social prescribing in their healthcare. However, that is not happening consistently around Scotland. I have had exciting conversations with representatives of our culture sector and our sport and physical activity sector, and we are pretty keen to bring social prescribing into a proper framework that means that it is accessible for everyone in Scotland.

Social prescribing is an amazing opportunity. On physical activity, for example, if we could get people moving more, that would be like a magic pill, except that you could not overdose on it. Physical activity is a phenomenal intervention, but it is quite hard to fit it into the health service, because we are very focused on medical interventions. However, we are working on that, because we recognise that we could make enormous progress through social prescribing.

I welcome the opportunity to be here and to talk about my very broad-ranging portfolio.

With regard to neurodiversity, you are absolutely correct. There has been an increased level of demand for services, which has caused a real challenge within the system. That has happened not just in Scotland, but all over the UK and, in fact, all over the world. We find our system overwhelmed.

We have committed to improving the system. We have committed to adopting a four-tier system for adults, as recommended by the Royal College of Psychiatrists in Scotland. The work started on that some time ago and, over the summer, I had a round-table meeting with a wide range of stakeholders to consider how we can implement the four-tier system. We have not quite decided what to call it—there is talk of a four-tier, four-level or four-phase model. It provides a number of ways for people to access care. The important thing is that individuals with neurodivergence need to be able to access support when and where they need it.

At the moment, we are very much focused on diagnosis, but although that is important, diagnosis is not the be-all and end-all. What people really need is support, and we are building a system of support for both adults and children.

The picture is slightly different for children than it is for adults, because of the work that we are doing with the education system. A number of pieces of work are under way, including the implementation of the recommendations of the McManus review, which will make a difference. However, the principle is the same: people should be able to access the right support, at the right time, where they need it and when they ask for it. Of course, we have an overarching system for children—getting it right for every child, or GIRFEC—which makes clear that there is no need to wait for a diagnosis in order to provide support. A child’s needs should be assessed. Every child has a right to access education, and any adaptations that need to be made can be put in place as soon as they are required.

I recognise that point, and we spoke about that a great deal when I met the lived experience advisory panel yesterday. I hope that I was able to reassure it that all its work has not gone to waste. We have absorbed the lived experience and now better understand how it feels to try to navigate the system and where we need to work harder to deliver better. Individual experiences are very useful in that respect. As a Government, we have also learned a great deal about how to use lived experience from population groups that are often considered heard to reach and to make sure that that experience is heard and acted on in Government. Therefore, none of the work that people have done to help us understand their situation has been wasted.

I was able to point to some tangible differences that have been made with regard to policy reform, service improvement and targeted investment. For example, there is the coming home work for individuals with learning disabilities. It is a devastating situation; so many individuals have been cared for far from home in institutions, and it has taken some time to build a system that is now delivering an impact. We are making a difference: we now have a dynamic support register, which means that we know who those people are and where they are in the system. That gives us good visibility at both the national and local levels.

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We now have the targeted investment into the independent living fund that was announced earlier this year. I am absolutely confident that that will bear fruit and support people to come home from institutions and live in their communities. Ms Thewliss leads on that work, which is undoubtedly having an impact. I see signs of progress where we have been able to take that approach.

People’s human rights are at the core of that work, including the rights to be supported to live a healthy and fulfilling life and to maintain a family life. I am absolutely delighted and am confident that we can make progress. It is not a case of those needs being deprioritised; rather, we are just approaching them in a different way. Legislation is hard to implement and takes a long time to bear fruit. We saw that in England with the Down Syndrome Act 2022, which was passed a number of years ago but has yet to be implemented and is not yet making a difference. The urgency is so acute that we must make a difference right now, and I am determined to do that.

We have that divide, because physical activity and sport are not the same. Although they go hand in hand, they are not the same, and the word “sport” puts a lot of people off. I cannot understand why myself, but that is the reality.

We have a strong physical activity strategy, which is in line with the World Health Organization’s work. We have been working on it for many years, with solid success, aided by a phenomenal academic sector that has helped us to make sure that everyone in Scotland has more opportunities to move more often.

You are right about Edinburgh Leisure. I have been to one of its falls classes, and it was absolutely phenomenal. It was led by an absolutely outstanding, incredibly talented physical instructor—I think that his name was Michael McIntyre, but I might have got that wrong—who has the power to get people moving, even when they are really quite incapacitated, and to give them confidence to continue living in their own homes, even when they have had difficult experiences.

I spoke to some of the individuals at that class. One elderly gentleman, who was very tall, had fallen into the bath and his wife could not get him out. There had been trauma associated with getting him help and support, but there they were at that class, working out how they would cope if they got into that situation again, what they would need to have close at hand so that they could call for help, and how not to panic but instead to move on to their front and get safely back up on to their feet. The class was full of simple but clever stuff, and it was delivered in a way that absolutely boosted people’s confidence. A lot of the class was about giving people confidence, after traumatic experiences, so that they could continue living independently and be confident that support would be provided if they needed it. It was great.

There is no evidence to support that hypothesis. What we see is that people who are very vulnerable and are using in the street—which is highly risky; they are likely to die taking drugs—are able to take drugs in a safe environment. They are able to access not just naloxone to reverse overdoses, but advice on safe injection technique. It is a sterile environment. A lot of harm, including amputations as well as deaths, is occurring because of injection site reactions and infections. There is also public health harm that comes from sharing needles and using drugs in unsanitary conditions. The Thistle is intended to reduce the risks associated with all those harms.

In the Thistle’s first year and a half, up to the end of August, it has registered more than 800 people. It has overseen more than 15,000 injecting episodes, and I would wager that that is 15,000 injections that could have happened outdoors, in the street. That is 15,000 needles not on the street, because the needles are safely disposed of after use. It has responded to 195 medical emergencies. Those will range from probably requiring just a bit of support with breathing and monitoring to full-blown resuscitation. We have absolutely no doubt that the facility has prevented deaths. In a country that is experiencing such a high level of drug-related deaths, that is absolutely something that we should continue to explore, study and scrutinise, and we should make decisions about whether it might be useful elsewhere.

A facility like the Thistle is being explored for Edinburgh. The effort on that has been led largely from the ground up. There are many people in the community who, because of the level of harm that they are seeing, are keen to explore a safe drug consumption room. I think that the consultation on that has now concluded. We will work with the City of Edinburgh Council to find out what we can do to bring that facility into being, should the council and the citizens of Edinburgh decide that that should be done. That is not a straightforward process, because the UK’s Misuse of Drugs Act 1971 prevents us from having safe drug consumption rooms. We have to work with the Lord Advocate very carefully to ensure that we meet the legal needs—the laws of the land need to literally be lifted in a particular geographical area in order for that harm reduction to proceed.

A number of strategies are under way. Core training is available to those on undergraduate courses, and there is access to continuing professional development for regulated professions, which helps them to support individuals with neurodivergence.

I visited Windygoul primary school last week—I think it might be in your constituency.