Emergency Cardiac Care

I am happy to kick off on that. Data underpins all of our programmes, not least on out-of-hospital cardiac arrest. We have a data-rich system for out-of-hospital cardiac arrest. The Scottish Ambulance Service publishes a report every year on behalf of the whole strategy partnership in Scotland. As has been alluded to, the report breaks down data by Scottish index of multiple deprivation scores, age and whether people are male or female, so we know the demographic and the age range of the patients who are having cardiac arrest.

Of course, cardiac arrest is caused by multiple things. It is not just caused by the heart; there can be many other causes, and that impacts on the types of treatments that we deliver. The causes are perhaps the elements in the data that are not as well defined or understood. We can give broad themes for the causes, but that much more granular data is not necessarily as available as it is for other elements. It probably could be but, at this point, we tend to report on slightly higher-level data.

Data is essential. The work that we do at Chest Heart & Stroke Scotland is always evidence and data driven. I think that everyone round the table and my colleagues here would agree with that. Our focus as an organisation is on helping people to live well after an event. When it comes to cardiac arrest, we invest about 10 per cent of our work and resources into prevention, but we are more focused on the other end of the chain of survival.

We believe that greater amounts of data would increase the ability to support movement on the issue that is raised in petition PE2067. On the data that is available at the moment, I do not have more than you have, but it is clear that there are data gaps and some disputes. Sudden cardiac death seems to be a tricky area. I know that the petitioner highlighted death certificates, for example. Those will not always be the best way to understand the full extent of the issue, as information is not always reported on them. It is a tricky area, but we agree that more data would be incredibly helpful. We are grateful for the Scottish cardiac audit programme and other sources of data starting to come through, because that allows us to create more effective strategies and it allows the health sector as a whole to understand the issue.

I agree with my colleagues, and the BHF is really supportive of improving data collection and better research. I want to highlight a bit of work that the BHF is funding at the moment.

You might be aware that the Scottish Government funded a pilot in the west of Scotland on inherited cardiac conditions, and the BHF has funded two clinical co-ordinators to roll out that programme to the rest of Scotland. In short, the pilot is a service to contact the families of those who have, sadly, passed away from a sudden cardiac death, where that has been indicated in their post-mortem. The service is there to give the family support and signpost them to genetic testing; to gather better data and research; to understand a bit better the risk factors; and to understand better the genetic relationships and who might be more at risk. That is being rolled out across Scotland, and it has been quite successful so far. We are funding those positions for two years, and we are at the beginning of the two years.

The programme is working closely with the Scottish cardiac audit programme to ensure that data is collected and that the programme is monitored. We are also working with colleagues in Denmark, which has a registry for sudden cardiac death and out-of-hospital cardiac arrest. Denmark’s population is equivalent in size to that of Scotland, and data collection there is really good, so we are working with international colleagues to improve ours. The work is highlighting the fact that better research is needed, which the BHF is committed to.

The BHF has funded £30 million-worth of research in the CureHeart programme, which is the biggest-ever research grant through our big beat challenge. The programme is about potentially finding a cure for genetic cardiomyopathy, which is a leading cause of and risk factor in sudden cardiac death. As you can see, we are committed to the work in that space.

I have a couple of quotes from people who are involved in the inherited cardiac conditions pilot on how their families have been supported through the programme. A family member said:

“Whoever had the gene”—

the gene related to the greater risk of sudden cardiac death—

“regardless of how scared we were, I knew we’d be looked after.”

That shows that having the clinical co-ordinator positions funded, and the work by the Scottish Government and the BHF is having a major impact on people’s families. This is, understandably, a really emotional and important topic. It is great that there is support on the ground for people who are going through bereavement. They are going through grief, but they are being supported through the whole process and not being left to signpost themselves to services.

Joining up the data is one of the challenges. Many agencies become involved in dealing with such tragic cases. Where patients survive, there is almost a pathway for providing follow-up. Where, tragically, the patient dies, it is a question of how we pull together all the agencies to make sure that we get that data. We can then fill the gaps to ensure that, for example, we make all the extra testing for other family members available to everyone. Through the work that is happening in the west of Scotland, we are learning a lot about data gathering and joining up data between agencies to help fill the gaps.

I agree. The continuation of work and pilots such as the one that Steven Short mentioned, and rolling them out Scotland-wide will, I hope, fill some of those data gaps. Through the work with colleagues in Denmark and the Scottish cardiac audit programme, we hope that, as the pilot is rolled out across Scotland, we will only get better data and evidence around that particular issue. We hope that that work will continue and that the data that we get from it will inform our policy.

The roll-out has started. It has been rolled out across Scotland through the two clinical co-ordinators that the BHF funded. It is being rolled out as we speak.

I do not have an exact answer for that at the moment, but we are very happy to write to the committee clerks after this meeting.

We report on children as part of the annual report, using available data, and through all the other measures in the report, but work on child death happens separately and is run by Healthcare Improvement Scotland. There is a multi-agency review into every death of a child in Scotland. We learn from those deaths and from that piece of work that is co-ordinated by Healthcare Improvement Scotland. Therefore, it is not that we do not do any work to improve cardiac arrests in children and young people. Lots of work is going on, but the way the data is reported and the processes for such cardiac arrests are slightly different. That is often because those cardiac arrests have different causes and different treatment options. There are themes within children’s deaths, which can be picked up through Healthcare Improvement Scotland for public awareness, for example.

Far from it—

Yes.

09:45

I am happy to jump in first. It is a really important topic, and, in some respects, it is a good news story in Scotland. Over the past decade, we have made massive improvements in terms of survival from cardiac arrest. A huge part of that is as a result of the public awareness raising and training that has been provided through the Save a Life for Scotland partnership. A decade ago, in the region of 45 per cent of all cardiac arrests had bystander CPR, which is poor and low. The improvement work has seen that figure get closer to 70 per cent, and the rate for 30-day survival from out-of-hospital cardiac arrest has doubled.

However, there is still work to be done. Denmark has already been mentioned in that regard. On the basis of some of the examples from Denmark, we know that we can probably improve further. Large swathes of the population still do not have awareness, whether of cardiac conditions or of how to perform bystander CPR or use a publicly available defibrillator.

On what more can be done, that is exactly the work that the Save a Life for Scotland partnership is doing. As well as its, for want of a better expression, business-as-usual activities—all the work that it has done over the past decade—we are now, and have been for some time, proactively looking for and reaching out to more difficult-to-reach communities, so that there is an equitable response to cardiac arrest across the country. The best care happens in the community before the Ambulance Service arrives. For these individuals, it is an immediately life-threatening emergency, and they need the public to intervene to help to save their life. It is through that partnership work and the Save a Life for Scotland partnership that the vast amount of that work is being done. We have seen improvements, but there is more to do.

I agree. The Save a Life for Scotland partnership is doing incredible work on this. The BHF works a lot on CPR training. We have RevivR, which is a free and accessible online tool to teach as many people as possible CPR. It takes only 15 minutes. The idea behind all these different ways of learning CPR is to make it accessible and to normalise it. We have just rolled out classroom RevivR. The idea is to socialise the idea of being aware of and doing CPR, knowing how to use a defibrillator and knowing where your nearest defibrillator is—knowing whether your community has one. I know that mine is on my road, but people need to know whether it is at their local church, the school or a few streets over, for example.

We are encouraging people to be aware of their communities and their environments but also to recognise that there are places in Scotland that are underserved, with regard to defibrillator access and CPR training, and that there is more work to do to ensure that those communities are CPR-ready and ready to support anybody who experiences a cardiac arrest.

I agree with my colleagues. We have made advances in Scotland through the Save a Life for Scotland partnership and the out-of-hospital cardiac arrest action plan—the data shows that—but we need to go further. Chest Heart & Stroke Scotland has been discussing that with our colleagues internationally.

We are one of the leading partners on the CPR bystander support service that is part of the OHCA plan. The support service provides aftercare for people who witness or provide CPR to someone in a cardiac arrest. It is a traumatic event, as I think that we can all recognise, and part of the challenge is ensuring that people know about the full chain of support that they can have. People need to know how to do CPR, and they also need to know that they are going to be supported afterwards.

Earlier this year, we held a symposium on recovering after a cardiac event with colleagues from Scandinavian and other countries that are doing work on after-are. We are going to make that an annual event in order to explore that aspect. One of the outcomes of the symposium was the understanding that we need to look at how we spread awareness of the good offering that we have in Scotland.

So far, more than 200 people have come through our bystander support service, which they can call and get on-going support from. For something that has been running for two years, that is good—we are happy and it is picking up pace—but we know that more people can benefit from that, so we hope that the next iteration of the strategy in Scotland will not only continue to look at what we are doing well, but consider how we communicate that throughout the population.

The other group that it is incredibly important for us to target in raising awareness is our amazing young people in Scotland. It is well recognised that CPR training in schools has a lot of benefits, not least because kids do not forget stuff. Twenty years down the line, guidelines may have changed, but children and young people will still remember what they were trained to do in school 20 years ago.

There is also a huge multiplier effect with kids. The committee may be aware that we held an amazing “Restart a Heart” live event just a couple of weeks ago, where we spent 12 hours livestreaming training to whoever wanted to see it. It was targeted at schools and young people, and 132,000 people, albeit from all across the UK, tuned into the event, which was amazing. When kids do things like that, they do not just learn themselves. They go home and grab their teddies off the bed or stick a coat in a pillowcase and show everyone else around them how to do chest compressions and make people more aware of defibrillators. That is a hugely important piece of the jigsaw when it comes to awareness raising.

I will jump in here—please stop me if I am jumping ahead. On the issue of CPR training in schools, I highlight that Scotland is the only nation across the UK where CPR is not mandated in the curriculum and is not reportable. There is some anecdotal evidence that leans in the direction that we need to make it mandatory for schools to train every child in CPR skills.

We need to normalise it in the same way that using a fire extinguisher or knowing where the nearest fire exit have been normalised. Kids need to be socialised to see knowing how to do CPR and being confident in it as a normal part of growing up.

At the moment, the picture in Scotland is quite unclear; it is really hard to gather data on how many kids in Scotland are being trained in CPR skills and when and how that is happening. We think that there may be a bit of inequality there. We do not know what is going on. If CPR training were to be made mandatory and reportable, it would be a lot easier for organisations such as ours to monitor how many people in Scotland have those skills. We would hope that that would be quite strongly reflected in the bystander CPR rate, and in more people being socialised to see knowledge of CPR as a norm in our society. That is something to consider.

I do not know the answer to that directly in terms of how effective we are. The campaigns help to raise awareness not just among the whole population, but among those people who are trying to do work within those campaigns. That is important, because it gives validity and support to what we are trying to achieve.

We are trying to reach out to people in the homeless communities in Scotland so that they are as likely as those in any other community to get bystander CPR if they need it, so having Scottish Government buy-in on out-of-hospital cardiac arrest is hugely valuable and very welcome for the whole Save a Life for Scotland partnership.

I do not have the answer either—it would be interesting to know whether there has been any evaluation of that so far. We know that certain groups are less likely to receive CPR training at work and through voluntary schemes; I have received it at work. People who are no longer working may not be keeping those skills live.

As Kym Kestell said, we do not know what is happening in schools. We have the commitment, but a few weeks ago, the Parliament heard a very moving speech from a young man, Cameron McGerr, who lost both his parents and did not know CPR, so we know that there is an issue.

There is more to be done, and that includes looking at the communities where people can be socialised well on CPR, and at those who may not receive training elsewhere, which is key.

A key message that has come out of some of the discussions that we have had is that people are scared of doing something wrong, but doing something is better than doing nothing. That is a really easy message to get behind, but we are not seeing it out there as much. I do think that we in the sector can collectively agree that that it would be worth while getting behind that—-the question is how we do so.

I am happy to start. It is a really important question, and I should say that we have never had better data on where defibs are or should be.

As to where defibs are, the BHF created the circuit—the United Kingdom’s national defibrillator network. Those defibs are mapped out geographically across the UK, and you can go online and look at where your nearest defib is. The Ambulance Service has all that information, too, so when you call 999, it can point you to the nearest defibrillator.

However, the circuit can hold only registered defibs and that is still a problem. We cannot put a figure on it, unfortunately, because we do not know how many defibs are not registered, but we believe that the number in Scotland is in the thousands. Therefore, the first thing is to ensure that we have every available defib registered on the circuit, and, if we are to expand provision of PADs, to ensure that all of them are registered, too.

The circuit has been around for quite a while now, and it has matured, so we are getting an incredible amount of data from it. For example, we have statistics on areas of Scotland that we know do not have enough defibrillators. Moreover, this year, we have a new tool in Scotland called PADmap, which has been funded by the Scottish Government with involvement from the BHF, the Scottish Ambulance Service and St John Scotland. We have never had a better tool for telling us where defibs need to be, because it brings together the information on historical cardiac arrest incident rates and the information on existing defibrillators that we get from the circuit and manages to mathematically optimise defib placement.

PADmap is a free online tool. You can google it on your phone; it will show you a number of green dots, and you can break things down by local authority or postcode. It will show you, for example, the best places in those communities to place a PAD, how many times the PAD is expected to be deployed and how many shocks are expected to be delivered, and it will even give you an estimate of how many lives it could save.

With PADmap and the circuit data that we have, the BHF has identified 12 areas across Scotland that have really long retrieval times for defibrillators. In Saltcoats in North Ayrshire, for example, you are looking at a retrieval time of 17 minutes, which is way too long. One would really hope that an ambulance would have got there before then.

However, the data also shows that we have really good coverage in some areas. We have other really successful schemes, too; the BHF has funded a community defibrillator scheme and provided more than 400 defibs in Scotland over the past 10 years. There is still a way to go, but the good news is that we know where they should be.

I will also say that, although all this data is amazing, it needs to be coupled with community support. We need boots on the ground to ensure that communities are engaged. Sometimes, we have problems with getting guardians for defibrillators so that they are emergency ready. We need members of the community to ensure that there are replacement PADs if batteries need to be replaced, check on the equipment and report back to the circuit. There are barriers and obstacles, but SALFS is doing great work to understand what they are and how to get around them.

In relation to where we put defibs, they are most needed in more deprived communities. We know where we need to put them, so, if there is a commitment to a roll-out, we have never been in a better position to do that.

10:00

There should be better socialisation of PADmap, the circuit and the tools that are available, and there should be robust signposting to those resources, because there are a lot of schemes and funds that community groups can apply for. As a sector, with the Scottish Government and the Parliament, we need to ensure that there is good awareness of those tools and maps.

We also need to ensure that community support is available for people. If people have questions about defibrillators, it can be quite difficult to know who to ask, so we need to ensure that things are joined up and that the system is robust. We are getting there. Amazing work is being done by partners across the sector to address that, so we are definitely moving in a positive direction.

We should not shy away from involving the industry. Ultimately, someone has to sell defibrillators to individuals. It is right that we have good, positive relationships with those in the industry, because they can be incredibly powerful in signposting people to PADmap when communities ask to buy a defibrillator from them. They are an important part of the jigsaw in many ways.

Everyone in the SALFS partnership, which includes some big organisations, does a phenomenal amount of work to support communities in always using PADmap to place defibrillators.

I echo the comments about Scotland being in a unique and positive position in relation to PADmap, which was launched only in the summer—that shows how cutting edge the technology is. A pilot has been done in Falkirk, where 104 defibs have been fitted. About 41 were fitted using PADmap, and those have been deployed twice as often, with a 66 per cent increase in the number of shocks that have been delivered.

I really welcome the question. It is about not just how many defibs there are, but where they are, and having the data to support that. We are now at the point of thinking how we roll that out. The sector is in a really good position, with support from the Scottish Government, to have those conversations. As has been said, there needs to be community buy-in and guardianship of defibs, so we need to utilise the data and have conversations with people about how the system will work in their communities.

When people think about public access defibrillators, they picture them in a cabinet on a wall somewhere. A lot of the time, that is the case, but that does not always work, depending on the community.

The two things in your questions that jumped out were about defibrillators near housing estates and in rural areas. If a member of the public attaches a defibrillator to you and delivers a shock before the ambulance service gets there, there is no question that you are much more likely to survive. Remember that not every cardiac arrest needs a shock. In Scotland, a defibrillator will only work on about a quarter of cardiac arrests.

Eighty per cent of cardiac arrests happen in the home, and often the only person with the victim of the cardiac arrest is the caller, so they are unable to leave to get the PAD off the wall that is 200 yards down the road, because they have to stay there and do chest compressions, which are guided by our call handlers. In more remote and rural parts, it is difficult to find places to put defibrillators where they will provide coverage.

There are two things here. We have the data on where PADs would be effective when more of them are put into the public space, and we can support that through PADmap. However, the other piece of support that we would welcome would be help to look at other ways to get defibrillators to people, such as community cardiac responders, community first responders or other types of co-response, such as with emergency service partners. When we know that ambulance response times are slower because of the rurality of the area, we need to work out how we can get people to the patient quicker.

We have had some success in that, and I will use Grampian as an obvious example. It has the Sandpiper wildcat project, which has a couple of hundred community cardiac responders all over the region and, on average, they get there six minutes quicker than we do. They are trained and equipped by the Scottish Ambulance Service. We know that they do excellent CPR because we have been able to download the metrics from the defibrillators that they use and analyse it. That is one example.

You might have seen on the BBC last week that we have now rolled out a community cardiac responder scheme in the Dumfries and Galloway area and, within a few days of going live, a responder was successfully deployed and saved a life. That was in a particularly rural region, so we send the PAD with someone who can use it, rather than expecting a member of the public to retrieve it from a fixed place.

The answer to the question about improving survival through the use of PADs is not necessarily to flood the place with more public access defibrillators because that does not equate to extra survival. It means thinking about different ways of getting public access to defibrillators in areas that need a different way of doing it, and how we can roll that out.

A lot of those communities need a nuanced approach. We have a very rural nation so we need to ask how we can best serve those communities.

I want to highlight some new data on PADs in schools that the BHF has produced using the circuit. We modelled what would happen to the average retrieval time for a defibrillator across the local authorities in Scotland if we put a registered PAD in every school. The results are just indicative, because the model covers a large area. In some cases, the results show a positive reduction in retrieval time. For example, the average retrieval time for a defibrillator in the Glasgow City Council area, which is a densely populated area, drops from 5 minutes 12 seconds to 3 minutes 48 seconds if a PAD is put in every school and registered on the circuit. That is a marked reduction in retrieval time and the reductions are most significant in the most deprived areas. The reduction in retrieval time is about 25 per cent in the most deprived communities. We would need to run that data at a local and more granular level, but putting a PAD into schools could be a good solution. However, as Steven Short said, there are other examples, and that solution might not work so well in rural communities.

We want to put more PADs in residential areas, and schools can be good for that. There is some research that shows that one third of out-of-hospital cardiac arrests can happen within 300m of a school. Locating registered defibrillators within residential areas could increase their number from just under 10,000 to 11,730. That is a big increase in the availability of defibrillators across Scotland, but the big thing to say is that that benefit is not seen equally across all local authorities.

For example, Aberdeen City Council already has defibrillators in a lot of its schools. However, in certain areas, such as North Ayrshire and Renfrewshire, we saw the retrieval time reduce by only a few seconds. So, there are reasons why it could be a good idea to put PADs on schools, but the more nuanced approach is to say that schools in certain areas, such as Glasgow city, might be good places to put PADs but that we should use tools such as PADmap and the learning from the Sandpiper wildcat project to make those decisions. We need to pull that information together to ensure that we are not leaving certain communities behind; that we are not doubling up defibs by, for example, putting one on a school that is next to a building that already has a defibrillator; and that all the unregistered defibs are registered, because that might change the picture. We could rerun all that data in six months’ time and find that we have quite a different picture. We need a nuanced approach to ensure that, in relation to the communities that need defibrillators the most, we look at the combination of all that information.

There is excellent work going on, not least from the third sector, which does some phenomenal work in communities right across Scotland. Any targeting of funding comes with the nuanced approach that we have been speaking about, and we can definitely identify areas that would benefit from having a greater increase in those public access defibs in the traditional way that we think of them.

The most deprived areas of Scotland are where we are most likely to see the types of cardiac arrest that are most likely to respond to defibrillation. We see survival across all the indexes of deprivation in Scotland, but the gap is getting wider. Survival rates are not climbing as quickly in the more deprived areas, which is often because, although individuals who live in areas of high deprivation are now probably just as likely to get bystander CPR as people in other areas, they are not as likely to be defibrillated. Looking at those types of areas in those types of communities and funding defibrillators is a win, but that needs to come with the resource that is required to raise community awareness. That is the key aspect of PADs. You cannot just stick one on a wall. Any of my colleagues will tell you that they have been at a cardiac arrest within sight of a PAD that has not been used and is still sitting in its case. That is soul destroying. It is the community engagement that comes with the placement of the PAD that is important. Funding to support that kind of stuff is just as important as funding for PADs in areas of need.

If you look at examples of taking the PAD to the patient, you will see that it is quite a resource-heavy operation to set up, provide training for and equip a cardiac responder scheme, for example. That takes resource, so funding for that would be beneficial, and it would help more remote and rural communities, too.

We have two quite nuanced approaches that we can take to the two issues that my colleagues have identified in relation to areas of deprivation and rural areas. Studies have shown that, in Scotland, if you are in a most deprived area, you are more than 300 metres further from a 24/7 access defib than you are in the least deprived area. In England, the difference between the most and least deprived areas is only 90 metres, so we have a huge issue in Scotland. However, we know that, and we know the areas that we need to look at, now that we have the data. We need a cross-sector approach. The third sector can play a role in bridging the gap between the communities that need defibrillators but might not apply for funds, as you said, and in raising awareness of the use of defibrillators, as Steven Short said.

We have used the model—BHF has got its funds—and we see success in that regard, but we need something additional, along with looking at the areas that might need a different approach. I commend the work of the Sandpiper wildcat project that Steven just described, and the data is showing that, in Dumfries and Galloway and in Grampian, we are seeing things change because of that work. Public funding needs to take a strategic approach, and partners want to be round the table, as you can see today, to be part of the solution. People have bought into that already.

10:15

I agree with my colleagues. Scotland is the only UK nation that has not committed investment for defibs. In England, Northern Ireland and Wales, they have been placed in schools, but we have an opportunity in Scotland to invest effectively and strategically. They could be placed in schools but, as we have heard, there are many other ways to do it. We welcome the investment, which we think is needed. We have an opportunity to reduce the marked inequalities that we see in this space and have a real impact on survival, particularly in areas of deprivation and the communities of greatest need. This year, the BHF has taken a more targeted approach with our funded defib scheme, using data to ensure that we are actively targeting areas in the communities that are in the greatest need, and aiming to encourage targeted investment to those communities. The good news is that we now know where those areas are.

There has been a graded approach to the work over the past decade. In the first out-of-hospital cardiac arrest strategy, there was a conscious decision to focus more on bystander CPR than on CPR and defibrillation, because our bystander CPR rates were so poor. For the first five years of the strategy, we decided not to focus as much on defibs, because, first and foremost, we needed to get people pressing up and down on cardiac arrest victims’ chests. However, in the past five years, the situation has changed completely and we now have a much greater push for CPR and the use of defibrillators.

Are we confident that the defibs are in the right places? I think that we can say that some of them are, but, as we have highlighted, we still have work to do. You mentioned Glasgow and the west of Scotland, and the highest rates of shockable cardiac arrests, which are the types of cardiac arrests that the defibrillators work on, are in our deprived urban areas. They occur most commonly in our service industry workforce, predominantly among males in their 50s, yet they are the people who are not close enough to the defibrillators, as Kym Kestell has described. So, I think that we can be confident in saying that the defibs are not always in the right places yet, despite the amazing work that is being done. We need to find the right areas and put them there.

Finding the funding to provide PADs to plug those gaps is the easy part. The challenging part is finding the guardians in the community who can maintain and check the defibrillators, be responsible for changing batteries when they run out after several years and all those kinds of things. Funding and placement are relatively easy to achieve; it is the community part of it that is difficult to achieve, in terms of both guardianship and raising awareness in the community, which is a key part of having the PADs.

This suddenly feels like the first question where I am under pressure. In adult learning, we know that we forget stuff. There is decay of any skill, and, if you do not keep performing it, your memory of a skill will decay relatively quickly. However, while acknowledging that you do not remember it—and you probably do not—you have had training and you are aware of it, so, when our call handler who supports you through telephone CPR advice says to you, “Kneel next to the patient,” something in your head will go, “Oh, I need to kneel next to the patient’s chest, and I need to put my hands in the centre of their chest—that’s right.”

Yes. It is almost a multimodal approach. You have had awareness and, although you may feel like you have forgotten it, those prompts will trigger your memory when you are speaking to the call handler.

We expect our clinicians to refresh the skills that they use, and that goes for any skill. Take our colleagues in the fire service—if you drive past any fire station, you will see firefighters out training all the time. They are practising the skills that they need to know, so that, when they have to use them in reality, it is much more automatic.

That is difficult to achieve in an entire population, because you cannot expect communities to train all the time, but the more that people get exposed to those skills—God forbid that they have to use them—the more confident they will feel. That is the important word for members of the public when it comes to performing CPR. It is not about competence; it is about having the confidence to have a go. We have spoken about the fear of doing harm, which is often the biggest fear, but training and awareness can allay some of the anxieties that people may have.

Chest, Heart and Stroke Scotland has been calling for prevention. We have had conversations with Brian Whittle and many of your other colleagues about it, and it has been nice recently to see a shift in understanding that we cannot continue just to plug the gaps and focus on the key metrics that we all see in the media about waiting times and hospital beds. Those are important, but studies show that, even if we ignore the tragic human impact of not focusing on prevention, economically we cannot sustain the direction that we are going in. The state of healthy life expectancy in Scotland is scary for us all.

We need a nuanced approach to what is prevention and the different stages of prevention. The study of the Italian screening programme is compelling, and I would love to know more about what the stages are once they have done that screening. We saw from the work of the national screening committee that we need pathways for people.

There are different levels of prevention. At the population level, there is eating well and looking after yourself. However, a lot of the cases of sudden cardiac death in young people that we are talking about have a genetic element—they cannot be prevented from occurring—so the question is about when they are detected and what the next steps of the pathway are. It is a compelling issue, and it would be good to have more conversations about pathway development for those cases.

On the schools issue, it is difficult to create a best practice model without having the data available to us to model what the provision looks like at the moment. All the local authorities in Scotland have committed to teaching CPR to all secondary school students, but, as you say, we do not know what the landscape of that is like at the moment.

If we want to make that teaching mandatory and reportable on, we and our partners in that space are committed to finding out, in collaboration with colleagues in education, how to design it so that it is as effective as possible. It might be taught in one school year, with a refresher course a couple of years down the line. I do not have any specifics about what the roll-out of that would look like, but we are committed to working across the sector to ensure that, if it were put in place, it would be really robust. It is on the curriculum in England, and we have colleagues in England who are looking at what a monitoring system looks like, what it could look like, what information we would get from it and what we could learn from it.

10:30

I think that this is a really important issue. As Steven Short said, when you learn these skills as a young person, they become a lot more normalised. You carry them with you for the rest of your life, and it means that you are probably more likely to do a refresher course. It is a case of “I’ve done first aid training at work, and we get a refresher course every year.” It just becomes a normal part of life, and that is really important in breaking down the barriers and addressing people’s unwillingness to perform CPR, especially on older or frail people, because they think that they are going to do harm. There are also misconceptions about, for example, needing to be trained to use a defibrillator. People do not need any training; in fact, defibrillators speak to you and tell you how to use the equipment.

There is still work to be done, but I think that there is a real opportunity here. There are also examples to look at. From memory, I think that CPR training is mandatory and reportable in schools in Denmark, and the Danes have higher survival rates. It is an interesting question that we really want to dig into a bit more. At the moment, we do not understand the landscape of CPR training in schools.

I do not know what those standards, or the legislation, would say—I have never run a business. However, I do know that there is a first aid at work programme, and there are initiatives to encourage workplaces to take up CPR and defibrillator training. SALFS has recently collaborated in a partnership with the Resuscitation Council UK and its “ResusReady” campaign. It is almost like a rubber stamp; your business is “ResusReady” if you have trained a certain number of individuals in your workplace.

There are things out there to encourage such activity. However, on your question about what workplaces have to do, I have to say that I do not know the answer.

That is an important and interesting question. I was having this very discussion at a meeting last Monday.

When it comes to CPR training, I think that, through some great working with SG colleagues, we have come to realise what work is imagined in health and what is achievable in education. We have probably not understood each other as well as we could or should have done over the years, and we are looking to break down some of the barriers by having some joined-up thinking between health and education to say, from a health point of view, “This is what we think needs to be done,” and to ask, from an education point of view, “How can we achieve that and ensure that it is done?”

There are other partners to consider, too. With education, it comes back to the local authority, and, as we know, what works in one local authority is not necessarily going to work in another. We are doing a little feasibility study with Dumfries and Galloway in which we are trying to join up a lot of this work, and we are looking at different levers at a local level through a sort of assets-based approach. Where we know that assets exist already, how can we join things up, say, to improve CPR awareness in schools and communities; to optimise PAD placement, which we have talked about already; and to find better ways of getting PADs to people through cardiac responders or people signing up to the GoodSAM app? We are proactively doing work in that space to join up different parts of the system in a better way.

Ahead of the next election, we have been calling for different public bodies—and, I guess, different policy areas—to see what role they can play in health creation. The population health framework that you mentioned is a starting point for making it clear that it is not just the health policy sector or health charities that play that role when it comes to prevention—we all do. That represents a shift, and it is a conversation that we need to have. We have all heard the stories about teachers’ workload, so we need to move away from that simple view and have that conversation. We need to include different sectors, too. The third sector definitely has a role to play, because it is often able to bring different policy angles together.

I agree with my colleagues. They have covered the points wonderfully.

I would just add that we welcome collaboration between health and education colleagues, especially on the issue of CPR training in schools. There needs to be collaboration on that and co-design of it, to ensure that it works for everyone. We are very committed to working in that space.

That is exactly what we are exploring just now in the Dumfries and Galloway care zones feasibility study. Health boards might know lots about the health metrics of their communities, but the local authority actually knows those communities. Steven Short from the Ambulance Service might say, “You need a defibrillator there”—that would be a really simple thing for him to say—but it is the local authority that, with all its community partnerships, knows who to tap into in its communities and say, “Look, we think that you need this there. Who in the community can support it?” That is one of the big pieces of learning that we are taking from the pilot that we are right in the middle of, but that joined-up collaboration and thinking are hugely important when it comes to what is happening locally on the ground.

It is a huge, and real, challenge. Ultimately, a guardian owns, or is responsible for, that defibrillator—however you want to put it—and the responsibility lies with them to ensure that the piece of kit is rescue ready. They buy the kit in good faith and register it on the circuit so that our call handlers can signpost people to go and get it when someone is having a cardiac arrest. However, when that happens, the pads need to be replaced, and they are expensive—and by “pads” I mean the pads that you stick to the chest, not the public access defibs themselves. It is not that the guardians in the communities forget about that; it is just that they do not necessarily factor it in, because it is not in their thought process at that point. Again, there is awareness raising to be done there.

Although the defibs are designed to be left alone—they do their own self-checks and so on—their batteries have a finite life, with anything between three and five years being pretty much standard. Therefore, the batteries will decay over time, even they are not used, and will need to be replaced, which is another cost.

There is also a time commitment. For the defibs to stay in the circuit, someone needs to go around periodically and confirm that they are still rescue ready. After all, the last thing that we want to do is to send a bystander to a defib cabinet only for them to find the defib or its pads missing or not working.

So, yes, this is a real challenge for us. I guess that, as we are not the owners of the defibrillator, our responsibility in the Ambulance Service is to continue to raise awareness of some of the challenges.

For sure.

We have some amazing partners out there who are doing brilliant work in this space, and there are some fairly large guardians managing multiple public access defibrillators in their areas. Indeed, they have come together as a group. You might have heard or be aware of the work of PAD Scotland, which is a bit of an offshoot of SALFS. Those involved are all partners in SALFS but they have their own working group to explore some of these challenges.

Absolutely.

I would just add that, if there is to be investment in increasing PAD access across Scotland, it should also take into consideration maintenance costs over, say, 10 years. We have figures for how much those costs would be, and we think that it is a really important part of ensuring the longevity of any PADs that they are funded and that we have the guardians, the community buy-in and the community engagement in place to ensure that those PADs are used and are known to the local community.

We have heard from community groups and fundraisers that they have been left out of pocket when they have had to replace the pads or the batteries. Steven Short is right to say that it is not a cost that everybody knows about, so we need to ensure that there is really good communication as well as really good expectations of how those maintenance costs will be met. I hope that that will be considered in any investment that is made in PAD access.