Healthcare

Thank you, convener. First, I want to express my appreciation for the opportunity to be here. As you said, it is my first time both in this room and appearing before the committee. I am very grateful for the work that the committee does in raising areas of concern and interest that the public have brought forward. I appreciate the opportunity to respond to some of those. Given the potential number of petitions that we are discussing and the time that we have available, I will attempt to be as pithy as possible in my responses.

As you have set out, convener, there can be gaps between policy and delivery. Where that is in evidence, it is normally due to capacity or demand-level constraints. There can be variation in delivery between health boards for geographical or demographic reasons, which members will understand. However, that said, I obviously want to narrow the gaps between demand and capacity and ensure that the patient experience is as positive as possible in what are sometimes very difficult circumstances, such as—as you set out, convener—a mental health crisis or other issues that are going on in people’s lives. That is what I am endeavouring to deliver, in concert with the 14 territorial health boards and the national boards, to ensure that we maximise improvements in patient experience.

Yes. I understand that, and that is the constant dilemma between local and national decision making. Where we rightly expect there to be local decision making and priority set at a local level, the compromise is a level of variance.

To answer the first part of your question, although our territorial health boards are independent legal entities that are responsible for the delivery of services in their jurisdiction, yes, I bring them together at a national level and ensure that there is shared understanding of best practice, resolving challenges and ensuring that there are treatment pathways available and that we blur the boundaries between health boards.

I will give you an example. We recently changed the way that we deliver planned care services, so that we have national treatment centres that people are referred to from territorial boards and regional treatment hubs, because we recognise that ensuring that treatment is delivered in the fastest way possible sometimes means delivering at a national rather than a regional or local level. That is where our regular interactions with board chairs and chief executives ensure that there is greater co-ordination. I expect that in planned care, in particular, but also in some acute services. The service renewal framework will allow us to have better co-ordination of services between board boundaries than we have right now.

Our colleague Emma Roddick has brought great attention to Ehlers-Danlos syndrome and to the work of the petitioner to ensure that the matter is brought to the attention of the Parliament and that there is greater public awareness of the effects of some rare conditions and diseases.

As you acknowledge, convener, we have perhaps not had information across our desks about some of these conditions before. In those cases, we have to find a balance with regard to demand—the level of need for treatment—and the ability to deliver the treatment safely. The clinician who is delivering the treatment must be able to do that at a level at which they continue to be safe to practice. That is always a balancing act.

Territorial boards have different levels of demand for treatment for these conditions, so local decision making is important, because the boards need to make decisions with regard to local priorities—for example, if they have higher levels of Ehlers-Danlos syndrome or other conditions that they need to prioritise and invest in treatment for.

I recognise that travelling for treatment can be extremely challenging. I am originally from the Northern Isles—from Orkney—and I recognise that travelling for healthcare can be challenging, but it is also an expected part of living in some communities. We need to ensure that the boundaries between health boards are blurred so that, where a specialist service is being delivered, it can be provided on a national basis, co-ordinated through National Services Scotland. Our rare disease action plan focuses on that, to ensure that we have better co-ordination of where services are delivered for some rarer conditions.

It goes back to the point that this is about specialisation rather than centralisation. On the point about patients having to travel, the national treatment centre initiative has demonstrated that it does not always have to be patients from rural areas travelling to the central belt. The national treatment centre Highland is a good example of patients travelling north from parts of the central belt. As someone who is originally from Orkney, it pleases me greatly that we have that level of co-ordination and that, rather than people having to travel towards the central belt, a level of service is being delivered in some of our more rural communities and is serving their interests, too.

A balance needs to be struck. Sometimes, we might need to take decisions nationally on diagnostic or treatment pathways; at other times, it is for local boards to determine how best to deliver and to serve patients in their areas, and they sometimes work in concert with other boards. Regardless of whether it is us, in Government, who help—whether through a cancer pathway or specialisation, or by ensuring that we provide neonatal services for the sickest babies—a condition must go through an assessment of need.

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In response to your exact questions, convener, it is about ensuring that we provide a service that is specialised but that does not restrict people’s access to it. Careful consideration has to be given, and public consultation and clinical input must be involved, to ensure that we provide the best services for people.

Mr Ewing and I, along with GPs in his constituency and with Mr Mountain, have corresponded and met repeatedly on the issue, and I well recognise the concerns that have been raised. I recognise the case that he has raises, but he will forgive me, because I clearly cannot comment on it.

Access to the whooping cough vaccine is clearly very important. Given the geopolitical discourse that has taken place this week, I encourage any expectant mother to access a vaccine that they are eligible for. As we approach winter, we should also take the opportunity to remind colleagues that they should take up the vaccines that are available to them, because of the preventative benefits that they offer. Vaccines are among the best public health measures that are available to us.

Mr Ewing asked why the contract change happened in the first place. In the lead-up to 2018, a request came from the British Medical Association during the GP contract negotiations. There is flexibility in the contract for local boards to take alternative measures, which, as I have made clear in my work with NHS Highland, needs to happen. There has been an assessment of the situation in Highland, and there will be flexibility in offering vaccination clinics, which GPs will lead on.

I have corresponded with Mr Ewing on the issue, and we are currently in discussions with the British Medical Association about its future funding provision and the services that it provides as a result. If requests come from the BMA again, we will consider them.

I understand that flexibility on such services is already offered, and it is up to NHS Highland to ensure that they are delivered. I am not sure whether that is an on-going process or whether it will happen before the winter, but I will ensure that Mr Ewing is updated on NHS Highland’s latest position.

Davy Russell has alighted on an incredibly salient point, on which we have been working with boards over the past six to 12 months to optimise the capacity that is available within the system. In some cases, that will involve asking people to travel—from Lanarkshire to Fife, from Grampian to the Golden Jubilee hospital, or to NTC Highland, with which Mr Mountain and Mr Ewing will be very familiar—in order to ensure that, where capacity is available, it is utilised according to demand. It might well be that NHS Lanarkshire needs help to get through its waiting times for cataracts, for instance. Exactly that process is under way, to optimise the planned care capacity.

Convener, I thank Edward Mountain for raising the issue, as he has done in correspondence with me, persistently ensuring that the needs of his constituents in the Highlands are across my desk on this issue and on others. As he will understand, I well know what that trip from Wick to Inverness looks like—I commute it regularly—so I well understand the challenge of accessing a service, even in Raigmore, for patients elsewhere in the Highlands.

A review of the national provision of vascular services is on-going. An interim position is in place at the moment to support the acute need for support for Highland vascular services. We are looking to move to a model that would ensure better vascular provision not just for the Highlands but across Scotland, to be delivered on population-based need while also understanding the clear points that Mr Mountain raised about travel within the Highlands and between the Highlands and other parts of the country. I will be happy to correspond with Mr Mountain on what that review is looking at.

I appreciate Mr Mountain’s point, although I do not agree with the first point that he made. I do not think that it is an inevitability that services will always be lost from the Highlands, not least because, in relation to all the points that I have already raised, there must be a balance between population-based planning and safety, travel and access to services for people who live in the Highlands. Given the travel that is already involved for people to get from Wick or Dingwall—or, indeed, from Skye, where I was in the summer—to Raigmore, and the onward travel to wherever that service might be, what Mr Mountain set out is not how we are approaching how services should be configured.

I have already given a good example of people in the central belt travelling to services that are provided in the Highlands, which is in good evidence through NTC Highland. I have no interest in seeing the situation that Mr Mountain has set out continue.

Ms Baillie and I talked about those points in the most recent of our one-to-one discussions, which I offer to Opposition health and social care spokespeople regularly. Discussions at that level allow me to share my vision and the Scottish Government’s intention with colleagues and to hear their concerns and examples of where things are not working.

I expect NHS Greater Glasgow and Clyde’s use of the Golden Jubilee hospital to increase. New management is in place at NHS Greater Glasgow and Clyde, as it is on an interim basis at the Golden Jubilee. As I said in response to the convener and to others, I expect, and we are seeing, greater co-operation between health boards to ensure that capacity is being optimised across their boundaries.

I recognise the point that Ms Baillie made about cancer waiting times in Glasgow compared with those in Lanarkshire. Can there be greater co-operation there, in relation to either how Lanarkshire has been able to meet its targets when other boards are struggling to do so, or whether the level of delivery in one health board area allows it to pick up some of the challenge that other boards face? That is exactly the type of work that is under way.

That work is under way now, so I expect that situation to start improving as of now.

Good morning. Following on from the earlier discussion, I am interested to hear, on behalf of petitioners and my constituents, how the Scottish Government is supporting organisations that are committed to raising awareness, promoting research and providing support to people with rare cancers, such as cholangiocarcinoma and other little-researched conditions.

On the cancer front, we work very closely with the Scottish cancer network, the Scottish Cancer Coalition and individual cancer charities that either help to fund and support research or are looking for us to provide that research funding. Cancer Research UK has a large footprint in Scotland. In its most recent session in the Parliament, it recognised that Scotland leads the world in many aspects of its cancer research work.

I am incredibly grateful for the work that is done by health boards and clinicians as well as by the academic community and industry to consider novel cancer treatments and diagnostic opportunities. We look to see that work continue to advance through the triple helix approach.

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Through the work of the Less Survivable Cancers Taskforce, I am conscious of the need to ensure that, for some of those cancers that are hardest to detect and are less survivable, earlier interventions and novel treatments are developed. We continue to work with that group and the stakeholder organisations to help to deliver that.

How are decisions made about introducing national screening programmes?

That is done in concert with the UK National Screening Committee. Like all Governments across the UK, we take our lead from the experts in that committee. Based on their recommendations, we seek either to implement a population-based screening programme or to target screening, if that is more appropriate.

One of the most experienced, shall we say.

I thank Mr Ewing for his advocacy on behalf of Mary Ramsay, who was on “Good Morning Scotland” this morning, giving very good testimony about the situation. I represent a constituent who has had essential tremor for some time, and I know that an ultrasound service, such as the one that Mr Ewing mentions, is being provided in Tayside. I recognise that travelling for treatment is a challenge for some people. If someone cannot get to Tayside, for whatever reason, the potential for travel to Liverpool or London is available, although I imagine that most people who are able to get to Liverpool or London are able to get to Tayside.

I will keep under review whether that provision needs to be broadened beyond being a specialist service in Tayside. We will work in concert with National Services Scotland, and, if it were found that a service had a level of demand that would merit provision being expanded beyond one specialist service in Scotland, that is something that we would consider.

I am very appreciative of that, and I am happy to have a discussion with her after the meeting, if that would be helpful.

I am grasping that particular jaggedy thistle and we are pursuing the process of reform. I pray in aid the merger of NSS and NHS Education for Scotland, which is happening in order to provide a new service for NHS delivery. We are blurring the boundaries between territorial boards to ensure that services are being delivered on the basis of it being a national health service, as Ms Baillie referred to earlier. As Mr Ewing is aware from his time in Government, structural reform is incredibly challenging and time consuming, and it can be very costly and distract from what we need to happen at the moment, which is an improvement in service delivery. I am focused on ensuring that we improve and reduce waiting times and improve people’s access to services. We are starting to see the fruits of that particular labour of our incredible NHS staff. That is not to say that structural reform is not required and that it could not be taken forward. However, right now, I am focused on getting the same outcomes that the type of reform that Mr Ewing speaks of could achieve but without having to go through the pain and cost of a top-down reform process.

In my response to Mr Ewing, I set out that there is a service available in Tayside and I will discuss with the petitioner whether that service is sufficient for her. It was certainly helpful for my constituent and his need. On whether more can be done, I am clearly happy to consider that with NSS, as I have already committed to do, in response to Mr Ewing.

I will need to check that. I am not aware of the answer, but I am happy to provide a response.

Douglas McLaren advises that the committee meets quarterly, but I am happy to provide a more detailed answer on its productivity, as you put it. I am happy to furnish that response.

Healthcare Improvement Scotland is leading on that, and I agree that we need to make progress. It is also working on the regulation of cosmetic implants and surgeries, which is another area where there is a pressing need for reform. It is my understanding that this will go to a public consultation—next year, I expect—and I expect progress to be made in that regard.

I absolutely agree with Mr Russell that that is part of the cancer treatment; it is the conclusion of the cancer treatment and it needs to be considered as such. In my role as health secretary, I have met women who are in those circumstances, and I understand their pain and anguish and the mental health impact of having to wait for surgery. The challenge is the demand on cancer treatment services, because the theatres that are used for what is sometimes very complex breast reconstruction surgery are the same theatres that are used for the initial treatment.

We need to get the balance right with regard to ensuring that we are concluding a woman’s cancer treatment through reconstruction surgery. However, I think that Mr Russell understands, as I do, the need to ensure that the initial treatment is prioritised. We are working with the relevant boards to ensure that there can be the necessary recruitment of specialist surgeons, so that we have the ability to get through the waiting lists. I absolutely agree that the length of wait that some people are experiencing is not acceptable.

You will understand that both those dates predate not just my time as health secretary but my time in the Parliament. However, I absolutely agree that there is a need to address the issue. As I said, we expect the public consultation to start early next year.

I very much appreciate the petitioner’s advocacy for the issue in an incredibly challenging situation—it is more than challenging; it is a tragic situation, for which I offer my deepest sympathies and condolences. A lot has changed since the petitioner lodged the petition and since the tragic situation that she set out happened. We have surpassed the commitment that we made to expand the number of mental health practitioners in accident and emergency units, general practice surgeries and other locations. We have surpassed the 800 that we anticipated. I recognise that, in many cases, that is still not enough—I have my own constituency cases where that has been the case—and we need to do better to support people in a crisis situation.

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I am also keen—this is where the Government’s real priority is—to move further upstream and prevent people from moving into crisis in the first place. That is about looking at whole-family support opportunities and enabling the drivers of poor mental health—in relation to poverty and other environmental and social factors that colleagues will be aware of—to be addressed much earlier, so that the acute level of mental health demand is lessened. Clearly, that is where we all wish to be, rather than having to treat the symptoms at an acute stage when people are in crisis.

I point Ms Baillie to the community link worker network, which seeks to move provision upstream, although I recognise the challenges that there are with that in some parts of the country.

I know that there is a petition from the deep-end practice network that calls for an expansion of the community link worker network. The CLW programme is under national review. Community link workers try to ensure that people, in a trusted place—the GP surgery—can be signposted to other services through which the root cause of the issue that they are presenting with can be addressed. Often, that support relates to housing, income maximisation, education and other elements of public service. It is also about the need to increase the opportunities that are available through social prescribing to address people’s mental health issues, which is in the population health framework.

The community link worker network is there to do that, and it is where we seek to move things upstream. The likes of the family nurse partnership is similarly about ensuring that we are supporting people much earlier in the journey than we are at the moment, where we treat the acute situation.

As Jackie Baillie will be aware, we stepped in to support the provision in Glasgow. We have also established a national review of the community link worker programme for exactly the reasons that she set out: in order to ensure that its sustainability can be afforded.

First of all, it is not the case that there is an 8 am rush in all GP practices. Same-day appointments are not the order for all GP practices. It is the responsibility of the GP practice to manage how their appointment system works. However, I recognise that, for many, that is the situation and that that is too often the case.

The way to resolve that is to support the expansion of the availability of practitioners—both general practitioners and those in the multidisciplinary team, who can often see patients, as it is not always the case that it needs to be the GP who sees them.

We have expanded the multidisciplinary network and we support, I think, more than 5,000 staff through the various resources that we have put in. As I think that I mentioned to the convener earlier, I am currently in discussion with the British Medical Association and the Royal College of General Practitioners on their long-term funding position in order to ensure that they are able to recruit from the record number of GPs who are in training—there are 1,200 of them. That greater level of employment will mean that greater levels of appointments can be offered, which will reduce the rush for appointments that Ms Baillie mentioned.

Agenda for change staff have protected time for developing skills and for training. We are asking our staff to go the extra mile in order to get through the Covid-related backlog. I am incredibly grateful to them for that, and recognise that we can see activity levels increasing and waiting times reducing. In July, we delivered the highest number of operations in the NHS in Scotland since February 2020.

Clearly, a shift in delivery has resulted from the investment that has been put in and the endeavours of staff, as well as the optimisation of capacity to ensure that we maximise the ability of the service to deliver. However, I recognise that, where we are asking staff to go further, that is putting stress and strain on them when they are already in a stressful situation, and is putting at risk their ability to undertake continuous training and upskilling. That is why the agenda for change contracts include protected learning time, which I expect boards to honour.

In recent years, we have made substantial investments in child and adolescent mental health services in order to deliver a substantial increase in the number of CAMHS practitioners. As a result, for the first time, we have met CAMHS waiting times standards for more than three consecutive quarters. There is a continued challenge around psychological therapies, which I recognise, but that is being worked on.

We have also provided substantial money—I would have to be reminded of the exact amount—via the communities mental health and wellbeing fund for adults. That investment relates to treatment as well as interventionist wellbeing support. As I pointed out in answer to Ms Baillie, we want to move upstream into a more preventative space. We need to respond to the demand as we see it now and get through the backlogs that we have, but we also need to move upstream. In the interests of the sustainability and viability of our health service, we must move to a more preventative model. We cannot see hospitals as the first port of call—they must be the last port of call—and we need to move much further upstream to ensure that we are providing health and wellbeing services that support people’s wellbeing, rather than treating the symptoms in an acute setting.

Following on from the discussion that Ms Baillie and I had previously about paediatric nurses and nurse vacancies, Ms Baillie will receive correspondence—she might already have received it—which will inform her that NHS Greater Glasgow and Clyde advertised for additional paediatric nurses this year, so there are jobs available.

I recognise the position in terms of resident doctors moving through specialty training, and, because we need the increased capacity, we are working with boards to ensure that they have the resource to be able to offer those places.

The short-term plans on priority areas and projects were set out and voted on by Parliament as part of the budget process. The long-term capital position is under review as part of the infrastructure investment plan, which we expect to bring forward as part of the budget and spending review process.

I appreciate Mr Golden’s question. I have probably seen many of the facilities that he is referencing, because I have committed to go into a substantial number of primary care facilities in order to see the current provision, particularly some of those that are most challenging, where there is a demand either for a replacement of buildings or renovation.

I recognise that, not just in relation to the immediate delivery of services and the capacity that we require in primary care but in order to fulfil the policy direction that this Government has set around shifting the balance of care, a move to the community hub model that Mr Golden outlined is important. That is what is contained in the health and social care service renewal framework—it is exactly the approach that I want us to move to.

We will need to see greater investment going into primary care facilities to allow that to happen and to enable more hospital-based services to be delivered in the community. That is under consideration at the moment, as part of the spending review, budget and infrastructure investment plan processes that I outlined in my first answer.

Of course, some of what needs to be done is determined by the capital allocation that we receive. I strongly encourage the UK Government to expand its capital investment. That is good for the economy and for public services, and it would certainly allow us to do much more.

We have clear areas of priority where we could use that investment. However, the issue that Mr Golden raises is under active consideration and is a clear priority for me at the present time.

There is a substantial amount in Mr Golden’s question, which points to the future provision that we will need to get to in order to ensure that we maximise the clinical capacity for the health service, that only humans can deliver on. We have already spoken about the demands that are upon us in the health service, and we need to ensure that we free as much clinical time as possible to meet those demands.

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I will point to a number of areas. First, we have a theatre optimisation tool, which is a digital-based product that has been rolled out across Scotland. I saw it in a demonstration in NHS Lothian, and it means that we are able to optimise—the clue is in the name—the level of productivity in our theatres. It ensures that the human estimations of how long an operation will take are being challenged through the application and that we have the maximum optimised level of bookings in the system.

Secondly, we will soon be setting out in detail the roll-out plan for the health and social care application—the app—in Scotland. It will start in Lanarkshire and be rolled out from there. That will initially be on a relatively minimal viable product basis, which will be about appointments, access to vaccinations and so on.

The question is how we scale that up. Part of the discussions that we are having with the BMA and the Royal College of General Practitioners—to address Mr Golden’s point—is about the data that we get from our general practitioners and how that can help to inform what can go through the app. The app can be integrated across health and social care, giving people much more power in their own hands and saving substantial amounts of resources in relation to appointments, bookings and other services that might be able to come through the app.

Lastly, Mr Golden referenced AI. There are good examples of where AI is being utilised, such as in NHS Grampian where it is being used in the lung screening process. Other services are coming through the system—good opportunities are coming through. When I was in Japan, I was able to see the phenomenal work that has been done by some of the companies that are based in Japan but work here in Scotland, which is looking at how AI can help to transform radiology. Alongside moving upstream into a more preventative health service, better utilising technology and having advancements come through the health service is also where we will meet the demands that are coming at us.

One such demand is the expectation of a 20 per cent increase in the burden of disease. How do we reverse that? How do we move forward? It is through the utilisation of innovation and new technology and moving further upstream into the preventative space. Mr Golden has struck an incredibly salient and pertinent point, which we are absolutely committed to moving forward with.

On the first point, I have been clear with our health board chief executives and chairs on my expectation about working with industry and academia on the utilisation of new health technology and medical products. We have set out a national programme for the adoption of health innovation called accelerated national innovation adoption. That is led by the chief scientific officer in Scotland, Dame Anna Dominiczak, who is well respected across the health service in Scotland and, indeed, in industry. That programme is helping to pull together the triple helix that I referred to earlier—the health service, industry and academia—to ensure that we are co-ordinated.

I will give the member an example, as I recognise his concern about start-up companies, which are often spin-outs from universities and which have, in the past, struggled to get access to the health service. That situation is changing. The linkage between the Techscaler network and the NHS test beds means that the risk to those who are innovating is reduced, because they have access to health service clinicians who are telling them, “Yes, this is the type of thing that we need,” or, “No, this won’t work in an NHS setting.” That gives them the opportunity to develop products and services that will be applicable to the health service. My challenge is to ensure that, rather than our having to go to 14 boards, the technology is proven and adopted nationally as quickly as possible.

The second point that the member raised is around how quickly we can adopt technology to ensure that it is not immediately outdated. That is built into the digital front door programme, as it is described, and the app is being developed to ensure that technology will be serviceable, can be used as it is rolled out and is still relevant to what people need and expect.

First, on Davy Russell’s point, no, they were not.

Secondly, on Mr Ewing’s point, we had a productive collaboration in order to resolve some of the issues around the pause for Grantown in his constituency. I was able to visit the fantastic Grantown medical practice as a result of collaboration with Mr Mountain and Mr Ewing, and I was very pleased to be able to bring that forward.

I encourage Culloden to engage with NHS Highland on its prioritisation of capital projects, because we have asked all health boards to set out their relative priorities as part of the infrastructure investment programme, which will help to guide our priorities. I encourage Mr Ewing and his constituents to engage with NHS Highland on its relative prioritisation of that particular project.

I absolutely agree with Mr Mountain’s point about insulin pumps, which are transformational for children’s lives. We have made significant investments in order to expand access to them. I will write to the committee to set out the exact figures that are involved in the investment, because I do not want to provide figures from the top of my head that I believe to be correct but might not be. I absolutely agree with Mr Mountain that the pumps are transformational, particularly for children and young people but also for adults who have diabetes. I will set out the detail in response to the committee.

Forgive me, convener, but I did not address Mr Ewing’s direct question. The answer is contained in my response to Mr Golden, which is that the infrastructure investment plan and the spending review will set out our capital investment plans. We will get to that as part of the process for this year’s budget.

The plans that we set out are part of the infrastructure investment plan process. He will be able to see our plans for the immediate period that runs through the budget process and through the infrastructure investment plan and spending review period.

For clarity, I have already set out that there is clear demand for capital investment in the health estate. I recognise that and want to make progress. I recognise that our health service is still impacted by the effects of Covid—particularly on waiting lists—as we continue to work through the cancellations that occurred during the pandemic and work through the current backlogs. Additionally, individuals are now presenting at general practices and consultant clinics with more complex comorbidities than they did pre-Covid.

Part of that is, understandably, because we asked people to pause some elements of their care, and we are catching up with some of that now. During Covid, as we were literally confined to our own homes, we started to discover more about ourselves. As a result of greater awareness being raised, we are now, rightly, presenting to services and asking more questions about our care.

Regarding our response to Covid and the way that the health service has changed, it needs to deal with the backlogs, recognise people’s greater awareness of their own health and keep up with the changing ways that people who have more complex issues present to services.

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The three documents that we published earlier this year are all about those things. The operational improvement plan is about the immediate operational demands that we need to address. The population health framework is about how, on a population basis, we need to be better at planning for our wellbeing and need to move upstream to a more preventative model. I recognise that it is not only a health service issue that needs to be answered. We must recognise the Organisation for Economic Co-operation and Development’s point that 80 per cent of the drivers of ill health—environmental factors, social factors and the drivers that come from poverty—are outside the health service’s responsibilities, and that is exactly where the Government’s prioritisation is going. We also need to address how, where and when we deliver our services. That comes through in the third document—the service renewal framework—which is more about the structural reform that we spoke about earlier.

Covid has had a profound impact on our health and social care services, which is why we need to make concerted, targeted and determined efforts to work through such challenges.

I need to defer that and come back to you in writing. I do not currently have that information, but I will ensure that that is part of the correspondence that comes back.

I recognise that we have cantered across quite a lot but might not have addressed all the issues that the petitioners have raised. I recognise that raising issues through a petition, which often involves talking about very personal healthcare issues that affect the petitioner or their family members, can be incredibly traumatic and difficult. If I have not fully responded to any points, for whatever reason, I am happy to address them in correspondence to you, convener, because it is very important that we continue to do so.